Transcript Video ERC Guideline Update 2022 - Practical ImplementationProf. Bernd Bottiger < Back to Boundaries of Temperature Session 7: Benefits ERC Guideline Update 2022 - Practical Implementation Presented by Professor Bernd Bottiger we come to the next lecture from professor bent particular, you know him already. However, some short remarks about his bio his today head of the department of anesthesiology and intensive care medicine at hospital of cologne Germany. He originally started medicine at the university in Heidelberg conducted a lot of medical research in the US came back and since many years years he is not only chair of the german resuscitation council but from the european resuscitation council. And he's a member of the advanced life support task for for sure exactly the right person person to talk about the er see guideline update 2022 practical implementation please. Professor vertigo. So thank you very much Manuela for this nice introduction and thank you very much for still being here. I was wondering whether there are any studies that you have not seen over the last two days that I can present you today and we will see what I can add to the knowledge that has already been generated during this wonderful conference. And I would first like to ask you do you know this guy who has not seen when he collapsed on the football field? I mean we all have seen it. He was immediately resuscitated. I don't know whether he was cooled or t t m treated or hypothermia treated but maybe he didn't need it because he was resuscitated immediately from the beginning and it's probably that is probably a very important message. And here are the disclaimers and here are oops my potential conflicts of interest mostly generated by the organizations we're working for And the chapters of the 2021 E. R. C. Guidelines are here can you please raise your hand whether you have at least read a summary of the E. R. C. Guidelines to make it a little bit more interactive. So many have seen the E. R. C. Guidelines. And for me the most important the most important chapter is System Saving Lives and why is that? I will bring you the most important messages from the chapter. System Saving Lives into this hall this afternoon and I will go through these five most important things very slowly together with you. And the first thing is raise awareness about cpr and defibrillation. And this is the new chain of survival generated by Charles deacon for out of hospital cartographic patients. And all these change. All these chains chains are different as you can see here and the size of these chains are based on real data. It was calculated by Charles dickens. So we are dealing over the last 1.5 days with post resuscitation care. So this is not the smallest but one of the smallest chains in the whole chain of survival. That is probably also the reason why why it is so hard to find positive effects. And maybe it's also the reason why it's so hard to find um therapies that work. And it's much more important than what we are doing here is what we are doing here Call for help And early Cpr is much, much more important as anything else. As we have seen with christian eriksen and others. And by the way, what we have seen with christian eriksen is happening 1000 times a day in europe every day, 1000 times in most of the cases at home. And therefore less than 10% survive out of hospital cardiac arrest. As we know, this is one of the reasons why we came up with a european restart a heart campaign already more than 10 years ago with 400 signatures from members of the european parliament supporting this. And in 2017 we suggested to the International Committee on Resuscitation to come up with a worldwide campaign. And fortunately they followed us because this is most important that everyone in the world knows how to do CpR. All that is needed is two hands. And that is the message. We have three times more survivors, not with T. T. M, but with early CpR and this message must be brought to the world. We did a lot of activities over the last years to bring this message to the world and I'm personally very proud that in the year before Covid we have reached more than 200 million people, most of them by the way in India and we have trained more than 5.4 million in cardiopulmonary laypeople in cardiopulmonary resuscitation Worldwide. So this is really a way how we can increase survival following out of hospital category rest. And fortunately the International Federation of the Red Cross helped us. We had a good contact with them and they have sent it out to kids in 192 countries in the world. And I needed to look it up at Wikipedia. How many countries the world has? Does anyone has an idea how many countries we have in our world? Yeah, It's 900 and um it's 194. So only two countries were missing or are still missing in our initiative. And you can see here the red cross, the anesthesiologist, the intensive ists, all seven ILCO countries. They are all participating in world restarted heart and this I'm sure has an impact on survival following out of hospital cardiac arrest which is by the way at least in the so called developed countries. The third leading cause of death In some it is around the same amount of deaths as with all cans with all different cancer entities. So we are doing world restart a heart always on October 16 and please join us if you have not already done so far. This is really something that helps the world. Next part of system saving lives is used technology to engage communities. This is first responder systems. First responders reach the victim in 50% earlier than the regular E. M. S. System. You all know these first responders alerted by the smartphones of volunteers. These systems can also be performed during the covid crisis. This is from Freiburg in Germany