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jobkash · 2 years
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Stormwater Engineer
Freese and Nichols seeking an experienced Stormwater Engineer in Charlotte, Raleigh, Winston Salem or Atlanta. The Stormwater Engineer will lead stormwater study
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architectnews · 3 years
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Foster School of Business, Founders Hall, Washington
Foster School of Business, Founders Hall, University Of Washington Building, Architecture Images
Foster School of Business, Founders Hall, University of Washington
September 21, 2021
Design: LMN Architects
Location: 4215 E Stevens Way NE, Seattle, Washington, USA
LMN Architects Celebrates The Design And Topping Out Of The Foster School Of Business Founders Hall At The University Of Washington
The Founders Hall Learning Facility Expands The Michael G. Foster School Of Business While Vitalizing The Historic Campus Core.
Founders Hall, Foster School of Business, University of Washington
Seattle, Washington – September 21, 2021 – LMN Architects is proud to celebrate the “topping out” of the mass timber structure for Founders Hall at the UW Foster School of Business. Framing the northeast edge of historic Denny Yard, the open space at the heart of the original campus plan, the new 85,000 sf building is expected to be completed in the Summer of 2022.
Founders Hall expands the Foster School business education complex with a diversity of student-facing programs to further embed its interactive culture of learning, strategic thinking, and entrepreneurial initiative fabric of the central campus. The building is organized in two parts to optimize program functionality of workplace, learning and collaboration activities.
Active-learning, collaboration and event spaces are positioned at the south edge of the site to engage the distinctive qualities of the Denny Yard landscape, as well as link to the intensively used pedestrian pathways that traverse the precinct. Landscaped terraces and rain gardens reinforce the natural slope and evergreen plantings of the treasured open space. By contrast, the north building façade along Stevens Way is clad in masonry in response to solidity of campus buildings that front the ring road.
An open circulation space serves as a central connector with a feature stair that provides shared access to tiered classrooms, student commons, special event venue and outdoor terrace. The tiered classrooms are designed to serve multiple group sizes, from 65 to 135 students, with active-learning functionality. The collaboration zone is further activated by twenty-eight team rooms, four conference rooms, a student commons, and an event forum with an adjacent roof terrace.
Frank Hodge, Orin & Janet Smith Dean, Foster School of Business, comments: “LMN Architects has been a true partner in designing Founders Hall. Decisions were made in a collaborative manner with ideas openly shared and outcomes respected by both parties. Our decision to switch from a concrete and steel structure to a mass timber structure was a monumental shift in design. LMN excelled at incorporating all of our ideas to celebrate the use of wood in the project, and created a more open, inviting, beautiful, and highly functional design.”
Founders Hall reflects the highly interactive nature of business in the new century and is designed for sustainable performance and social connection to inspire future generations of business leaders. The project is a model for sustainable design at the University of Washington and is embracing UW’s Green Building Standards to reduce emissions from embodied carbon by 83%.
Mark Reddington, Partner, LMN Architects, comments: “This project completes a complex of interconnected buildings and spaces which we have been designing for the Foster School over many years. It serves multiple program functions with an inclusive and equitable social environment, integrated into the historic landscape of the UW campus.”
The building features a system of collaboration spaces designed to encourage teamwork and foster spontaneous interaction amongst students, program staff, and the broader business community. The classrooms, conference facilities, and recruiting spaces provide expanded opportunities for community and corporate engagement through hosting events and inviting outside speakers, alumni, and corporate recruiters.
Robert Vincent, Project Manager, Hoffman Construction Company, comments: “The guiding principle for our design-build team has been to identify the best alternatives and solutions for the project. We embraced the client’s desire for a mass timber structure, and although we experienced some supply chain disruption due to the pandemic, we are on track to become a model of what is possible with new technologies and construction techniques. It has been a pleasure to collaborate with everyone at the University of Washington, LMN Architects, the team of consultants, and all the trade partners involved in the success of the project.”
