Implantable Cardiac Devices Standardized Throughout Fraser Health

Effective September 2012, a regional model to standardize the service and delivery of Implantable Cardiac Electrical Devices (ICED) has been implemented throughout the Fraser Health Authority (FHA).

The purpose of the ICED project is to improve inpatient and outpatient access to device implants and replacement.

The types of Implantable Cardiac Devices included are:

  • Permanent pacemakers (PPM)
  • Implantable cardioverter defibrillators (ICD)
  • Cardiac resynchronization therapy (CRT) devices

Implantable Cardiac Devices

In his role as Hospital Medical Coordinator for the Jim Pattison Outpatient Care and Surgery Centre (JPOCSC), Dr. Holmes (founder of Iridia Medical) was involved with the ICED project by assisting and providing input into the project to the extent it impacted on physicians and/or service planning at the JPOCSC.

The team at Iridia Medical also contributed to revisions to the transport and admission protocols for the JPOCSC and other FHA facilities for patients receiving cardiac implants.

Presently, two hospitals have been designated as regional ICED sites:

  • Royal Columbian Hospital (RCH) – PPM, ICD and CRT devices
  • Jim Pattison Outpatient Care and Surgery Centre (JPOCSC) – PPM only

Royal Columbian and JPOCSC

The development of the ICED project has led to a variety of new clinical practice tools with the standing goal of improving device implants and replacement:

  • Regional referral form
  • Pre and post-procedure pre-printed physician orders
  • Inter-hospital transfer instructions and checklists, outpatient checklist and pamphlets
  • Patient and Family Information booklets

Current pacemaker practices were refined to align with the new regional model, such as the exclusion of an anaesthesiologist during PPM implantation for certain patients who meet defined criteria.

In lieu of an anaesthesiologist there will be trained personnel present during the procedure dedicated to monitoring the patient. In the future, this practice change will allow for PPMs to be implanted in procedure rooms other than operating rooms; allowing for more versatile use.

Dr. Holmes and Iridia applaud Fraser Heath for their excellent work developing the ICED project.

WHO Novel Coronavirus Infection – Update

As a leader in risk management and emergency preparedness services, we would like provide an update from the BC Centre for Disease Control and the World Health Organization regarding further detections of the novel coronavirus originally posted by the WHO  in September, 2012. 

What’s New – Novel Coronavirus

Four additional confirmed cases of the novel coronavirus identified.

  • Three in Saudi Arabia (including one death)
  • One in Qatar

The Qatar case had onset of severe respiratory symptoms in October, recovered and was released from care in November. Onset dates for the recent Saudi Arabia cases are not yet available.

To date, this brings the total number of laboratory confirmed cases to six.

  • Two cases fatal
  • All linked either to Saudi Arabia or Qatar

Of the four most recently confirmed cases, two are from the same family in Saudi Arabia and represent the first epidemiologically-linked cases.

One of these died and the other has recovered. In addition, two other members of the same family presented with similar symptoms of which one also died and one is recovering.

It has yet to be determined whether this family cluster signifies human-to-human transmission or rather shared exposure to a common animal (i.e. bat) source. Investigations are underway.

Novel Coronavirus

What’s Advised

The WHO advises that until more information is available; consider the novel coronavirus virus likely to be more broadly distributed than Saudi Arabia and Qatar.

Information on the full clinical presentation is only available for the first two cases reported in September 2012.

In the absence of other details or guidance, clinicians may reasonably consider novel coronavirus testing for patients presenting with signs or symptoms of severe acute respiratory infection (SARI), particularly in the absence of other explanation.

Acute Respiratory Infections

Worldwide Acute Respiratory Infections

Any clusters of SARI or SARI in health care workers should be thoroughly investigated regardless of where they occur.

Where this novel coronavirus is considered, the local health unit and/or Medical Health Officer should be immediately notified and guidance sought.

Patients should be managed in strict respiratory isolation including contact and droplet precautions.

The message from the WHO is not to panic but rather to  ask countries to be more vigilant.

WHO Update – November 23

The most recent WHO update is available at the following link:
http://www.who.int/csr/don/2012_11_23/en/index.html

Quiz – What’s your AED IQ???

Think your AED knowledge is top notch? Try our AED IQ quiz to find out!

http://www.proprofs.com/quiz-school/story.php?title=whats-your-aed-iq

First aid and AEDs save lives. The better you understand the process, the better equipped you are to help those around you. And as always, keep up to date on the latest first aid guidelines. You can find the current guidelines here at the heart and stroke foundation’s website:

http://www.heartandstroke.com/

How ETCO2 may inform vasopressor use!

