Aaron M. Orkin

Part 3: Adult Basic Life Support and Automated External Defibrillation: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations

This review comprises the most extensive literature search and evidence evaluation to date on the most important international BLS interventions, diagnostics, and prognostic factors for cardiac arrest victims. It reemphasizes that the critical lifesaving steps of BLS are (1) prevention, (2) immediate recognition and activation of the emergency response system, (3) early high-quality CPR, and (4) rapid defibrillation for shockable rhythms. Highlights in prevention indicate the rational and judicious deployment of search-and-rescue operations in drowning victims and the importance of education on opioid-associated emergencies. Other 2015 highlights in recognition and activation include the critical role of dispatcher recognition and dispatch-assisted chest compressions, which has been demonstrated in multiple international jurisdictions with consistent improvements in cardiac arrest survival. Similar to the 2010 ILCOR BLS treatment recommendations, the importance of high quality was reemphasized across all measures of CPR quality: rate, depth, recoil, and minimal chest compression pauses, with a universal understanding that we all should be providing chest compressions to all victims of cardiac arrest. This review continued to focus on the interface of BLS sequencing and ensuring high-quality CPR with other important BLS interventions, such as ventilation and defibrillation. In addition, this consensus statement highlights the importance of EMS systems, which employ bundles of care focusing on providing high-quality chest compressions while extricating the patient from the scene to the next level of care. Highlights in defibrillation indicate the global importance of increasing the number of sites with public-access defibrillation programs. Whereas the 2010 ILCOR Consensus on Science provided important direction for the “what” in resuscitation (ie, what to do), the 2015 consensus has begun with the GRADE methodology to provide direction for the quality of resuscitation. We hope that resuscitation councils and other stakeholders will be able to translate this body of knowledge of international consensus statements to build their own effective resuscitation guidelines.

Part 10: Special Circumstances of Resuscitation: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.

This Part of the 2015 American Heart Association (AHA) Guidelines Update for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC) addresses cardiac arrest in situations that require special treatments or procedures other than those provided during basic life support (BLS) and advanced cardiovascular life support (ACLS). This Part summarizes recommendations for the management of resuscitation in several critical situations, including cardiac arrest associated with pregnancy (Part 10.1), pulmonary embolism (PE) (10.2), and opioid-associated resuscitative emergencies, with or without cardiac arrest (10.3). Part 10.4 provides recommendations on intravenous lipid emulsion (ILE) therapy, an emerging therapy for cardiac arrest due to drug intoxication. Finally, updated guidance for the management of cardiac arrest during percutaneous coronary intervention (PCI) is presented in Part 10.5. A table of all recommendations made in this 2015 Guidelines Update as well as those made in the 2010 Guidelines is contained in the Appendix. The special situations of resuscitation section (Part 12) of the 2010 AHA Guidelines for CPR and ECC 1 covered 15 distinct topic areas. The following topics were last updated in 2010: Additional information about drowning is presented in Part 5 of this publication, “Adult Basic Life Support and Cardiopulmonary Resuscitation Quality.” The recommendations in this 2015 Guidelines Update are based on an extensive evidence review process that was begun by the International Liaison Committee on Resuscitation (ILCOR) with the publication of the ILCOR 2010 International Consensus on CPR and ECC Science With Treatment …

Part 3: Adult Basic Life Support and Automated External Defibrillation

This Part of the 2015 International Consensus on Cardiopul monary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC) Science With Treatment Recommendations (CoSTR) presents the consensus on science and treatment recommendations for adult basic life support (BLS) and automated external defibrillation (AED). After the publication of the 2010 CoSTR, the Adult BLS Task Force developed review questions in PICO (population, intervention, comparator, outcome) format.1 This resulted in the generation of 36 PICO questions for systematic reviews. The task force discussed the topics and then voted to prioritize the most important questions to be tackled in 2015. From the pool of 36 questions, 14 were rated low priority and were deferred from this round of evidence evaluation. Two new questions were submitted by task force members, and 1 was submitted via the public portal. Two of these (BLS 856 and BLS 891) were taken forward for evidence review. The third question (368: Foreign-Body Airway Obstruction) was deferred after a preliminary review of the evidence failed to identify compelling evidence that would alter the treatment recommendations made when the topic was last reviewed in 2005.2 Each task force performed a systematic review using detailed inclusion and exclusion criteria, based on the recommendations of the Institute of Medicine of the National Academies.3 With the assistance of information specialists, a detailed search for relevant articles was performed in each of 3 online databases (PubMed, Embase, and the Cochrane Library). Reviewers were unable to identify any relevant evidence for 3 questions (BLS 811, BLS 373, and BLS 348), and the evidence review was not completed in time for a further question (BLS 370). A revised PICO question was developed for the opioid question (BLS 891). The task force reviewed 23 PICO questions for the …