Robert Smith, Principal, LMN Architects, comments: “This project demonstrates how an integrated client and design-build team can translate a vision of sustainability into a building that is equally successful at fostering social performance of the users as well as the operational performance of the building. The 83% reduction in operational carbon is a result of careful balancing between envelope performance, the mechanical system design, and the users’ commitment to leverage operable windows and ceiling fans in lieu of energy-intensive air conditioning.”
The building is LMN’s most recent project within the Foster School of Business, which began with the initial master plan in 2002 and also includes the PACCAR Hall and Dempsey Hall projects. Founders Hall is one of the first projects at the University of Washington to be delivered through progressive design-build project delivery.
LMN Architects has designed more than 140 projects on 47 campuses in the United States, including the Bill & Melinda Gates Center for Computer Science & Engineering at the University of Washington in Seattle; the Voxman Music Building at the University of Iowa in Iowa City; Edward J. Minskoff Pavilion at Michigan State University in East Lansing; and the Wilbur O. and Ann Powers College of Business at Clemson University.
Founders Hall, Foster School of Business, University of Washington – Building Information
Design: LMN Architects
Project Title: Founders Hall, Foster School of Business, University of Washington.
Location: 4215 E Stevens Way NE, Seattle, WA 98105, USA
Design Years: 2018-2020
Construction Years: 2020-2022
Major Building Materials: Curtain wall, brick, mass timber structure (cross-laminated timber floors with glulam post and beam), concrete shear cores, steel long-span beams at classrooms.
Program: Case study classrooms, event space, student commons, team rooms, conference rooms, informal learning areas, administration and research offices, lounges, and outdoor event terraces. Includes surface parking, bike parking, and shower rooms.
Site Area:: 80,200 SFT (7,450 s.m.)
Floor Area: 85,000 SFT (7,897 s.m.)
Building Height:70’. (21.3 m.)
Number of Floors: 5
Project Images
Project Renderings: LMN Architects
Construction Images: Adam Hunter/LMN Architects
Project Credits
Architect: LMN Architects 801 Second Avenue, Suite 501 Seattle, Washington 98104
Project Team: Kjell Anderson, AIA David Backs James Blanchard Hank Butitta Nicholas Freese Andrew Gustin Emily Hankins Hanna Kato, AIA Mark La Venture, AIA John Lim, AIA Susan Lowance, AIA Vanessa Ly-Nguyen, AIA Veronica Macalinao, AIA Chris Patterson, AIA Mark Reddington, FAIA Chris Savage, AIA George Shaw, FAIA Robert Smith, AIA Masako Wada Kate Westbrook, AIA John Woloszyn, AIA Rushyan Yen
Design-Builder: Hoffman Construction Company.
Structural Engineer: Magnusson Klemencic Associates with Katerra.
Civil Engineer: Mayfly Engineering & Design, Pllc.
Landscape Architect: Gustafson Guthrie Nichol, Ltd.
Lighting Design: HLB Lighting Design.
Mechanical and Electrical Engineer: PAE Consulting Engineers, Inc.
Plumbing Engineer: Burman Design.
Signage: Studio Matthews.
Commissioning: Wilson Jones Commissioning.
Envelope Consultant: Morrison Hershfield.
LEED Administration and Energy Modeler: O’Brien360.
Environmental Graphic Designer: Advent, LLC.
Acoustics: The Greenbusch Group.
Trade Partners: Pellco Construction (Earthwork & Utilities), Steelkorr (Steel), Performance Contracting, Inc. (Interiors), McKinstry (Mechanical), VECA (Electrical), and Herzog Glass (Glazing).
