第一場 09：10－09：50 《 2015年您該知道的十大救護新知 》

Presentation on theme: "第一場 09：10－09：50 《 2015年您該知道的十大救護新知 》"— Presentation transcript:

1 第一場 09：10－09：50 《 2015年您該知道的十大救護新知 》
社團法人中華緊急救護技術員協會 2015年TEMTA年會 暨 EMS研討會 第一場 09：10－09：50 《 2015年您該知道的十大救護新知 》 TEMTA 理事 江文莒醫師 台大醫學院助理教授 台大醫院急診部主治醫師 13:24-1 3:42 - Wen-Chu Chiang (Taiwan): Factors influencing the bystander CPR rate and optimizing dispatch-directed bystander CPR in Taipei EMS Hollow everyone My name is Dr. Chiang Wen-Chu from Taiwan. I will talk about bystander CPR in Taipei My Topic today is factors influencing the bystander CPR rate and optimizing dispatch-directed bystander CPR in Tapiei EMS 2018/11/27

2 十大救護新知選取原則 考慮…2013~2015年(& ACLS 2015) 不考慮… Practice-changing 改變流程
Life-saving 起死回生 Idea-innovating 創新作法 不考慮… 「我們」、「現在」、 「能不能」這樣作 2018/11/27

3 Show me the evidence, EMS believer!
給我證據，其餘免談!!

4 第 10 名 CPR! 家屬外面等!…? New Engl J Med 2013;368: 2018/11/27

5 CPR 時要清場，因為… 怕家屬看了會難過 !? 怕家屬日後會有嚴重的心理創傷 !? 還是… 急救失敗、怕家屬找麻煩? 2018/11/27

6 法國巴黎EMS 研究 Family Presence during Cardiopulmonary Resuscitation
大巴黎地區十五個社區 EMS OHCA病人 OHCA 需要 CPR，N= 570人 離場家屬 比 在場家屬 90天發生心理創傷症候群PTSD 比例 為1.5倍 (41% vs 27% p< 0.01) 感到焦慮 x 1.5倍 p< 0.01 感到憂鬱 x 1.5倍 p< 0.01 開始吃精神病藥物x 1.5倍 p< 0.01 RCT 請家屬在場 N=266 願在場 211 (79%) 仍離場 55 (21%) 請家屬離場 N=304 仍在場 131 (43%) 願離場 173 (57%) Family Presence during Cardiopulmonary Resuscitation New Engl J Med 2013;368: Background The effect of family presence during cardiopulmonary resuscitation (CPR) on the family members themselves and the medical team remains controversial. Methods We enrolled 570 relatives of patients who were in cardiac arrest and were given CPR by 15 prehospital emergency medical service units. The units were randomly assigned either to systematically offer the family member the opportunity to observe CPR (intervention group) or to follow standard practice regarding family presence (control group). The primary end point was the proportion of relatives with posttraumatic stress disorder (PTSD)–related symptoms on day 90. Secondary end points included the presence of anxiety and depression symptoms and the effect of family presence on medical efforts at resuscitation, the well-being of the health care team, and the occurrence of medicolegal claims. Results In the intervention group, 211 of 266 relatives (79%) witnessed CPR, as compared with 131 of 304 relatives (43%) in the control group. In the intention-to-treat analysis, the frequency of PTSD-related symptoms was significantly higher in the control group than in the intervention group (adjusted odds ratio, 1.7; 95% confidence interval [CI], 1.2 to 2.5; P = 0.004) and among family members who did not witness CPR than among those who did (adjusted odds ratio, 1.6; 95% CI, 1.1 to 2.5; P = 0.02). Relatives who did not witness CPR had symptoms of anxiety and depression more frequently than those who did witness CPR. Family-witnessed CPR did not affect resuscitation characteristics, patient survival, or the level of emotional stress in the medical team and did not result in medicolegal claims. Conclusions Family presence during CPR was associated with positive results on psychological variables and did not interfere with medical efforts, increase stress in the health care team, or result in medicolegal conflicts. (Funded by Programme Hospitalier de Recherche Clinique 2008 of the French Ministry of Health; ClinicalTrials.gov number, NCT ) 第90天心理創傷嚴重度 (PTSD) (有475家屬完成評估) 病人急救成功率 急救團隊的壓力評估與法律糾紛率 2018/11/27

7 CPR! 家屬外面等!…? OHCA CPR時家屬在場，可以減輕他(她)們日後精神上的痛苦。
However, recent physiologic data suggest that even as little as 15 minutes of oxygen can cause hyperoxia, leading to a reduction in coronary blood flow, increased coronary vascular resistance, increased oxygen free radicals, and disturbed microcirculation, he said, "and this all may contribute to increased reperfusion injury, myocardial injury during acute coronary syndromes." 2018/11/27

8 第 9 名 沒有電擊器，試試胸前重擊!…? Resuscitation 2013; 84: 2018/11/27

9 胸前重擊治療OHCA 最早在1920年提出 (by Dr. Schott E) 有沒有用? (小型報告:OHCA 98.8%無效)
併發症? (胸骨骨折、骨膸炎、中風、VT打成VF…) Acls 2010 絕對不能：非目擊 ohca 可以考慮：目擊有監視器之vf/無脈vt， 而去顫無法立刻進行時。 Schott E. Uber Ventrikelstillstand (Adams-Stokes’sche Anfalle) nebstBemerkem-gen uber andersartige Arhythmien passagerer. Deutsches Arch KlinMed 1920;131:211–29.2. 有沒有用?好像沒用 (小型研究:98.8%無效) 併發症報告? 陸陸續續：胸骨骨折、骨膸炎、中風、VT打成VF Precordial Thump This section is new to the 2010 Guidelines and is based on the conclusions reached by the 2010 ILCOR evidence evaluation process.38 A precordial thump has been reported to convert ventricular tachyarrhythmias in 1 study with concurrent controls,39 single-patient case reports, and small case series.40–44 However, 2 larger case series found that the precordial thump was ineffective in 79 (98.8%) of 80 cases45 and in 153 (98.7%) of 155 cases of malignant ventricular arrhythmias.46 Case reports and case series47–49 have documented complications associated with precordial thump including sternal fracture, osteomyelitis, stroke, and triggering of malignant arrhythmias in adults and children. The precordial thump should not be used for unwitnessed out-of-hospital cardiac arrest (Class III, LOE C). The precordial thump may be considered for patients with witnessed, monitored, unstable ventricular tachycardia including pulseless VT if a defibrillator is not immediately ready for use (Class IIb, LOE C), but it should not delay CPR and shock delivery. There is insufficient evidence to recommend for or against the use of the precordial thump for witnessed onset of asystole. 2018/11/27

