Gary Strong's presentation at the Paramedics Australasia NZ CPD event in Auckland on 3 July 2013. Gary is the Programme Leader BHSc Paramedic at Whitireia Polytechnic, and prior to that was the Education & Training Manager at Wellington Free Ambulance. Prior to coming to New Zealand, Gary was the Paramedic Clinical Lead at the Great Western Ambulance Service, an Education and Development Tutor at the Gloucestershire Ambulance Service, and worked as a paramedic with the West Midlands Ambulance Service NHS Trust.

1. Sudden Cardiac Arrest
Can we do better?
Gary Strong July 2013

4. The challenge:
• To reduce the gap between what science
tells us is correct and what clinicians
actually do
• Measure, improve, measure, improve
• Change the culture: expect success

5. • Understand key concepts relating to CPR
• Understand how to get better results
• Discuss research issues in cardiac arrest
management
• Save lives!
Learning outcomes

7. • ‘invented’ paramedics
• 40 years’ experience
• Best place in the world to survive a
sudden cardiac arrest
• Resuscitation Academy – sharing good
practice
Why Seattle?

9. 52%

10. 5%

11. 7%

12. 0%

13. 33%

14. 32%

15. 32%

16. ??%

17. Why learn from Seattle and King
County?
• 46% survival rate for witnessed VF arrest
• 40+ years’ experience and research
• Whole systems approach
• Continuous self improvement
• ‘we will never stop looking for new ways to
save lives’

18. Why focus on cardiac arrest?
• ‘a community that can successfully
respond to & manage this emergency is
likely to perform well on the other 99% of
emergencies’ Eisenberg (p. 18)
• survival from witnessed VF should be the
main criteria for rating a community's
EMS system (Utstein)

19. •Eisenberg, M.S. (2009). Resuscitate! How Your
Community Can Improve Survival From Sudden
Cardiac Arrest. Seattle: University of Washington
Press
•New edition just published!

20. •Patient factors
•Event factors
•System factors
•Therapy factors
What makes the difference?

21. Time to CPR
Quality of CPR
Time to defibrillation
Interaction of CPR and defibrillation Time to ALS care
Telephone CPR
Community CPR
Public access defibrillation
Chain of Survival

22. What makes the difference?

23. Three Phases of Cardiac Arrest
• Electrical
– 1-5 mins
• Circulatory
– 4-15 mins
• Metabolic
– The land of no return

24. The importance of
time to defibrillation

26. The importance of
time to CPR

28. Time to first shock
Time to CPR 0-6 minutes 9-12 minutes 13+ minutes
0-4 minutes 45% 31% 23%
5-8 minutes 34% 21% 17%
9+ minutes N/A 10% 0%
Survival from Cardiac Arrest
King County, Witnessed
VF rhythm
1980-2009

29. New Zealand Initiatives
HEARTsafe New Zealand
•http://www.stjohn.org.nz/about-st-john/st-
john-projects
Operation Heartbeat
•http://www.operationheartbeat.org.nz

31. St John boss in push to improve services
Access to patient survival data critical for lifting care, says chief.
Survival rates for cardiac arrest, strokes and trauma victims are
among the medical records that the new St John boss wants hospitals
to provide in order to improve patient care.
Chief executive Peter Bradley is making a number of changes to the
organisation in a bid to cope with ever increasing 111 calls and
funding shortfalls of millions of dollars each year.
He told the Herald that a restructure of senior management positions
was to ensure "accountability and transparency" in a drive for better
performance and a strong focus on patients.
Currently, the only measure for St John is response times to
emergency calls which have particularly deteriorated in urban areas,
such as Auckland.
However, Mr Bradley wants access to medical records to measure the
survival rates of patients taken to hospital by ambulance after they
have suffered from cardiac arrest, strokes and trauma.
Similar data was collated by the Department of Health in Britain,
where Mr Bradley was running the London Ambulance Service until
late last year. The most recent statistics showed the London
ambulances had a survival rate of 32 per cent for cardiac arrests, the
best in the country and comparable with the best in the world.