Founders Hall, Foster School of Business, University of Washington images / information received 210921
LMN Architects
Location: 4215 E Stevens Way NE, Seattle, Washington, 98105, USA
Washington Architecture
Seattle Architecture Designs – chronological list
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Seattle Fire Station 32 Architects: Bohlin Cywinski Jackson photography : Nic Lehoux Seattle Fire Station 32
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Federal Way Performing Arts and Event Center Design: LMN Architects photo : Jeremy Bittermann Federal Way PAEC Seattle Building
Rocky Pond Winery Tasting Room, Chelan, Washington Design: SkB Architects photo : Benjamin Benschneider Rocky Pond Winery Tasting Room in Chelan, Washington
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KEXP Headquarters, Seattle photo : Jeremy Bittermann Washington building by SkB Architects
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Comments / photos for the Founders Hall, Foster School of Business, University of Washington page welcome
Website: USA
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songwriternews · 3 years
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New Post has been published on SONGWRITER NEWS
New Post has been published on https://songwriternews.co.uk/2020/12/the-secret-to-writing-lyrics/
The Secret To Writing Lyrics
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Lyrics are one of the most important aspects of songwriting: They’re the first thing most people listen to, and they convey your song’s story more clearly than anything else. But they’re really hard, right? Language is so complicated and weird that many of the structural approaches we theorists like to take for chords and stuff just don’t work. Well, fortunately for us, we’re not the only ones asking these sorts of questions, and the answers are out there. We just have to look a little further afield.
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Last: https://youtu.be/t2uNFpCRG9I Rhyming video: https://youtu.be/ToOqsk8m220 One Week: https://youtu.be/fC_q9KPczAg Cardboard Castles: https://youtu.be/FN1OR1aa2cM Accents video: https://youtu.be/JMxzLOSlhbs Sonnets video: https://youtu.be/-qoT5oReP0k
Script: https://docs.google.com/document/d/1ARBcjTR_0EkZt3Nb3ATtobroLCnyhPbiwNVmKtN2gQU/edit?usp=sharing
Huge thanks to our Elephant of the Month Club members:
Susan Jones Jill Jones Ron Jones Howard Levine Gabi Ghita Kaylor Hodges Elaine Pratt Ken Arnold Brian Etheredge Josh King Gene Lushtak Tom William (Bill) Boston Khristofor Saraga Nicolas Mendoza Anton Smyk Wolf Bennett RAD Donato Mitchell Fund Dale Monks Duck Chris Prentice Jack Carlson Len Lanphar Paul Ward Benjamin DeLillo Budjarn Lambeth Branden Randall Dov Zazkis Jesse Russo James Treacy Bagshaw Christopher Lucas Hendrik Payer Thomas Morley Abhijit Patel Andrew Beals
And thanks as well to Henry Reich, Eugene Bulkin, Logan Jones, Abram Thiessen, Anna Work, Oliver, Jc Bq, Dialup Salesman, Adam Neely, nico, Justin Donnell, Michael Fieseler, Rick Lees, Ben LaRose, rhandhom1, Harold Gonzales, Marc Himmelberger, Chris Borland, StarsServant, jason black,Nick Olman, Dutreuilh Olivier, Davis Sprague, Justin Bronstein, Justin Aungst, David Roulston, Dave Mayer, Thomás, billy roberts, Elliot Burke, Alex Atanasyan, Joey Strandquist, Daniel Gilchrist, Amlor, Greg Borenstein, Tim S., Elias Simon, Paul Quine, Anamol Pundle, David Tocknell, Jerry D. Brown, blalo’u, Christopher Wright, Lauren Steely, Fabian, Nikolay Semyonov, Ohad Lutzky, Jon White, Eivind Vatshaug, Josiah R. Hazel, Kurtis Commanda, Bate Goiko, James A. Thornton, Jacob Friend, Benjamin Cooper, Kevin, Joe Galetti, Arnas, CodenaCrow, Sarah