10 澳洲 VACAR 資料庫研究 Victorian Ambulance Cardiac Arrest Registry
2003~11年EMT目擊且心律為VF/VT的OHCA 目擊且心律為VF/VT的OHCA，N= 434人 立即電擊 比 先胸前重擊 當場ROSC的機會是12倍 (57.8% vs 4.9% p< ) 兩組存活出院率則沒有差別 EMT 作法不同 先立刻去顫 N=325 約佔 75 % 先胸前重擊 N=103 約佔 25% Background: Few studies have described the value of the precordial thump (PT) as first-line treatment of monitored out-of-hospital cardiac arrest (OHCA) from ventricular fibrillation and pulseless ventricular tachycardia (VF/VT). Methods: Patient data was extracted from the Victorian Ambulance Cardiac Arrest Registry (VACAR) for all OHCA witnessed by paramedics between 2003 and Adult patients who suffered a monitored VF/VT of presumed cardiac aetiology were included. Cases were excluded if the arrest occurred after arrival at hospital, or a ‘do not resuscitate’ directive was documented. Patients were assigned into two groups according to the use of the PT or defibrillation as first-line treatment. The study outcomes were: impact of first shock/thump on return of spontaneous circulation (ROSC), overall ROSC, and survival to hospital discharge. Results: A total of 434 cases met the eligibility criteria, of which first-line treatment involved a PT in 103 (23.7%) and immediate defibrillation in 325 (74.8%) cases. Patient characteristics did not differ sig-nificantly between groups. Seventeen patients (16.5%) observed a PT-induced rhythm change, including five cases of ROSC and 10 rhythm deteriorations. Immediate defibrillation resulted in significantly higher levels of immediate ROSC (57.8% vs. 4.9%, p < ), without excess rhythm deteriorations (12.3% vs. 9.7%, p = 0.48). Of the five successful PT attempts, three required defibrillation following re-arrest. Overall ROSC and survival to hospital discharge did not differ significantly between groups. Conclusion: The PT used as first-line treatment of monitored VF/VT rarely results in ROSC, and is more often associated with rhythm deterioration. 胸前重擊後的 心律變化 兩組的急救成功率 2018/11/27

11 很少有效 (4.9%)。 兩倍機會可能變得更糟 (Asys/PEA)。
沒有電擊器，試試胸前重擊!…? 很少有效 (4.9%)。 兩倍機會可能變得更糟 (Asys/PEA)。 3. 在電視上比較有效 (7成)。 2018/11/27

12 第 8 名 更多TP能救活更多OHCA!…? Resuscitation 2014;85:732-40 (epinephrine)
Resuscitation 2014;85: (airway) JAMA Intern Med (E-pub, Nov 24, 2014) (ALS) 2018/11/27

13 ALS VS. OHCA 這些救護對 OHCA…有效? 沒效? ALS (TP) vs. BLS-D (EMT-I/II)
正反皆有 (加NEJM 2004; 台Resus 2007; 美JAMA 2014) Advanced airway vs. SGA vs. BVM 莫衷一是 (韓Resus 2012; 日JAMA 2013; 美Resus 2014) Epinephrine vs. Non-Epinephrine 短多長空 (澳Resus 2011; 挪Resus 2012; 日JAMA 2014) ALS vs. BLS-D 正反皆有 (加NEJM 2004; 台Resus 2007; 美JAMA 2014) NEJM 2004 B-&-A, OPALS Resus 2007 Ma-Taipei ALS JAMA 2014 From January 1, 2009, and October 2, 2011, Medicare data; ALS or BLS ambulance services were billed to Medicare ( ALS cases and 1643 BLS cases) Patients with out-of-hospital cardiac arrest who received BLS had higher survival at hospital discharge and at 90 days compared with those who received ALS and were less likely to experience poor neurological functioning. Advanced airway vs. SGA vs. BVM 莫衷一是 (韓Resus 2012; 日JAMA 2013; 美Resus 2014) Enthusiasm from North America since the 1970s. Reports of non-different survivals from the 2010s. Negative association by Korea data (LMA vs. BVM) Negative association by Japan data (ETvs. BVM; N=649,359; OR=0.38 ( ) ) Negative association by CARE data (Outcome: BVM >> ET > SGA) Epinephrine vs. Non-Epi 短多長空 (澳Resus 2011; 挪Resus 2012; 日JAMA 2014) Increase ROSC in two RCTs but non-difference in long-term survival ~ Resus 2011 (602 in AU), 2012 (916 in Oslo). Better ROSC but worse functional recovery~ Japan data with 417,188 cases. JAMA 2013. 2018/11/27

14 OHCA: Medication or NOT?
OHCA: 其它藥物 (all RCTs) Amiodarone D5W vs H/S Lidocaine Dexamethasone Calcium chloride Phenylephrine Large-dose vs. standard-dose epinephrine Nimodipine Vasopressin Aminophylline MgSO4 雖然之前通通沒有成功，大家依然繼續努力 … 院內 intra-arrest VSE-combo: better CPC ~JAMA 2013 院外 post-arrest lidocaine: better survival ~ Resus 2014 (3) 院外 ROC new trial: A-L-P-S 研究進行中 ~ Am Heart J 2014 演講重點 藥物研究1975年來，無差異的多。LARGE-DOSE BOSMINE 甚至可能有害存活者之心臟功能(TREND BUT NS)。 所以只剩下 AMIODARONE AND VASOPRESSIN 尚存在 ACLS 第一線用藥。 AMIODARONE: 1999年SEATTLE 研究，到院前三次電擊後的VF病人。可增加到院存活(住院)率，但出院存活率無差。 VASOPRESSIN: 與BOSMIN效果相當，但在ASYSTOLE/PEA 的病人次群分析發現可能較有益(ROSC)。 所以ACLS2005的改變可以了解。 另提：VASOPRESSIN 在動物實驗可減少外傷鼠出血性休克的死亡率，目前已在進行 trauma RCT (VITRIS trial)。 ROC new trial: A-L-P-S 研究進行中 ~ Am Heart J 2014 Amiodarone, Lidocaine or Placebo / RCT/ VFVT adult OHCA 補充資料 Prospective randomized controlled study in Norway from 2003/5~2008/4 IV drugs in ALCS (epinephrine, atropine, amiodarone) vs. No-IV ACLS 415 vs. 420 patients without difference in hands-off, compression and ventilation rate Survival to discharge: 10.6 vs. 9.0 % (p=0.523) NO difference in survival between two groups!! ~ Olasveengen TM, et al. Oslo, Norway in AHA Scientific Session 2008. JAMA Nov 25;302(20): doi: /jama Intravenous drug administration during out-of-hospital cardiac arrest: a randomized trial. Olasveengen TM1, Sunde K, Brunborg C, Thowsen J, Steen PA, Wik L. Author information 1Institute for Experimental Medical Research, Oslo University Hospital, Ullevaal, N-0407 Oslo, Norway. Abstract CONTEXT: Intravenous access and drug administration are included in advanced cardiac life support (ACLS) guidelines despite a lack of evidence for improved outcomes. Epinephrine was an independent predictor of poor outcome in a large epidemiological study, possibly due to toxicity of the drug or cardiopulmonary resuscitation (CPR) interruptions secondary to establishing an intravenous line and drug administration. OBJECTIVE: To determine whether removing intravenous drug administration from an ACLS protocol would improve survival to hospital discharge after out-of-hospital cardiac arrest. DESIGN, SETTING, AND PATIENTS: Prospective, randomized controlled trial of consecutive adult patients with out-of-hospital nontraumatic cardiac arrest treated within the emergency medical service system in Oslo, Norway, between May 1, 2003, and April 28, 2008. INTERVENTIONS: Advanced cardiac life support with intravenous drug administration or ACLS without access to intravenous drug administration. MAIN OUTCOME MEASURES: The primary outcome was survival to hospital discharge. The secondary outcomes were 1-year survival, survival with favorable neurological outcome, hospital admission with return of spontaneous circulation, and quality of CPR (chest compression rate, pauses, and ventilation rate). RESULTS: Of 1183 patients for whom resuscitation was attempted, 851 were included; 418 patients were in the ACLS with intravenous drug administration group and 433 were in the ACLS with no access to intravenous drug administration group. The rate of survival to hospital discharge was 10.5% for the intravenous drug administration group and 9.2% for the no intravenous drug administration group (P = .61), 32% vs 21%, respectively, (P<.001) for hospital admission with return of spontaneous circulation, 9.8% vs 8.1% (P = .45) for survival with favorable neurological outcome, and 10% vs 8% (P = .53) for survival at 1 year. The quality of CPR was comparable and within guideline recommendations for both groups. After adjustment for ventricular fibrillation, response interval, witnessed arrest, or arrest in a public location, there was no significant difference in survival to hospital discharge for the intravenous group vs the no intravenous group (adjusted odds ratio, 1.15; 95% confidence interval, ). CONCLUSION: Compared with patients who received ACLS without intravenous drug administration following out-of-hospital cardiac arrest, patients with intravenous access and drug administration had higher rates of short-term survival with no statistically significant improvement in survival to hospital discharge, quality of CPR, or long-term survival. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT OHCA: Medication or NOT? ~ A RCT with 851 OHCAs in Oslo. Olasveengen TM, et al. JAMA, 2009.