Development and Implementation of an Opioid Overdose Prevention and Response Program in Toronto, Ontario

ObjectivesWe describe the development of the first community-based opioid overdose prevention and response program with naloxone distribution offered by a public health unit in Canada (Prevent Overdose in Toronto, POINT).ParticipantsThe target population is people who use opioids by any route, throughout the City of Toronto.SettingThe POINT program is operated by the needle exchange program at Toronto Public Health (The Works) and offered at over 40 partner agency sites throughout Toronto.InterventionPOINT is a comprehensive program of overdose prevention and response training, including naloxone dispensing. Clients are instructed by public health staff on overdose risk factors, recognizing signs and symptoms of overdose, calling 911, naloxone administration, stimulation and chest compressions, and post-overdose care. Training is offered to clients one-on-one or in small groups. Clients receive a naloxone kit including two 1 mL ampoules of naloxone hydrochloride (0.4 mg/mL) and are advised to return to The Works for a refill and debriefing if the naloxone kit is used.OutcomesIn the first 8 months of the program, 209 clients were trained. Clients have reported 17 administrations of naloxone, and all overdose victims have reportedly survived. Client demand for POINT training has been high, and Toronto Public Health has expanded its capacity to provide training. Overall, reception to the program has been overwhelmingly positive.ConclusionWe are encouraged by the initial development and implementation experience with the naloxone program and its potential to save lives in Toronto. We have planned short-, intermediate-, and long-term process and outcome evaluations.RésuméObjectifsNous décrivons l’élaboration du premier programme communautaire de prévention et de lutte contre les surdoses d’opioïdes par la distribution de naloxone offert dans un bureau de santé publique au Canada (Prevent Overdose in Toronto, POINT).ParticipantsLa population cible est constituée des personnes consommant des opioïdes, par n’importe quelle voie, dans la ville de Toronto.LieuPrevent Overdose in Toronto est exécuté par le programme d’échange de seringues du Service de santé publique de Toronto (The Works) et offert sur plus de 40 sites d’organismes partenaires à Toronto.InterventionPOINT est un programme complet de formation à la prévention et à la lutte contre les surdoses incluant la distribution de naloxone. Le personnel de santé publique explique aux clients les facteurs de risque de surdose, les signes et les symptômes de surdose, quand composer le 911, le mode d’administration de la naloxone, la stimulation cardiaque et les compressions thoraciques, ainsi que les soins après une surdose. La formation est offerte aux clients individuellement ou en petits groupes. Les clients reçoivent une trousse de naloxone avec deux ampoules de chlorhydrate de naloxone de 1 mL (0,4 mg/mL); s’ils ont utilisé la naloxone, on leur demande de retourner à The Works pour renouveler leur trousse et faire un bilan.RésultatsAu cours des huit premiers mois du programme, 209 clients ont été formés. Les clients ont fait état de 17 administrations de naloxone; toutes les victimes de surdoses auraient survécu. La demande des clients pour la formation POINT étant élevée, le Service de santé publique de Toronto a renforcé ses capacités d’offrir cette formation. Globalement, l’accueil réservé au programme est extrêmement positif.ConclusionNous sommes encouragés par l’expérience d’élaboration et de mise en oeuvre initiale du programme de naloxone et par les vies qu’il pourrait sauver à Toronto. Nous planifions des évaluations à court, moyen et long terme du processus et des résultats.

Tamper-resistant drugs cannot solve the opioid crisis

Tamper-resistant formulations, designed to make drugs harder to crush, snort or inject, are being promoted in Canada and the United States as a strategy to prevent opioid-related harms such as overdose and addiction. In a research article published in CMAJ Open , Gomes and colleagues[1][1] examined

Push hard, push fast, if you’re downtown: a citation review of urban-centrism in American and European basic life support guidelines

Bystander cardiopulmonary resuscitation (CPR) improves out-of-hospital cardiac arrest (OHCA) survival. In settings with prolonged ambulance response times, skilled bystanders may be even more crucial. In 2010, American Heart Association (AHA) and European Resuscitation Council (ERC) introduced compression-only CPR as an alternative to conventional bystander CPR under some circumstances. The purpose of this citation review and document analysis is to determine whether the evidentiary basis for 2010 AHA and ERC guidelines attends to settings with prolonged ambulance response times or no formal ambulance dispatch services. Primary and secondary citations referring to epidemiological research comparing adult OHCA survival based on the type of bystander CPR were included in the analysis. Details extracted from the citations included a study description and primary outcome measure, the geographic location in which the study occurred, EMS response times, the role of dispatchers, and main findings and summary statistics regarding rates of survival among patients receiving no CPR, conventional CPR or compression-only CPR. The inclusion criteria were met by 10 studies. 9 studies took place exclusively in urban settings. Ambulance dispatchers played an integral role in 7 studies. The cited studies suggest either no survival benefit or harm arising from compression-only CPR in settings with extended ambulance response times. The evidentiary basis for 2010 AHA and ERC bystander CPR guidelines does not attend to settings without rapid ambulance response times or dispatch services. Standardized bystander CPR guidelines may require adaptation or reconsideration in these settings.

