Resus Today Summer 2017

Volume 4 No. 2

Summer 2017

Resuscitation Today A Resource for all involved in the Teaching and Practice of Resuscitation

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See cover story on page 3 Try Brayden Pro at Life Connections, June 6th & 7th at Telford on WEL Medicals stand near the main catering area

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CONTENTS

CONTENTS 4

EDITORS COMMENT

6

EDUCATION

25

EVIDENCE

27

NEWS

29

COMPANY NEWS

Resuscitation Today This issue edited by: Lizzie Ryan c/o Media Publishing Company Media House 48 High Street SWANLEY, Kent BR8 8BQ ADVERTISING & CIRCULATION: Media Publishing Company Media House, 48 High Street SWANLEY, Kent, BR8 8BQ Tel: 01322 660434 Fax: 01322 666539 E: info@mediapublishingcompany.com www.MediaPublishingCompany.com PUBLISHED: Spring, Summer and Autumn COPYRIGHT: Media Publishing Company Media House 48 High Street SWANLEY, Kent, BR8 8BQ

COVER STORY Highly anticipated Brayden Pro – Now Available Following on from the huge success of the Brayden Manikin launched in late 2014, Innosonian Europe are delighted to announce the launch of Brayden Pro. Developed in conjunction with leading members of the European Resuscitation Community in pre-hospital, hospital, university and voluntary sectors, the Brayden Pro provides healthcare professionals with quantitative data driven feedback. This can be used to enable students to improve their CPR performance. Brayden Pro provides students with real time feedback during CPR training. It enables detailed post CPR training debriefing by providing quantitative data of key CPR parameters as outlined in the ERC 2015 Guidelines such as compression depth, compression rate, hand position and compression release. Feedback on hands off time and ventilation performance is also provided from the Brayden Pro manikin.

For information or a formal demonstration please contact enquiries@innosonian.eu or call 03333 445534. More information can be found at www.innosonian.eu.

PUBLISHERS STATEMENT: The views and opinions expressed in this issue are not necessarily those of the Publisher, the Editors or Media Publishing Company.

Next Issue Autumn 2017 Subscription Information – Summer 2017 Resuscitation Today is a tri-annual publication published in the months of March and September. The subscription rates are as follows:UK: Individuals - £12.00 inc. postage Commercial Organisations - £30.00 inc. postage Rest of the World: Individuals - £60.00 inc. postage Commercial Organisations - £72.00 inc. postage We are also able to process your subscriptions via most major credit cards. Please ask for details.

Cheques should be made payable to MEDIA PUBLISHING. Designed in the UK by Hansell Design

RESUSCITATION TODAY - SUMMER 2017

Up to six students can be monitored simultaneously by one instructor and when in ‘assessment mode’ a full scenario assessment on a student or students can be performed – including the use of an AED. The results can be shared, saved, printed or exported as data, ready to be imported into a learning management system or saved as a student record.

PRO

3

EDITORS COMMENT

EDITORS COMMENT This is the first edition that I have written an editorial for and I am pleased to have the opportunity to share my thoughts on the content and the value it brings to this arena.

There are a number of interesting articles in this edition which include: ‘Altered Pharmacological Effects of Adrenergic Agonists During Hypothermia’ (Sveberg Dietrichs et al. 2016) a peer-reviewed article that contains some interesting thought processes on this aspect of post warming processes following cardiac arrest. It begins to fill the gaps we see when considering cardiac pharmacologic support application when rewarming these patients using a literature review process and concludes that drugs producing adrenergic receptor agonism should be used carefully during hypothermia and rewarming.

Methoxyflurane (Penthrox) is a new pre-hospital inhalational analgesic, a drug currently in use in the UK for adult trauma only at the moment. There are some articles to support this on the NICE Website that would bear reading to consider the uses that it has outside the trauma arena in the emergency setting in Australia. It has also been trialled in South Central Ambulance Service and this has shown quality pain relief.

A Profile Of Out-Of-Hospital Cardiac Arrests In Northern Emirates, United Arab Emirates (Batt et al. 2017) details an interesting study carried out in the Emirates on out of hospital cardiac arrest as recent comparisons of the survival rates in Middle, East and Asia and Western Europe and North America have shown that survival rates are lower in the former areas. It has provided some interesting strategies for improving survival rates but also recommends further studies are needed and continued investment, public engagement and education. This is interesting in light of recent studies in the UK around this area.

In the Evidence Section there is an interesting letter to the Editor (Batt et al 2017) about the ‘Urgent Need to Strengthen The Chain of Survival in the Arab Emirates’ that fits with the previous article on Out of Hospital Cardiac Arrests in the Northern Emirates.

This letter calls for clinicians, researchers and policy makers in the Emirates to be aware of the data provided in the article and provides data in the letter to support the need to increase public awareness of the need for early intervention by EMS. It also supports the introduction of defibrillators in the community, an initiative in place in the UK that works well alongside public information and training.

In the News Section we highlight the Great Western Air Ambulance Charity and the valuable work that they do in the South West where the demographics include major roadways and rurality. This provides a fascinating overview of the type of work being done by this service including blood transfusion, useful when attending traumatic injury incidents across the area. The section also introduces the work being done to change the approaches to cardiac arrest treatment and the need to improve survival rates (fitting nicely with the article by Batt et al. 2107). It highlights the need for partnership working with the public, emergency services and hospitals being key in this area, and introduces the new report Resuscitation to Recovery, that provides statistics on this area and recommendations for improvements.

RESUSCITATION TODAY - SUMMER 2017

4

There is significant evidence of healthcare providers calling for a review of the processes in place for cardiac arrest in the UK. Some of the ambulance services have introduced cardiac arrest checklists as a way of supporting users through accurate task completion in stressful or complex situations. In the UK the average survival to hospital discharge is around 8%. However, in Holland and Norway this increases to over 20%. The focus is on improving CPR, non-technical resuscitation skills and postresuscitation care, as well as the introduction of the improvement mechanisms.

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EDUCATION

ALTERED PHARMACOLOGICAL EFFECTS OF ADRENERGIC AGONISTS DURING HYPOTHERMIA Erik Sveberg Dietrichs1,2*, Georg Sager3 and Torkjel Tveita1,4 Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine201624:143 DOI: 10.1186/s13049-0160339-8 © The Author(s). 2016

Abstract Rewarming from accidental hypothermia is often complicated by hypothermia-induced cardiac dysfunction, calling for immediate pharmacologic intervention. Studies show that although cardiac pharmacologic support is applied when rewarming these patients, a lack of updated treatment recommendations exist. Mainly due to lack of clinical and experimental data, neither of the international guidelines includes information about pharmacologic cardiac support at temperatures below 30 °C. However, core temperature of accidental hypothermia patients is often reduced below 30 °C. Few human studies exploring effects of adrenergic drugs during hypothermia have been published, and therefore prevailing information is collected from pre-clinical studies.

The most prominent finding in these studies is an apparent depressive effect of adrenaline on cardiac function when used in doses which elevate cardiac output during normothermia. Also noradrenaline and isoprenaline largely lacked positive cardiac effects during hypothermia, while dopamine is a more promising drug for supporting cardiac function during rewarming. Data and information from these studies are in support of the prevailing notion; not to use adrenergic drugs at core temperatures below 30 °C. Keywords Hypothermia, Cooling, Rewarming, Rearming shock, Pharmacology, Cardiovascular dysfunction, Adrenergic drugs, Inotropic, Vasopressor

Background Rewarming victims of accidental hypothermia is often complicated by

clinical and clinical studies on use of inotropic drugs during hypothermia

hypothermia-induced cardiac dysfunction. In its fulminant form this

and rewarming, with interesting findings. Most studies, including several

condition is described as rewarming shock; an acute heart failure with

from our group, focus on adrenergic receptor agonists. The information

a progressive fall in cardiac output (CO) where the patient terminates

provided, presents a valuable insight in hypothermia-induced changes in

in a sudden and intractable fall in blood pressure [1]. This serious

cardiovascular pharmacology, laying foundation for development of new

complication to clinical therapy adds to the virtually unchanged low

treatment strategies and guidelines in a patient group exposed to lethal

survival rate of accidental hypothermia over the last decades [2, 3].

cardiac complications during rewarming.

Cardiac supportive therapy has to be instituted during rewarming in an attempt to prevent the imminent cardiovascular collapse. Inotropic drugs, i.e. drugs that enhance force of cardiac contraction [4] could RESUSCITATION TODAY - SUMMER 2017

6

Methods

provide such pharmacologic support, but current guidelines do not

The aim of this paper was to describe effects of adrenergic agonists

support this view. Both the American Heart Association and the European

during hypothermia. Relevant publications were found through literature

Resuscitation Council advise against using drugs like adrenaline below

search, using PubMed (Medline) and Google Scholar search engines.

30 °C [5, 6]. Studies investigating patient treatment do however report

Experimental and clinical studies included in this narrative review were

that inotropic drugs are administered during rewarming in 47–66% of

selected according to their relevance by the authors, who all have a

patients [7, 8]. Only about 10% of patients with acute heart failure caused

special interest in hypothermia and pharmacology. Reference lists of

by disease or events other than hypothermia receive the same treatment

included papers were studied to discover publications that were not

[9]. This lack of consensus-based guidelines on cardiac inotropic support

detected through use of search engines. Additional articles describing

in hypothermic patients cause confusion, even within the British health

pathophysiology of hypothermia, treatment guidelines and general

care system [10]. Importance of finding optimal treatment for these

knowledge on adrenergic agonists and receptor function, were included

patients is manifest from that survival is possible after extreme exposure

for background information.

to hypothermia. Case-reports show that early resuscitation enables survival after cooling to 13.7 °C [11] or cardiac arrest close to 7 h [12],

Adrenergic receptors (Table 1)

but mortality rate is still reported at 30% [2]. Seeking evidence-based

Extracellular binding of adrenergic receptor agonists facilitates initiation

pharmacologic treatment options, we have explored the literature for pre-

of intracellular processes through G-protein coupled signalling.

Correspondence: erik.sveberg.dietrichs@uit.no Anesthesia and Critical Care Research Group, Department of Clinical Medicine, UiT, The Arctic University of Norway, 9037 Tromsø, Norway 2 Department of Research and Education, Norwegian Air Ambulance Foundation, 1441 Drøbak, Norway Full list of author information is available at the end of the article *

1

EDUCATION Table 1 Adrenergic receptors Subgroups

α-receptor

β-receptor

Dopamine-receptor

α1, α2

β1, β2, β3

D1, D2, D3, D4, D5

Mechanism of action

G-protein coupled receptors

G-protein coupled receptors

G-protein coupled receptors

Molecular effects

α1: Activation of PLC, IP3 mediated intracellular calcium increase α2: Decreased cAMP production

Increase of cAMP, protein phosphorylation (β1, β2, β3), intracellular calcium increase (β1) or decrease (β2)

D1, D5: Increase of cAMP D2, D3, D4: Decreased cAMP production

Hemodynamic effect

α1: Vasoconstriction↑ α2: Mixed (vasoconstriction or vasodilation)

β1: Heart rate↑, contractility↑ β2: Vasodilation↑

D1, D5: Vasodilation↑ D2, D3, D4:: Vasoconstriction↓

Dominant location

α1: Smooth muscle α2: Central nervous system

β1: Cardiac tissue β2: Smooth muscle β3: Adipose tissue

D1, D2, D3, D4, D5: Central nervous system

In 1948, Ahlquist described how the adrenergic receptors are divided into two main groups [13], named α- and β-receptors. Subgroups have later been identified and separated the receptors into α1–2 and β1–3, which have a broad variety of effects, among them hemodynamic. The β1-receptor is

considered most important for inotropic effect and is also more numerous in the mammalian heart (75%) than β2 and β3 [14]. β1-stimulation enhances heart muscle contraction, increase heart rate and enhance relaxation of myocardial tissue [15]. The effect of β1-agonists is mediated through stimulation of adenylyl cyclase, which elevates cyclic AMP (cAMP). This activates protein kinase A (PKA), which phosphorylates several proteins.