Spath, Skylar J Eckdahl, Kristian Bredenbeck, John Bejarano, Gerhard Blab, drunkwookiee64, Brian Dinger, SD, Revolution Harmony, Aa Markus, Paul Apicella, Pawel Sit, David Barker, Adam Wurstmann, Dave Wray, Shadow Kat, Adam Kent, Michael Alan Dorman, Caroline Simpson, Lee Rennie, Richard T. Anderson, Thomas Schryver, Angela Flierman, Matthis Knopf, Kelsey Freese, Peter Wells, Zion Suppasan, Dan Lizotte, Seth Keller, Mark Feaver, Tyler Lukasiewicz, Kevin Johnson, Brian McCue, Kevin Hellon, Stephan Broek, Richard Walker, Wú QióngYuǎn, Nathan Petchell, Blake Boyd, alex, Calvin Blitman, Magnus Guldbrandsen, Ross Relic, Stefan Strohmaier, Lilith Dawn, David Baker, Jonathan Beck, Dmitry Jemerov, Jason Foster, Ian Seymour, Brett Haines, christian madsen, Luke Rihn, Rob Holton, Devon Wilhelmy, Ben Horwood, Jaroslav fedorčák, Allen Edwards, Brandon Lanning, Ryan Nicholls, ml cohen, Brandon Hamele, Darzzr, Rodrigo Roman, Francois LaPlante, Matthew Fox, Paper Coelacanth, Britt Ratliff, Patrick James Morley, Koen Hoogendoorn, Tae Wook Kim, Eddie O’Rourke, Ryan, Timothy Field, Jon Bauman, Drew Mazurek, Jacob Luedecke, Vincent Sanders, Victor L., Tommaso Ghidetti, JJ Deman, Volker Wegert, Linus Abrahamson, Matthew Kallend, Patrick Callier, JH, Joshua Gleitze, Ben Zotto, Jan Macek, Trevor, Michael McCormick, Charles Gaskell, Sylvain Chevalier, Yuriy Honcharuk, Roger Grosse, David Hardin, Jeremy Zolner, Leon Saleh, Valentin Lupachev, Paul Koester, and Danny! Your support helps make 12tone even better!
Also, thanks to Jareth Arnold and Jade Tan-Holmes for proofreading the script to make sure this all makes sense hopefully! source Find out More about becoming a PRO-HIT SONGWRITER here
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goalhofer · 4 years
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Freese And Nichols Inc. building in Tulsa, Oklahoma.
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neeeeeiiiiiiigh · 6 years
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City Walk plans close to being final
Morgan McIlwain, a program manager with the consulting firm Freese and Nichols, said the plan would be to “fast-track” the main spine of the project between Lenoir-Rhyne University and Ninth Street NW while the Union Square portion, as well as the pieces of art, will be bid as a separate package. from Google Alert - Spine News http://ift.tt/2ESkwz1
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It's Too Late To Do Anything About Climate Change.... Right?
Global Weirding is produced by KTTZ Texas Tech Public Media and distributed by PBS Digital Studios. New episodes every other Wednesday at 10 am central. Brought to you in part by: Bob and Linda Herscher, Freese and Nichols, Inc, and the Texas Tech Climate Science Center.
Global Weirding with Katharine Hayhoe
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christianworldf · 5 years
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New Post has been published on Christian Worldview Institute
New Post has been published on https://christianworldviewinstitute.com/bible-prophecies/end-time-events/book-of-daniel/understanding-the-chain/
Understanding The Chain
In many ways, The Chain is the story of Fleetwood Mac. Located right in the middle of Rumours, widely viewed as one of the best albums of all time, The Chain breaks from the soft rock sound of the rest of the album, stripping back the layers of false happiness and revealing a darker, harder, and more painful side of the band. Written in parts by all five band members, it lays bare the turmoil going on between them, and shows just how hard they’re working to keep things together just a little bit longer.
