Focus on World-Leading Cardiac Survival Rates in Norway Sponsor of London’s Cardiac Arrest Symposium
Professor Eldar Søreide gives a lecture on some of the local heroes who made contributions to the cardiac arrest survival rates in Stavanger. Photo: Conrad Bjørshol.
Automated External Defibrillators (AEDs) In the early 1990’s the EMS began a formal cooperation with the local fire brigades. Fire-fighters are regularly dispatched by the EDC as first responders in addition to ambulances; in particular when the fire brigade is closer to the scene than the ambulance. This protocol is implemented both in urban and rural areas. Approximately 10% of all cardiac arrest patients are defibrillated by fire fighters before the arrival of the first ambulance, many of whom have a shockable rhythm. This cooperation with the fire service has been strengthened over the last two decades. There are also a huge number of on-site AED’s, especially at hotels, schools, shopping centres and golf courses. Unfortunately, there is currently no national AED registry so their prevalence is uncertain. Still, a significant number of them are registered at the EDC. Recently, home nursing services have joined the regional first responder AED service. Ambulance Service All ambulances are staffed with two ambulance workers, one of which is an advanced life support-certified paramedic. The European Resuscitation Council’s (ERC) guideline changes in 2000 and 2005 were implemented shortly after their approval. Unlike the ERC guidelines, Norwegian 2005 advanced life support guidelines recommend three minutes between defibrillation attempts and that the pulse and monitor check is performed
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one minute after analyzing the heart rhythm and eventually defibrillation.7 Epinephrine is administered immediately after the pulse and monitor check. The ambulance service normally use their defibrillators in AED mode, but paramedics are licensed to defibrillate in manual mode if necessary. There is a strong focus on basic CPR quality. Therefore only basic CPR (according to ERC guidelines) and defibrillation (one shock every three minutes) is accepted when fewer than four paramedics are present. Advanced life support is only initiated after arrival of the second ambulance. There has been a strong focus on basic CPR skills both among paramedics and first responders, with regular certification on basic skills. The highlight of these basic skills has been supported by research. Airway management has been a challenge. Until recently paramedics have been certified to perform endotracheal intubation. However, due to the extensive training needs and restricted access to anaesthesized patients, we changed the advanced airway method to a supraglottic device in 2013. This change will be followed by evaluations and research and we will later decide if some paramedics will retain their certification to perform endotracheal intubations.
Air Ambulance The air ambulance at SUH was established in 1981. It consists of a helicopter and fastresponse car. The anaesthesiologist on call is employed by SUH and switches between pre-hospital and in-hospital duty. They also take part in teaching and certification of paramedics and EDC personnel. In addition to the anaesthesiologist, a rescue man assists the physician and also assists the pilot during flight. In cardiac arrests, the air ambulance offers facilitation of good quality CPR, advanced airway techniques, manual defibrillation, insertion of chest tubes and the use of ultrasound. In addition they offer rapid air transport to the regional cardiac arrest centre from rural areas, and interhospital transfer. They also participate in the training of health care providers and offer observer slots on a weekly basis.
Local general physicians are dispatched simultaneously with the ambulance service. They are a valuable resource for collecting information from bystanders, they can assist in CPR and they can also take care of relatives. Finally, they can also discontinue futile resuscitation attempts.
The Hospital For several decades, emergency medicine has been a prioritized area for Stavanger University Hospital (SUH) with a focus on integrating pre-hospital and in-hospital emergency care. SUH have been the operator of the ambulance service for more than 30 years and was the second city in Norway to establish an air ambulance service. CPR has been a specific target area for SUH for several decades within emergency care, development and research. The Emergency Room (ER) focuses on avoiding any unnecessary delays when the coronary intervention lab is ready. Necessary delays can be due to securing airways or initiating therapeutic hypothermia (TH).
ECGs are recorded immediately postROSC and transmitted to a cardiologist at the coronary care unit with whom the pre-hospital team discuss the anamnesis and specific therapy. When there is suspicion of an ischaemic reason for the arrest, the interventional coronary team is alarmed upon leaving the scene.
Most cardiac arrest patients are dispatched directly from the ER to the coronary intervention lab. The indication for acute angiography is made by the invasive cardiologist based on anamnestic information and usually a 12-lead ECG transmitted to the hospital from the ambulance immediately after ROSC.
All paramedics at the Stavanger Hospital Trust need to attend different retraining sessions. Each of these sessions last one day and are arranged 8-10 times, and all paramedics need to attend one of these dates. The subject changes every three months, and they all need to attend all four subjects each year. These retraining sessions are usually arranged at the simulation centre.
By arrival at the intensive care unit, target temperature (33°C) is normally already achieved, and TH is maintained by invasive technique or by surface cooling. TH is maintained for at least 24 hours. Instead of making decisions on whether to start TH we try to focus on making decisions on when NOT to initiate TH. The post-resuscitation treatment is regulated by a post-cardiac-
Spring 2014 | Ambulancetoday