Opioid Overdose Fatality Prevention

1. Levin GP, Robinson-Cohen C, de Boer IH, et al. Genetic variants and associations of 25-hydroxyvitamin D concentrations with major clinical outcomes. JAMA. 2012;308(18):1898-1905. 2. Martineau AR, Timms PM, Bothamley GH, et al. High-dose vitamin D(3) during intensive-phase antimicrobial treatment of pulmonary tuberculosis: a doubleblind randomised controlled trial. Lancet. 2011;377(9761):242-250. 3. Sonderman JS, Munro HM, Blot WJ, Signorello LB. Reproducibility of serum 25-hydroxyvitamin d and vitamin D-binding protein levels over time in a prospective cohort study of black and white adults. Am J Epidemiol. 2012;176(7): 615-621. 4. Martineau AR, Leandro AC, Anderson ST, et al. Association between Gc genotype and susceptibility to TB is dependent on vitamin D status. Eur Respir J. 2010; 35(5):1106-1112. 5. Lips P. Worldwide status of vitamin D nutrition. J Steroid Biochem Mol Biol. 2010;121(1-2):297-300.

Where There Is No Paramedic: The Sachigo Lake Wilderness Emergency Response Education Initiative

Aaron Orkin and colleague describe their collaboration that developed, delivered, and studied a community-based first response training program in a remote indigenous community in northern Canada.

Teaching wilderness first aid in a remote First Nations community: the story of the Sachigo Lake Wilderness Emergency Response Education Initiative

Objective. To understand how community members of a remote First Nations community respond to an emergency first aid education programme. Study design. A qualitative study involving focus groups and participant observation as part of a community-based participatory research project, which involved the development and implementation of a wilderness first aid course in collaboration with the community. Methods. Twenty community members participated in the course and agreed to be part of the research focus groups. Three community research partners validated and reviewed the data collected from this process. These data were coded and analysed using open coding. Results. Community members responded to the course in ways related to their past experiences with injury and first aid, both as individuals and as members of the community. Feelings of confidence and self-efficacy related access to care and treatment of injury surfaced during the course. Findings also highlighted how the context of the remote First Nations community influenced the delivery and development of course materials. Conclusions. Developing and delivering a first aid course in a remote community requires sensitivity towards the response of participants to the course, as well as the context in which it is being delivered. Employing collaborative approaches to teaching first aid can aim to address these unique needs. Though delivery of a first response training programme in a small remote community will probably not impact the morbidity and mortality associated with injury, it has the potential to impact community self-efficacy and confidence when responding to an emergency situation.

An Agenda for Naloxone Distribution Research and Practice: Meeting Report of the Surviving Opioid Overdose with Naloxone (SOON) International Working Group

Opioid-related mortality is a serious and growing issue in North America. Naloxone distribution and basic life support training for people at risk of overdose is a promising opportunity to improve access to potentially lifesaving bystander interventions and essential healthcare. We convened a unique international working group of experts in public health, resuscitation science, and health research methodology, along with clinical, community, policy, industry stakeholders and members of the lay public to explore and address key challenges and opportunities for rigorous research on this intervention. The findings from the Surviving Opioid Overdose with Naloxone (SOON) International Working Group explored potential research opportunities and identified barriers in four priority areas: research methods, resuscitation guidelines, naloxone delivery device development, and knowledge translation. This novel collaborative effort: • Identified key steps and challenges for developing an appropriate, feasible and rigorous pragmatic trial of naloxone distribution in various clinical settings; • Identified emerging naloxone delivery devices and technologies, and described how these devices may alter standards of care for overdose prevention research and practice • Engaged resuscitation experts in the development of bystander resuscitation protocols for opioid-associated resuscitative emergencies; and, • Identified strategies to overcome knowledge translation barriers for patients and providers, as well as characteristics for effective educational tools and program implementation. The SOON collaboration aims to advance the investigation, implementation, and practice of overdose education and naloxone distribution. Through diverse collaborations, we can use best science to improve practice for individuals at risk of opioid overdose.