15 更多TP能救活更多OHCA!…? 總體來說，目前還無法否認或肯定。 也許 OHCA 的救活重點要回歸 BLS-D
也許 所有ALS 不是對所有OHCA都有效… Maybe the question is not if (ETI/EPI/ALS/EMTP) but rather when, where, by whom and to whom! However, recent physiologic data suggest that even as little as 15 minutes of oxygen can cause hyperoxia, leading to a reduction in coronary blood flow, increased coronary vascular resistance, increased oxygen free radicals, and disturbed microcirculation, he said, "and this all may contribute to increased reperfusion injury, myocardial injury during acute coronary syndromes." 2018/11/27

16 第 7 名 那訓練這麼多TP…能救活什麼…? Ann Emerg Med 2014 ;63: 2018/11/27

17 EMTP = EMT2 + 插管 + 給藥…? 當然不是!! 加拿大安大略省15個城市聯合ALS研究 (OPALS study) 發現： 1997~2000年8138位呼吸窘迫病患以ALS救護 vs BLS救護 總死亡率下降 1.9% (B:14.3% vs A:12.4% p < 0.001) 相當於每年多救活40條人命 OHCA 的存活看天! 運氣好不好、旁邊有沒有人立刻作BLS-D… 危急個案的存活看 EMT! 危急個症，靠的是正確的判斷與對應的處置 Chest pain: better by ALS Respiratory Distress: better by ALS 危急個案的存活看 EMT! Chest pain ~Acad Emerg Med 2003 Respiratory Distress ~N Eng J Med 2007 8138 patients in 15 cities: 3920 in the 6-months BLS phase (January 1995 to February 1998), 4218 in the ALS phase (from February 1998 to November 2000) Major groups: CHF(51%), COPD(37%) BLS : O2, BVM, AED, bronchodilator inhalation and ASA, NTG… ALS : Ditto + (IV drugs (Lasix and Morphine) & EIT) Inclusion: >16 y/o, Primary symptom: short of breath Exclusion: full cardiac arrest, primary symptoms were chest pain or other nonrespiratory symptom, respiratory distress due to trauma, postictal state, another nonrespiratory illness Basic-life-support phase: Oxygen, bag-valve-mask ventilation, automated external defibrillation Advanced-life-support program: Intubation, insert intravenous lines, administer intravenous medications ( furosemide, morphine) Mortality Outcome Intubation in the ED, evidence of aspiration, admission to a Hospital, the length of stay in the hospital, patient’s destination after discharge, patient’s functional status Overall mortality: 14.3%12.4% (decrease in the in-hospital mortality, not in the ED) Cerebral-performance category score of level 1CPC increased survivors significantly (52.3% to 62.5%, P<0.001) Patients’ condition have improved on arrival at the ED (from 24.5% to 45.8%, P<0.001) The rate of intubation in the ED decreased from the BLS phase to the ALS phase (from 5.3% to 3.1%, P<0.001) Patients in the two phases had similar characteristics Median response intervals were similar in the two phases Intravenous medication (furosemide)15% Symptom relief (nebulized salbutamol) increased (from 17.5% to 59.4%) ~OPALS study, Acad Emerg Med 2003 ~ OPALS study, NEJM 2007 2018/11/27

18 在呼吸窘迫病患， EMTP 判斷並使用CPAP/NIPPV 比一般救護方式， 病患預後(插管率、死亡率)是否有差別?
~ Meta-analysis from 7 qualified trials (632 pts), Ann Emerg Med 2014. 在呼吸窘迫病患， EMTP 判斷並使用CPAP/NIPPV 比一般救護方式， 病患預後(插管率、死亡率)是否有差別? 圖片：紐約州 TP使用 CPAP Study objective: Noninvasive positive-pressure ventilation (NIPPV) is increasingly being used by emergency medical services (EMS) for treatment of patients in respiratory distress. The primary objective of this systematic review is to determine whether out-of-hospital NIPPV for treatment of adults with severe respiratory distress reduces inhospital mortality compared with “standard” therapy. Secondary objectives are to examine the need for invasive ventilation, hospital and ICU length of stay, and complications. Methods: Electronic searches of MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and Cumulative Index to Nursing and Allied Health Literature were conducted and reference lists of relevant articles hand searched. Randomized controlled trials comparing out-of-hospital NIPPV with standard therapy in adults (aged 16 years) with severe respiratory distress published in English were included. Two reviewers independently screened abstracts, assessed quality of the studies, and extracted data. Data were pooled with random-effects models and reported as risk ratios (RRs) with 95% confidence intervals (CIs) and number needed to treat (NNT). Results: Seven randomized controlled trials were included, with a combined total of 632 patients; 313 in the standard therapy group and 319 in the NIPPV group. In patients treated with NIPPV, the pooled estimate showed a reduction in both inhospital mortality (RR 0.58; 95% CI 0.35 to 0.95; NNT?18) and need for invasive ventilation (RR 0.37; 95% CI 0.24 to 0.58; NNT?8). There was no difference in ICU or hospital length of stay. Conclusion: Out-of-hospital administration of NIPPV appears to be an effective therapy for adult patients with severe respiratory distress. [Ann Emerg Med. 2014;63: ] Please see page 601 for the Editor’s Capsule Summary of this article. A 2018/11/27

19 病患總死亡率及到院後插管率皆能有效減少。
非侵入性正壓呼吸器 CPAP/NIPPV ~ Meta-analysis from 7 qualified trials (632 pts), Ann Emerg Med 2014. 最新統合分析證實 呼吸窘迫病患到院前 以 NIPPV/CPAP (ALS救護) 病患總死亡率及到院後插管率皆能有效減少。 相當於每8趟救護就能減少1次插管， 每18趟救護就能減少1次死亡。 圖片：紐約州 TP使用 CPAP Study objective: Noninvasive positive-pressure ventilation (NIPPV) is increasingly being used by emergency medical services (EMS) for treatment of patients in respiratory distress. The primary objective of this systematic review is to determine whether out-of-hospital NIPPV for treatment of adults with severe respiratory distress reduces inhospital mortality compared with “standard” therapy. Secondary objectives are to examine the need for invasive ventilation, hospital and ICU length of stay, and complications. Methods: Electronic searches of MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and Cumulative Index to Nursing and Allied Health Literature were conducted and reference lists of relevant articles hand searched. Randomized controlled trials comparing out-of-hospital NIPPV with standard therapy in adults (aged 16 years) with severe respiratory distress published in English were included. Two reviewers independently screened abstracts, assessed quality of the studies, and extracted data. Data were pooled with random-effects models and reported as risk ratios (RRs) with 95% confidence intervals (CIs) and number needed to treat (NNT). Results: Seven randomized controlled trials were included, with a combined total of 632 patients; 313 in the standard therapy group and 319 in the NIPPV group. In patients treated with NIPPV, the pooled estimate showed a reduction in both inhospital mortality (RR 0.58; 95% CI 0.35 to 0.95; NNT?18) and need for invasive ventilation (RR 0.37; 95% CI 0.24 to 0.58; NNT?8). There was no difference in ICU or hospital length of stay. Conclusion: Out-of-hospital administration of NIPPV appears to be an effective therapy for adult patients with severe respiratory distress. [Ann Emerg Med. 2014;63: ] Please see page 601 for the Editor’s Capsule Summary of this article. A 到院後死亡率 到院後插管率 2018/11/27

