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Whats New in Resuscitation Greg Christiansen DO, MEd, FACOEP VCU Department of Emergency Medicine.

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Presentation on theme: "Whats New in Resuscitation Greg Christiansen DO, MEd, FACOEP VCU Department of Emergency Medicine."— Presentation transcript:

1 Whats New in Resuscitation Greg Christiansen DO, MEd, FACOEP VCU Department of Emergency Medicine

2 Disclosure No Industry or Third Party Affiliation No Conflict of Interest Credits: Dr. Kevin Ward Dr. Joe Ornato

3 Goals Recognize processes to follow in an emergent cardiac arrest as part of a resuscitation effort Be familiar with acute resuscitation concepts guiding acute cardiac care

4 Perceptions and Reality Television drama demonstrate 75 % survival rate Correlates with public perception of CPR success Adams found 81% of elderly admitted to a hospital believed there was a > 50% chance of their own survival if they had CPR Derrick Adams How mispercetpions among elderly pt regarding survival outcomes…JAOA 106 July 2006 Diem Cardiopulmonary resuscitation on TV: miracles & misinformation NEJM 1996:

5 Myths & Reality Successful field resuscitation rates 2-5% Long held belief… out of hospital cardiac arrest efforts are futile

6 Some Myths Die Hard

7 Flatliners..\..\..\Image File\recorded video\video\resuscitation\Flatlinev2.mpg

8 Question: Which One of these Organs are Primarily Perfused During Diastole? Brain Heart Kidney Intestines

9 Question: Which One of these Organs are Primarily Perfused During Diastole? Brain Heart Kidney Intestines

10 Which Patient has the Highest Chance of ROSC During CPR? A.ABP: 120/20, CVP: 20 B.ABP: 160/10, CVP: 30 C.ABP: 60/30, CVP: 0

11 Which Patient has the Highest Chance of ROSC During CPR? A.ABP: 120/20, CVP: 20 B.ABP: 160/10, CVP: 30 C.ABP: 60/30, CVP: 0 CPP = end diastolic atrial pressure – Right atrial pressure ( CVP) 30 – 0 = 30 CCP

12 Which Patient has Highest Likelihood of ROSC During CPR? A.PetCO2: 6 mmHg: ABP 100/30 B.PetCO2: 9 mmHg: ABP 120/20 C.PetCO2: 20 mmHg: ABP 70/20

13 Which Patient has Highest Likelihood of ROSC During CPR? A.PetCO2: 6 mmHg: ABP 100/30 B.PetCO2: 9 mmHg: ABP 120/20 C.PetCO2: 20 mmHg: ABP 70/20 CPP > 15 tend to have higher ROSC

14 What effect will Epinephrine or Vasopressin have during CPR? A.Lower PetCO2 levels B.Increase PetCO2 levels C.Increase Cardiac output D.Decrease Cardiac Output

15 What effect will Epinephrine or Vasopressin have during CPR? A.Lower PetCO2 levels B.Increase PetCO2 levels C.Increase Cardiac output D.Decrease Cardiac Output Vasopressors after load, COCPP ETCO2

16 Rosamond et al., Heart Disease & Stroke Statistics, 2008 Update. Circulation 2008; 117:e1-e122

17 Case: MR Ve Thach – 46 yo male collapsed on the tread mill Full arrest CPR ALS medication 10 minute down time

18 My First Case Fluid resuscitation ROSC Coma Decorticate Posturing Sent to CT Instituted therapeutic hypothermia

19 Were not making vegetables

20 Lessons learned What it is & why it works … sometimes

21 Cardiac Arrest Final common pathway: Everyone has it once A symptom or finding of a disease process Myocardial ischemia, profound hypoxia, conduction defects, toxicologic, hemorrhage, etc The ultimate state of shock: Global ischemia Neurologic outcomes better than commonly believed

22 Goals (when appropriate) Return of Spontaneous Circulation (ROSC) and reversal of underlying causes. What is the best therapy for the brain during CPR? Restart the Heart

23 Methods Electrical Therapy Pharmacological Therapy Mechanical perfusion

24 Ischemia: The Problem ATP ATP Failure

25 Importance of Myocardial ATP Myocardial Cell 100% ATP Myocardial Cell <10% ATP Myocardial Cell 30-40% ATP

26 Courtesy of Dr. Stig Steen University Hospital Lund, Sweden Cardiac Image No CPR

27 Cardiac Resus image with CPR

28 Coronary Perfusion Pressure (CPP) Key to Successful Resuscitation CPP = Ao d - RA d Ao d RA d

29 Effect of Chest Compression Pauses on Coronary Perfusion Pressure Aorta RA CPP

30 The Higher the CPP the Better

31 Mechanism for Cardiac Compression Direct Compression of Chambers Functional Aortic Valve Trend for higher CPP

32 Thoracic Pump Mechanism Global changes in intrathoracic pressure Heart is passive conduit Harder to achieve CPP Maybe better CePP Beware of Chest tubes

33 Which Pump? Not mutually exclusive Body habitus dependent? Both markedly deteriorate over time as valves become less functional.