Patreon: https://www.patreon.com/12tonevideos Discord: https://discord.gg/QapX2MS Mailing List: http://eepurl.com/bCTDaj Facebook: https://www.facebook.com/12tonevideos Twitter: https://twitter.com/12tonevideos Instagram: https://www.instagram.com/12tonevideos/ Email: [email protected]
Last: https://youtu.be/xC6xLhSy7uw Polyphonic’s video: https://youtu.be/RqTARzw7j_w
Script: https://docs.google.com/document/d/1LK8DgQBEFrs3JADcYyA3-uKEiV4q0LoWQmVe09JXgmU/edit?usp=sharing
Huge thanks to our Elephant of the Month Club members:
Susan Jones Jill Jones Ron Jones Howard Levine Duck Brian Etheredge Gabi Ghita Elaine Pratt Ken Arnold Khristofor Saraga William (Bill) Boston Owen Campbell-Moore Mitchell Fund Len Lanphar Paul Ward Benjamin DeLillo Susan Lingenfelter Anton Smyk Chris Prentice Jack Carlson Dov Zazkis James Treacy Bagshaw Christopher Lucas Hendrik Payer Andrew Beals Thomas Morley Jacob Helwig Duncan Dempsey Patrick James Morley Alex Knauth Lukas Gigler Tyler Leite Paul Grieselhuber
And thanks as well to Corvi, Henry Reich, Gene Lushtak, Eugene Bulkin, Logan Jones, Abram Thiessen, Anna Work, Oliver, Jc Bq, Adam Neely, nico, Michael Fieseler, Rick Lees, Ben LaRose, Justin Donnell, rhandhom1, Dave Mayer, Thomás, Davis Sprague, Justin Aungst, Harold Gonzales, Paul Quine, Alex, Marc Himmelberger, Chris Borland, CodenaCrow, Nikolay Semyonov, Daniel Gilchrist, Arnas, Sarah Spath, Skylar J Eckdahl, billy roberts, Elliot Burke, Alex Atanasyan, Amlor, Greg Borenstein, Tim S., Elias Simon, Caroline Simpson, Michael Alan Dorman, Jerry D. Brown, Lauren Steely, Fabian, Nathan Petchell, Blake Boyd, Trevor, Michael McCormick, Lilith Dawn, Jonathan Beck, Dmitry Jemerov, Ian Seymour, Charles Gaskell, Luke Rihn, Rob Holton, Ohad Lutzky, Jon White, Kurtis Commanda, James A. Thornton, Benjamin Cooper, Kevin, Elliot Jay O’Neill, Elliot Winkler, Payden Nissen, Tom Evans, John Bejarano, Brian Dinger, Nervilis, Stefan Strohmaier, Adam Wurstmann, Kelsey Freese, Shadow Kat, Adam Kent, Max Wanderman, Lee Rennie, Richard T. Anderson, Angela Flierman, Mark Feaver, Tyler Lukasiewicz, Kevin Johnson, Brian McCue, Stephan Broek, Hape Company, Matt Giallourakis, Marcøs, Ryan Nicholls, ml cohen, Sylvain Chevalier, Darzzr, Roger Grosse, David Hardin, Rodrigo Roman, Francois LaPlante, Jeremy Zolner, Matthew Fox, Paper Coelacanth, Britt Ratliff, Koen Hoogendoorn, Tae Wook Kim, Eddie O’Rourke, Ryan, Jon Bauman, Vincent Sanders, John July, Volker Wegert, Paul Koester, Danny, Matthew Kallend, Patrick Callier, JH, Joshua Gleitze, Jake Lizzio, Ben Straubinger, Emilio Assteves, Alex Keeny, Alexey Fedotov, Charles Hill, Harry Hume, Valentin Lupachev, Joshua La Macchia, David Conrad, John Paul Welsh, Lisa Lyons, DSM, Gary Butterfield, Niko Albertus, Luke Wever, Elizabeth von Teig, Steve Brand, Rene Miklas, Connor Shannon, Chris Chapin, max thomas, Jamie Price, Kennedy Morrison, Red Uncle, Tiago de Caux, Toby M. Schreier, Daniel Garcia, Kirk Natoza, Doug Nottingham, Scott Howarth, Barendo, Smackdab, Nicholas Wolf, Ben Phillips, Hex86, Scott Nystrom, Douglas Anderson, ZagOnEm, Robert Beach, Todd Davidson, Fahzbehn, chaoticgeek, Lionel Dresta, veleum, and Kevin Boyce! Your support helps make 12tone even better!
Also, thanks to Jareth Arnold for proofreading the script to make sure this all makes sense hopefully! source
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landscapeusa · 5 years
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Never Underestimate The Influence Of Award Winning Landscape Photos | award winning landscape photos
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CPR First? Or Defibrillation First?
https://www.aclsmedicaltraining.com
Ventricular Fibrillation is considered the most favorable cardiac arrest rhythm, and if treated promptly can result in ROSC with a favorable neurological outcome. Most survival rates are reported using witnessed arrest with a shockable rhythm as opposed to asystole or PEA, as the outcomes of these rhythms are comparatively very poor. The Resuscitation Academy mantra “everyone in VF survives” has been adopted by many EMS systems around the world to emphasize that these patients can and do survive, and it’s up to us to save them. Major advances have been made over the past 10 years but CPR and defibrillation are still the bedrock of resuscitation science. The attributes of high-quality CPR were re-affirmed in the 2015 AHA ECC Guidelines.