The relationship between an apparent increase in β-receptor sensitivity and decreased inotropic effect below a core temperature of 30 °C is uncertain. Mann [28] found excessive cAMP levels, seen during β1-receptor stimulation in hypothermic rats [21], to be cardiotoxic, through initiating un-physiological increase of cytosolic calcium levels, mediated by increased phosphorylation of L-type calcium channels [28]. Hypothermia-induced calcium overload is also known to take place in response to prolonged hypothermia in rats per se [29, 30] and an additional increased calcium load in response to a pharmacologic stimulation might explain lacking effect of β1-agonists

Phosphorylation of sarcolemmal L-type calcium channels gives increased

during hypothermia. Another observed effect of temperature reduction

calcium influx, thus enabling contraction, while phosphorylation of cardiac

in rats is reduced myocardial calcium sensitivity due to hypothermia-

troponin I enhances myocardial relaxation [14]. β2-stimulation most

induced elevation of PKA-mediated phosphorylation of Ser 23/24 at

importantly gives vasodilation due to smooth muscle relaxation [16]. Both

cardiac troponin I [31]. Increased levels of cAMP will increase such

α1- and α2- receptors are divided into three subgroups. Stimulation of all

PKA-mediated Ser 23/24 phosphorylation and give a negative inotropic

α1-receptors will in general induce smooth muscle contraction, which gives vasoconstriction [17]. The α2-receptor subgroups have differing abilities,

among them both vasodilation and vasoconstriction [18]. Cardiovascular

effect. Such phosphorylation will also enhance cardiac relaxation [32], which is normalized during rewarming from hypothermia as diastolic function is restored [33]. Thus, favorable or harmful effects of β1-

effects of adrenergic stimulation are also transmitted through dopamine

agonists administration in hypothermic subjects appears associated

receptors by direct effect on smooth muscle, giving vasodilation mediated

to inotropic rather than lusitropic properties, as hypothermia-induced

by D1-like receptors and indirectly by D2-like receptors. Several dopamine

cardiac dysfunction is an isolated impairment of systolic function [1].

receptor subtypes are located in the human heart, namely D1, D2, D4, and D5 [19], but stimulation of these receptors does not have a pronounced effect on cardiac contractility in rats [20]. Adrenergic receptor agonists have varying affinity for β-, α- and dopamine-receptors and their subgroups, explaining their distinct properties.

The aforementioned studies do however show differences in species and experimental conditions and use several β1-receptor agonists

with varying properties, including α-receptor agonism that promotes vasoconstriction. A resulting increase of systemic vascular resistance (SVR) cause a pronounced negative effect on cardiac function in

β1-receptor function during hypothermia

rats during hypothermia [21, 27, 34, 35]. For assessment of clinical properties of these drugs, it is therefore necessary to evaluate their

effect in normothermic conditions [14] studies on administering

individual pharmacologic effects when used during hypothermia.

adrenergic drugs to ameliorate rewarming shock have also targeted this receptor. In a study from our lab we have reported a 4-fold

Adrenergic receptor agonists (Table 2, Fig. 1)

increase of in vivo cardiac cAMP content during β1-receptor stimulation

Adrenaline

at 15 °C, showing that β1-receptor function is not depressed at low

Adrenaline will enhance cardiac contraction and heart rate and either

temperatures. This was confirmed by an in vitro 9-fold increase of

decrease (low-dose) or increase (high-dose) SVR in normothermic

β1-receptor sensitivity in isolated rat cardiomyocytes cooled to 15 °C

conditions [36], conducted by loss of β-adrenergic selectivity at low

[21]. Such hypothermia-induced in vitro β1-receptor super-sensitivity

doses with increasing α-stimulation at higher doses.

was also described in isolated heart preparations from guinea pig [22, 23] and rabbit hearts at 22 °C [24]. Results from intact (in vivo) animal

Adrenaline during hypothermia

experiments studying effects of adrenergic receptor-ligands

Pharmacodynamic effects of adrenaline do not seem to be independent of

and -blockers indicate that both β1- and β2-receptor function is

temperature changes. Rubinstein found that doses inducing vasodilation

maintained during cooling to 28–30 °C, but that response to agonist

in normothermic dogs would give increased SVR during hypothermia and

binding is depressed by cooling below 30 °C [25, 26, 27].

stated that the inotropic effect of adrenaline is reduced at 25 °C [37].

RESUSCITATION TODAY - SUMMER 2017

As the β1-receptor is considered most important for providing inotropic

7

EDUCATION Table 2 β1-receptor agonists Species

Adrenaline

Noradrenaline

Isoprenaline

Dobutamine

Dopamine

Rat, dog

Cat, dog,

Rat, dog, rabbit, guinea pig

Dog, pig, rabbit, guinea pig

Dog, pig

Dosage (in vivo)

0.4 μg/kg/min – 4.2 μg/kg/min

0.2 μg/kg/min – 5.0 μg/kg/min

5.7 ng/kg/min – 1 μg/kg (bolus)

2.0 μg/kg/min – 30 μg/kg/min

2.0 μg/kg/min – 30 μg/kg/min

Administration

i.v. (in vivo studies), Retrograd coronary perfusion (in vitro studies)

i.v. (in vivo studies)

i.v. (in vivo studies), Retrograd coronary perfusion or in preparation solution (in vitro studies)

i.v. (in vivo studies), Retrograd coronary perfusion or in preparation solution (in vitro studies)

i.v. (in vivo studies)

Target temperature

12 °C–28 °C

28 °C–30 °C

20 °C–28 °C

22 °C–31 °C

25 °C–30 °C

Cardiac effect (hypothermia)

Elevated CO (low dose) [27, 34, 38]. Depressed CO (high dose) [21, 27, 34, 35, 37].

Negative inotropic effects (in vitro) [41, 42].

Increased contractile force [26, 45]. Depressed CO [40].

No effect on CO [50, 51].

Negative or depressed inotropic effect (in vitro) [52, 53].

Positive inotropic effects (in vitro) [22, 24, 54].

Elevated CO [38, 57]. Increased contraction velocity (in vitro) [24].

Reduced or depressed inotropic effect (in vitro) [56].

Elevated CO or positive inotropic effects [57, 61, 63].

No effect on CO [62, 63].

A similar study on rats conducted in our lab, showed that a high dose of adrenaline (1.25 μg/min) increased stroke volume (SV) and CO in normothermic animals. When an equal dose was administered during

this hypothermia-induced reduction of inotropic effect via β1-receptor

stimulation is seen in the presence of in vivo and in vitro β1-receptor super-sensitivity. Both increased β1-receptor binding and elevated

rewarming from 15 °C however, SV and CO were unaffected. In contrast,

cAMP levels were seen during administration of β1-receptor ligands

a low dose (0.125 μg/min) adrenaline, which induced vasodilation

in hypothermic conditions, as compared to normothermia. This study

during normothermic conditions, failed to reduce SVR or mean arterial

indicates that the detrimental effects of adrenaline during hypothermia

pressure (MAP) during rewarming, but led to an elevated CO [34].

is a consequence of adrenaline-induced increase in SVR via peripheral

The positive effect of low-dose adrenaline during hypothermia has

vascular α-receptor stimulation [21]. Failure of low doses of adrenaline

also been reported from experiments using dogs [38]. We found the

to reduce MAP during hypothermia [34], further implies the presence of

same dose–response relationship during cooling, where 0.125 μg/min

increased α-receptor agonism, or reduced effect of β2-receptor agonism

but not 1.25 μg/min adrenaline gave positive cardiac effects during

in hypothermia.

cooling to 28 °C. After rewarming, only rats that had received saline during cooling showed pre-hypothermic hemodynamic responses to adrenaline [27]. An additional study on rats from our lab showed that 1 μg/min of adrenaline given during cooling caused a maintained depression of cardiac function during rewarming [35]. These results indicate that hypothermia has a severe impact on cardiac inotropic effects mediated by the β1-receptor pathway, as β1-adrenergic stimulation during hypothermia also has a negative impact on inotropic effect of β1-agonists after rewarming. The same phenomenon is also observed in a feline model of hypothermia and rewarming [39, 40].

From a combined in vitro and in vivo study in our lab, we showed that

Altogether, the present hypothermia-induced alteration of pharmacodynamic effects and an expected narrowed therapeutic window of adrenaline, advocate against the use of this drug during hypothermia. This assumptions gain support by data from in vitro experiments. In isolated rat hearts, both SV and CO were depressed by adrenaline at 28 °C [41], while at 12 °C positive inotropic effects were absent [42]. Interestingly, Schiffmann et al. demonstrated that in normothermic rat hearts, the presence of additionally added calcium would potentiate the inotropic effects of adrenaline. In the hypothermic heart however, increased calcium concentrations [41] mediated a depressive effect of adrenaline on SV and CO. Thus, the negative effects of adrenaline at low temperatures could be a consequence of

OH

hypothermia-induced calcium overload, reported in vitro [43], as well as

OH

HO HN

HO

Epinephrine

in vivo [29,30].

H N

HO

Noradrenaline

HO

CH3

Noradrenaline has high affinity for α-receptors in concert with β1-

Isoprenaline

RESUSCITATION TODAY - SUMMER 2017

receptor affinity. Infusion of noradrenaline therefore leads both to vasoconstriction of arterioles and a positive inotropic effect [44].

OH HO

HO

NH2 HO Norepinephrine

HO

NH2 Noradrenaline during hypothermia Cotten et al. demonstrated positive inotropic effect of noradrenaline in

Dopamine OH

HO HO

H N Dobutamine

Fig. 1 Molecular structure of adrenaline, noradrenaline, isoprenaline, dopamine and dobutamine

both normothermic controls and hypothermic (30 °C) dogs [26]. They further described that although this effect was positive, the inotropic effect of noradrenaline was reduced by hypothermia [45]. In cats subjected to moderate hypothermia and rewarming, noradrenaline had a negative effect on CO during hypothermia. The ability of noradrenaline to induce vasoconstriction did however appear intact during cooling, with consistent dose-related increase in MAP [40]. Intact α-receptor function is also apparent during noradrenaline infusion in humans cooled on cardiopulmonary bypass to 28–32 °C. In these patients MAP increased significantly with noradrenaline [46]. This can be explained

8

EDUCATION by intact α1-receptor function during a wide range of temperatures,

dog model during reperfusion following 60 min global ischemia at 28 °C

as demonstrated in sheep arteries where vascular response to

also showed promising cardiac effects, with increased SV during

noradrenaline abolished first when cooling to 5 °C [47]. The sensitivity

rewarming using cardio-pulmonary bypass [38].

of α-receptors was even found to be increased in human skin artery preparations cooled to 24 °C [48].

Dopamine Like adrenaline, noradrenaline, isoprenaline and dobutamine, dopamine

Isoprenaline

is a catecholamine, giving dose-dependent stimulation of α- and

Isoprenaline is a non-selective β-receptor agonist, lacking α-agonist

β-receptors and giving a dose-dependent positive inotropic effect

effect. On this background studies looking exclusively at β-receptor

in normothermia [58]. Different from selective adrenergic agonists,

stimulation often use isoprenaline as a model drug. During

dopamine also exerts its inotropic and vasoactive effects through

normothermic conditions, isoprenaline will increase CO and decrease

stimulation of dopamine receptors [59].

SVR through β1- and β2-receptor stimulation [49].