34 Driving Blindly: Rule #1: Palpating Pulses to Monitor CPR Effectiveness ….. Is for Those Who Dont Know What to Do.

35 How to Improve CPP? Pharmacologically Vasopressors: Epinephrine vs. Vasopressin Mechanically Type of CPR: Regular, new and improved, delux

36 Effects of Epinephrine

37 Summary Many critical components to Successful Resuscitation (Neurological Recovery) Limiting Total Arrest time is Key!!! Obtain ROSC ASAP (5-10 minutes) After ROSC….Real work begins Similar to Trauma Care…Should be one with Cardiology/Pulmonary Critical Care

38 Improving Blood Flow during Resuscitation

39 Quality of Chest Compressions in OOH-CA Wik et al. JAMA 2005: 293: adult patients Sweden, Norway, England ROSC 35%

40 Minimally Interrupted CPR Experience Wisconsin & Arizona: Emphasis on compression quality and quantity New protocol 200 pre shock compression before defibrillation 200 post shock compression. Delays endotracheal intubation and eliminates pulse checks. Bobrow, B.J. et.al., Minimally Interrupted Cardiac Resuscitation by Emergency Medical Services for Out-of-Hospital Cardiac Arrest. JAMA; 2008; 299: pp

41 Minimally Interrupted Cardiopulmonary Resuscitation (MICR) by EMS Bobrow et al. JAMA 2008; 299: Peberdy MA, Ornato JP: JAMA 2008; 299: EMS agencies in Arizona 75% of state population 200 CCs first Rhythm check Single DF 200 CCs post-DF Early epinephrine Delayed intubation

42 CPR Prior to Defibrillation Christenson J et al. AHA ReSS 2007 ROC Epistry N= 7,963 Male 81% Byst CPR 51%

43 Compression Rate vs. ROSC Abella BS. Circulation 2005; 111:428-34

44 Effect of Incomplete Chest Decompression On Coronary and Cerebral Perfusion Pressures Yannopoulos D et al. Resuscitation 2005;64: Effect of Incomplete Chest Decompression On Coronary and Cerebral Perfusion Pressures Yannopoulos D et al. Resuscitation 2005;64: ǂ n=9 instrumented swine 6 minutes untreated VF standard CPR* x 3 min CPR with 75% recoil (residual 1.2 cm sternal end decompression) x 1 min standard CPR* x 1 min defib x 3 ACLS Critical pressure for ROSC (Paradis, JAMA 1990;263: ) % Chest Wall Decompression

45 Hands-Off Interval vs. DF Success Eftestol T et al. Circulation 2002; 105:2270-3

46 CPR Fraction prior to DF Christenson J et al. AHA ReSS 2007 ROC Epistry N= 7,963 Male 81% Byst CPR 51%

47 Improving Blood Flow During Resuscitation Summary 1.CPR necessary to provide coronary perfusion 2.Must restart the heart for survival 3.Conclusion – focus of the heart! Whats the evidence to support this focus?

48 Therapeutic hypothermia during or immediately after resuscitation

49 Today 500 of 5,000 hospitals use therapeutic hypothermia Capturing on 20% of all eligible patients If the patient cant walk out of the hospital then… A hospital bed is a parked taxi with the meter running - Groucho Marx

50 BRAIN INJURY is the most common cause of death after initial resuscitation from sudden cardiac arrest HIPPA

51 Contemporary Headlines Cooling off cardiac arrests More Hospitals Offering Therapeutic Hypothermia For Comatose Survivors Of Cardiac Arrest. When heart stops, hypothermia helps- Sunday Gazette Charleston WV

52 Public blogs say…

53 Public Commentary

54 Metabolic Chain of Events in Cardiac Arrest No Blood Flow Cerebral Ischemia O 2 Reperfusion Free Radicals Cell Death and Cerebral injury CPR / Pulse Cell Damage

55 Induced Hypothermia (32-34º C) The Hypothermia after Cardiac Arrest Study Group N Engl J Med 2002; 346 : European EDs 275 VT/VF pts with ROSC Cooled to 32-34º C using an external cooling device +/- ice packs for 24 h Sedated with midazolam and fentanyl, paralysed with pancuronium 6 month follow-up