Ensuring adequate rate (100-120)
Ensuring adequate depth (2 to 2.4” or 5 to 6 cm)
Allowing full chest recoil (avoid leaning)
Minimizing interruptions to chest compressions
Avoiding excessive ventilations
Is CPR Before Defibrillation Dogmatic?
In the context of a witnessed arrest by a trained first responder or bystander who has an AED or manual defibrillator, the importance of early defibrillation is irrefutable. We have been told repeatedly that early defibrillation saves lives. I initially began my research under the assumption that providing 1.5 to 3 minutes of CPR before defibrillation provides oxygen and nutrients to the heart therefore making defibrillation more likely to be successful. However, recent evidence suggests that performing chest compressions while setting up the defibrillator and charging the capacitor may be adequate. A “CPR first” approach is rooted in evidence suggesting the existence of 3 time-sensitive phases of VF arrest.
Electrical phase (0-4 minutes)
Circulatory phase (5-10 minutes)
Metabolic Phase (> 10 minutes)
Researchers suggested that a period of CPR prior to defibrillation might confer a benefit during the so-called “circulatory phase” of the cardiac arrest.
Evolution of American Heart Association Recommendations
Because it is rare for EMS to arrive on scene during the electrical phase, the 2005 AHA ECC Guidelines made this recommendation: When an out-of-hospital cardiac arrest is not witnessed by EMS personnel, they may give about 5 cycles of CPR before checking the ECG rhythm and attempting defibrillation (Class IIb). One cycle of CPR consists of 30 compressions and 2 breaths. When compressions are delivered at a rate of about 100 per minute, 5 cycles of CPR should take roughly 2 minutes (range: about 1½ to 3 minutes). This recommendation regarding CPR prior to attempted defibrillation is supported by 2 clinical studies (LOE 2, LOE 3) of adult out-of-hospital VF SCA. In those studies when EMS call-to-arrival intervals were 4 to 5 minutes or longer, victims who received 1½ to 3 minutes of CPR before defibrillation showed an increased rate of initial resuscitation, survival to hospital discharge, and 1-year survival when compared with those who received immediate defibrillation for VF SCA. One randomized study, however, found no benefit to CPR before defibrillation for non-paramedic-witnessed SCA. Fast forward 10 years to the 2015 Guidelines. Observational clinical studies and mechanistic studies in animal models suggest that CPR under conditions of prolonged untreated VF might help restore metabolic conditions of the heart favorable to defibrillation…others have suggested that prolonged VF is energetically detrimental to the ischemic heart, justifying rapid defibrillation attempts regardless of the duration of arrest. Evidence summary Five RCTs, 4 observational cohort studies, 3 meta-analyses, and 1 subgroup analysis of an RCT addressed the question of CPR before defibrillation. The duration of CPR before defibrillation ranged from 90 to 180 seconds, with the control group having a shorter CPR interval lasting only as long as the time required for defibrillator deployment, pad placement, initial rhythm analysis, and AED charging. These studies showed that outcomes were not different when CPR was provided for a period of up to 180 seconds before attempted defibrillation compared with rhythm analysis and attempted defibrillation first for the various outcomes examined, ranging from 1-year survival with favorable neurologic outcome to ROSC. Subgroup analysis suggested potential benefit from CPR before defibrillation in patients with prolonged EMS response intervals (4 to 5 minutes or longer) and in EMS agencies with high baseline survival to hospital discharge, but these findings conflict with other subset analyses. Accordingly, the current evidence suggests that for unmonitored patients with cardiac arrest outside of the hospital and an initial rhythm of VF or pVT, there is no benefit from a period of CPR of 90 to 180 seconds before attempted defibrillation. Specifically, the ROC PRIMED trial concluded that: Among patients who had an out-of-hospital cardiac arrest, we found no difference in the outcomes with a brief period, as compared with a longer period, of EMS-administered CPR before the first analysis of cardiac rhythm. The ROC Investigators subsequently found that EMS systems with a VF survival rate < 20% appeared to do better with an “analyze first” strategy. Conversely, EMS systems with a VF survival rate > 20% appeared to do better with a “analyze late” strategy.
