Now we suffer the dinosaur Professor Douglas Anthony Chamberlain CBE KSG Some of you may know him Compassionate Short, bald, visionary bespectacled Iconoclast Ugly, old and lame- Claims to be the worst houseman in the history of St. Bartholomew s Dear friend CHAMBERLAIN
Now we suffer the dinosaur, Some of you may know him, Short, bald, bespectacled Ugly, old and lame- CHAMBERLAIN
RC(UK) Scientific Symposium 2015 The Laerdal Lecture Resuscitation 55 Years On: Still Against the Odds Douglas Chamberlain
O Asmund Laerdal (1913-81) And his tradition continues
First Annual Symposium RPG Med School 11th Dec 1990 Retrieved: Dr David Zideman
Compressions: A re-discovery Kouwenhoven, Jude, Knickerbocker JAMA 1960; 173: 1064 The use of the technique on 20 patients has given an overall permanent survival rate of 70%. Anyone, anywhere, can now initiate cardiac resuscitative procedures. All that is needed are two hands. And now the world was ready
We now have had 55 years of resuscitation science, experience, and reflection since the great paper of 1960 that set many of us on the road that we still travel today but still against the odds.
And why against the odds then, now, and indeed in 2040? Survival OOHCA rarely > 10% Berdowski et al. Resuscitation 2010;81:1479-87 Survival IHCA usually < 20% Peberdy et al. Resuscitation 2003;58:297-308 In order to be with the odds: > 50!!!
But can we close some of the gap? Indeed we should But how can we do so?
But can we close some of the gap? Indeed we should But how can we do so? By better adherence to the guidelines By improvement in our guidelines By implementing other useful policies
1. By better adherence to the guidelines The 2015 RC(UK) guidelines are packed with excellent information and advice. They warrant the very closest scrutiny!
By better adherence to the guidelines Aided within organisations by Leadership Supervision Feedback techniques
Feedback Techniques (Download Analysis) Compress 170/min (2004) Ventilate 50/min (2015) Against the odds!!
2. By improvement in our guidelines The guidelines ARE as they should be but they may still not be optimal in just a few minor respects
Let s examine some key points My personal opinion
Rescue breaths or not for lay rescuers The 2015 guidelines state that only if rescuers are unable to give rescue breaths should they do compression-only CPR. But is this optimal? What evidence do we have about performance after CPR training?
269 lay volunteers after CPR training took 16 s for breaths! Assar, Chamberlain, Colquhoun et al. Resuscitation 2000; 45: 7-15 53 first year medical students after CPR training took 14 s for 2 breaths! Heldenreich, Higdon, Kern et al. Resuscitation 2004: 62: 283-9 Guidelines suggest 10 s (too long?) For most adult OOHCA, are not compression only the best bet??
Guidelines have Refs 54-57 supporting breaths with BLS:- Ref 54: children Ref 55: children Ref 56: non-cardiac Ref 57: very prolonged > 15 mins Accepting the notion of doing most for the mostest, compression only for non-professionals IS best bet!
Dispatcher-assisted: comp. only better Hupfl et al. Lancet 210;376:1552 Dumas et al. Circulation 2013;127:435 But overall evidence to date is inconclusive The guidelines MUST be evidence based On advising breaths for laymen trained in CPR, the guidelines are therefore reasonable, though may not be optimal But we need more research
Compression Sequences The 2015 guidelines call for compression sequences of 30 But is this optimal? What evidence do we have about sequence length?
Value increases over first 15 or so Berg et al. Circulation 2001; 104: 2465
Delay in peak value greater in diastole Ewy. Circulation 26 April 2005 (but known earlier)
But we have no major randomized trials to guide us The guidelines MUST be firmly evidence based For compressions, the guidelines are therefore as they should be, though may not be optimal But we need more research
But by the way Healthcare professionals CAN deliver longer sequences But Mrs Smith cannot. Why must professional and layman guidelines be the same?
Compressions First or Shock ASAP The 2015 guidelines state that a pre-specified period of CPR before a shock is delivered is not recommended But is this advice optimal? What evidence do we have about shocks in relation to compressions?
