The Prehospital

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The Prehospital Transport Medicine Research
Program
Sunnybrook Health Sciences Centre
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Objectives

• Resuscitation Outcomes Consortium (ROC)
• ROC P.R.I.M.E.D.
• Impedance Threshold Device (ITD)
• Early versus Later Analysis
• Optimizing CPR
• ZOLL E Series
• New defibrillation pads
• The transfer of data

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ROC Sites

• Birmingham, AL
• Dallas, TX
• Iowa City, IA
• Milwaukee, WI
• Pittsburgh, PA
• Portland, OR
• Ottawa/OPALS/B.C.
• San Diego, CA
• Seattle/King Co., WA
• Toronto, ON

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Participating Toronto Sites (Toronto Regional
RESCUeNET)

• Durham
• Hamilton
• Muskoka
• Ontario Air Ambulance Program
• Peel
• Simcoe
• Toronto
• York

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Toronto Regional RESCUeNET

• 8 EMS Services
• 32 Fire Services
• 28 Dispatch Centres
• 5 Base Hospitals
• 53 Receiving Hospitals

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EPISTRY Enrollment
Dec 1, 2005 to Sept 14, 2006
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Please bear in mind..

• First qualifying vitals even if the vitals
  improve during the course of treatment (BP or
  GCS)
• Initial fluid bolus ROC HS study fluid
• Call the enrollment line immediately after
  transferring care to the trauma team.

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ROC HS Enrollment
July 6 to Sept 15, 2006
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P.R.I.M.E.D.
Prehospital Resuscitation using an IMpedance
valve and Early vs. Delayed analysis trial
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P.R.I.M.E.D

• ITD

• ANALYZE
• EARLY VS. LATE

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Impedance Threshold Device
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ITD - What is it?

• Hemodynamic adjunct (not ventilatory adjunct)
• Used with
• BVM
• ETT
• Genesis II (Manual setting only)

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Understanding the ITD

• Compression
• Increased intrathoracic pressure
• Compression of heart and lungs

• Decompression (recoil)
• Decreased intrathoracic pressure
• Refilling of heart and lungs
• Complete chest recoil is critical!

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ITD - What are we asking you to do?
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Using the ITD with a Mask or ETT
Ventilate using timing lights (10/minute)
Mask ventilate at 2 30
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ITD Timing Lights

• Flash 10 times per minute 10 breaths/min.
  (q 6 seconds)
• May be used to guide compression rate.
  (10 compressions / breath)
• Use timing lights when ETT established

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If Ventilation Timing Lights Fail

• The ITD functions independent of timeing lights
• Turn off the lights and ventilate patient at
  proper rate (10 breaths/min).

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Important Reminders

• Mask Continuous tight seal
• Connect ITD as soon as possible start with mask
  then transfer to ETT
• Dont hyperventilate (timing lights 10/min)
• Continue to use ITD if gasping or agonal
  breathing
• (in absence of a pulse).

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Remove ITD immediately if

• Chest does not rise.
• Device fills with fluid.
• Device breaks or does not function properly.
• Patient gets a pulse (ROSC).

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Important reminders

• Re-apply ITD immediately if patient re-arrests
• Do not open a second study kit
• The ITD is for single-patient use only
• No medication through ITD (impede function)
• All trials are PREHOSPITAL and end on arrival to
  the ED.

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Supplies

• 1 Study kit (Genesis pocket of airway bag)
• Restocking points
• Sunnybrook
• St. Mikes
• Call enrollment line 1-866-nrol-911

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Analyze Early vs. Analyze Late
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What is it?
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Randomized to Either
AnalyzeEARLY
30 sec. of CPR
then analyze rhythm
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Why are we doing this?
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(No Transcript)
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What are we asking of you?
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Analyze Early
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Analyze Late
DO NOT interrupt CPR to perform ALS procedures
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Remember

• Bystander CPR does not count, you must still do
  CPR per study protocol
• Analyze early or analyze late assignment will be
  determined by the first arriving vehicle

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Randomization

• Device level
• Each defibrillator is assigned (centrally by
  serial number) to either Early or Later Analysis
• Via
• Dog Tags
• Switching
• At 9 months the devices will be re-randomized

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Indications (both protocols)

• Patients 18 years of age
• Non-traumatic out of hospital cardiac arrest

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Contraindications (both protocols)

• Pre-existing DNR order.
• Known pregnancy.
• Known prisoner.