20 Emtp = emt2 + als 技術 + 判斷應變 + 【…】
OHCA 的存活機會，看倒地當時運氣(有沒有BysCPR、有沒有PAD…)。ALS 也無力變天。 但是對於呼吸窘迫的危急病患，EMTP能增加他們的存活機會。 EMTP ≠ EMT2 + 插管 + 給藥 However, recent physiologic data suggest that even as little as 15 minutes of oxygen can cause hyperoxia, leading to a reduction in coronary blood flow, increased coronary vascular resistance, increased oxygen free radicals, and disturbed microcirculation, he said, "and this all may contribute to increased reperfusion injury, myocardial injury during acute coronary syndromes." Emtp = emt2 + als 技術 + 判斷應變 + 【…】 2018/11/27

21 敗選十大的…遺珠之憾 (上) CPR上課：45分鐘比3小時一年後作得好 Acad Emerg Med 2014
CPR上課：教「快快壓」常常壓到150下 Am J Emerg Med 2014 真壓胸：最高的ROSC 出現在125下(100~120是ROSC比率的 高原期，<80 或 >140 都下降ROSC) Circulation 2012 真壓胸：最好的ROSC 出現在4.5公分(4.0~5.5公分OK) Circulation 2014 真壓胸：施救者品質最好是1分鐘內(2分鐘後下降) J Emerg Med 2012 機器壓：再比一次，還是無法勝過手壓 Lancet 2014 去顫充電時：CPR不要停, 品質才算好! Resuscitation 2014 ETCO2看CPR品質: 與「用力壓, 快快壓」最有關 AHA-ReSS 2014 OHCA現場: 德國小研究說高張溶液有好處 Resuscitation 2014 CPR上課：教「快快壓」常常壓到150下 Am J Emerg Med Dec;32(12): 真壓胸：最高的ROSC出現在125下(<80 或 >140 都下降ROSC) Circulation 2012 ;125: 真壓胸：最好的存活率出現在4.5公分(4.0~5.5公分OK) Circulation 2014 Sep 24 真壓胸：施救者品質最好是1分鐘內(2分鐘後會下降) J Emerg Med 2012; 1-5 in press 機器壓：再一次還是無法勝過手壓 Lancet 2014 Nov 16 去顫充電時：CPR不要停! Resuscitation 2014;85: OHCA: 德國小研究說高張溶液有好處Resuscitation 2014 Jan 23; ETCO2看CPR品質:與「用力壓」「快快壓」最有關 AHA-ReSS 2014 現場TOR：在亞洲好像沒有美國說的這麼準 EMJ 2013 ECMO-CPR：日本說即使心跳停止15分鐘以上仍有幫忙 Resuscitation 2014 ECMO-CPR：日本說即使瞳孔<4mm者清醒機會高Kunihiko Maekawa, et al. Crit Care Med, 2013 救活後：過高血氧狀態存活出院少 Intensive Care Med 2015 Jan 41:49 AMI: 英國報告到院前心電圖能增加存活率 Circulation 2014 Sep 24 創傷OHCA：用AED應該沒幫助 Resuscitation 2013:84;586 創傷張力性氣胸：澳洲根本很少作，但改變流程可以增加。Injury. 2014;45:71 創傷張力性氣胸：第五肋間腋前線比傳統第2肋間鎖骨中線好。 Arch Surg.2012,147:813. 創傷張力性氣胸：壯漢 (平均BMI=26.8) 第四肋間腋前線8公分比傳統第2肋間鎖骨中線5公分好J Trauma Acute Care Surg.2014,76:1029 創傷頸圈長背板：我們可能用太多 Prehospital Emerg Care. 2013, 17:392 2018/11/27

22 第 6 名 救OHCA，其實說的比做的有效! Resuscitation 2014, 85:34–41
Bentley Bobrow et al, AHA Scientific Sessions; Nov 19, 2014; Chicago, IL. 2018/11/27

23 Bystander CPR 增加 OHCA 的存活!
No CPR Dispatcher Assisted CPR Bystander CPR 存活機會倍數 (Odds ratio) 每 30次 Bystander CPR 就能增加 1位 OHCA病患存活出院! Systematic review of from 1980 to 2008 involving more than 142,000 patients About 1/3 OHCAs received bystander CPR Survival to discharge: x 2.5 if having bystander CPR NNT= 24~36 (survival chance; mostly to discharge) ~ Sasson et al, Circ Cardiovasc Qual Outcomes, 2010. If adjusted cause of death, the OR of bystnader CPR to ROSC were 2.28 The NNT = 15.5 (to ROSC) The filling in of the cause of death was an liberal choice , so many hospital user did not complete the question. We did not put the cause of death (cardiac vs non-cardiac) into consideration because there were too much missing data (around 60%) ~ A systematic review from 1980 to 2008, involving more than 142, 000 patients. Sasson et al, Circ Cardiovasc Qual Outcomes, 2010.

24 增加 Bystander CPR 的捷徑! 派遣員線上指導報案者 首爾市 2011年 開始派遣員線上指導報案者CPR
(6.3% vs 31.8% p< 0.001) ~ Song KJ et al, Resuscitation 2014. 2018/11/27

25 社區推廣+ 線上指導 = 能提高OHCA清醒存活!
~ B&A trial of 4174 OHCAs, by Bentley Bobrow, AHA-ReSS 2014, awarded the best study. 亞歷桑那州 2011年開始系統性訓練派遣員線上指導報案者CPR 不但使 bystander CPR 率增加 連OHCA病患清醒出院率都增加 42% (5.5% vs 7.8% p=0.01) ~ Bentley Bobrow, AHA-ReSS 2014, awarded the best original study. Before and after trial 911 audio recordings of OHCA (2010/ /10), enrolled 4174 (1398 vs. 2601) 2018/11/27

26 台北市影響旁觀者 CPR的因素 ~ Chiang WC et al, Resuscitation 2014. 2018/11/27

27 救OHCA，其實說的比做的有效! 每 30次 Bystander CPR 就能增加 1位 OHCA病患存活出院!。
台灣EMS救護的 「緊箍咒」要解開才行! However, recent physiologic data suggest that even as little as 15 minutes of oxygen can cause hyperoxia, leading to a reduction in coronary blood flow, increased coronary vascular resistance, increased oxygen free radicals, and disturbed microcirculation, he said, "and this all may contribute to increased reperfusion injury, myocardial injury during acute coronary syndromes." 60秒…45秒…30… 2018/11/27

28 AHA Scientific Sessions; Nov 19, 2014; Chicago, IL.
第 5 名 頭部外傷、過度換氣降腦壓!…? EPIC-TBI from Arizona AHA Scientific Sessions; Nov 19, 2014; Chicago, IL. 2018/11/27