Can the VF Waveform Determine the Likelihood of Successful Defibrillation?
Ventricular fibrillation sometimes begins as ventricular tachycardia, and if left untreated deteriorates into fine VF. Fine VF predictably results in conversion to asystole or continued VF, but rarely to a perfusing rhythm. Berg et al. performed a randomized, controlled trial using animals. After inducing VF in swine for 8 minutes, they were randomly assigned to either immediate defibrillation, or defibrillation provided after 90 seconds of CPR. Nine out of 15 attained ROSC in the CPR first group, and zero out of 15 who were defibrillated first resulted in ROSC. Their conclusion? Pre-countershock CPR can result in substantial physiologic benefits and superior response to initial defibrillation attempts compared with immediate defibrillation in the setting of prolonged ventricular fibrillation. Additionally, they determined there was a mathematical relationship between the VF waveform and chances of successful defibrillation. The animals who received CPR first had a much higher median frequency, and a much higher rate of ROSC than those that did not. In the field, whether or not VF is “fine” or “coarse” is typically based on visual inspection of the waveform. What if there was a way to accurately determine which patients would benefit from defibrillation and those that would not, thus eliminating unnecessary pauses and ineffective shocks? Callaway et al. and Eftestol et al. supported the theory that VF frequency and amplitude could be used to determine which patients will respond to countershock. Eftestol et al. concluded: CPR done by professionals can improve the chance for ROSC and ultimate survival of patients with prolonged cardiac arrest and significantly deteriorated myocardium. This study also indicates that CPR periods of 3 minutes might be better for the myocardium than shorter periods. Finally, together with the studies showing rapid deterioration of the myocardium in even a few seconds without CPR after a cardiac arrest, it gives the important message that periods without CPR (for ECG analysis, defibrillation charging, pulse checks, intubation attempts, etc) should be kept to a minimum. This is frequently not the case clinically. As promising as this may have seemed, an article in Circulation by Freese et al. evaluated the theory of defibrillation based on waveform analysis, and the results were disappointing. Use of a waveform analysis algorithm to guide the initial treatment of out-of-hospital cardiac arrest patients presenting in VF did not improve overall survival compared with a standard shock-first protocol. Further study is recommended to examine the role of waveform analysis for the guided management of VF.
The Bottom Line
The totality of the evidence suggests that defibrillation as soon as practicable (with the caveat that high quality chest compressions are performed while setting up the defibrillator) is equivalent to a prescribed interval of CPR prior to the first shock in most instances. EMS systems that measure the “patient’s side to first shock” interval know that it usually takes at least 1 minute to power on the defibrillator, extend the cables, attach the pads, charge the capacitor, and deliver the shock. During that interval, there’s no reason that the patient can’t receive continuous chest compressions. One benefit to emphasizing a “shock as soon as possible” approach is that it’s the same for EMS-witnessed cardiac arrest. Alternatively, defibrillation can be delivered after the first 2-minute cycle. It seems likely that CPR quality plays a more important role than the exact timing of the first shock.
References
Baker PW, Conway J, Cotton C, Ashby DT, Smyth J, Woodman RJ, Grantham H; Clinical Investigators. Defibrillation or cardiopulmonary resuscitation first for patients with out-of-hospital cardiac arrests found by paramedics to be in ventricular fibrillation? A randomised control trial. Resuscitation. 2008;79:424–431. doi: 10.1016/j.resuscitation.2008.07.017.