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Contraindications Analyze Early or Analyze Later

• EMS-witnessed arrest (shock immediately)
• AED / defibrillator pads attached prior to your
  arrival by
• Non-ROC responders - EMS or fire services OR
• PAD, law enforcement, layperson OR
• Off duty medic or fire fighter, medical
  professional, etc.
• Consider enrolling ITD only

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Contraindications ITD

• Tracheostomy
• Mechanical CPR
• Patient with a pulse

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Study Kits

• Inside
• Study name randomization number
• Inclusion / exclusion criteria
• 1 King mask
• 1 ITD (mini extension tube attached)
• Paramedic Data Collection Sheet
• 1 Arm Band
• Notification of Study Enrollment Sheet
• Research Data Collection Envelope
• Extra labels with randomization number

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After Transfer of Care
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ITD Packaging Randomization Labels
Randomization Labels
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Hospital Documentation

• After you have transferred care to the ED staff
  please ensure the following has been completed

• The patient bracelet has been placed on the
  patients arm
• The Notification of Study Enrollment sheet has
  been given to the documenting nurse
• A study label has been affixed to the ED chart

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Your Documentation

• Please ensure the following has been completed

• ROC PRIMED Paramedic Data Collection Sheet
• Adverse events or concerns have been reported
• Study labels have been affixed to
• the ACR (white yellow copies) and
• Research Data Collection Envelope
• the patients chart
• All documents have been placed in the Research
  Data Collection Envelope
• Upload defibrillator data

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ZOLL E Series

• New Defibrillator Pads
• Data Transfer

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Optimize CPR
!
Five key aspectsof CPR
Incomplete chest recoil will interfere with the
ability of the ITD to improve blood flow to heart.
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ZOLL E-SeriesCPR-D padz

• Rate of compression
• Rate of ventilation
• Depth of compression
• Hands off time

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ZOLL E-SeriesCPR-D padz / Defib Cable Adaptor
Insertion point for defibrillation cable
Insertion point for CPR-D padz cable
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ZOLL E-SeriesCPR-D padz / Defib Cable Adaptor
!
IMPORTANT to Know
You can defibrillate without the adaptor
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ZOLL E-SeriesConnection to Computer (Cable)

• Rear panel of defibrillator
• Serial cable from defib to computer

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ZOLL E-SeriesTransferring Data

• 1. Turn selector switch off
• 2. Wait 10secs press hold left-most soft key
  and turn selector switch to on.

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ZOLL E-SeriesTransferring Data

• 3. Activate RescueNet Code Review on MobiCAD by
  pressing ZOLL RescueNet Code review icon.

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ZOLL E-SeriesTransferring Data

• 4. In RescueNet Code Review select Serial Cable
  icon

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ZOLL E-SeriesTransferring Data

• 5. Press Upload Trend softkey
• 6. Select RS-232

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ZOLL E-SeriesTransferring Data

• 7. Press Send softkey

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ZOLL E-SeriesTransferring Data

• Unit displays progress bar

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ZOLL E-SeriesTransferring Data

• Following successful transmission

Card Uploaded
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Adverse Event?

• Pulmonary edema.
• Suspected device malfunction, including timing
  lights.
• If you feel protocol may have led to a safety
  problem for the patient and/or EMS
• Any other study-related issue that may have
  effected the patient or you.

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What do you do if you encounter an Adverse Event?

• Call the enrolment line

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Questions / Comments / Concerns?
Call or e-mail
Jamie Frank [phone], ext.
3451 Jamie.Frank_at_sunnybrook.ca