29 北美最新到院前頭部外傷指引 EPIC-TBI (Excellence in Prehospital Care-Traumatic Brain Injury)
降低腦血流  增加腦細胞死亡  惡化預後 ! 低血壓 低血氧 過度換氣 到院前有一次 SpO2 < 90% x2 到院前進行過度換氣 x 2 ~ 6 到院前有一次SBP < 90mmHg x 2  EPIC-TBI Excellence in Prehospital Care - Traumatic Brain Injury 只要在到院前測得一次低血氧 (SpO2 < 90%)，到院後死亡率將增加一倍! 只要在到院前測得一次低血壓 (SBP < 90mmHg)，到院後死亡率將增加一倍! 過度換氣 (1)　增加胸內壓  減少回心血流  減少腦血流　(2) 減少二氧化碳  腦血管收縮  但降腦壓也同時減少腦血流 EPIC report 2014: While hypoxia and hypotension increase mortality by four– and three-fold respectively, when combined, mortality is in-creased 14 times. Asian EPIC TBI_ Ver 1.0

30 小心「氫」彈 (H-Bombs) !! 頭部外傷的 “H-Bombs” Hypoxia Hypotension 2014 台北市新流程
Hyperventilation Hypoglycemia H-Bombs 「氫」彈 殺死腦細胞，使病人活不了 即使只有一次也不行! 2014 台北市新流程 使用BVM給氧治療頭部外傷傷患時，其換氣速率同一般急救 (每分鐘8-10次通氣)，切勿過度換氣。 輕度過度換氣治療 (每分鐘14-16次通氣)」僅能由EMTP執行在備有ET-CO2監測下因大腦脫疝徵象昏迷而插管的傷患，目標為維持ET-CO mmHg。 Asian EPIC TBI_ Ver 1.0

31 頭部外傷：Monitor! Monitor! Monitor!
頭部外傷、過度換氣降腦壓!…? 頭部外傷：Monitor! Monitor! Monitor! O2 Saturation 血氧值 B/P 血壓值 Ventilation rate 換氣太快 Ventilation depth 換氣太深 ETCO2 插管卻未監測 (TBI目標：35-40) Hypoxia: Apply high-flow oxygen IMMEDIATELY! Hypotension: Give fluids if SBP is <90 mmHg Hyperventilation: Keep ETCO2 at 40 mmHg (range: 35-45) Hypoglycemia: Check glucose, treat if below 70 mg/dL When you treat the H-bombs, you treat the injured brain! 2018/11/27

32 第 4 名 心肌梗塞! MONA!! MONA? AVOID study (ClinicalTrials :NCT01272713)
AHA Scientific Sessions; Nov 19, 2014; Chicago, IL. Stub D, Smith K, Bernard, S, et al. A randomised controlled trial of oxygen therapy in acute ST-segment elevation myocardial infarction: The Air Versus Oxygen in Myocardial Infarction (AVOID) study. American Heart Association 2014 Scientific Sessions; November 19, 2014; Chicago, IL. Abstract Cabello JB, Burls A, Emparanza JI, et al. Oxygen therapy for acute myocardial infarction. Cochrane Database Syst Rev2013; 8:CD DOI: / CD  Article 2018/11/27

33 M-O-N-A Morphine ：小心使用 Oxygen：應該有用 (1900年代開始建議) NTG：可能有用 Aspirin: 確實有用
特別是在 UAP ( 不穩定性心絞痛) or NSTEMI (非ST節段上升心肌梗塞) Oxygen：應該有用 (1900年代開始建議) NTG：可能有用 Aspirin: 確實有用 ~ ACLS 2010 2018/11/27

34 AVOID 研究 AVOID - Air Verses Oxygen In myocarDial Infarction Study
澳洲 Melbourn/Frankston 十家醫院441病人 STEMI 胸痛12小時內 血氧值 >= 94% 且意識清楚 使用氧氣者 比 呼吸空氣者 72小時心肌梗塞總面積為 1.26倍 (p< 0.01)(by CK) 6個月MRI定量心肌梗塞面積為 1.55倍 (p=0.04) RCT EMS + ER 給面罩 8 L/min N=218 EMS + ER 呯吸空氣 N=223 AVOID Oxygen? Evidence of Harm in MI The Air Versus Oxygen in ST-Elevation Myocardial Infarction (AVOID) trial suggests supplemental oxygen therapy in patients with STEMI may be harmful for patients who are not hypoxic. Oxygen may increase myocardial injury, recurrent MI, and major cardiac arrhythmia and may be associated with greater infarct size at 6 months, said lead author Dr Dion Stub (St Paul's Hospital, Vancouver, BC, and the Baker IDI Heart and Diabetes Institute, Melbourne, Australia). "These findings certainly need to be confirmed in larger randomized trials that are powered for hard clinical end points, but the AVOID study investigators would really question the current practice of giving oxygen to all patients and certainly to those who have normal oxygen levels to begin with," he concluded.  Eligibility Ages Eligible for Study:  18 Years and olderGenders Eligible for Study:  BothAccepts Healthy Volunteers:  NoCriteria Inclusion Criteria: Adults ≥ 18 years of age. Chest pain for < 12 hours ST-elevation Myocardial Infarction including either: 1) Persistent ST-segment elevation of ≥1mm in two contiguous limb leads; 2) ST-segment elevation of ≥ 2mm in two contiguous chest leads, or; 3) New left bundle branch block (LBBB) pattern. Able to be transported to a participating hospital Exclusion Criteria: Hypoxia with oxygen saturation measured on pulse oximeter < 94% with the patient breathing air Bronchospasm requiring nebulised salbutamol therapy using oxygen Altered conscious state 72小時內心肌梗塞總面積 (以 心肌酵素 CK 與TnI 代替) 6個月心肌 MRI 確認梗塞面積 2018/11/27

35 心肌梗塞! MONA!! MONA? 高氧狀態 (hyperoxia) 會減少冠狀動脈血流及增加自由基。
即使只給15分鐘的高濃度氧氣也會造成高氧狀態 。 沒有缺氧 (SpO2 >= 94%) 的心肌梗塞病患，不應該給氧。 However, recent physiologic data suggest that even as little as 15 minutes of oxygen can cause hyperoxia, leading to a reduction in coronary blood flow, increased coronary vascular resistance, increased oxygen free radicals, and disturbed microcirculation, he said, "and this all may contribute to increased reperfusion injury, myocardial injury during acute coronary syndromes." 2018/11/27