Consider the following scenario. While in the emergency department a man suffers a witnessed cardiac arrest, for which he receives prompt high quality CPR, 200 joules defibrillation for an initial rhythm of V-Tach. The defibrillation is followed by a further 2 minute round of high quality CPR during which time an advanced airway with minimal interruptions in chest compressions. ETCO2 monitoring is initiated and shows 12mm/Hg. From this resuscitators can see that patient remains without pulmonary circulation and that the quality of CPR is satisfactory. After the 2 minutes, a quick pause in CPR reveals persistent V-Tach on the monitor. Chest compressions are resumed while the defibrillator is charged, the patient is cleared, 200 joules are delivered chest compressions are immediately resumed.


ECTO2

Let’s now consider two different paths that the ETCO2 scenario can take from here:

  • The defibrillation is unsuccessful, and during the 2 minutes of high quality CPR that follow the ETCO2 hovers around 7 mm/Hg. Seeing this low number, the team changes chest compression providers, and a new clinician is able to get the waveform up to 12mm/Hg. In this case, there is no ETCO2 indication of return of spontaneous circulation, and since there remain no signs of life, CPR is continued and as the code progresses the clinicians consider giving IV epinephrine.
  • Alternatively, the defibrillation is successful, and during the 2 minutes of high quality CPR that follow the ETCO2 jumps to 40mm/Hg. In this case there is ETCO2 indication of return of spontaneous circulation, and the team searches for other signs of life, which may include a pulse. Finding none: high quality CPR is continued however this time the decision is made to withhold the IV epinephrine.

The above scenario illustrates how continuous ETCO2 can not only serve to confirm ongoing placement of advanced airways, but can also be used to inform the quality of CPR, illuminate ROSC and help guide vasopressor use during resuscitation attempts. This being said there still remains no evidence that using epinephrine in this way contributes to neurological intact survival to hospital discharge.

Lastly, this practice of ETCO2 monitoring during resuscitation attempts relies on placement of advanced airways, which have been deemphasized in the ACLS Guidelines since 2005. As such we can see how with increased emphasis on ETCO2, the latest Guidelines may result in an increased use of advanced airways. This unto itself is not necessarily a bad thing, as long as we do not do so to the detriment of our patients. When using advanced airways there is an increase in responsibility to not interrupting chest compressions for too long, and to avoid the hyperventilation of our patients with tidal volumes that are too large and ventilation rates that are too excessive.

Darin Abbey RN
Clinical Nurse Educator
Emergency Department
Nanaimo Regional General Hospital

A Journey North

My second trip to north this year has come to an end and I’m back to sunny Vancouver. Sunny you say? It is actually beautiful and sunny as I write this on the 9th of November and I can barely believe my eyes.

This trip was longer than usual – 3 nights instead of 2 – and was great. Things got off to a good start with an uneventful trip to Ft. Nelson. While cool, at -12, it was sunny and clear.

I had the pleasure of driving to camp with Ginette, one of our PCPs. She has been a regular in camp for the past year and knows the road well. She handled all the radio duties while I drove. The road conditions could not have been better for gravel roads. They are frozen solid and very firm. With little snow on them, I had to be conscious of my speed. 80km/hr is the max and after all the emails I’ve sent reminding people not to speed it was time for me to walk the walk.

When we finally made it to camp, some 2.4hrs later, it was almost time for dinner. We greeted the other members of the team and found our rooms.

The food in camps can be interesting. Because the workers are typically doing labour intensive work, there is usually lots of food available and there is usually gravy! This night was no different – gravy was on order. I’m afraid it wasn’t my favorite meal but it was quickly forgotten with a prime rib dinner on day 2.

The next day I had my first rig tour. It was fascinating to climb the stairs to the rig floor. We were lucky enough to be there when the action started. The drill bit had to have a bearing replaced. As the drill was removed, the men got to work. This is not a job for those afraid of getting dirty! There is black colored fluid everywhere.

The guys move quickly and efficiently to replace the broken part and within a few minutes the bearing has been replaced and drilling resumes. If you ever get a chance to tour a drilling rig don’t pass it up.

The following day I headed was due to head to Ft. St. John. I good drive out and was in Ft. Nelson with plenty of time to spare. I visited the local library to get internet access – Rogers doesn’t work in Ft. Nelson – and reconnect to the world. After a couple hours I headed to the airport. The first thing I did was drop my rental keys in the drop box.

At check in, I was notified that the plane was going to be 2 hours late and did I want to leave the airport? Yes, I’d love to leave the airport but sadly I don’t have access to my truck anymore. Oh well, I guess I had better get comfy.