Dopamine during hypothermia

Isoprenaline during hypothermia

The use of dopamine as a vasopressor is recommended in the Up To

Conflicting results exist of pharmacologic effects of isoprenaline

Date accidental hypothermia guidelines [60]. This is supported by a

at low temperatures, especially when comparing results obtained

better cardiovascular recovery in dopamine-treated dogs, after core

from in vitro interventional studies of cardiac tissue from different

cooling to 25 °C and subsequent rewarming [61]. Likewise, positive

species. Lauri et al. studied in vivo hemodynamic effects of

inotropic effects of dopamine were found in pigs core cooled to 30

isoprenaline before, during and after severe hypothermia (25

°C [57]. However, in pigs surface cooled to 32 °C [62] and 25 °C [63]

°C) in dogs. Isoprenaline had no positive inotropic effect during

dopamine did not elevate CO. In the latter study, which was conducted

hypothermia, but a significant decrease in SVR indicated at least

in our lab [63], dopamine infusion at 25 °C gave a four-fold increase in

partly intact β2-receptor response to stimulation [50], also seen in

plasma concentration compared to normothermia. In difference from

man at 28–32 °C [46]. Inotropic effects of increasing isoprenaline

other β-adrenergic drugs, cardiovascular responses of dopamine were

doses have been investigated in our intact rat model [51] at

restored during rewarming to 30 °C [63]. It is therefore apparent from

normothermia and during cooling to 24 °C. We reported that the

different animal models that dopamine supports cardiac function during

dose-related positive inotropic response (increase in SV and CO)

rewarming, but it is uncertain whether these positive effects are present

to isoprenaline at 37 °C were lost during cooling to 24 °C except

during hypothermia below 30 °C. Based on these findings, dopamine

for the highest dose (20 ng/min). This alteration in response to

is the preferred drug for giving cardiac support during rewarming in the

β-receptor stimulation also remained after rewarming as only the

Northern-Norwegian guidelines for accidental hypothermia [64].

highest dose of isoprenaline managed to elevate SV above baseline [51]. In vitro studies have shown depressed β 1-mediated inotropic effect of isoprenaline in rat left atrial preparations at 28 and 20 °C,

Conclusion

compared to at 35 °C [52]. This finding finds support in another

Pharmacodynamics

study reporting reduced inotropic response to both isoprenaline

A lack of human studies evaluating cardiovascular effects of adrenergic

and adrenaline in hypothermic rabbit atria at 23 °C [53]. In

drugs during hypothermia exists [65]. In the meantime such information

contrast, in isolated guinea pig hearts cooled to 27 °C isoprenaline

can be collected from preclinical experimental studies. This information

still increased the contractility parameter LV dp/dtmax, this was

provide important insight on the effects of pharmacologic interventions

accompanied by a similar increase in heart rate, also mediated by

already applied in the hypothermic patient. It is apparent that inotropic

β1-receptor stimulation [54]. Further, an experiment on isolated atria

response to β-adrenergic stimulation seems to be depressed during

from guinea pig showed increased inotropic effects of isoprenaline

severe hypothermia. This response is also depressed after rewarming

at 25 °C [22]. Sustained ability of adrenaline and isoprenaline to

in animals that have received such drugs during hypothermia [51].

increase contraction amplitude and rate has also been reported

In hypothermic animals, adrenaline increases SVR [21]. Studies on

when cooling rabbit hearts to 22 °C [24].

dobutamine administration indicates a positive effect, but these studies current guidelines, not to use adrenergic drugs like adrenaline below 30

Dobutamine predominantly binds to β1-receptors and has a weak

°C is supported by these preclinical observations, but recommendations

effect on β2- and α-receptors. Thus, administering dobutamine in

for inotropic support in severe accidental hypothermic (>30 °C) patients

normothermic conditions elevates CO [55].

are needed. Dopamine does not seem to have the same detrimental effects on cardiovascular function in severe accidental hypothermia

Dobutamine during hypothermia

as adrenaline, even in high plasma concentrations [63], but lack effect

The inotropic effects of dobutamine shows temperature dependency

before patients are rewarmed to higher temperatures.

when tested in in vitro guinea pig trabecula. Rieg et al. [56] therefore concluded that elevating cAMP through β1-receptor stimulation for

Pharmacokinetics

providing inotropic support in hypothermic hearts is not an optimal

Knowledge about pharmacokinetic effects of adrenergic drugs

strategy. In isolated rabbit hearts however, dobutamine infusion

during hypothermia is limited. However, all pharmacokinetic

increased contraction velocity at 22 °C [24]. Increased cardiac

processes are temperature-dependent; including absorption,

output was also observed in response to dobutamine infusion during

distribution and elimination (metabolism and excretion). In general,

hypothermia (30 °C) in pigs [57]. Administering dobutamine in an intact

lowered temperatures slow all these processes down.

RESUSCITATION TODAY - SUMMER 2017

are carried out at temperatures around 30 °C [38, 57]. Advice of the Dobutamine

9

EDUCATION The time to reach distribution equilibrium will be lengthened and

pharmacological interventions are being used to provide cardiovascular

metabolism in the liver and active excretion in the kidneys reduced.

support in a large proportion of patients during rewarming from

Thus half-life (T1/2) of active substances is increased at low temperatures

accidental hypothermia [7, 8]. Hypothermia is also used as a

[66]. In humans, it is known that the cytochrome P450 enzyme

therapeutic measure. Comatose survivors of cardiac arrest are often

system is affected by hypothermia. Tortorici [67] found that this

cooled to temperatures between 32–36 °C for cerebral protection [73].

resulted in a 7–22% reduced clearance per degree below 37 °C of

More than 50% of this patient group are in need of inotropic support to

opiates, barbiturates, benzodiazepines and neuromuscular blockers.

facilitate adequate circulation [74]. Cooling and rewarming of patients

Hypothermia does also induce changes in pharmacokinetics of

down to, and occasionally below 20 °C is also used for cerebral

adrenergic drugs. Reduced catechol-O-methyl transferase activity

protection during procedures like aortic arch surgery [73]. Providing

has therefore been suggested to explain a hypothermia-induced

optimal pharmacological, cardiovascular support in hypothermic

hypersensitivity to β-adrenoceptor agonists [24]. Increased T1/2 of

patients therefore seems essential, both in therapeutic hypothermia,

adrenaline might therefore have contributed to elevated stimulation

and when aiming to improve a high mortality rate associated with

of β-adrenoceptors in a recent study reporting increased cAMP levels

accidental hypothermia [2]. In pigs, dopamine appear a safe way to

during 5 min adrenaline administration in hypothermia [21], as the

provide inotropic support, but lack effect at lower temperatures. Further,

normothermic T1/2 of adrenaline is 2 min [68]. Reduced enzymatic

experimental studies have explored effects of inotropic pathways like

breakdown of cAMP through reduced phosphodiesterase 3 activity, or

PDE3 inhibition and calcium sensitizing, drugs that avoid the G-protein

reduced extracellular release of cAMP as observed in cold fibroblasts

coupled adrenergic receptors. These experiments show promising

[69], might also have boosted adrenaline-mediated cAMP increase

results [75, 76, 77,78, 79] on cardiovascular function, both during

in hypothermic hearts [21]. Hypothermia-induced increase in T1/2 is

cooling and rewarming. However, information from such pre-clinical

apparent for other catecholamines. At 25 °C in anesthetised pigs,

studies should be interpreted with care, when translated to a clinical,

we found that dopamine infusion yielded plasma concentrations 4

human setting. Aiming to provide better treatment, we call for further

times higher than during normothermia. The half-life of dopamine was

studies on physiology, therapeutic interventions and careful evaluation

doubled at this temperature and returned to normothermic values first at

of inotropic drugs, used in hypothermic patients.

35 °C during rewarming [63]. The high concentrations of dopamine were however not associated with any negative hemodynamic effects.

Abbreviations cAMP: Cyclic AMP; CO: Cardiac output; MAP: Mean arterial pressure

Apart from temperature–dependent pharmacologic changes in

PKA: Protein kinase A; SV: Stroke volume; SVR: Systemic vascular

ligand-receptor kinetics, changes in temperature also exert significant

resistance; T1/2: Half-life

alterations in other determinants of cardiac function, which may limit the expected pharmacologic effects achieved at normothermia. During cooling, studies on isolated papillary muscle show a positive inotropic

Declarations

effect of hypothermia per se [70]. In the intact pig however, cooling

Acknowledgements

induce a reduction of cardiac contractile function and SV [33]. Lewis

Not applicable.

and colleagues showed that the inotropic effect of increasing heart rate during normothermic conditions in man, is lost at a core temperature of

Funding

33 °C [71], independent of pharmacologic interventions. Consequently,

The authors’ salaries were funded by their respective affiliations.

hypothermia-induced changes in physiology, not related to ligandreceptor kinetics, could also be involved in altered pharmacodynamics of β-adrenoceptor agonists during hypothermic conditions. Important determinants of blood flow, like blood viscosity, are affected already at

Availability of data and materials Not applicable. All data and material are available in the referenced articles.

moderate hypothermia [72]. Thus, lack of ability of the cold blood to

RESUSCITATION TODAY - SUMMER 2017

10

increase flow may be part of the challenging task to provide positive

Authors’ contributions

inotropic, pharmacologic support during hypothermia. The apparent

Wrote, or contributed to write the manuscript: ESD, GS and TT. All

depressed function of β1-receptor agonists to provide inotropic

authors have read and approved the final version of the manuscript.

effect in vivo below 30 °C, might therefore be multifactorial. Updated guidelines on treatment of hypothermic patients depend on further

Competing interests

studies exploring physiological effects of hypothermia and rewarming,

The authors declare that they have no competing interests.

as well as broader knowledge on the hypothermia-induced changes on pharmacodynamic and pharmacokinetic effects of drugs applied in

Consent for publication

clinical practice.

Not applicable.

Clinical implications

Ethics approval and consent to participate

Findings in the reviewed literature indicate that negative or lacking

Not applicable.

effects of adrenergic drugs during hypothermia appears to be of multifactorial origin. Our findings from a majority of pre-clinical studies

Author details

therefore advocate that drugs providing adrenergic receptor agonism

1

should be used carefully during hypothermia and rewarming. Such

Medicine, UiT, The Arctic University of Norway, 9037 Tromsø, Norway.

information is highly relevant in the clinical setting. Reports show that

2

Anesthesia and Critical Care Research Group, Department of Clinical Department of Research and Education, Norwegian Air Ambulance

EDUCATION Foundation, 1441 Drøbak, Norway. 3Experimental and Clinical Pharmacology, Department of medical biology, UiT, The Arctic University of Norway, 9037 Tromsø, Norway. 4Division of Surgical Medicine and Intensive Care, University Hospital of North Norway, 9038 Tromsø, Norway.

Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons. org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons. org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

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.M

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Manual SphygMode

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RESUSCITATION TODAY - SUMMER 2017

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13

EDUCATION

METHOXYFLURANE (PENTHROX) - A NEW PRE-HOSPITAL INHALATIONAL ANALGESIC History Methoxyflurane gained popular use in the early 1960s as an inhaled

in patients over 18 years of age, a decision that was influenced by the

anaesthetic agent. However, following extensive use reports of kidney

STOP study – a randomised double blinded – placebo-controlled study

damage (nephrotoxicity) emerged(1).

of efficacy and safety of Methoxyflurane in the treatment of acute pain(5).

Methoxyflurane, a fluorinated hydrocarbon was shown to produce

Although restricted to adult trauma in the UK it is worth noting the wider

damage as a dose related complication related to fluoride ions(2). As a

reported use in Australia for over 30 years which includes minor surgical

consequence the drug was withdrawn from use for general anaesthetic,

procedures, medical emergencies and obstetrics.

but was noted to exhibit excellent analgesic properties in much smaller doses than that used for anaesthesia(3).

Utilisation of the analgesic properties of Methoxyflurane was taken forward commercially in 1978 with the introduction of a 3mL vial of Methoxyflurane and an inhaler by Medical Development International (MDI) in Australia and subsequently branded Penthrox in 2003.

Safety Since 1978 over 5 million doses have been sold for use in Australia.

Only one questionable case of potentially Methoxyflurane related renal failure has been reported as an adverse drugs event in Australia between 1975-2016. It is accepted that the recommended low dose Methoxyflurane is not associated with nephrotoxicity, and no clear cut cases of renal failure have been reported in the literature(4).

An understanding of the safety margin for the use of Methoxyflurane was eloquently demonstrated by Professor Dayan in terms of the minimum alveolar concentration (MAC) which is the minimum concentration of an inhaled anaesthetic necessary to produce surgical anaesthesia in 50% RESUSCITATION TODAY - SUMMER 2017

of healthy individuals.

Using a maximum exposure possible to Methoxyflurane using the Penthrox system the MAC was 0.3 MAC hours which is much lower than the safe upper limit for exposure to Methoxyflurane of 2 MAC hours. In addition the fluoride levels were much lower than that associated with renal damage.

Utilisation Although Methoxyflurane is available in 16 countries worldwide it was only introduced into the UK in 2015 following a successful application to the Medicines and Healthcare products Regulatory Agency (MHRA).

The initial license has been granted for use in moderate to severe trauma

14

The Product Methoxyflurane (Penthrox) is available in 3mL ampoules, and is a clear, almost colourless volatile fluid with a characteristic fruity odour.

EDUCATION Each Penthrox pack contains one 3mL bottle and one activated charcoal chamber to absorb any exhaled Penthrox in the patient’s breath. A second 3mL bottle may be utilised with a maximum of 6mL in 24 hours. No more than 15mls or 5 vials should be used in a week.