32. THE NEW ZEALAND
MEDICAL JOURNAL
Survival from out-of-hospital cardiac arrest in Wellington in
relation to socioeconomic status and arrest location
Aimee L Fake, Andrew H Swain, Peter D Larsen
Abstract
Aims The study examined the influence of physical location on survival from out-of hospital
cardiac arrest (OHCA). Firstly, OHCAs occurring in residential settings were
compared to those occurring in public locations. Secondly, the residential OHCAs
were classified according to socioeconomic status and the relationship between
socioeconomic status and outcome from OHCA was examined.
Methods For all OHCAs that occurred between 1 July 2007 and 30 June 2010, we
compared OHCA characteristics and outcomes between public and residential
locations, and for residential locations examined across deciles of socioeconomic
status.
Results Of the 445 arrests that occurred during the study period, 413 met the
inclusion criteria. Survival from OHCA in public locations was approximately twice
that for residential OHCA (19.8% vs 10.7%, p=0.021). We found no association
between survival from residential OHCA and socioeconomic status. Similarly, we
found no association between socioeconomic status and witnessing of the event,
bystander cardiopulmonary resuscitation, the initial presenting rhythm, and
ambulance response time.
Conclusion Residential OHCA in the Wellington region has a much poorer prognosis
than OHCA in public locations. There is no evidence to suggest that any
socioeconomic group in the Wellington region is disadvantaged when a community
and ambulance response is required for an OHCA.

33. What makes for good CPR?

34. • Get started rapidly
• Recognise agonal breathing
• Rate
• Depth
• Recoil
• Minimum pauses – ‘pit stops’
• Do not overinflate
• Change every two minutes
• Communicate well
• Know your roles
Good CPR

35. Positive & Negative

38. How good do you think you are?

39. A cardiac arrest in Seattle (1)
• Patient collapses
• 911 call
• Aggressive telephone CPR advice
• Display tells call taker if there is a PAD nearby
• BLS crew on scene 4-6 mins
• 1st
shock 6-8 mins
• ALS crew on scene 4-10 mins

40. A cardiac arrest in Seattle (2)
• BLS crew in charge
• ‘choreographed’ CPR
• CPR ‘density’ 90% +
• Continuous chest compressions/30:2
• Change operator every 2 mins
• Max interruption 10 secs
• Post resuscitation hypothermia
• In hospital 100%
• Pre hospital trial – active cooling

41. A cardiac arrest in Seattle (3)
• BLS medic downloads data and voice
recording from AED
• Completes & submits cardiac arrest QI form
• ALS medic downloads data and voice
recording from LP12
• Completes & submits cardiac arrest QI form
• Registry co-ordinator may request further
information from either crew

42. A cardiac arrest in Seattle (4)
• Every cardiac arrest is debriefed
• Medical Director personally reviews every
cardiac arrest
• Feedback to crews
‘you should develop the attitude & expectation that a
patient who presents with VF as an initial rhythm will
make it to the hospital alive’ Eisenberg (p. 129)

43. CREATE THE CULTURE

44. Research – the size of the task
• ILCOR
• http://www.ilcor.org/en/home
• CoSTR: Consensus on Science and
Treatment Recommendations
• Just how much resuscitation research is
there?

45. Why Utstein?
• 1990 conference
• Utstein Abbey in Norway
• Consensus paper
• http://depts.washington.edu/survive/utstein
.php

46. Some unresolved questions:
• Why is the incidence of VF falling
• Do we need oxygen?
• What is optimum airway maintenance?
• Do we need drugs?
• What about human and team
performance?
• Equipment positioning?
• ‘Man vs machine’

47. Some useful links:
• http://www.slideshare.net/Hiltz/improving-
community-based-response-to-cardiac-
arrest-nz3
• http://www.londoncardiacarrestsymposium
.com/videos-whitbread-2012.html
• http://circtrial.com

48. Eisenberg book: Resuscitate!
• Print version:
http://books.google.com/books/about/Res
uscitate.html?id=5daNMgEACAAJ
• FREE ebook:
https://itunes.apple.com/us/book/ten-
steps-for-improving-
survival/id603675538?mt=11

49. The Future ?
• Sam Parnia – the Lazarus Effect
• The CHEER Study
Refractory Out-of-hospital Cardiac Arrest
Treated with Mechanical CPR,
Hypothermia, ECMO (extracorporeal
membrane oxygenation machine) and
Early Reperfusion.

50. Questions?