The plane arrived ‘early’ when it landed after 1.5hrs instead of two. The fun continued in Ft. St. John when the rental agency was closed. After a wait someone arrived and I was off to camp again. This drive was not as idyllic as my drive with Ginette. It was dark (8pm) and snowing. What a great combo! The good news is that for the most part the snow was not sticking to the ground and I made it camp. I had a good visit with Mark, the night ACP.

This morning started with breakfast with the whole team – night and day medics. We had a good visit and I had a chance to catch up with a safety advisor I had met nearly 5 years ago on my first trip to camp. By 10 in the morning it was time to hit the road again for the airport. I’m happy to report that my flight back to Vancouver was uneventful.

While I always enjoy my trips up north, getting home is even better.

Until the spring!

– Tom

View the slideshow

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Automated External Defibrillators and Children

Automated External Defibrillators

An automatic external defibrillator is used to restart a heart that is pumping with an ineffective rhythm that does not adequately circulate blood. In most cases AEDs come equipped with defibrillator electrode pads made just for children, but not always.

To address a few concerns, the following is a recent statement to our first-responders on the use of Automated External Defibrillators (AEDs) for children.

Automated External Defibrillators and Children

Position Statement

Iridia supports the use of Automated External Defibrillators (AED) in the pediatric population.

The following recommendations are provided for First-Responder Services with AED programs and are consistent with the current Heart and Stroke Foundation guidelines:

  • AEDs equipped with pediatric dose attenuator and pads should be used on children (aged 1-8) and infants (less than 1 year) with no signs of life
  • Pads should be placed in the standard anterior-apex position or in the anterior-posterior position
  • Should pediatric dose attenuator and pads not be immediately available, adult pads may be used on both children and infants with no signs of life.

For more information on AEDs  and their use, please visit our website.

Best Regards,
Dr. Allan Holmes
Medical Director, Iridia

Resuscitation and ETCO2: So what’s the use?

Resuscitation and ETCO2

Remember back in 2005 when it became ACLS Guideline directed practice to resume CPR immediately after defibrillation. Did that freak you out? Do you still pause after defibrillation, and try to sneak a quick peak at the monitor to check for a life sustaining rhythm?  Do you delay chest compressions to quickly feel for a pulse? If you answered, “yes” to either or both of these questions, perhaps you are doing so propelled by a combination of hope and or fear. Hope that your efforts at defibrillation were successful, and fear that your ongoing resuscitation efforts will cause harm. Indeed after defibrillation, the curious practitioner is left to wonder “what if our shock was successful and we obtained return of spontaneous circulation [ROSC], could we cause harm with chest compressions or by pushing IV epinephrine?”  At first glance delaying a rhythm and pulse check can feel like a great leap of faith, and for some members of the resuscitation community this leap represents a significant clinical hurdle to overcome. The 2010 ACLS Guidelines have given us a way to jump over that hurdle and keep on running safely through our resuscitations. In this latest iteration, emphasis has been placed on continuous waveform or capnometric ETCO2 monitoring. Achieved in cardiac arrest by inserting a line onto an advanced airway to a receiving monitor, this metric is used not only for ongoing confirmation of advanced airways, but also provides real time breath-by-breath physiological evaluation of patients. The study of capnography is multi-faceted and as a simplified statement normal values are 35-45 mm/Hg. The waveform below shows a patient with an ETCO2 of 34 mm/Hg: ETCO2 Naturally a pulseless patient, who has no pulmonary circulation, will in turn have no ETCO2. However when high quality CPR is performed, the exhaled ETCO2 jumps from 0 mm/Hg to greater than 10mm/Hg.  If during compressions, the ETCO2 lowers; code team members should turn their attention to the quality of the CPR being given. Rescuer fatigue for instance can dramatically decrease chest compression efficiency. The waveform below shows a patient receiving CPR with an ETCO2 rising from around 10 to 16 mm/Hg: ETCO2 If during high quality CPR there is a return of spontaneous circulation then the ETCO2 will display “an abrupt sustained increase” and as shown below will jump into the 35-45 mm/Hg range. ETCO2 This is how employing the use of continuous ETCO2 monitoring during CPR, that resuscitators are provided with insight into the outcome of their defibrillation attempts and with a window to ROSC. Indeed it is this information that allows clinicians to jump over the hurdle described above, and to gain an increased sense of comfort with the decision to resume chest compressions immediately after defibrillation. CPR

    Darin Abbey RN Clinical Nurse Educator Emergency Department Nanaimo Regional General Hospital

It’s Never Too Late For AED Training

Every Tuesday night a group of ex-university basketball players get together to duke it out on the court. This may not be all that unusual, unless you factor in the fact that the players are in their 60s and 70s.