Conflicts of Interest Professor Porter was involved in the preparation of the submission to the MHRA for licence approval and is a member of the Penthrox Clinical Advisory Board funded by the UK distributor, Galen.

The Penthrox solution is poured into the inhaler via a one way valve and is absorbed into a wick and following vaporisation is inhaled through a mouthpiece by the patient.

References 1. Crondell WB, Pappas Sg, Macdonald A Nephrotoxicity associated with Methoxyflurane anaesthetic Anesthesiology 1966;27:591-607

Key features include:

2. Cousins MJ, Mazze RI

• Rapid onset usually 6-10 breaths(5)

Methoxyflurane nephrotoxicity: A study of dose response in man

• No adverse effect on blood pressure

(6)

• No adverse effect on respiratory rate(6) • No adverse effect on conscious levels • 3mL inhaler lasts 25-30 minutes if used continuously

JAMA 1973;225:1611-6 3. Tumi K, Mashimo T, Tashiro C Alteration in pain threshold and psychomotor response associated with subanaesthetic concentration of inhaled anaesthetics in humans Br J Anaesth 1993;70:683-6

• Self-administered • Can be used over a wide range of temperatures • The device is light in weight, easy to use and portable

4. Dayan AD Analgesic use of inhaled Methoxyflurane: Evaluation of its potential nephrotoxicity Hum Exp Toxicol 2016;35:91-100 5. Coffey F, Wright J, Hartshorn S

Pre-Hospital Use Penthrox can be used at the first point of patient contact either as definitive pain relief or as a bridge until the patient is successfully cannulated and intravenous analgesics administered, for example the elderly patient with a neck of femur fracture in extreme pain and no visible veins for vascular access.

STOP: a randomised double-blind placebo controlled study of efficacy and safety of Methoxyflurane to the treatment of acute pain Emerg Med J 2014;31:613-8 6. Oxer HF Effects of Penthrox (Methoxyflurane) as an analgesic on cardiovascular and respiratory function in the pre-hospital setting J Mil Veterans Health 2016;24:14-20

Provision report from South Central Ambulance Service reported quality pain relief and this is supported by the experience of Cheshire & Merseyside Fire Service.

(Personal Communication - Mark Forrest)

helicopter services and BASICS schemes as well as Emergency Departments there is scope for more detailed evaluations and publication.

Conclusions Methoxyflurane (Penthrox) is a new to the UK self-administered inhalatory analgesic with a proven safety record and a history of over 5 million uses in Australia. With increasing usage in pre-

RESUSCITATION TODAY - SUMMER 2017

With increasing use (some on trial) by Ambulance Services,

hospital care and Emergency Departments it is being recognised as a useful adjunct to the choice of analgesia available.

15

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EDUCATION

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EDUCATION

A PROFILE OF OUT-OF-HOSPITAL CARDIAC ARRESTS IN NORTHERN EMIRATES, UNITED ARAB EMIRATES Alan M. Batt, MSc(c), Ahmed S. Al-Hajeri, BHSc EMHCA, Fergal H. Cummins, MB, MSc (DM).

Abstract ‫ دراسة خصائص ضحايا السكتات القلبية خارج‬:‫األهداف‬ ‫املستشفى واملخرجات في إمارات الشارقة ورأس اخليمة وأم‬ .‫القيوين والفجيرة وعجمان‬ ‫ هذه دراسة وصفية استباقية ملجموعة من حاالت‬:‫الطريقة‬ ‫سكتات القلب خارج املستشفى والتي نقلها طواقم اإلسعاف‬ .2015 ‫ حتى مارس‬2014 ‫الوطني في الفترة من فبراير‬ ‫ من احلاالت‬76% ‫شكلت‬.‫ حالة‬384 ‫ تناولت الدراسة‬:‫النتائج‬ ‫ متوسط العمر ملجموعة البحث هو‬.‫ذكور اصيبوا بسكتات قلبية‬ ‫ نسبة استعادة الدورة الدموية التلقائية التي ُوثقت‬.‫ سنة‬50.9 ‫ من اإلنعاش القلبي‬30% ‫ إلى جانب توثيق نسبة‬3.1% ‫كانت‬ ‫ اس ُتعني بأجهزة‬.‫الرئوي الذي قام به حاضرون في مكان احلدث‬ ‫ من‬0.5% ‫إزالة الرجفان البطيني اخلارجية املتاحة للجمهور في‬ .‫احلاالت و ُعرضت البيانات وفق مقاييس أوتستاين للتقارير‬ ‫ ألول مرة مت حصر البيانات األساسية اخلاصة بحاالت‬:‫اخلامتة‬ ‫سكتات القلب في اإلمارات التي تقع في شمال اإلمارات‬ ،‫ نسبة ضعيفة حلاالت النجاة من سكتة القلب‬.‫العربية املتحدة‬ ‫ونسبة ضعيفة لإلنعاش القلبي الرئوي الذي قام به احلاضرون في‬ .‫مكان احلدث واستخدام اجلمهور أجهزة إزالة الرجفان البطيني‬ ‫بالرغم من أن النسب تعد ضعيفة مقارنة بالبلدان الغربية إال أن‬ ‫ حتديد البيانات‬.‫النتائج مشابهة في بلدان منطقة الشرق األوسط‬ ‫األساسية الواردة في هذه الدراسة وتنفيذ استراتيجيات ضرورية‬ .‫للحد من الوفيات الناجمة عن السكتة القلبية خارج املستشفى‬

Objectives: To report the characteristics of out-of-hospital cardiac arrest patients and their outcomes in the emirates of Sharjah, Rasal-Khaimah, Umm Al-Quwain, Fujairah, and Ajman in the United Arab Emirates (collectively known as the Northern Emirates).

Methods: This is a prospective descriptive cohort study of outof-hospital cardiac arrest incidents transported by the national ambulance crews between February 2014 and March 2015 in the Northern Emirates.

Results: A total of 384 patients were enrolled in this study. Male victims of out-of-hospital cardiac arrest represented 76% of the participants. The mean age of the study population was 50.9 years. An over-all prehospital return of spontaneous circulation rate of 3.1% was documented, as well as a 30% rate of bystander cardiopulmonary resuscitation being performed. Public access defibrillators were applied in 0.5% of cases.

Data is presented according to Utstein reporting criteria.

Conclusion: Baseline data for out-of-hospital cardiac arrest was established for the first time in the Northern Emirates of the United Arab Emirates. A low survival rate for out-of-hospital cardiac arrest, low rates of bystander cardiopulmonary resuscitation, and low public access defibrillator use were discovered. Although low by comparison to established western systems results are similar to other systems in the region. Determining the baseline data presented in this study is essential in recommending and implementing strategies to reduce mortality from out-of-hospital cardiac arrest. emergency medical technicians (EMTs), manning 24 ambulances based

worldwide. Survival rates from OHCA vary drastically around the world

at 14 stations, and 25 standby points across the Northern Emirates

with survival rates lower in the Middle East and Asia compared to

area. The geographic area covers approximately 12,100 km2, and

those in the Western Europe and North America. Recent studies have

contains a population of approximately 4.7 million persons. The service

demonstrated low survival rates for cardiac arrests in Saudi Arabia,1

responded to 31,786 emergency medical calls in the same period,

and the Emirates of Dubai.2,3 The National Ambulance (NA) LLC began

with a total of 33,467 patients transported to hospital. All emergency

Emergency Medical Service (EMS) operations in the Emirates of Al-

medical calls received from the NE service area are received in the

Sharjah, Ras-al-Khaimah, Umm Al-Quwain, Al-Fujairah, and Ajman in

Ambulance Communications Center (ACC) in Abu Dhabi. The NA

February 2014. These 5 Emirates are collectively known as the Northern

ACC uses King County Criteria Based Dispatch (CBD) under licence,

Emirates. Prior to the establishment of the NA service in the Emirates,

and has 2 on-site licensed CBD trainers. The CBD ensures that early

the existing ambulance services were unevenly distributed, varied

pre-arrival information is provided to the caller. The communications

largely in their ability to provide uniform levels of care, equipment was

center is staffed by 25 call takers and dispatchers, with support from

variable, and data capture was inconsistent. The NA Northern Emirates

5 team leaders, operating 24-hours a day. A backup communications

service area is a single-tier Basic Life Support (BLS) ambulance

center based off-site is also located in Abu Dhabi. Members of the

service, which was initially staffed (during the study period) with 269

public ring 998 in a medical emergency, and this call is routed directly

Saudi Med J 2016; Vol. 37 (11): 1206-1213 doi: 10.15537/smj.2016.11.16126 From the National Ambulance LLC, Etihad Towers, Abu Dhabi, United Arab Emirates. Received 21st June 2016. Accepted 3rd August 2016.

Address correspondence and reprint request to: Mr. Alan M. Batt, National Ambulance LLC, Etihad Towers, Abu Dhabi, United Arab Emirates. E-mail: batt.alan@gmail.com

RESUSCITATION TODAY - SUMMER 2017

Out-of-hospital cardiac arrest (OHCA) is a major cause of mortality

17

EDUCATION to the NA communications center. Call takers speak Arabic and other

were included in this study. Cardiac arrest was defined as cessation

languages to aid callers. Other languages include English, Tagalog,

of cardiac mechanical activity that was confirmed by the absence of

and Spanish. The call details are then passed to a dispatcher who

a palpable pulse, unresponsiveness, and absence of spontaneous

dispatches an ambulance to cardiac arrest all ideally within a 60-second time frame from receipt of call. Other details are then gathered from the caller. An optional 998 mobile application is also available through

respirations at the site of arrest. The NA clinical treatment protocols

Prehospital in the UAE ... Batt etGuidelines al (based oncardiac the 2010arrest American Heart Association for

Cardiopulmonary Resuscitation and Emergency Cardiovascular Care)

during the period of this period.

The findingthesuggests gender variation during themandated period of this data collection mandated transportation which registered users can request an ambulance to attend their data collection the transportation of all OHCA cases to the hospital of OHCA presentation.

Male of all OHCA cases to the hospital (unless obviously dead with rigorpatients tended GPS-fixed location. The UAE has an age standardized death rate for (unless obviously dead with rigor mortis, younger than the female patients (49 years ve mortis,decapitation, decapitation, dependant lividity, incineration, other injuries totally cardiovascular disease of 308.9 per 100,000 for males and 203.9 4 dependant lividity, incineration, other injuries totally years, p=0.029).

There were missing incompatible with life, and so forth). Do-not-resuscitate orders do not data for age, per 100,000 for females. This figure includes expatriate and national incompatible with life, and so forth).

Do-not-resuscitate of birth forability 12 to ofobtain cases,12-lead theseECGs cases were exclu exist within the UAE. The EMTs have no populations. In the United Arab Emirates (UAE) there are approximately orders do not exist within the UAE. The EMTs have no analysis.

Patients age ranged were <1 year to 9 during the study period.

2 males for every female in the population, and the majority of the 5 during the study period. ability to obtain 12-lead ECGs old (mean age: 50.9 years, SD Âą 21.1 years, med population are expatriates of working age (median age 33.3 years).

Exclusion criteria were patients who were not years, interquartile range [IQR]: 35.5, 65.0) (Fi Exclusion criteria were patients who were not treated by EMTs due An estimated 15-20% of the total population of UAE are UAE nationals, Males comprised of 76% (n=291).

Patients e treated by EMTs due to recognition of death at scene. to recognition of death at scene. Return of spontaneous circulation with the remainder comprised of expatriate workers from all around the in this study with known chronic illnesses repr Return of spontaneous circulation (ROSC) rate only (ROSC) rate only includes patients who gained ROSC on-scene, or globe. As part of its commitment to improving the health and well-being 78.1% population. includes gained ROSC prior on-scene, or arrival. prior Patients to hospital who of had the ROSCstudy subsequent to hospital Reported of both UAE nationals and residents in thepatients UAE, NA who is a contributing illnesses included known history of diabetes m to hospital arrival.

Patients who had ROSC subsequent arrival were excluded from analysis for this outcome. Results from postmembers to the Pan-Asian Resuscitation Outcomes Study (PAROS), 7 cardiovascular disease, renal disease, to hospital arrival were excluded from analysis for this mortem examinations were not utilized. Utstein style of reporting data is and resp an international cardiac arrest registry study comprising member states 6outcome. diseases.