implementation. Who has the first responder system in his or her area. It can be improved, isn't it? Because this is really what matters with regard to survival next Kids save lives. Who has ever trained schoolchildren in cardiopulmonary resuscitation. Some very few. So if you are once in a while you are frustrated about anything. My recommendation is go to the next school and train school Children because this is a lot of fun. There is a lot of positive feedback and they are extremely enthusiastic and they know then how to do cpR it's for them like bicycling or swimming. They will never forget and they will bring this information to the families and we will gain more survivors. This is one of our activities here in Berlin some years ago. Together with our health minister. This is the logo and this is the covid logo of Kids Save Lives. We are supported by the World Health Organization since 2015. They are recommending educating schoolchildren in cardiopulmonary resuscitation and this is the european map of CpR education in schools. We are have a chief that it is the legislation now in six european countries, congratulations to the colleagues that help with that. And at least the suggestion including Germany, it's only a suggestion and not so many schools are doing this. Our suggestion for kids is starting the kindergarten. They can do check and call very easily. They can also add compressions at the age of 10 to 12 years then they have enough physical power to do so. And to educate them in ventilation and A. D. Is probably possible at the age of 14 or 16 years. Nevertheless, as we have seen here, implementation is not really very covering all over the world categories centers who has in his area categories center, only very few. Again, another area where we can approve this is the german resuscitation council logo of Cartago rest centers. We have roughly two times more survivors if a patient is not going to the after following out of hospital, cardiac arrest, if a patient is not going to the next hospital but to the next specialized hospital with hypothermia, T. T. M. With Pc. I facilities um working 24 hours and seven days a week, two times more survivors roughly In Germany. The german resuscitation council has established together with the German Society of Cardiology. Such a system since 2017 we have close to 100 certified centers right now. More than 108 audits. We also have contacts to Austria Vienna and Switzerland. Bern in Switzerland implementation is not bad, at least in german speaking countries, but in europe we are just starting together with the european Society of Cardiology. So this is another pillar of the four most important issues in system saving lives and last not least telephone cpr telephone cpr means if late person is calling the dispatcher, he or she will be will get explanations how to do compressions. You can do this as a dispatcher in less than one minute. The number needed to treat is seven. So seven is the number needed to treat. So if the E. M. S. Needs 10 minutes for arrival, a dispatcher can save a life in seven times 10 minutes and 70 minutes, this is much better than all of us can do. So can you please raise your hand when you have telephone CpR in your area? Some have many don't have there is room to improve. I would say implementation as we have seen here is mixed. It should be the law in my eyes all over the world to get the right to get received. Telephone CPR by the way, this man 43 years old was dead. This guy 10 or 11 years old called the dispatcher and the dispatch explained him how to do cpR. She opened the door for the E. M. S. This was some weeks ago in Northern Germany in Lubeck and they saved the life of their father and they were allowed to go to the next station and received some presents thereafter. So telephone CpR and school Children education CpR is very important. What are these animals are doing in a lecture on a conference of T. T. M. So what are these animals called? These are the big five and what you have seen right now have been the Big five in improving outcome. Following out of hospital cardiac arrest. We have published that. And these are the Big Five you can see here lay Cpr telephone cpr first responder systems experienced A. L. S. Teams and cardiac arrest centers. And here temperature management has a role and this is the estimated impact on survival. And you can see all these different um Big Five are associated with the 2 to 3 fold increase in survival. So Systems Systems really saving lives and that's in my eyes. The most important chapter in the new er see guidelines. All the other things have not changed so very much. And I brought one or two other studies with me coronary angiography and P. C. I. N. Category patients without return of spontaneous circulation. Can you again raise your hands? Who is doing this? In selected cases it is probably worth the effort and then cool them after. You have done this. Close to 700 out of hospital categories patients, 23% did not have Rusk at admissions of ongoing cpr during hospital admission longer resuscitation times. For sure. In those not having Rusk patients without return of spontaneous circulation had higher rates of acute coronary occlusion and Pc. I was performed in 50% with patients without Rusk and 55% of patients with Rusk. The success rate was nearly 90% in patients with Rusk and 90% in patients without risk and 90%. In patients with Rusk. 30 day survival was 24 70% respectively. So it is worth the effort to do P. Ci in patients that are you receiving in your hospital with ongoing cardiopulmonary resuscitation. The conclusion, very recent study out of hospital patients with Roscoe and admission to hospital had higher acute coronary occlusion rates than patients with pre hospital return of spontaneous circulation. P. C. I. Is