ROC Cardiac Arrest Research Trials – Analyze Early/Analyze Late and ITD

A bit unexpectedly, we’re wrapping up the “ROC PRIMED” cardiac arrest research trials on November 6 2009 since enough data is now in to allow important conclusions to be reached by the independent “Data Safety Monitoring Board” which controls the studies.

Major Success!

These trials were a major success, but some of the conclusions may surprise you.

1. Since we started these trials, we have significantly improved our cardiac arrest survival rate. We believe it’s likely that the high quality CPR you have been doing was behind this. This is a significant finding and tells us a lot about how to improve survival even further.

2. Despite nearly universal paramedic optimism, the ITD (the yellow Impedance Threshold Device in the airway “stack”) did not improve survival from cardiac arrest. It may have improved the number of ROSC cases where circulation was restored, but it turns out the same percentage of patients were discharged alive whether or not a real ITD or the “sham” or “fake” ITD was used. This conclusion was based on 7,706 cases in 14 sites, and the results from the Toronto Regional RescuNET were exactly the same as from Milwaukee, a site similar to Toronto in their excellent adherence to ITD use.

3. No difference in survival to discharge was seen between those patients in “Analyze Early” who got immediate rhythm analysis (and defibrillation where indicated), and those in “Analyze Late” who got extended “up-front” CPR before first analysis and shock. Again, this conclusion is based on huge numbers of patients (8,497 cases) and would not change if we continued to enroll more cases.

Was this trial a failure?

No way! This is prehospital science at its best, and only paramedics and firefighters (i.e. you) could have achieved this. Your hard work showed what probably improves survival the most (i.e. great CPR) – and you saved a lot of lives in the process. Your work showed the difference between laboratory science (which, for instance, thought the ITD worked) and the reality in the field, which proved that the ITD didn’t improve survival.

Only your hard work can achieve results like this and keep us focused on what really works for patients.

Finally and very importantly, these studies did not harm anyone – the results from each trial were exactly balanced between patients who got the new therapies – ITD and extended up-front CPR—and those who did not. That’s important as it shows we can safely try new things in the prehospital environment.

The trials created a treasure trove of data about cardiac arrest, and we’re going to carry right on collecting that data for all out-of-hospital cardiac arrests as we move towards trying out new post-arrest care approaches and new ideas in improving “compression-only” CPR.

What you need to know:

• As of November 6, 2009 all ITDs have been removed from the vehicles. If you find one, please return it to Rescu.
• With respect to defibrillator programming, RescuNET is working to gain consensus with participating EMS Services to have all defibrillators programmed to the “Analyze Early” configuration. This is the “up front CPR” treatment that most closely resembles the current patient care standards as well as treatment prior to the start of ROC PRIMED. Your early management of cardiac arrest will otherwise remain unchanged.
• Above all, remain focused on high quality CPR throughout the cardiac arrest – press harder, press faster and minimize hands-off time.

What does the future hold?

We will continue to look for ways to improve survival from cardiac arrest and we need your help! Please continue to the Cardiac Arrest Notification line for all arrests and upload your defib monitor file as per usual practice since the information is critical for our continued Cardiac Arrest (Epistry) database.

Thank you!

Every paramedic and firefighter who took part in this trial is highly respected for making this happen. Sure, we’re surprised by some of the results, but there are a lot more people alive out there because of your efforts in the ROC cardiac arrest trials - and that’s not going away.

On October 14^th, 2009, Dr. Rick Verbeek, Dr. Sheldon Cheskes and Dr. Steven Brooks presented “Between a ROC and a Hard Place: Resuscitation Science at the University of Toronto” as part of the University of Toronto - Division of Cardiology, University Rounds chaired by Dr. Paul Dorian. Learning Objectives were:

1. to understand the functioning, clinical, and research activities of the RESCU Network
2. to be aware of the new developments in basic resuscitation
3. to understand advances in post resuscitation care and their impact on outcomes

Resuscitation Outcomes Consortium  Overview-Ganging up on sudden death - Dr. Rick Verbeek
CPR Process - A new measure of CPR quality during cardiac resuscitation - Dr. Sheldon Cheskes
Life After Death - Optimizing care for the post cardiac arrest patient – Dr. Steve Brooks

September 16th, 2009

Presented by videoconference from St. Michael's Hospital to Baycrest, Mount Sinai, Sunnybrook Health Sciences Centre, Toronto General, Toronto Western, Trillium and Women’s College Hospital as part of “City Wide Medical Grand Rounds" 

ROC Solid – New approaches to resuscitating victims of sudden cardiac arrest – by Dr. Laurie Morrison focuses on the importance of real-time feedback on the quality of CPR – the confounder of outcome in cardiac arrest, and recognize the unrealized potential of improved post-arrest care – pushing survival rates up.