56 Induced Hypothermia (33º C) Bernard SA et al. N Engl J Med 2002; 346 : Australian study 73 OOH-CA pts with ROSC Cooled to 33º C for 12 h

57

58

59 Cooling Techniques

60 Cooled IV Fluid Infusion

61 Pilot Randomized Trial of Prehospital Induction of Hypothermia in OOH-CA with Rapid Infusion of 4ºC Saline Kim et. al. Circ 2007;115: p=.15 p=.13

62 Specialized Post-Resuscitation Centers

63 Resuscitation Care ROSC

64 In-Hospital Factors Associated with Improved Outcome from OOH-CA Langhelle A et al. Resuscitation 2003; 56: regions in Norway

65 Implementation of a Standardized Treatment Protocol for Post Resuscitation Care After OOH-CA Sunde K, et al. Resuscitation, 2007 Before and after study on the effects of a comprehensive post resuscitation treatment protocol on neurologically intact survival to hospital discharge Early reperfusion with PCI Therapeutic hypothermia Standardized treatment protocol for glucose control, hemodynamic and ventilator management, seizure treatment Before group: 26% neuro intact survival After group: 56% neuro intact survival

66 Richmond Strategic Approach to Resuscitation Pre-arrival (phone CPR) Autopulse CPR (2 min) before DF 1 medic makes 1 attempt at ET, then use King LTS device 1 medic makes 1 attempt at IV, then insert EZ-IO device Vasopressin 40u IV alternating with epinephrine 1 mg IV every 5 min 2 L NS at 4º C IV started during CPR All pts brought to single center

67 RAA Field Hypothermia Induction Indications Initial VF or Witnessed arrest w/ PEA or asystole Initial core temperature >34 ºC No contraindications to cooling (e.g., terminal illness, DNAR, obvious signs of biological death)

68 RAA Field Hypothermia Induction Protocol Summary EMS Supervisor carries iced saline Expose patient; icepacks to neck, axilla, groin 4 ºC saline 30 ml/kg (up to 2 L) IV with pressure bag 18F orogastric tube Novotemp orogastric probe

69 Significant improvement with protocol change Citywide ROSC & Survival to Discharge Richmond, VA: vs p=.002 p=.0001 N= 1,233

70 Richmond Ambulance Field Hypothermia Induction T delta = -1.9 [95% CI -4.3, 0.4] ROSC= 86%

71 A dvanced R esuscitation C ooling T herapeutics I ntensive C are

72 ARCTIC 24/7 post-resuscitation team that can initiate endovascular cooling w/in 30 min of ED arrival Trained, dedicated support team of ED and CCU physicians and nurses ED team responsible for primary patient care CCU/cath team responsible for cooling Catheters placed by interventional cardiologist Alert initiated by EMS, activated by EM attending physician

73 Relative Contraindications to Continued Cooling After ED Arrival Persistent hypotension MAP <60 despite IVF and stable doses of vasopressors Known coagulopathy or thrombocytopenia Active bleeding Existing DNAR status Known end-stage terminal illness pre- arrest Severe neurological dysfunction pre-arrest

74 Goal-Directed Protocols Tight glucose control Cortisol screening for relative adrenal insufficiency Immediate neurology and critical care specialty consultation Continuous EEG monitoring with aggressive seizure management

75 Continuous EEG Monitoring Rossetti AO et al. Neurology 2007; 69: EEG monitoring in 166 adult comatose cardiac arrest pts 59% therapeutic hypothermia 33% survival Status epilepticus associated with poor survival

76 Consistent MD Direction Attending physicians experienced in post-resuscitation hypothermia care involved in every case 72h moratorium on offering withdrawal of life support Detailed neuropsychiatric testing

77 ARTIC Program Survival 2008

78 ARCTIC Cases 42 F arrest at church 42 F arrest at church 50 M lawyer arrest at YMCA 50 M lawyer arrest at YMCA 28 M Marfans arrest at home 28 M Marfans arrest at home 55 M prisoner arrest at City jail 55 M prisoner arrest at City jail 16 F MVP arrest at cheerleading 16 F MVP arrest at cheerleading

79 Summary Reviewed the latest information on what occurs physiologically during cardiac arrest Discussed ways to improve blood flow during resuscitation Described techniques to initiate therapeutic hypothermia during or immediately after resuscitation Discussed the importance of specialized post-resuscitation centers

80 Questions Thank you to Dr. Ornato & Dr. Ward for providing the slides & data support for this lecture


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