Individuals from the Indian subco Results from post-mortem examinations incomplete due to non-availability of hospital data. across the Asia-Pacific region. Through their contribution of data to the 7 of reporting data is represented the largest group of OHCA, acco were not utilized.

Utstein style PAROS study, member states aim to share information to allow for a incomplete due to non-availability of hospital data. for 38.8% of all cases (n=149) while patien Statistical analysis was performed using the Statistical Package for Social collaborative problem-solving approach to the issue of OHCA. Statistical analysis was performed using the Statistical other Arab countries represented 23.7% (n=91 Sciences (IBM SPSS Version 20, NY, USA). Descriptive analysis was Package for Social Sciences (IBM SPSS Version 20, NY, cases.

The UAE nationals accounted for 16.7% performed to determine distribution and frequency, independent group Limited data surrounding OHCA in the Gulf region has been published, Descriptive analysis to determine Further patient characteristics are out 1 t-test was used to compareof agecases. and gender means, and percentages Withwas performed with the exception of studies inUSA).

Saudi Arabia and Lebanon.

Table 1 . distribution and frequency, independent group t-test were used to describe and report variables and patient characteristics. the exception of Dubai, no OHCA data has been published for the Of the 384 OHCA cases, over half occu wasTheused and gender means, and remaining 6 Emirates in the UAE. aim ofto this compare study was toage identify a home residence (n=208; 54.2%). The nex percentages were used to describe and report variables patient characteristics and outcomes of all OHCA cases presenting to common location was on a street, or highway and patient characteristics.

NA crews in the Northern Emirates. The collation and publication of this Results 18.5%).

Other locations are summarized in Tab data represents the profiling of OHCA cases in these 5 Emirates.

Results. A total of 384 OHCA patients who Figure 2.

A total of 384 OHCA patients who presented to the NA EMT crews were The median response time was 9 minute presented to the NA EMT crews were enrolled in this in this study. Based on the population in the 5 Emirates studied study. Based on the population in the 5enrolled Emirates studied receipt of emergency medical call to arrival of t (estimated at 4.7 million), this equates to 8.2 OHCA resuscitation Methods (estimated at 4.7 million), this equates to 8.2 OHCA at the scene (IQR: 6, 14). An ambulance arrive attempts per 100,000 persons during this period. resuscitation attempts per 100,000 persons during this within 14 minutes of receipt of an emergency A prospective cohort study design was applied to the study of all presenting cases of OHCA between February 2014 and March 2015 in the NA Northern Emirates service area of the UAE.3 A literature search was also performed.

The study complies with the Declaration of Helsinki and received ethical approval from the Office of the Chief Medical Advisor, NA LLC. The implementation of the PAROS study RESUSCITATION TODAY - SUMMER 2017

has received various institutional review board approvals from the countries involved in the PAROS study to which NA LLC is a contributing member.

Emergency medical technicians who provided care for cardiac arrest patients completed PAROS data collection forms specifically designed for this study and approved by PAROS, which were then reviewed by the PAROS coordinator in the NA. Data requiring clarification such as dispatch and arrival times were cross-referenced with dispatch information before entry into PAROS database.

All cases of OHCA treated by the EMT crews

18

Figure 1 - Age distribution and frequency of OHCA cases in Northern Emirates, UAE between 2014 and March 2015. OHCA - Out-of-hospital cardiac arrest, UAE - United Arab Emirates

Disclosure: Authors have no conflict of interests, and the work was not supported or funded by any drug company.

1208

Saudi Med J 2016; Vol. 37 (11)

www.smj.org.sa

EDUCATION Prehospital cardiac arrest in the UAE ... Batt et al The finding suggests gender variation in age of OHCA presentation.

call in tended 75% of cardiac arrival scene Male patients to be youngerarrests. than theTime femaleto patients (49at years was p=0.029). missing There for 4were cases.

Almost allage, patients versusdata 55 years, missing data for or datewere of

transported to the hospital (n=382; 99.5%)

by NA birth for 12 of cases, these cases were excluded for analysis.

Patients crews,were with 2 patients pronounced dead theSDscene age ranged <1 year to 95 years old (mean age: 50.9 at years, a physician.

OHCArange cases[IQR]: presented to ± 21.1by years, median: 53Data years, for interquartile 35.5, 65.0)

Characteristics

Population (n=384) n (%)

Age (years) Mean±SD 50.9±21.1 Median (IQR) 53 (35.5, 65.0) Gender Male 291 (76.0) Female 93 (24.0) Past medical history Heart disease 53 (13.8) Diabetes mellitus 63 (16.4) Hypertension 56 (14.6) Yes, but unknown 152 (39.6) Location type Home residence 208 (54.2) Healthcare facility 10 (2.6) Public/commercial building 36 (9.4) Street/highway 71 (18.5) Industrial place 20 (5.2) Transport centre 1 (0.3) Place of recreation 22 (5.7) In EMS/private ambulance 2 (0.6) Others 14 (3.6) Time from receipt of call to scene arrival (mins) Median (IQR) 9 (6.1) Arrest witnessed Not witnessed 140 (36.4) Bystander 212 (55.2) EMS 30 (7.8) First arrest rhythm VT/VF/unknown shockable 67 (17.5) Unknown unshockable 94 (24.5) Asystole 146 (38.0) Pulseless electrical activity 14 (3.6) Unknown 63 (16.4) Prehospital intervention Bystander CPR 115 (30.0) Prehospital defibrillation 181 (47.1) Bystander AED application 2 Bystander defibrillation 0 Time to first shock from EMS arrival (mins) Median (IQR) 8 (3.2) Prehospital advanced airway Oral/nasal endotracheal tube 5 (1.3) Laryngeal tube airway 2 (0.6) Laryngeal mask airway 1 (0.3) iGel 314 (81.8) None 62 (16.1) Location of cardiac arrest by Emirates Al-Sharjah 174 (45.3) Ras al-Khaimah 56 (14.6) Ajman 51 (13.3) Al-Fujairah 34 (8.8) Umm al-Quwain 16 (4.2) Unknown 53 (13.8) Outcomes ROSC prehospital 12 (3.1) ROSC in emergency department Survived to admission Not available Survived to discharge Not available Post arrest CPC 1/2 Not available EMS - emergency medical services, VF - ventricular fibrillation, VT - ventricular tachycardia, CR - cardiopulmonary resuscitation, RSC return of spontaneous circulation, CPC - cerebral performance category, CPR - cardiopulmonary resuscitation, AED - automated external defibrillator, IQR - interquartile range, ROSC - return-of-spontaneouscirculation

ROSC rate was observed in-hospital during, or immediately after EMS

hand-over. This percentage group is not included in the data analysis.

Full Utstein style7 of reporting data is shown in Figure 4.

was inserted in 322 cases (84%) with the most commonly used airway device being the iGel (Intersurgical Ltd., UK). A total of 181 cases had

A mechanical CPR device (LUCAS-2, Physio-Control Inc., USA) was

defibrillation attempted (47.1%) onSaudi a shockable rhythm at some 1209 www.smj.org.sa Med J 2016; Vol. 37 (11) stage,

applied in 273 cases (71%) by EMTs. A supraglottic airway device

either on-scene or en-route to receiving facility. The median time to

RESUSCITATION TODAY - SUMMER 2017

the to Emergency Departments (ED) by means other than (Figure 1).

NA crews is unavailable for this study period as hospital sites did not begin collecting OHCA data until March Males comprised of 76% (n=291). Patients enrolled in this study with 2015. known chronic illnesses represented 78.1% of the study population.

A total of 212 incidents were witnessed by a Reported chronic illnesses included known history of diabetes mellitus, bystander (55.2%) and 30 events were witnessed by cardiovascular disease, renal disease, and respiratory diseases. the NA EMTs (7.8%). There were 140 incidents that Individuals from the Indian subcontinent represented the largest group were not witnessed (36.4%). Data was missing for 2 of OHCA, accounting for 38.8% of all cases (n=149) while patients incidents.

Cardiopulmonary resuscitation (CPR) advice from other Arab countries represented 23.7% (n=91) of all cases. The was offered by ACC call-takers and dispatchers to all UAE nationals accounted for 16.7% (n=64) of cases. Further patient callers once a diagnosis of cardiac arrest was confirmed characteristics are outlined in Table 1. or suspected, utilizing King County CBD. Of this, a total of 268 (69.9%) callers acknowledged using these Of the 384 OHCA cases, over half occurred at a home residence (n=208; CPR instructions.

54.2%). The next most common location was on a street, or highway Bystander CPR was attempted in 30% (n=115) of (n=71, 18.5%). Other locations are summarized in Table 1 and Figure 2. cases as confirmed by NA crews on arrival at scene. A bystander automated external defibrillator (AED) was The median response time was 9 minutes from receipt of emergency applied in only 2 cases, and no shocks were delivered in medical call to arrival of the crew at the scene (IQR: 6, 14). An either case. Only 67 patients (17%) were in a shockable ambulance arrive at scene within 14 minutes of receipt of an emergency rhythm at time of first rhythm analysis. The prevalence medical call in 75% of cardiac arrests. Time to arrival at scene data of presenting rhythms is outlined in Figure 3. was missing for 4 cases. Almost all patients were transported to the Of the total 382 patients transported to ED, 370 hospital (n=382; 99.5%) by NA crews, with 2 patients pronounced patients were transported with no record of ROSC at dead at the scene by a physician. Data for OHCA cases presented to any stage pre-hospital. An overall out-of-hospital (at the to Emergency Departments (ED) by means other than NA crews scene, or en-route) return-of-spontaneous-circulation is unavailable for this study period as hospital sites did not begin (ROSC) rate of 3.1% (n=12) was observed. In addition collecting OHCA data until March 2015. a further 2.3% ROSC rate was observed in-hospital during, or immediately after EMS hand-over. This A total of 212 incidents were witnessed by a bystander (55.2%) and 30 percentage group is not included in the data analysis. events were witnessed by the EMTs (7.8%). There were 140 incidents Full Utstein style7 ofNA reporting data is shown in Figure 4. that were not witnessed (36.4%). Data was missing for 2 incidents.

A mechanical CPR device (LUCAS-2, PhysioCardiopulmonary resuscitation (CPR) advice was offered by ACC callControl Inc., USA) was applied in 273 cases (71%) takers and dispatchers to all callers once a diagnosis of cardiac arrest

by EMTs. A supraglottic airway device was inserted in was confirmed or suspected, utilizing King County CBD. Of this, a total 322 cases (84%) with the most commonly used airway of 268 (69.9%) callers acknowledged using these CPR instructions. device being the iGel (Intersurgical Ltd., UK). A total of 181 cases had defibrillation attempted (47.1%) on Bystander CPR was attempted in 30% (n=115) of cases as confirmed a shockable rhythm at some stage, either on-scene or

by NA crews on arrival at scene. A bystander automated external en-route to receiving facility. The median time to first defibrillator (AED) was applied in only 2 cases, and no shocks were shock from arrival of EMTs at the patient’s side was 8 delivered in either case. Only 67 patients (17%) were in a shockable minutes (IQR 3,16). All patients were transported to rhythm at time of first rhythm analysis. The prevalence of presenting tertiary level centers. Cardiopulmonary resuscitation rhythms is outlined in Figure 3. quality data was not collected for the study period.

A total of 12 cases gained ROSC at some stage in the Of thepre-hospital total 382 patients transported ED,these 370 patients setting.

Eightto of cases were had bystander transported with no record of ROSC at any stage pre-hospital.

An(67%). overall CPR performed prior to ambulance crew arrival out-of-hospital (at scene, or en-route) return-of-spontaneous-circulation Seven of the ROSC group were female (58%) and the (ROSC) rate ofage 3.1% (n=12) observed.

In addition 2.3%at a mean was 42.was Seven of these casesa further occurred

Table 1 - Patient demographics, out-of-hospital cardiac arrest (OHCA) characteristics and outcomes of OHCA cases in Northern Emirates, United Arab Emirates between February 2014 and March 2015.

19

EDUCATION Prehospital cardiac arrest in the UAE ... Batt et al

Discussion The median age found in our study corresponds with data recently published from our colleagues in the Dubai PAROS data collection site (Dubai Corporation for Ambulance Services), who report a median age of 50.0 years (IQR 38.0, 63.0). Males accounted for 82.7% (n=405) of all arrests in the emirate of Dubai, and again, the majority of arrests (n=220, 54.3%) occurred at home. Of these 405 arrests, 205 (50.6%) were witnessed, similar to our findings. However, bystander CPR was only performed in 41 Figure 2 - Location of out-of-hospital cardiac arrest (OHCA) cases in Northern Emirates, Arab Emirates between February 2014 and March 2015.