36 落選十大的…遺珠之憾 (下) 現場TOR：在亞洲好像沒有美國說的這麼準 Emerg Med J 2013
ECMO-CPR：日本說心跳停止15分鐘以上仍有救 Resus 2014 ECMO-CPR：日本說瞳孔<4mm者清醒機會高 Crit Care Med 2013 OHCA 救活後：過高血氧狀態存活出院少 Intensive Care Med 2015 AMI: 英國報告到院前心電圖能增加存活率 Circulation 2014 張力性氣胸：澳洲根本很少作，但改變EMT流程可以增加 Injury 2014 張力性氣胸：第五肋間腋前線比傳統第2肋間鎖骨中線好。 Arch Surg 2012 張力性氣胸：壯漢 (平均BMI=26.8) 第四肋間腋前線8公分比傳統第2肋間鎖骨中線5公分好 J Trauma Acute Care Surg 2014 頸圈長背板固定術：我們可能用太多 Prehosp Emerg Care 2013 CPR上課：教「快快壓」常常壓到150下 Am J Emerg Med Dec;32(12): 真壓胸：最高的ROSC出現在125下(<80 或 >140 都下降ROSC) Circulation 2012 ;125: 真壓胸：最好的存活率出現在4.5公分(4.0~5.5公分OK) Circulation 2014 Sep 24 真壓胸：施救者品質最好是1分鐘內(2分鐘後會下降) J Emerg Med 2012; 1-5 in press 機器壓：再一次還是無法勝過手壓 Lancet 2014 Nov 16 去顫充電時：CPR不要停! Resuscitation 2014;85: OHCA: 德國小研究說高張溶液有好處Resuscitation 2014 Jan 23; ETCO2看CPR品質:與「用力壓」「快快壓」最有關 AHA-ReSS 2014 現場TOR：在亞洲好像沒有美國說的這麼準 EMJ 2013 ECMO-CPR：日本說即使心跳停止15分鐘以上仍有幫忙 Resuscitation 2014 ECMO-CPR：日本說即使瞳孔<4mm者清醒機會高Kunihiko Maekawa, et al. Crit Care Med, 2013 救活後：過高血氧狀態存活出院少 Intensive Care Med 2015 Jan 41:49 AMI: 英國報告到院前心電圖能增加存活率 Circulation 2014 Sep 24 創傷OHCA：用AED應該沒幫助 Resuscitation 2013:84;586 創傷張力性氣胸：澳洲根本很少作，但改變流程可以增加。Injury. 2014;45:71 創傷張力性氣胸：第五肋間腋前線比傳統第2肋間鎖骨中線好。 Arch Surg.2012,147:813. 創傷張力性氣胸：壯漢 (平均BMI=26.8) 第四肋間腋前線8公分比傳統第2肋間鎖骨中線5公分好J Trauma Acute Care Surg.2014,76:1029 創傷頸圈長背板：我們可能用太多 Prehospital Emerg Care. 2013, 17:392 2018/11/27

37 PHANTOM-S study from Berlin (Germany),
第 3 名 增加 CVA 栓溶施打率的終極方法? 院前辛辛那提+ 通報醫院的方法最能夠達到縮短D-To-N 的時間!…? PHANTOM-S study from Berlin (Germany), JAMA 2014; 311: 2018/11/27

38 2 佰 萬 一寸光陰一寸金 急性腦中風一旦發生… 1分鐘延遲 = 死 個腦細胞 10分鐘延遲 = 少 1 個完全康復的人
1分鐘延遲 = 死 個腦細胞 10分鐘延遲 = 少 1 個完全康復的人 2 佰 萬 每一分鐘腦中風死掉的腦細胞

39 如果 emt 發現你救護的區域，黃金時間常常來不及，怎麼辦? Acls 2010 栓溶施打 愈早愈好，有些人到 4.5小時仍然有效 !
急性中風：症狀到治療的過程 如果 emt 發現你救護的區域，黃金時間常常來不及，怎麼辦? 中 風 發 生 119 求 救 EMT 到 場 EMT 後 送 EMT 到 院 病 人 交 接 急 診 醫 師 看 啟 動 中 風 小 組 完 成 電 腦 斷 層 中 風 小 組 確 認 決 定 藥 物 治 療 打 通 血 管 Acls 2010 栓溶施打 愈早愈好，有些人到 4.5小時仍然有效 ! D2 Stroke team＜10mins D2 CT report＜45mins D2N＜60mins 症狀到打通＜3hrs (愈早愈好)

40 美國：打完再走 (Drip-&-ship)
如果 emt 發現你救護的區域，黃金時間常常來不及，怎麼辦? 美國：打完再走 (Drip-&-ship) 德州 (Huston) 中風醫療網 570萬人、6大中心22小醫院 治療效果和「一步到位」一樣好!! ~ J Emerg Med. 2011; 41(2):135-41

41 如果 emt 發現你救護的區域，黃金時間常常來不及，怎麼辦?
德國： PHANTOM-S研究 PreHospital Acute Neurological Treatment and Optimization of Medical care in Stroke Study 柏林中風救護車 STEMO (Stroke Emergency Mobile) 備配有  CT 電腦斷層  point-of-care 一滴血檢測機 telemedicine 影像通訊設備 德國 (Berlin) PHANTOM-S 研究報告 Prehospital Acute Neurological Treatment and Optimization of Medical care in Stroke Study 150 million / ambulance 目前德國有 So far only 1 STEMO van is in use, serving an area defined by a 75% chance of reaching patients within 16 minutes, covering more than 1 million inhabitants. In a German study, time to thrombolysis was faster when treatment was provided by neurologists in a speciallyequipped ambulance than in the ED. Investigators in Germany compared time to thrombolysis between stroke patients receiving routine care in an emergency department and those evaluated in the prehospital setting by a special ambulance called “stroke emergency mobile” or STEMO. The STEMO was staffed by a neurologist and was equipped with a mobile computed tomography scanner and a pointofcare laboratory. RESULTs: RESULTS Time reduction was assessed in all patients with a stroke dispatch from the entire catchment area in STEMO weeks (3213 patients) vs control weeks (2969 patients) and in patients in whom STEMO was available and deployed (1804 patients) vs control weeks (2969 patients). Compared with thrombolysis during control weeks, there was a reduction of 15 minutes (95%CI, 11-19) in alarm-to-treatment times in the catchment area during STEMO weeks (76.3 min; 95%CI, vs 61.4 min; 95%CI, ; P < .001). Among patients for whom STEMO was deployed, mean alarm-to-treatment time (51.8 min; 95%CI, ) was shorter by 25 minutes (95%CI, 20-29; P < .001) than during control weeks. Thrombolysis rates in ischemic stroke were 29% (310/1070) during STEMO weeks and 33% (200/614) after STEMO deployment vs 21% (220/1041) during control weeks (differences, 8%; 95%CI, 4%-12%; P < .001, and 12%, 95%CI, 7%-16%; P < .001, respectively). STEMO deployment incurred no increased risk for intracerebral hemorrhage (STEMO deployment: 7/200; conventional care: 22/323; adjusted odds ratio [OR], 0.42, 95%CI, ; P = .06) or 7-day mortality (9/199 vs 15/323; adjusted OR, 0.76; 95%CI, ; P = .53). CONCLUSIONS AND RELEVANCE Compared with usual care, the use of ambulance-based thrombolysis resulted in decreased time to treatment without an increase in adverse events. Further studies are needed to assess the effects on clinical outcomes. €1 million