Bradley SM, Gabriel EE, Aufderheide TP, Barnes R, Christenson J, Davis DP, Stiell IG, Nichol G; Resuscitation Outcomes Consortium Investigators. Survival increases with CPR by Emergency Medical Services before defibrillation of out-of-hospital ventricular fibrillation or ventricular tachycardia: observations from the Resuscitation Outcomes Consortium. Resuscitation. 2010;81:155–162. doi: 10.1016/j. resuscitation.2009.10.026. Cobb LA, Fahrenbruch CE, Walsh TR, Copass MK, Olsufka M, Breskin M, Hallstrom AP. Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillation. JAMA. 1999;281:1182–1188.
Freese J, Jorgenson D, Liu P et al. Waveform Analysis-Guided Treatment Versus a Standard Shock-First Protocol for the Treatment of Out-of-Hospital Cardiac Arrest Presenting in Ventricular Fibrillation: Results of an International Randomized, Controlled Trial. Circulation. 2013;128(9):995-1002. doi:10.1161/circulationaha.113.003273.
Gilmore C, Rea T, Becker L, Eisenberg M. Three-Phase Model of Cardiac Arrest: Time-Dependent Benefit of Bystander Cardiopulmonary Resuscitation. The American Journal of Cardiology. 2006;98(4):497-499. doi:10.1016/j.amjcard.2006.02.055.
Hayakawa M, Gando S, Okamoto H, Asai Y, Uegaki S, Makise H. Shortening of cardiopulmonary resuscitation time before the defibrilla- tion worsens the outcome in out-of-hospital VF patients. Am J Emerg Med. 2009;27:470–474. doi: 10.1016/j.ajem.2008.
Huang Y, He Q, Yang LJ, Liu GJ, Jones A. Cardiopulmonary resuscitation (CPR) plus delayed defibrillation versus immediate defibrillation for out-of-hospital cardiac arrest. Cochrane Database Syst Rev. 2014;9:CD009803. doi: 10.1002/14651858.CD009803.pub2.
Jacobs IG, Finn JC, Oxer HF, Jelinek GA. CPR before defibrillation in out-of-hospital cardiac arrest: a randomized trial. Emerg Med Australas. 2005;17:39–45. doi: 10.1111/j.1742-6723.2005.00694.x.
Kleinman M, Brennan E, Goldberger Z et al. Part 5: Adult Basic Life Support and Cardiopulmonary Resuscitation Quality. Circulation. 2015;132(18 suppl 2):S414-S435. doi:10.1161/cir.0000000000000259.
Koike S, Tanabe S, Ogawa T, Akahane M, Yasunaga H, Horiguchi H, Matsumoto S, Imamura T. Immediate defibrillation or defibrillation after cardiopulmonary resuscitation. Prehosp Emerg Care. 2011;15:393–400. doi: 10.3109/10903127.2011.569848.
Ma MH, Chiang WC, Ko PC, Yang CW, Wang HC, Chen SY, Chang WT, Huang CH, Chou HC, Lai MS, Chien KL, Lee BC, Hwang CH, Wang YC, Hsiung GH, Hsiao YW, Chang AM, Chen WJ, Chen SC. A randomized trial of compression first or analyze first strategies in patients with out-of-hospital cardiac arrest: results from an Asian community. Resuscitation. 2012;83:806–812. doi: 10.1016/j.resuscitation.2012.01.009.
Meier P, Baker P, Jost D, Jacobs I, Henzi B, Knapp G, Sasson C. Chest compressions before defibrillation for out-of-hospital cardiac arrest: a meta-analysis of randomized controlled clinical trials. BMC Med. 2010;8:52. doi: 10.1186/1741-7015-8-52.
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Kenall-Freese And Nichols 8A Mentor Protege won a $10,000,000.00 contract from Department of the Army
Kenall-Freese And Nichols 8A Mentor Protege won a $10,000,000.00 contract from Department of the Army for conducting PRESOLICITATION - Indefinite Delivery Contract (IDC) for Architect-Engineer (A-E) Services, Southwestern Division (SWD), Fort Worth D http://www.environmentguru.com/pages/bids/opportunity.aspx?utm_source=dlvr.it&utm_medium=tumblr&id=3048611
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Construction Representative IV
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