CPR before defibrillation in patients with out-of-hospital VF P=0.2 P=0.61 P=0.006 RI = dispatch to stop Wik L. JAMA 2003; 289: 1389-95 (see also ROC investigators: Resus Feb 2010)
These discounted: ERC refers to ESC refs:- 1. Baker et al. Resuscitation 2008;79:424 2. Stiell et al. NEJM 2011;365:787 3. Ma et al. Resuscitation 2012;83:806 4. Jacobs et al. Emerg Med Australas 2005;17:39 6. Koike et al. Prehosp Emerg Care 2011;15:393 Note that in these studies Results were variable, most n.s. One later ref (ROC) No rigid control compression quality But real life and so valid and useful
Compression first could be correct only if compressions are known to be of high quality This demands feedback checks that are not feasible for most We hope compressions first are permissible with proper audit
A recent SECAmb Audit Compressions 120/min (all aspects checked)
But compression first could be correct only if compressions are known to be of high quality This demands feedback checks that are not feasible for most We hope compressions first are permissible with proper audit For shock as soon as possible the guidelines are as they should be, and for general use are optimal
The use of drugs in OOHCA The 2015 guidelines call for adrenaline every 3-5 mins But is this optimal? What evidence do we have for the benefit of adrenaline in OOHCA?
The evidence does not support adrenaline in the dose currently recommended.
Adrenaline: 23% Adr+ (n=367) ROSC n= 150 41% Admitted ICU n=104 28% Discharged n= 24 7% Included (n=848) Adr (n=481) ROSC n= 121 25% Admitted ICU n= 108 23% Discharged n= 60 13% P<0.001 P=0.06 P=0.006 56% P<0.001
ROSC for OOHCA Japan 2005-8 15025 adrenaline, 402091 no adrenaline
Studies cited as indicating lack of certainty about benefit or harm:- Lin et al. Resuscitation 2014;85:732 There was no benefit of adrenaline in survival or neurological outcomes Patanwala et al. Minerva Anestesiol 2014;80:831 Epinephrine use during cardiac arrest is not associated with improved survival to hospital discharge
But we have as yet no major randomized trials to guide us The guidelines are usually firmly evidence based but here they only follow tradition For adrenaline, the guidelines are not as we would wish But research will be available by 2017 (Paramedic 2)
The use of drugs in OOHCA The 2015 guidelines call for amiodarone every 3-5 mins But is this optimal? What evidence do we have for the benefit of amiodarone in OOHCA?
None yet for survival But ROC-ALPS report soon For amiodarone, the guidelines are reasonable
So can we not do all the research we need? o Complexities of ethics & time needed o Research grants take more time o May be irrelevant by completion For OOHCA:- o Many trusts have no research staff o Paramedics may lack research training o Pressure to meet time standards
Not all the research we need, but we do nevertheless have much to guide us, from many excellent centres, in battling against the odds
Research Some missing? Lots have fallen off
I would like to see research: Immediate start for known problem Recruiting large numbers Completed within months Appropriately address all issues How s that for against the odds?!!!!
Some trials have been mis-directed, or have been conducted on matters with too many variables Mechanical CPR: why for ALL arrests??? Hypothermia: inevitably MANY variables
3. By implementing other useful policies Community First Responders OOHCA cannot be a problem for ambulances. It is a problem for the ambulance service and the community! Chamberlain s dictum: If a nearby CFR is not mobilized within 30 s of the ambulance for a known OOHCA then the system is defective!!
Confident wide use of AEDs Familiarisation with AEDs to be taught with CPR in schools
Other things may include:- More extensive use ultrasound Wider use ECLS (ECMO) Prevention of reperfusion damage Adoption of the Great Unknowns
Summary 1 Cardiac Arrest always against the odds! But we can and should improve them! Some measures should be easy Other measures will be challenging
Summary 2 Measure Compare Download, Video, Feedback Utstein Comparator Improve Laerdal Foundation
I want to come back again to give another Laerdal lecture in 25 yrs to review our progress in the battle!! The odds will still be against us But they should be better!! And be fun for an old hand