42 德國柏林 PHANTOM-S 研究 以STEMO車救護 比 一般救護車 急性腦中風病患
Call-To-N: 減少 25 分鐘 (P < .001) 接受栓溶劑施打的機會增加 12% (33% vs. 21%, P < .001) 併發症 (腦出血或死亡)：沒有增加 依星期 隨機分配 無 STEMO車週， 由一般車救護 N=2969 5億 個腦細胞 有 STEMO車週， 由STEMO車救護 N= 1804 RESULTS Time reduction was assessed in all patients with a stroke dispatch from the entire catchment area in STEMO weeks (3213 patients) vs control weeks (2969 patients) and in patients in whom STEMO was available and deployed (1804 patients) vs control weeks (2969 patients). Compared with thrombolysis during control weeks, there was a reduction of 15 minutes (95%CI, 11-19) in alarm-to-treatment times in the catchment area during STEMO weeks (76.3 min; 95%CI, vs 61.4 min; 95%CI, ; P < .001). Among patients for whom STEMO was deployed, mean alarm-to-treatment time (51.8 min; 95%CI, ) was shorter by 25 minutes (95%CI, 20-29; P < .001) than during control weeks. Thrombolysis rates in ischemic stroke were 29% (310/1070) during STEMO weeks and 33% (200/614) after STEMO deployment vs 21% (220/1041) during control weeks (differences, 8%; 95%CI, 4%-12%; P < .001, and 12%, 95%CI, 7%-16%; P < .001, respectively). STEMO deployment incurred no increased risk for intracerebral hemorrhage (STEMO deployment: 7/200; conventional care: 22/323; adjusted odds ratio [OR], 0.42, 95%CI, ; P = .06) or 7-day mortality (9/199 vs 15/323; adjusted OR, 0.76; 95%CI, ; P = .53). CONCLUSIONS AND RELEVANCE Compared with usual care, the use of ambulance-based thrombolysis resulted in decreased time to treatment without an increase in adverse events. Further studies are needed to assess the effects on clinical outcomes. [求救至給藥 ] 的時間 栓溶劑的施打率 及 併發症比率 2018/11/27

43 增加 CVA 栓溶施打率的終極方法? EMS 永遠都有進步的方法。 你的EMS 適合用什麼方式來提高急性腦中風病患的栓溶率?
如果捐救護車的人太多，何不請他們聯合起來捐一台 STEMO? However, recent physiologic data suggest that even as little as 15 minutes of oxygen can cause hyperoxia, leading to a reduction in coronary blood flow, increased coronary vascular resistance, increased oxygen free radicals, and disturbed microcirculation, he said, "and this all may contribute to increased reperfusion injury, myocardial injury during acute coronary syndromes." 2018/11/27

44 第 2 名 增加社區旁觀者CPR 的終極方法? Resuscitation 2014, 85:1444–1449 2018/11/27

45 世界 OHCA 存活率: 平均是7.6% 但各地差異非常大的原因是…
OHCA救活的關鍵在最初的BLS BLS 世界 OHCA 存活率: 平均是7.6% 但各地差異非常大的原因是… ~ Iwami T, et al. Circulation 2009. ~ Sasson C, et al. Circulation 2013. 世界各國 旁觀者 CPR 比率! 美國 33% ~MMWR Surveill Summ. 2011 日本 41% ~Circulation 2009 丹麥 31% ~JAMA 2013 荷蘭 61% ~Resuscitation 2014 台北市 5.6% ~AJEM  17.3% ~Resuscitation 2014 2018/11/27

46 世界旁觀者CPR比率最高的城市， 如何再突破?
荷蘭首都 Amsterdam 自 2010 年起， 開始建立 TMR (Text Message Responder) (AmsteRdam REsuscitation Studies ARREST 計畫之一)。 至 2013年7月止 已有自願登錄合格的召喚獸 14,112 位 (當地人口約：120萬人/2900km2) (台北市約：270 萬人/270km2 ) (新北市約：400 萬人/2000km2 ) 2010年2月~2013年7月期間 共有1536名OHCA病患 派遣中心啟動 893人次召喚獸 達成 旁觀者CPR 100% (背景值61%) 六分鐘內電擊 10.5% (背景值2.4%) Aim: Public access defibrillation rarely reaches out-of-hospital cardiac arrest (OHCA) patients in residen-tial areas. We developed a text message (TM) alert system, dispatching local lay rescuers (TM-responders). We analyzed the functioning of this system, focusing on response times and early defibrillation in relation to other responders. Methods: In July 2013, TM-responders and 1550 automated external defibrillators (AEDs) were reg-istered in a database residing with the dispatch center of two regions of the Netherlands. TM-responders living <1000 m radius of the patient received a TM to go to the patient directly, or were directed to retrieve an AED first. We analyzed 1536 OHCA patients where a defibrillator was connected from February 2010 until July Electrocardiograms from all defibrillators were analyzed for connection and defibrillation time. Results: Of all OHCAs, the dispatcher activated the TM-alert system 893 times (58.1%). In 850 cases ≥1 TM-responder received a TM-alert and in 738 cases ≥1 AED was available. A TM-responder AED was connected in 184 of all OHCAs (12.0%), corresponding with 23.1% of all connected AEDs. Of all used TM-responder AEDs, 87.5% were used in residential areas, compared to 71.6% of all other defibrillators. TM-responders with AEDs defibrillated mean 2:39 (min:sec) earlier compared to emergency medical services (median interval 8:00 [25–75th percentile, 6:35–9:49] vs. 10:39 [25–75th percentile, 8:18–13:23], P < 0.001). Of all shocking TM-responder AEDs, 10.5% delivered a shock ≤6 min after call. Conclusion: A TM-alert system that includes local lay rescuers and AEDs contributes to earlier defibrillation in OHCA, particularly in residential areas. 2018/11/27

47 孔夫子的禮運大同篇在 荷蘭 實現了! 再次證實：EMS 永遠都有進步的方法。 公民意識 + 網軍推廣 + 科技運用 = 無限可能
增加社區旁觀者CPR 的終極方法? 孔夫子的禮運大同篇在 荷蘭 實現了! 再次證實：EMS 永遠都有進步的方法。 公民意識 + 網軍推廣 + 科技運用 = 無限可能 荷 蘭 2018/11/27

48 第 1 名 高品質不中斷 CPR 的終極方法? Resuscitation. 2014; 85: 1541–1548
Am J Emerg Med. 2013; 31 : 910–915 BioMed Research International. 2014，e-pub ID AHA Scientific Sessions; Nov 19, 2014; Chicago, IL. 2018/11/27

49 絕不中斷的CPR 是否有可能? ACLS 2010 規定 CPR 中何時可以「停手」? 去 顫 電 擊 分 析 心 律 2018/11/27

50 CPR 去顫電擊 不停手 丹麥研究 一般醫用膠手套：無法安全「不停手去顫」 一級電絕緣手套：可以安全「不停手去顫」
一級電絕緣手套：不影響「按壓深度」 ~ Resuscitation. 2013; 84:895-9 電絕緣膠手套 PC-HOME 有在賣，一雙 2000 ~ 5000 不等 Resuscitation Jul;84(7):895-9 AHA Scientific Sessions; Nov 19, 2014; Chicago, IL. EMT + manikin ~ AHA Scientific Sessions; Nov 19, 2014; Chicago, IL. 2018/11/27

51 CPR 分析心律 不停手 VF Waveform Analysis During Chest Compression
Preliminary trial of AC-CPR Machine in MA. Barash DM, et al. Prehosp Emerg Care 2011. 將 VF 從 CPR 中分出，許多研究室都作得到 (包括台大與中研院團隊)。 但 Zoll 公司搶得先機。發表 AC-CPR (analyzing and charging during CPR) 在麻省的初步研究，大幅減少 EMT 作 CPR 三中斷時間。 ~ (Zoll See-Thru CPR) Preliminary trial of AC-CPR Machine in MA. Barash DM, et al. Prehosp Emerg Care 2011. 2018/11/27

