EMS OPERATIONS & CARDIAC ARREST - ACMT
EMS OPERATIONS & CARDIAC ARRESTUPDATE FROM THE FRONT LINES: BRAZILJUNE 10, 2020
WEBINAR SERIES PARTNERSAmerican Academy of Clinical Toxicology (AACT)American Academy of Emergency Medicine (AAEM)American Academy of Emergency Nurse Practitioners (AAENP)American Association of Poison Control Centers (AAPCC)American College of Medical Toxicology (ACMT)Asia Pacific Association of Medical Toxicologists (APAMT)European Association of Poison Centers and Clinical Toxicologists (EAPCCT)Middle East & North Africa Clinical Toxicology Association (MENATOX)
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MODERATORSPaul M. Wax, MD FACMT¡ Executive Director, AmericanCollege of Medical Toxicology(ACMT)Ziad Kazzi, MD, FACMT¡ Board Member, AmericanCollege of Medical Toxicology(ACMT)¡ President, Middle East &North Africa ClinicalToxicologyAssociation (MENATOX)
CONFLICT OFINTERESTTHE SPEAKERS DO NOT HAVE ANY CONFLICTS OFINTEREST TO DISCLOSE
OUT-OF-HOSPITAL CARDIAC ARRESTIMPACT OF CORONAVIRUSMEDICAL AND PUBLIC HEALTH CONSIDERATIONS OF COVID-19Bryan McNally, MD, MPHProfessor, Emergency Medicine, Emory University School ofMedicine, Atlanta, GALekshmi Kumar, MD, MPHAssociate Professor, Emergency Medicine, Emory UniversitySchool of Medicine, Atlanta GA
Out-of-Hospital Cardiac Arrest (OHCA)Presentation Overview Optimizing OHCA Care CARES – Cardiac Arrest Registry to Enhance Survival - COVID Data Enhanced Communication EMS/MDs Non-ROSC Patients That May Benefit From Transport Reviewing Termination of Resuscitation (TOR) Guidelines Minimizing Transport of Medically Futile Patients
CARES PARTICIPATION 2020
CARES 2020 FOOTPRINT 144 million catchment area Almost 45% US pop covered More than 1,800 EMS agencies More than 2,200 hospitals 28 state based registries 45 additional communities in14 states
OHCA SURVIVAL1) Bystander Witnessed OHCA patients presenting in a shockable rhythm -- 33% Survival2) Bystander CPR more than doubles survival3) The most powerful predictor of survival is ROSC in the field,35X greater chance of survival compared to non-ROSC4) Unequivocal evidence that the battle to save an OHCA patient is won or lost at thescene.5) Hospital care is important but can not compensate for a failed field resuscitation.Annals of EM, Kellermann, October 2010, Vol. 56 No 4.
Impact of the Links in the Chain of SurvivalNew England Journal of Medicine, 2004; 351(7): 647-656
Number Needed to Treat for OHCA Epinephrine – 112 Early Recognition of OHCA – 11 Bystander CPR – 15 Early Defibrillation – 5NEJM, PARAMEDIC2 Trial, July 2018
Local Field Termination of Resuscitation (TOR)Rates Range from 9-22% 90% Non ROSC patientsPresented in aNon-shockable rhythm
Coronavirus
Etiology of ArrestFebruary – April2019February – April2020
Other Etiology
Shockable Presenting Rhythms
Public Location of Arrest
Bystander AED in Public Location
Bystander CPR
Field Termination of Resuscitation
Coronavirus Impact
Out of Hospital Cardiac Arrestin the times of COVID19
Dispatch SurveillanceArrest ic setting29
Personnel & PPE Least number of personnel required Don PPE prior to entering scene Full PPE Single pair of gloves; change gloves if torn or contaminated Disposable isolation gown Respiratory protection N-95 with shield or eye protectionthat fully covers the front and sides of the face
Airway management Early airway control with iGel (SGA) HEPA filter use
ResuscitationStaying in place to provide high quality CPR
Resuscitation CPR on scene until ROSC or asystole Sustained asystole – on scene termination Online Medical Control
Cessation Criteria 18 years of age No ROSC Remains in asystole/ PEA Adequate ventilation IV/IO access established and ACLS medication administered No hypothermia Non traumatic Considered reversible causes
Special situations Pediatrics Witnessed arrests Persistent shockable rhythm Public arrests
Future guideline changes Personnel PPE Airway ACLS
Thank YouBryan McNally: bmcnall@emory.eduLekshmi Kumar: lekshmi.kumar@emory.edu
UPDATE FROM THEFRONT LINES:SÃO PAOLO, BRAZILAlvaro Pulchinelli Jr, MD, PhD¡ Clinical Toxicologist and Clinical Pathologist, Affiliate Professor atFederal University of São Paulo¡ Medical Supervisor at Planitox, Medical Advisor at Fleury Laboratory,Scientific Director of the Brazilian Society of Clinical Pathology
A PERFECT STORM.¡ Here we have thefour horsemen ofthe apocalypse:¡ Pandemic¡ Fragility of ourhealth system¡ Vanity¡ Ignorance
THE FIRST:A PANDEMIC¡ Unknown behavior¡ The second country in number of cases¡ The epicenter of the pandemic
THE SECOND: FRAGILITY OF OUR HEALTH SYSTEM¡ 220 million inhabitants¡ with great social inequality¡ Private health system covers only 25% of the population¡ Public health system covers 100%¡ (25% of the population has access to both systems)¡ The spread of the disease caused concern throughout the health system¡ Best private hospitals are under constant concern with the prospect of not being able to meet thedemand¡ Public hospitals have an average occupancy rate of 90%.¡ There are places where the system has collapsed¡ City of Manaus – AM; Belém – PA; Fortaleza – CE and Rio de Janeiro - RJ
THE THIRD: THE GREAT VANITY¡ Vanity of our politicians and the medical profession¡ The president with an attitude that denies the magnitude of the problem, does not fulfill his role as aleader and attacks the governos¡ Governors counterattack, however, governors do not have a unified proposal¡ There is a large underreporting of cases¡ The number of tests is still low¡ Doctors are also lost in useless discussions¡ We have never had so many “scientists and experts” in COVID-19¡ And we've never been so poor in information
THE FOURTH: OUR IGNORANCE¡ Result of the low educational level of our population¡ Part of the population simply does not meet the isolation norms¡ The factors of non-compliance are:¡ denialist atitude¡ ignorance of the danger of the disease¡ not having financial resources to remain in isolation¡ From the toxicological point of view:¡ increase in cases of poisoning by household cleaning products
¡ The Brazilian Society of Clinical Pathology / Laboratory Medicine carries out a project with the aim oftesting the diagnostic kits used in our country. The results are still being analyzed, but partial results arealready published on the website: testecovid19.orgHTTPS://WWW.TESTECOVID19.ORG/
Thank you!Alvaro Pulchinelli Jr, MD, om.br
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OHCA SURVIVAL 1) Bystander Witnessed OHCA patients presenting in a shockable rhythm --33% Survival 2) Bystander CPR more than doubles survival 3) The most powerful predictor of survival is ROSC in the field, 35X greater chance of survival compared to non-ROSC 4) Unequivocal evidence that the battle to save an OHCA patient is won or lost at the
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