Aptly named, the “Tuesday Knights”,this group of men is still committed to being active and to sharing their love of the game. It`s no small feat to be playing a sport with that kind of intensity at their age, but as evidenced in this Greg Douglas column in the Vancouver Sun, one member of the group accomplished an amazing feat.  

basketball

John McLean, 74 last week, joined a group of young guys at the YMCA on Burrard for a spontaneous free-throw showdown. Seven straight was the number he had to beat. McLean, a Magee high school grad and UBC alumnus, nailed 61 free throws in a row as jaws dropped from the crowd that quickly gathered. “I was getting tired and although I didn’t try to miss on purpose, I was glad when I did,” he said. “I’ve never been in a groove like that before.”

Read more:  The Vancouver Sun

Having said that, there are some natural concerns about 60 and 70 year olds demonstrating that level of physical exertion every week. At their age, the risk of a cardiac event is higher than it was in their younger days. For this reason, the group decided to purchase an Automated External Defibrillator (AED) and were trained in its use by our founder, Dr. Allan Holmes.

“I was approached at a golf tournament by one of the Knights’  members who was aware that many golf courses had AEDs, but many of the indoor basketball venues such as community centers and schools, did not.” said Holmes “This was an exceptionally bright bunch of guys who quickly picked up on the training, asked tough questions and were soon very confident in using the AED, should the need arise.”

defibrillators

This means that if one of the players were to have a sudden cardiac arrest, any of the Tuesday Knights would be there, immediately able to assist, and increase the chances of survival.

Iridia is thrilled to have provided the Knights with their AED and AED Training and training, and applauds their proactive measures. By staying active they are reducing one of the risk factors for cardiac issues, and by having an AED on hand, they are ensuring they’ll continue to play together for many more years. 

Medical Director Update – BC Ambulance AEDs reconfiguration

BC Ambulance AEDs

A recent memo was circulated by the Director of First Responder Services Randy Shaw regarding the reconfiguration of the BC Ambulance AEDs. In part this memo outlines the following. The BCAS AEDs are being reset to eliminate the “charge‐up whine” when a shockable rhythm is detected and instead prompt the responders to resume CPR – See appendix 1 for the complete memo.

This AED reconfiguration is being done to encourage crews to continue chest compressions during the charge‐up phase of the AED and is one more step in maximizing time on the chest.

Although I am in agreement in principle with this initiative, it has come to my attention that there may be a considerable cost for some Fire Service AEDs to be reconfigured. This cost depends on the software version installed in the AED. In discussions with BCAS and the Emergency Health Services Commission, the following is recommended based on the model of AED and the software version:

lp500/1000

1. LP 1000s with software version 2.42
Recommend – reconfigure as these units contain the same software as BCAS AEDS (no costs incurred)

2. LP 1000’s with software versions older than version 2.42
Recommend – reconfigure not required ‐ The cost to upgrade ($700.00 per unit) does not justify the benefit

3. LP 500
Recommend – reconfigure not required ‐ The cost to upgrade ($300.00 per unit)does not justify the benefit

For those units where there is a recommendation not to reconfigure, the same benefit (chest compressions during charge‐up) can be obtained by reminding crews that chest compressions should continue throughout the “charge‐up whine”.

Best regards,
Allan Holmes
Medical Director, Iridia Medical

Appendix 1

TO ALL FIRST RESPONDER AGENCIES, SENT ON BEHALF OF RANDY SHAW, DIRECTOR, FIRST RESPONDER SERVICES

This note is to advise you that effective this week BC Ambulance Service (BCAS) AEDs will begin to undergo a minor reconfiguration. The AEDs are being reset to eliminate the “charge‐up whine” when a shockable rhythm is detected and instead prompt the responders to resume CPR.

If a shockable rhythm was detected on analysis, the AED will begin to charge and a 15 second timer will show in the display window. At 12 seconds, the AED will warn the responders that a shock is advised and at 15 seconds, prompt the responders to stand clear and to push the shock button.

There is no change in the procedures for CPR.

As you know, we teach that chest compressions are to resume during the charge‐up phase. This change in AED configuration is purely intended to support the re‐establishment of chest compressions during that phase. Please notify your first responder agencies accordingly both so that they are aware of the BCAS AED change and so that first responder agency medical oversight may consider the change with their own AEDs if similarly configurable.