(10.5%) OHCA cases in Dubai.

The majority of arrests in Dubai (n=362, 89.4%) were presumed cardiac in nature. Hospital survival data is available for Dubai, and an overall survival to discharge rate of 3% (n=12) with a cerebral performance score (CPC) of 1 or 2 in 11 (2.7%) of these cases.2 Many of the witnessed arrests in our study had a large delay in time before activation of the emergency response system. The reasons for this are unknown, but it could be hypothesized from previous studies and anecdotal reports provided by NA crews that many members of the public simply do not understand the time-critical nature of cardiac arrest, and may have trouble identifying the patient who needs immediate medical assistance.

Utilisation of ambulance services

Figure 3 - Prevalence of presenting in out-of-hospital cardiac arrest (OHCA) cases in Northern Emirates, Arab Emirates between February 2014 and March 2015. VT - VT - ventricular tachycardia, PEA - pulse less electrical activity, VF - ventricular fibrillation

RESUSCITATION TODAY - SUMMER 2017

1210

20

in general is low in the Arab gulf region, as demonstrated in a study in 2013, where only 25% of patients presenting to the ED with acute

first shock from arrival of EMTs at the patient’s side was 8 minutes

coronary syndrome arrived via

(IQR 3,16). All patients were transported to tertiary level centers.

ambulance.8 Cultural norms regarding death at home and being taken to

Cardiopulmonary resuscitation quality data was not collected for the

the hospital may also have influenced the delay in seeking help.

study period.

Saudi Med J 2016; Vol. 37 (11)

www.smj.org.sa

The relatively low rate of bystander CPR may also be attributed to cultural

A total of 12 cases gained ROSC at some stage in the pre-hospital

norms, as highlighted in a study of CPR and AED utilization in Bahrain.9

setting. Eight of these cases had bystander CPR performed prior to

It may also be attributed to a lack of knowledge surrounding first aid and

ambulance crew arrival (67%). Seven of the ROSC group were female

CPR in general. There is also no established, coordinated public access

(58%) and the mean age was 42. Seven of these cases occurred

defibrillator scheme in the UAE. Although there are leadership wishes to

at a home residence (58%), 2 at a healthcare facility, 2 in a public/

promote public access defibrillation, take up of the initiative in the UAE

commercial building (17% each) and one in a place of recreation (8.3%).

has been suboptimal. Many members of the public are also afraid or

Seven had a mechanical CPR device applied (58%), and nine had an

hesitant to intervene and assist a person in need due to lack of knowledge,

advanced airway inserted (75%).

fear of litigation and uncertainty surrounding ‘Good Samaritan’ status.

EDUCATION Prehospital cardiac arrest in the UAE ... Batt et al

While a stand-alone â&#x20AC;&#x2DC;Good Samaritanâ&#x20AC;&#x2122; law does not exist within the UAE,

by all people in accordance with Sharia law. In accordance with this Fatwa,

a Fatwa issued in 2010 by the Official Iftaa Center, General Authority of

no criminal liability will attach to an individual, in respect of Sharia and UAE www.smj.org.sa Saudi Med J 2016; Vol. 37 (11) 1211 law, when they provide first aid to someone in need.10

Islamic Affairs & Endowments states that first aid should be administered

RESUSCITATION TODAY - SUMMER 2017

Figure 4 - Full Utstein reporting data in Northern Emirates, Arab Emirates between February 2014 and March 2015. EMS - Emergency Medical Service, BLS - Basic Life Support, VF - ventricular fibrillation, ROSC - return-of-spontaneous-circulation, VT - ventricular tachycardia, ASYS Asystole, CPR - cardiopulmonary resuscitation, AED - automated external defibrillator, DC - survival to discharge, 3od - survival at 30 days, MRS - modified Rankin Scale, mm;ss - time in minute:seconds format, vent - ventilations, DNAR - did not attempt resuscitation

21

EDUCATION The high incidence of cardiac arrests occurring in the emirate of Al-Sharjah

low rates of bystander CPR, and the poor availability of public-access

can possibly be attributed to a number of factors, but requires urgent

defibrillators. Further collaborative research is urgently needed on the

further research. The emirate of Sharjah is home to a large expatriate

topic of OHCA in the UAE as the current literature on the topic is sparse.

population, with over 37% from the Indian subcontinent (India, Pakistan, and Bangladesh).11 This population are prone to developing CHD at a

Acknowledgment: The authors would like to acknowledge the Pan-

younger age, a risk factor for OHCA. We cannot say this is a certain factor

Asian Resuscitation Outcomes Study (PAROS) steering committee and

that influences the cardiac arrest rate in this Emirate, the proportion of

all National Ambulance staff for their engagement with the PAROS study.

12

emergency medical calls within the Emirate of Sharjah is indeed higher than other areas of the Northern Emirates service area. This could also partly be due to building design in the larger cities, which are home to many high-rise buildings, an independent predictor of OHCA survival.13 The results from this one-year of data collection support the implementation of certain initiatives. Ong et al6 identified 5 potential strategies for improving survival rates in the participating PAROS countries.These include widespread community-based and systemic efforts to increase bystander CPR; investing in Public Access Defibrillation schemes, having a BLS EMS system, but investing in reducing response times; developing Advanced Life Support EMS systems and investing in hospital-based post-resuscitation care (cardiac arrest centers).The findings from this study support the continued need for system investment, public engagement and education and awareness campaigns for the general public and healthcare professionals on rapid recognition and management of OHCA. An interdisciplinary approach is essential to reduce mortality from OHCA. This approach needs to be guided by data. This data limitation is currently being addressed, since the findings of this study were collated, the NA LLC has worked with hospital sites in the Northern Emirates service area, who have begun the process to collect and enter OHCA data into the PAROS database. This will allow for construction of datasets representing all prehospital cardiac arrest cases in the UAE. By engaging a data collection site of PAROS, a clearer picture of OHCA outcomes in the UAE will be available in the future. The primary outcome data that will be available through publication of full PAROS datasets will be survival to hospital discharge, or survival to 30 days post-cardiac arrest for those who have not yet been discharged from the hospital by the 30th day post-arrest, along with CPC on discharge.

There are several limitations to this study that need to be highlighted. Data collection was limited to data collected by NA crews in the prehospital setting utilizing PAROS forms and patient care records. Limited data was obtained on other prehospital variables, such as time from arrest to hospital, cases which were transported by other means, and any performed interventions during these transports. The cause of arrest was RESUSCITATION TODAY - SUMMER 2017

not confirmed by post-mortem examination due to the cultural standards.

A significant number of OHCA cases might still arrive at a hospital via private transport rather than by transport in an ambulance. Some of these cases may have been attended to by primary care/community care providers, pronounced dead at home, or not be conveyed to hospital at all. This possibly resulted in incomplete enrolment of patients into our study, which may introduce selection bias. Our own data collection is incomplete for several variables, and may not be totally representative of the true situation.

Our inability to discuss findings beyond the prehospital care phase, and the missing data in Utstein reporting as a result, is an obvious limitation.

In conclusion, the data collected in this study documented a low ROSC rate for OHCA patients in the Northern Emirates. The findings of this study are to be expected given the low prevalence of early EMS activation,

22

References 1. Bin Salleeh H, Gabralla K, Leggio W, Al Aseri Z. Out-of-hospital adult cardiac arrests in a university hospital in central Saudi Arabia. Saudi Med J 2015; 36: 1071-1075.

2. Ong MEH, Shin S Do, De Souza NNA, Tanaka H, Nishiuchi T, Song KJ, et al. Outcomes for out-of-hospital cardiac arrests across 7 countries in Asia: The Pan Asian Resuscitation Outcomes Study (PAROS). Resuscitation 2015; 96: 100-108.

3. Batt A, Al-Hajeri A, Minton M, Haskins B, Cummins F. National Ambulance Northern Emirates PAROS Study Annual Report 2015. Abu Dhabi (UAE): Pan-Asian Resuscitation Outcomes Study (PAROS); 2015.

4. Loney T, Aw T, Handysides D, Raghib A, Blair I, Grivna M, et al. An analysis of the health status of the United Arab Emirates: the “Big 4” public health issues. Glob Health Action 2013; 1: 1-8.

5. Euromonitor International. United Arab Emirates country profile [Cited 2013 December 6]. Available from: http://www.hdcglobal. com/upload-web/cms-editor-files/21bc5b40-5eff-40e8-b4ff5b6a20931fed/file/United_Arab_Emirates_Country_Profile.pdf 6. Ong ME, Shin SD, Tanaka H, Ma MH, Khruekarnchana P, Hisamuddin N, et al. Pan-Asian Resuscitation Outcomes Study (PAROS): rationale, methodology, and implementation. Acad Emerg Med 2011; 18: 890-897.

7. Perkins GD, Jacobs IG, Nadkarni VM, Berg RA, Bhanji F, Biarent D, et al. Cardiac arrest and cardiopulmonary resuscitation outcome reports: update of the Utstein Resuscitation Registry Templates for Out-ofHospital Cardiac Arrest: a statement for healthcare professionals from a task force of the International Liaison Committee on Resuscitation (American Heart Association, European Resuscitation Council, Australian and New Zealand Council on Resuscitation, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation Council of Southern Africa, Resuscitation Council of Asia); and the American Heart Association Emergency Cardiovascular Care Committee and the Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation. Circulation 2015; 132: 1286-300.

8. AlHabib KF, Alfaleh H, Hersi A, Kashour T, Alsheikh-Ali AA3, Suwaidi JA, et al. Use of emergency medical services in the second gulf registry of acute coronary events. Angiology 2014; 65: 703-709.

9. Merrigan OH. Abstract 229: Are there any cultural barriers to automated external defibrillator use in Middle Eastern Countries?

Circulation 2015; 124 (Suppl 21): A229-A229.

10. Kelly R. “Good Samaritan” principles in the UAE : legal liabilities when administering first aid. [Cited 2015 Jun 14]. Available from: http://www.clydeco.com/insight/updates/view/good-samaritanprinciples-in-the-uae-legal-liabilities-when-administering-f 11. Khamis J. Indians, Pakistanis make up 37% of Dubai, Sharjah, Ajman population. Gulf News [Internet]. Abu Dhabi; 2015 Aug 6; Available from: http://gulfnews.com/news/uae/society/indians-pakistanis-makeup-37-of-dubai-sharjah-ajman-population-1.1562336 12. Enas E, Garg A, Davidson M, Nair V, Huet B, Yusuf S. Coronary heart disease and its risk factors in first-generation immigrant Asian Indians to the United States of America. Indian Heart J 1996; 48: 343-553.

13. Drennan IR, Strum RP, Byers A, Buick JE, Lin S, Cheskes S, et al. Out-of-hospital cardiac arrest in high-rise buildings: delays to patient care and effect on survival. CMAJ 2016; 188: 413-419.

EDUCATION

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23

EVIDENCE

Resuscitation Today Conference Programme

Wednesday 7th June 2017

The International Centre, Telford, TF3 4JH

Thanks to the generosity of our Sponsor, Distinctive Medical, we can offer the first 50 registered delegates a reduced rate of £30 (inc VAT) to include lunch/tea/coffee, etc.

Time

Presentation

Speaker

Position

David Halliwell

MSc Paramedic Flfl

Dr Simon Le Clerc

Military Consultant in Emergency Medicine

RESUSCITATION TODAY - SUMMER 2017

08.30 – 09.30

Registration

09.30 – 09.45

Introduction

09.45 – 10.30

Future Haemorrhage Control Techniques

10.30 – 11.15

Alveolar Ventilation via Continuous Chest Compression (AV-CCC) – No pause should be your cause

11.15 – 12.00

Tea/Coffee, Exhibition

12.00 – 12.30

Grown-Up Congenital Heart Disease ABC

Amy Chan-Dominy

Paediatric Consultant

12.30 – 13.00

Pitcrew Resuscitation….Microgains to Improve Outcome

Andy Thomas

Senior Paramedic Critical Care Ambulance Response Unit

13.00 – 13.30

Fatal Fractures

Prof. Sir Keith Porter

Professor of Traumatology

13.30 – 15.00

Lunch and Exhibition

15.00 – 15.45

Sepsis – The Hidden Killer

Georgina McNamara

UK Sepsis Trust

15.45 – 16.15

Difficult Airway Management

16.15 – 16.45

T.B.C.