52 你有沒有 vf 一電就成 Asystole 的經驗?
不停手分析：研究已進行20年 最近兩篇報告： 心律紀錄分析 過濾 VF/VT/ PEA/Asys： 80%，79%，73%，61% 臨床實測 過濾出 VF/VT：100% (99%-100%) 過濾出 PEA / Asys：58% (54%-64%) ~ Resuscitation. 2014; 85: 1541–1548 ~ Am J Emerg Med. 2013; 31 : 910–915 Am J Emerg Med. 2013; 31 : 910–915 For the nonshockable rhythms, the probabilities of delivering at least 2 and 3 minutes of uninterrupted CPR were 58% (95% confidence interval, 54%-62%) and 48% (44%-52%), respectively. These are the probabilities of reducing and substantially reducing the frequency of CPR interruptions for rhythm analysis. For the shockable rhythms, the probability of avoiding unnecessary CPR prolongation beyond 2 minutes was 100% (99%-100%). Resuscitation. 2014; 85: 1541–1548 The AUC was 0.80, 0.79, 0.73 and 0.61 for VF/VT, PEA, PR and AS respectively. BioMed Research International. 2014，e-pub ID Survival from out-of-hospital cardiac arrest depends largely on two factors: early cardiopulmonary resuscitation (CPR) and early defibrillation. CPRmust be interrupted for a reliable automated rhythmanalysis because chest compressions induce artifacts in the ECG. Unfortunately, interrupting CPR adversely affects survival. In the last twenty years, research has been focused on designing methods for analysis of ECG during chest compressions. Most approaches are based either on adaptive filters to remove the CPR artifact or on robust algorithms which directly diagnose the corrupted ECG. In general, all themethods report low specificity values when tested on short ECG segments, but how to evaluate the real impact on CPR delivery of continuous rhythm analysis during CPR is still unknown. Recently, researchers have proposed a new methodology to measure this impact. Moreover, new strategies for fast rhythm analysis during ventilation pauses or high-specificity algorithms have been reported. Our objective is to present a thorough review of the field as the starting point for these late developments and to underline the open questions and future lines of research to be explored in the following years. 不只如此… 你有沒有 vf 一電就成 Asystole 的經驗? 2018/11/27

53 他們都是 VF ! 電擊會不會成功 ? Making Chaos in Order? 亂中有序? VF 1 min VF 3 min
Amplitude measure 振輻轉換 RMS, Peak to Peak… (Hilbert transform) VF 3 min Frequency measure 頻率轉換 AMSA, Centroid Frequency… (Fourier transform) 希爾伯特-黃轉換（Hilbert-Huang Transform），由台灣中央研究院院士黃鍔（Norden E. Huang）等人提出，將欲分析資料分解為本質模態函數（intrinsic mode functions, IMF），這樣的分解流程稱為經驗模態分解(Empirical Mode Decomposition, EMD)的方法。然後將IMF作希爾伯特轉換(Hilbert Transform)，正確地獲得資料的瞬時頻率。此方法處理對象乃針對非穩態與非線性訊號。與其他數學轉換運算（如傅立葉變換）不同，希爾伯特-黃轉換算是一種應用在數據資料上的演算法，而非理論工具。 RANDOM SIGNAL: 不懂天文的人看滿天的星星。 CHOAS SIGNAL: 星象是成群成群在移動的。 VF 是一種 CHOAS SIGNAL 整理出亂中有序的方法可從 振幅 (希爾伯特轉換) 或 頻率 (傅立葉轉換) 著手 換轉後的指標可以和 VF 的結構時序 (相當於電擊成功的機率) 成線性關系 目前研究最多是 AMSA… (接下一張) VF 5 min ~Review of waveform analysis of VF. Curr Opin Crit Care 2005. VF Waveform Changes Over Time! VF 波型隨時間改變 VF: Chaotic signal but NOT random signal! 混亂但非隨機

54 Detrended Fluctuation Analysis (DFA)
Non-shockable Shockable Shockable DFA 中研院中央大學羅孟宗博士與台大的團隊合作，經 希爾伯特轉換 發展出的 DFA 指標。 Figure 1A. Two ventricular fibrillation (VF) waveforms. S0 indicated a shockable VF and S1 indicated an non-shockable VF (persisted VF or asystole after defibrillation). A sinusoidal wave with similar oscillation frequency was also demonstrated. Figure 1B. Detrended fluctuation analysis of two VF waveforms and a sinusoidal wave with similar frequency. Two scaling exponents (slopes) of DFA were called DFAα1 (scale 2-6) and DFAα2 (scale 6-11). 愈接近 正弦波　（想像如　ＶＴ） 愈容易被電擊成功 結果：DFA New amplitude measure (Hilbert transform) Better association with the organization of VF Better association with ischemic time of heart Better prediction (AUC under ROC) c/w AMSA OHCA in Taipei ECG and voice records in AED data cards were retrieved ; final N = 155 Reviewed by 2 cardiologists blinded to the outcomes and parameters Defibrillation success: organized rhythm within 10 sec after defib Count only first shock VF Non-stationary, complex, non random process Linear approach limited To rapidly distinguish between early and late VF Early VF - immediate defib Late VF - reperfusion followed by delayed defib New amplitude measure (Hilbert transform) Better association with the organization of VF Better association with ischemic time of heart Better prediction (AUC under ROC) c/w AMSA Non-shockable ~Lin LY, et al. Resuscitation 2010 (prediction of defib by DFA). ~Lin LY, et al. Resuscitation 2012 (monitor of CPRQ by HHT+ACF).

55 例：內建有 AMSA 的電擊器 Amplitude Spectrum Analyses (AMSA)
Early VF 去顫會成功 Late VF 去顫會失敗 AMSA 高，可電擊成功 AMSA 低，建議再 CPR 一陣子，穩定增加 CPP再電

56 高品質不中斷 CPR 的終極方法? 在你的想像， 未來的 pad 或 cpr 機器會怎樣? 目前：CPR品質品管 + 流程改進
即將：歡迎參加 2015/1/29 台灣首場 Zoll See Thru 試用會。 未來：會限制 EMS 進步的，只有我們的想像力! 在你的想像， 未來的 pad 或 cpr 機器會怎樣? 2018/11/27

57 2020 年社區裏的 AED (PAD)長這樣 Basic function 簡配 Advanced function 全配
Equipment status (pads, battery…etc.) 狀態顯示 Activation of 119 simultaneously 自動撥號119 Current location 自動地理定位 Reminder of CPR quality 提醒按壓品質 Advanced function 全配 Hands-on analysis 不停手分析功能 Delivery shock only to salvageable VF 只電成功的 2018/11/27

58 An Universal Algorithm for AED Electrocardiogram
2020 年醫院裏的 All-in-one CPR 機 CPR quality estimation CPR signal HHT+ACF An Universal Algorithm for AED Electrocardiogram DFA calculation VF HHT+LMS Shockable estimation Asystole VT CPR Shock 連結 ETCO2 即可偵測 ROSC 之後的急救 醫師可以更專注在 原因尋找 (5H5T) 及判斷是否需要 葉克膜 的事情上。 Organized rhythm PEA? ROSC ETCO2 Future Prospects: Hands-on analysis + appropriate shock + ROSC detector + Cooling… !

59 江文莒醫師 drchiang.tw@gmail.com 本投影片可在 TEMTA 網頁下載
社團法人中華緊急救護技術員協會 2015年TEMTA年會 暨 EMS研討會 謝謝參加 * 歡迎討論 13:24-1 3:42 - Wen-Chu Chiang (Taiwan): Factors influencing the bystander CPR rate and optimizing dispatch-directed bystander CPR in Taipei EMS Hollow everyone My name is Dr. Chiang Wen-Chu from Taiwan. I will talk about bystander CPR in Taipei My Topic today is factors influencing the bystander CPR rate and optimizing dispatch-directed bystander CPR in Tapiei EMS 江文莒醫師 本投影片可在 TEMTA 網頁下載 2018/11/27