feasible with a high success rate in patients with Rusk despite prolonged resuscitation times meaningful survival in patients admitted without risk is achievable. And after this they should undergo temperature management or hypothermia or something like this. These are the 30 day survival curves according to the P. C. I. Status, successful PC. I. And blue, No P. C. I. And green and failed PC. I. In red. And this is the same graph for patients without pre hospital return of spontaneous circulation. So these are the patients that were received in the PC. I. Lab during ongoing cardiopulmonary resuscitation. So very impressive positive effects of successful pc. I don't forget that at least 50 maybe 60 or 70% of patients who are have a collapse in the out of hospital setting. In these the collapses due to acute coronary problems are acute coronary problems. Post resuscitation care we have heard a lot about that. This is the message of the guidelines not too less and not too much oxygen. P. C. I. Please think about you need a protocol whether you put them into the Pc. I. Lab or not temperature management. The guidelines have been published before the T. T. M. To trial was published. So we recommended during these days 32 through 36 degrees Celsius for at least at least 24 hours And avoid fever for 72 hours prognostication. We already discussed that in death not earlier than 72 and maybe not earlier than 96 hours. And rehabilitation is also very important to get a better neurological and overall survival. And we have nice pictures in the guidelines prognostication again not less than 72 hours. And then please use at least two of these um different um science and signals and investigations and then the T. T. M. To trial has been published. And then the E. R. C. Together with the I. C. E. S. I. C. M. Decided to adapt the guidelines. You have seen this already so I can be very fast on that. You have seen this and you have probably also seen this and as you can see here there is not so much of an evidence. It's a good practice statement. It's a low level of evidence. Good practice, good practice moderate. We do not recommend pre hospital cooling. We have already heard that. And the most important sentence in these guidelines and I can tell you I have fight ID for this sentence very much because many of the colleagues who have been involved were not convinced anymore that temperature management has any Any role in post resuscitation care in this group. But the most important sentence here is there is currently insufficient evidence to recommend for again against temperature control at 32 through 36° in populations of category rest patients or using early cooling. And future research may help to elucidate this. So the door is open to cool patients subgroup patients to 32 through 36 degrees Celsius. Because most of my patients are different to the T TM one and tM to trial. They have more than one minute of ischemia. They have less than 80% of Les Cpr think about christian eriksen and if we call patients it will not last until 78 or nine hours until we reach target temperature in our clinical practice and animal experiments, experimental studies to support this view. You have also seen this already we have analyzed um and our statistician said he never, ever has seen such a high level of correlation. If you have hi bystander CpR rate, this is the bystander cpr rate like in T T M one and two. More than 70 or 80%. The effect of temperature management or hypothermia is is not there. But if you have lower bystander cpR rates. The effect is tremendous And please raise your hand if in your city or country, the Bystander CPR rate is above 75 or 80%. I don't see any hand here. Maybe one. I'm not sure. So please think about this guy again. You also have seen that severity is important. I can be very fast here because already um really bearing I showed this slide there is only an effect of temperature management. If you have moderate encephalopathy a if you don't have any or mild like christian eriksen you do not need temperature management. And if it is very severe there is no effect of temperature management. We take 32 through 34 degrees Celsius for at least 24 hours and we do it as soon as possible in my department in adults and Children regardless whether it is out of hospital or whether it is in hospital category rest you know this person here and you have seen this meta analysis. Thanks for that slide. Billy. I thought it's very important to repeat it because this is the most important message. So cooling is also the signal of cooling is also supported as having a favorable effect on your neurological outcome by different meta analysis if you're doing them correctly and including all studies that are that should be included here favorites cooling. So with this I would like to summarize um Everyone and can and must save lives. We can start with Children. Please join us at the world. We started hard on October 16 you can have more information on our website. If you don't have established telephone CPR, please do so. Same applies to first responder systems and post resuscitation care in cardiac arrest centers. We need the support of politicians. Please think about the Big five on resuscitation temperature management is a very small, very small part of the Big five. By establishing the Big Five, we would be able to save additional 100,000 lives in europe and maybe several 100,000 lives in the world. Think about the new chain of survival. This is post resuscitation care. Yeah. And this is a message coming from south America where we have trained Children in favelas and they are extremely enthusiastic and brought the information how to do CpR to their families once again very loud, please. It only takes two hands to save a life. Thank you very much. Created by