David Halliwell

MSc Paramedic Flfl

16.45 – Close

Q&A

David Halliwell

MSc Paramedic Flfl

Dr Marc Gillis

Head of Emergency Service Imelda Hospital, Bonheiden,Belgium

Dr Kate Crewdson

Topics & Speakers correct at the time of press but may be subject to change.

To register please visit: www.lifeconnections.uk.com or call: 01322 660434

24

EVIDENCE

URGENT NEED TO STRENGTHEN THE CHAIN OF SURVIVAL IN THE UNITED ARAB EMIRATES; A LETTER TO THE EDITOR Alan Michael Batt1*, Ahmed Saleh Mohamed Al-Hajeri 1, Fergal Henry Cummins1 A chain is only as strong as its

Further to our recently published findings, we have completed the analysis of our second year of prehospital data collection for the same service (1). We wish to expedite the availability of this data to clinicians, researchers and policy makers in the region.

Our 2015/2016 out-of-hospital

A chain is only as strong as its weakest link. As such, increasing public awareness of the need for early EMS activation, improving bystander CPR rates, and increasing the availability of public access defibrillators still remain significant challenges in implementing the chain of survival in full to address this public health issue in the United Arab Emirates.

attempts were attended by national ambulance (NA) emergency medical

public awareness of the need for early EMS activation, improving bystander CPR rates, and increasing the availability of public access defibrillators still remain significant challenges in implementing the chain of survival in full to address this public health issue in the United Arab Emirates.

cardiac arrest (OHCA) data displayed the following demographic results: 514 OHCA resuscitation

weakest link. As such, increasing

References

services (EMS) in the Northern Emirates region (75% male). Male patients continued on average to be younger than female ones (50 vs. 61 years), and

1. Batt A, Al-Hajeri A, Cummins F. A profile of out-of-hospital cardiac

the median age of OHCA cases in the United Arab Emirates remains well

arrests in Northern Emirates, United Arab Emirates. Saudi Med J.

below that of cases in Western countries (52 years, interquartile range:

2016;37(11):179–86.

38; 69).

Over half of these cases occurred at a home residence, with the next most common location being a street or highway. A total of 282 incidents were

2. Cummins RO. Emergency medical services and sudden cardiac arrest: the “chain of survival” concept. Annu Rev Public Health.

1993;14:313–33.

witnessed by a bystander, 43 events by NA crew, and 189 incidents were not witnessed. Bystander cardiopulmonary resuscitation (CPR) was attempted in 135 (28.6%) of non-EMS-witnessed cases (n=471). A bystander or public access defibrillator was applied in only five cases (1%) and no shocks were delivered by bystanders in any case. A total of 34 (6.6%) patients had a return demonstrated in the first year of our study. Survival to discharge data has been collected for the first time by our hospital partners, and the publication of these results in the near future will contribute greatly to our understanding of the OHCA issue in the region.

The increase in the number of OHCA responses by NA crew is notable in our findings. This may be attributable to several reasons, including greater public awareness of EMS capabilities, and improved access to EMS via the dedicated 998 emergency number and the NA mobile application. This trend is to be welcomed, as implementation of the chain of survival increases the odds for survival (2). However, similar to

RESUSCITATION TODAY - SUMMER 2017

of spontaneous circulation in the pre-hospital setting, over twice the rate

our previous findings, a large number of the cases that were witnessed still had a significant time lapse before EMS was activated.

1. National Ambulance LLC, Abu Dhabi, United Arab Emirates. * Corresponding Author: Alan Michael Batt; Etihad Towers, Level 6 Tower 3, Abu Dhabi, United Arab Emirates. Email: batt.alan@gmail.com, Tel: +971-2-5968600

25

EVIDENCE

Life Connections 2017 Telford International Centre, Telford Tuesday June 6 & Wednesday June 7 Conference/Workshop information to date:

Tuesday June 6

Wednesday June 7

Paramedic Practice Conference

Resuscitation Today Conference

Only 100 places are available, early bird delegate offer £42.00 (incl VAT)

50 places are available at the early bird delegate rate of £30 (incl VAT)

First Aid Conference

Emergency First Responders Conference

Delegate rate tba

PHTLS for First Responders Course Only 12 places are available at a rate of £80.00 + VAT (50% below normal Course costs)

60 places are available at the early bird delegate rate of £24 (incl VAT)

Essentials of Advanced Airway Management Course Only 10 places are available at a delegate rate of £80 plus VAT (50% below normal Course costs)

‘Early Bird’ offers include lunch, tea/coffee, etc. plus free parking.

Full conference/workshop details will shortly be available on our dedicated website: www.lifeconnections.uk.com

Welcome to the next generation in simulation technology.

The iSimulate ALSi Simulation platform provides an economical, highly advanced and realistic patient condition simulation package that enables advanced patient simulations that can be run quickly and easily without the need for expensive and complex manikins or monitors.

• Smart and easy to use scenario builder • Over 50 ECG waveforms • Over 20 additional parameter settings

It is so easy to use you can be up and running in less than 2 minutes allowing you to train anywhere and at anytime with a fully featured, multi-parameter monitor, AED and defibrillator without the cost and complexity of traditional simulators.

RESUSCITATION TODAY - SUMMER 2017

26

• Ability to use 12-lead ECG, import video and x-ray images • Realistic trending of vitals over time

Run off only two iPad’s, students view a realistic patient monitor while the instructor uses a handheld control ipad to control everything from parameters to time.

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Advanced simulation, without the cost The iSimulate ALSi Simulation Platform provides an economical, highly advanced and realistic patient condition simulation package that enables advanced patient simulations that can be run quickly and easily without the need for expensive and complex manikins or monitors.

education

equipment

enterprise

NEWS Great Western Air Ambulance charity It is something that can save a life.

Something that could be the difference between a patient dying at the roadside or surviving to hospital. The ability to give a pre-hospital blood transfusion is a vital step forward - and one that the Great Western Air Ambulance Charity (GWAAC) is proud to be able to provide.

Covering a wide area, which includes major motorways and rural areas, the Critical Care Team treat traumatically injured casualties on a regular basis. From road traffic collisions, to horse riding incidents, these patients are severally injured - and have potentially lost a lot of blood. Waiting until they arrive at hospital for a blood transfusion could be too late, and in a situation where every minute counts giving blood at the scene can be crucial to their survival.

With this in mind GWAAC Critical Care Doctors Harvey Pynn and Tim Hooper set out on an 18 month journey of information gathering, meetings and planning to carry blood on board the helicopter and critical care cars.

Due to their previous military experiences they were the best people to lead this project. Both have experience of treating soldiers who have been wounded on the battlefield. The injuries these soldiers sustained required them to receive blood in the remote pre-hospital setting in order to ensure they had the greatest chance of survival.

The GWAAC Critical Care Team attend to the most seriously ill and injured people across Bristol, Bath and North East Somerset, Gloucestershire, South Gloucestershire, North Somerset and parts of Wiltshire. Of these cases in 2016 25.9% were trauma injuries, and 19.8% were RTCs.

trained in the indications and delivery of prehospital blood transfusion.

August 2015 saw the hard work paying off - as GWAAC went live with blood. A few days after the launch a biker was seriously injured in an RTC, and so became the first person to receive a transfusion from the GWAAC team.

Although the patterns of injury in the military and civilian environments are different, the severity of injuries may be similar and therapy transferable.

GWAAC now carries two units of O negative blood - which can be given to any patient.

When that patient reaches hospital they may receive further blood products that match their

Dr Pynn said: “There is evidence that it is beneficial for patients to receive a blood transfusion no more than an hour post injury. Often patients are in the pre-hospital setting for longer than this so the ability to give a blood transfusion at the roadside will be beneficial, and could help improve their chances of survival.”

During the planning stage Dr Pynn and Dr Hooper worked with Critical Care Paramedics Neil Hooper, and Matt Baskerville (who recently joined the team from Wiltshire Air Ambulance), to enable GWAAC to become one of the first air ambulances in the South West to carry blood.

This is a joint venture with WAA though with GWAAC providing all the senior governance and leadership advice for them.

The process involved a service level agreement with the North Bristol Trust Transfusion Laboratory at Southmead Hospital, who would supply the blood, and the charity Freewheelers EVS, who would deliver it to the airbase in Filton. All the GWAA clinicians were

blood type.

The blood is collected daily from the North Bristol Trust Transfusion Laboratory at Southmead Hospital and delivered to GWAAC’s airbase in Filton by the charity Freewheelers EVS, which covers the South West. Additional deliveries can be made if required by the air crews.

If the blood is not used, it will be returned to Southmead Hospital by the volunteer blood bikers after 24 hours. The blood storage boxes maintain the temperature of the blood within in very narrow limits for well over 24 hours. Any unused blood units are therefore able to be put back into the Southmead Hospital blood bank, preventing waste.

During the first year 62 pre-hospital blood transfusions were carried out. Of these 84% were in trauma cases. In total over 80 transfusions have taken place since the project went live.

The next step for the charity is to start carrying plasma, which helps the blood to clot.

Blood is made up of several components.

GWAAC carry red blood cells, which is one part.

By carrying plasma it will aid the resuscitation by improving the patient’s ability to clot.

When plasma is stored it is frozen so a specialist defroster is required to thaw it before the crew receive it. This will take place at the laboratory in Southmead Hospital. The plasma will then be delivered with the blood by Freewheelers to the base. By carrying it with the blood it means that the components are together, and can be given to a patient at the same time.

RESUSCITATION TODAY - SUMMER 2017

The other two parts are plasma and platelets.

It is hoped that this will go live by summer 2017.

27

NEWS Leading organisations call for overhaul of cardiac arrest treatment to save thousands of lives every year: Urgent need to improve low survival rates

In England, resuscitation is attempted in

“Currently, there is significant variation in

around 30,000 out of hospital cardiac arrests

treatment around the country so it is vital that

each year. The chance of survival for these

we provide all people with the best possible

patients is almost zero if someone collapses

chances of survival, wherever they live. This

and no bystander CPR is attempted.

report offers the recently established Urgent & Emergency Networks a blueprint for how this

Simply waiting for the emergency services to saved are actually lost.

Leading organisations are calling for an overhaul of treatment for cardiac arrest patients to prevent thousands of deaths every year in the UK. A new report, Resuscitation to Recovery, reveals that currently just 8 per cent of patients survive a cardiac arrest in England, and less than half (30-40%) of bystanders intervene when they witness someone collapse.

Survival rates in other parts of the world are much higher, prompting clinicians in NHS England, the British Heart Foundation (BHF) and other leading health organisations to develop new guidance for patient care, from resuscitation to recovery.

could be achieved.”

arrive means that many lives that could be Professor Sir Nilesh Samani, Medical Director at the British Heart Foundation, said: Fewer than half of adults feel able to intervene when they witness someone having a cardiac

“Cardiac arrest survival rates in England are

arrest, partly because of a lack of confidence

disappointingly low and have remained so for

and training.

many years,

But Resuscitation to Recovery emphasises

“There is potential to save thousands of lives

that bystander intervention can help treble the

but we urgently need to change how we think

chances of survival.

about cardiac arrest care.

Professor Huon Gray, National Clinical Director

“It’s clear that we need a revolution in

for Heart Disease, NHS England, said:

CPR by educating more people in simple lifesaving skills and the use of external

“Thousands of deaths from cardiac arrests

defibrillators, and for the subsequent care of a

could be prevented every year, but we need to

resuscitated patient to be more consistent and

work with the public, the emergency services

streamlined.”

and hospitals in order to achieve this.

The bold plans aim to create a cultural shift in attitudes towards performing cardiopulmonary resuscitation (CPR) and support NHS England’s wider plans to improve Urgent & Emergency Care services.

It is hoped that this could help save thousands more lives every year.

The new guidance brings together evidence from world-leading experts including NHS clinicians, and have been supported and endorsed by several major associations, societies and research institutions.

The recommendations include:

RESUSCITATION TODAY - SUMMER 2017

28

• Greater awareness amongst the general public of recognising a cardiac arrest and knowing how to perform CPR • All pupils at secondary schools should learn CPR techniques • Collaboration between ambulance and fire services, police and first responders to ensure that a CPR lifesaver can be at the scene with a defibrillator as soon as possible • All resuscitated patients to be taken straight to specialist cardiac arrest centres • All recovering patients should be assessed for rehabilitation to improve chances of maintaining quality of life

The BHF supplies free Call Push Rescue “This new guidance sets out the best care

training kits to secondary schools and

for a patient, from the moment they’re found

community groups across the UK to help

collapsed, to their recovery in hospital and

people learn life saving CPR. You can find out

subsequent rehabilitation.

more by visiting bhf.org.uk/cpr

COMPANY NEWS The Brayden Pro App calculates an Overall CPR

To conclude, the Brayden Pro manikin and

BRAYDEN PRO – lessons learnt to help develop the ideal CPR training manikin.

Quality score which is clearly presented after

the Brayden Pro App address a number of

each practice or assessment. Individual CPR

the issues highlighted during the SJTREM

metrics are also presented against a theoretical

study. IE, working closely with leading UK and

ideal in an easy to understand but innovative

European Resuscitation experts, together with

format. This data can be investigated

support from those who routinely use manikins

Dr Jonathan R Smart

interactively quickly and easily. This was

to undertake BLS training and assessment,

another feature that SJTREM study participants

appear to have produced a relatively simple

In 2015 a paper published in the Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (SJTREM) described a study carried out in 10 different professional healthcare institutions in 9 different European Countries1. The SJTREM study investigated

requested. All CPR metric results are stored by the tablet and can be accessed quickly and easily for further review. The Brayden Pro App allows the results of all CPR sessions to be easily shared, printed or exported into an excel spreadsheet and used for further assessment.

the effectiveness of real time objective feedback and competition to improve performance and quality in manikin CPR training. The study concluded that real time objective feedback can significantly improve CPR performance. This conclusion is in line with other reported studies2.

This facility would have made the SJTREM

The recently launched Brayden Pro manikin utilises personal lessons learnt from the SJTREM study since the manikins employed in that study had some practical limitations (not reported in the SJTREM paper). IE have sought the advice of leading Resuscitation experts in the UK and Europe to help IE correct these limitations with the Brayden Pro manikin.

These discussions have also resulted in the manikin having useful additional capabilities to help improve the quality of CPR training.

shape. The Brayden Pro (and Brayden) has a

study analysis far easier to carry out!

Feedback from the SJTREM study suggested that ventilation with a Bag Valve Mask (BVM) on the SJTREM study manikins was relatively easy compared with real life. This was because they had a wide and flat face relatively ‘thin’ face which, IE believe, makes the Brayden Pro more realistic to real life patients when ventilating with a BVM. Also, the compliance of the Brayden Pro lung has been designed to make it feel as realistic as possible. Again, UK and European Resuscitation experts have given excellent feedback to help IE achieve this goal.

The Brayden Pro App records ventilation rate and also inspiratory time. This feature (not available on the SJTREM study manikins) allows students to practice delivering 2015 ERC Guideline compliant ventilations over approximately 1 second3. The Brayden Pro also measures the delivered ventilation volume whilst providing real-time feedback. The Guidelines state that ventilations should be in the range of 6-7 ml/kg but anecdotal evidence suggests that ventilations using currently available manikins frequently exceed these volumes4,5. The Brayden Pro should help address this ventilation need.

of the boxes for the ‘ideal CPR manikin’.

Conflict of Interest Statement Dr Jonathan Smart is currently a Director of Innosonian Europe (IE) and also continues to work as a volunteer CFR with South East Coast Ambulance NHS Trust.

References 1. Smart JR, Kranz K, Carmona F, Lindner TW, Newton A. Does real-time feedback and competition improve performance and quality in manikin CPR training – a prospective observational study from several European EMS. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. 2015 23:79 2. Yeung J, Meeks R, Edelsen D, Gao F, Soar J. Perkind GD et al. The use of CPR feedback/prompt devices during training and CPR performance: A systematic review.

Resuscitation. 2009 80:743-51 3. Monsieurs KG, Nolan J, Bossaert LL, Greif R, Maconochie IK et al. European Resuscitation Council Guidelines for Resuscitation 2015. Section 1. Executive Summary. 2015 95:1-80 4. Perkins GD, Handley AJ, Koster RW, Castren M, Smyth MA et al. European Resuscitation Council Guidelines for Resuscitation 2015.

Section 2. Adult basic life support and automated external defibrillation. 2015 95:81-99 5. Baskett P, Nolan J, Parr M. Tidal volumes which are perceived to be adequate for resuscitation. Resuscitation 1996 31:231-234

RESUSCITATION TODAY - SUMMER 2017

The new Brayden Pro shares the same anatomical landmarks, chest compliance and ventilation ‘feel’ as the currently available Brayden manikin. This similarity between these means that students can practice on the relatively inexpensive Brayden (with lights) and then transition to the anatomically identical Brayden Pro when a numerical score and detailed debrief are required. Therefore any performance differences due to different manikins being used for self-training and numeric assessment can be discounted.

and cost effective manikin which ticks most

29

COMPANY NEWS entrepreneurial, engineering and technological

rigorously tested in extremely harsh and

UK MOD awards £14 million medical monitor contract to RDT

talent available in Basingstoke. This talent pool

challenging locations. Traditionally, several

supports a thriving hub of high growth, high

various monitor types have had to be used

tech businesses in the town. The contract will

at different levels of care in the patient

sustain over 60 jobs at RDT’s local facility and

pathway. Thanks to the modular and flexible

has helped in the creation of 20 new roles.

nature of RDT’s Tempus Pro system, the

The Ministry of Defence has awarded a £14 million tri-service contract for medical monitors to Hampshire-based company RDT, a world-leader and fastgrowing specialist in pre-hospital care solutions.

I congratulate Graham and his team on this

UK MOD is now able to standardise on one

tremendous achievement.”

monitor to provide streamlined medical

The new agreement will see the delivery of

support and critical patient care information The MOD selected RDT’s Tempus Pro

from the battlefield onwards. This means

monitoring system after an extensive

the Record of Care of all sick and injured

evaluation programme that highlighted how

patients can easily move with them as they

this very small and robust monitoring platform

progress through different levels of care,

delivers significantly more capability for British

and ultimately be saved into their permanent

troops than existing solutions. Over the next

patient record. A single monitoring solution

five years, the MOD will replace all existing

has been an objective of the UK military for

monitors with the Tempus Pro system. RDT

some time. It is only possible because of the

incidents in the remote and challenging

has already delivered 444 monitors to the

forward-thinking and innovative way in which

locations in which they regularly operate.

Armed Forces.

RDT has approached the development of its

around 900 compact, easy-to-use and reliable vital signs Tempus Pro monitors, which will enable the UK military to manage medical

medical monitoring technology.

Tempus Pro uniquely consolidates several functions onto one system, ensuring that Armed

Minister for Defence Procurement Harriett

Forces medical personnel can provide the

Baldwin said: “Our Armed Forces serve with

Chief Executive Officer of the DE&S, Tony

best quality of care possible to critically injured

incredible commitment and bravery, and

Douglas, said: “This state-of-the-art piece

service men and women in very challenging

the new Tempus Pro monitor will ensure that

of equipment shows how we are delivering

environments. Tempus Pro monitors will be

they will receive the best possible care and

proven, world-leading equipment to our

deployed on medical evacuation vehicles and

treatment should they be wounded or taken ill

Armed Forces. The Tempus Pro monitor

aircraft, battalion aid stations, hospital ships,

on operations. Backed by our rising defence

is a step forward in innovation and safety,

field hospitals and in far forward locations by

budget and our £178 billion equipment plan,

demonstrating how we are committed to

special operations teams.

our investment in these cutting-edge medical

improving the medical care received by

monitors demonstrates how we are working

those keeping our country safe. This deal

This award is the latest in a long line of

with our NATO allies to provide lifesaving

also highlights DE&S’ strong, collaborative

successes for RDT, which has achieved

equipment to our frontline personnel.”

partnership with industry, benefitting both our Armed Forces and the wider UK economy by

60% growth in the last 12 months. RDT is a

sustaining around 60 UK jobs.”

significant exporter, generating more than 60%

Before awarding the contract, the Defence

of its revenue from international sales. Maria

Equipment and Support organisation

Miller, MP for Basingstoke, said: “RDT is a

(DE&S) conducted an intensive year-

Graham Murphy, RDT CEO, added: “We are

ground-breaking company and its success in

long, multi-discipline monitor evaluation

incredibly proud to be providing the Tempus Pro

securing this contract demonstrates the strong

process that saw the system deployed and

to our Armed Forces, who do such important work to keep us all safe. One of the reasons the Tempus Pro is being adopted by the UK and many other NATO militaries is because of its unique ability to be enhanced in the field as new technologies emerge or needs evolve.

RESUSCITATION TODAY - SUMMER 2017

The world is an ever-changing place and this flexibility is important to all our customers.

To that end, RDT has an exciting set of new features in development to which the MOD will have full access as they become available.”

For more information, please contact: RDT Pavilion C2, Ashwood Park, Ashwood Way, Basingstoke, Hampshire, England RG23 8BG +44 (0)1256 362 400

30

COMPANY NEWS

Introducing a NEW device Cardio Pulmonary Resuscitation with no “no-flow” B-CARD (Boussignac Cardiac Arrest Resuscitation Device) is intended for cardio-pulmonary resuscitation. It can be used with a face mask, a supra-glottic system, or via an endo-tracheal tube.

Operating mode B-CARD is a non-invasive open system allowing continuous passive oxygenation and continuous chest compressions during CPR. The aim of the device is based on the use of a virtual valve generated by the acceleration of a flow of oxygen via micro channels. The presence of this virtual valve maintains a positive intra-thoracic pressure during compression of the thorax, and a negative intra-thoracic pressure during decompression.

It works with the same efficiency, whether thoracic compressions are manual or mechanical.

Clinical interest 1

The continuous insufflation associated with the utilisation of a virtual valve eliminates periods of “no-flow” because thoracic compressions are continuous. It is a device allowing CPR with no “no flow”.

2

The intra-thoracic pressure generated preserves Functional Residual Capacity and improves gaseous exchange.

No pulmonary damage: Pillow effect.

3

The variations of intra-thoracic pressures improve venous return and hemodynamics. Better organ perfusion.

4

Classic CPR with BVM ventilation (30/2) induces 5,000ml of intra-gastric gas every six minutes.

Continuous insufflation with B-CARD and face mask, induces 200ml of intra-gastric gas during the same time.

Avoids the side effects of BVM.

Conclusion B-card is the device suited to meet the requirement of the international guidelines on CPR by allowing continuous chest compressions and avoiding “no-flow” periods in cardiac circulation.

Gaseous flow at thoracic compression Gaseous flow at thoracic decompression

External air O2 : 15 L /min

RESUSCITATION TODAY - SUMMER 2017

Virtual valve

For more information about B-CARD and how it can help your team, contact:

Tel: 01793 748830 or Email: marketing@vygon.co.uk quoting AD240.

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when every breath counts EVE Transport Ventilator

Intensive Care ventilation performance for emergency hospital use ‘Safe-start’ ventilation without compromise in ‘80 seconds’ for Neonate > Child > Adult Invasive & Non-Invasive ventilation modes: CPAP, nCPAP, DUOPAP, nDUOPAP, PRVC, VC-CMV VC-SIMV, PSV, PC-CMV, PC-SIMV, PC-ACV, PC-ACV+, PC-APRV, nPC-ACV, nPC-ACV+, nPC-CMV, nPC-SIMV

All Patient use

Capnography & Sp02

Battery Optimisation

Fully Adjustable Oxygen

Adult, Paediatric, Neonate 0.5kg > >200+ kg {Vt 2 > 2000ml}

Waveform EtC02 Options: Sp02 ,SpCO, SpHB

6 hours continuous use + ‘hot swap’ battery pack

Adjustable 02 mixing 21 to 100%

Robust & Lightweight

8.4 inch Touch Screen

Independent Air Supply

Patient Data Transfer

Rugged design, compact & portable ~5 kg

Configurable display, loops alarms, curves & trends

Integrated air turbine

Transfer capability for patient data, events

Ventilation Innovation since 1974

MEDACX LIMITED • ALEXANDER HOUSE • 60-62 STATION ROAD • HAYLING ISLAND • HAMPSHIRE • PO11 0EL

02392 469737 info@medacx.co.uk www.medacx.co.uk