CaPP Goes up in Aortic pressure increases Or CVP goes down
What is Coronary Artery Perfusion Pressure? Aortic diastolic Pressure Determinants 1.Vasodilation 2.Pump pressure Right Atrial Pressure Determinants 1.Volume 2.Right Heart Output
So in the arresting patient… Let’s focus on restoring CAPP Chest Compression
Chest Compressions First chest compressions Stopped compressions CPP
Chest Compression In studies of healthcare provider CPR, no chest compressions were provided in 24% to 49% of total arrest time. Need hard, fast and interruptions kill CPP Hard – get CPP > 15 mmHg Fast – Area under this curve best when at least 100 beats per minute
More about Chest Compressions Chest compressions effective at > 4 min post arrest Backboard helps with compressions Significant decrease in CPR quality occurs after 1 minute of chest compressions Need to change frequently Emphasis on recoil (neg intrathoracic pressure)- do not lean on patient
Chest Compressions The low-down is… – Even the best CPR has trouble getting CaPP > 15 mmHg – But when they do, a bunch of people come back – Open Cardiac Massage
So in the arresting patient… Let’s focus on restoring CPP Chest Compression Epinephrine
Alpha – vasoconstriction B1 – cardiac contractility Alpha is what we want, Beta can hurt us Beta Blockers – since widespread use, Vtach/Vfib arrests have dramatically dropped Beta blockade calms the electrical storm
Vasopressin Found to be more effective in animal model with pretreated pigs with beta blockers Increased CaPP
Epinephrine Epi does increase CPP High dose epi – 5.7 mm Hg (1 mg) vs. 11.3 mm Hg (0.2 mg/kg) change in CPP The effect of standard- and high-dose epinephrine on coronary perfusion pressure during prolonged cardiopulmonary resuscitation. N A Paradis; G B Martin; J Rosenberg; E P Rivers; M G Goetting; T J Appleton; M Feingold; P E Cryer; J Wortsman; R M Nowak (Profiled Author: Jack M Rosenberg) JAMA : the journal of the American Medical Association 1991;265(9):1139-44.Jack M Rosenberg Subsequent studies showed no improvement
The Cost of Epi Cerebral micro-vasoconstriction Bowel Infarction/Ischemia Renal Ischemia The Result Increased free radicals (More to come about the dreaded FRs!)
Use of IV in the arresting patient Time to Epi important for CPP 17.7 min is average time to first IV Epi given IO more effective and much faster Zuercher M, Kern KB, Indik JH, Loedl M, Hilwig RW, Ummenhofer W, Berg RA, Ewy GA.Epinephrine improves 24-hour survival in a swine model of prolonged ventricular fibrillation demonstrating that early intraosseous is superior to delayed intravenous administration. Anesth Analg. 2011 Apr;112(4):884-90. Epub 2011 Mar 8. Zuercher MKern KBIndik JHLoedl MHilwig RWUmmenhofer WBerg RAEwy GAAnesth Analg.
The Great IO No Difference in time to central circulation of various IO sites and peripheral IV sites – Crit Care Med. 1994 May;22(5):838-43. Pharmacokinetics from multiple intraosseous and peripheral intravenous site injections in normovolemic and hypovolemic pigs. Warren DW, Kissoon N, Mattar A, Morrissey G, Gravelle D, Rieder MJ.
So in the arresting patient… Let’s focus on restoring CPP Chest Compression Epinephrine Shock the Arrhythmia
Arrest < 5 minutes – Electrical Phase – Shock as soon as possible Prime the Pump – Circulatory Phase – May or may not be beneficial – ACLS algorithm (>5 minutes w/o CPR) – Recent studies have not shown benefit with this strategy >10 minutes Metabolic phase – Survival greatly decreased
When do I shock? Shock as soon as possible post compression stop
So in the arresting patient… Let’s focus on restoring CAPP But just because it’s necessary it’s not sufficient In some instances restoring CAPP comes at the cost of creating bad effects in other places (brain,kidneys)
Reperfusion Injury Return of blood flow causes damaged cells to release/disseminate their toxic metabolites Free Radicals/Interleukins Apoptosis Leads to more free radicals and interleukins
Therapeutic Hypothermia Two big studies, many more coming Indicated for Vfib/Vtach arrests, but has been generalized. One recent study in PEA/Asystole did not show benefit. Duration required (we will be participating in a large trial concerning this) and ideal temperature not known 32-34 degrees is our current goal
Intra – arrest cooling PRINCE Study – Not powered to show improvement – Designed to show it is safe – BUT…34% Neuro intact with intra-arrest cooling, 21% in standard care Circulation. 2010 Aug 17;122(7):729-36. Epub 2010 Aug 2. Circulation. Intra-arrest transnasal evaporative cooling: a randomized, prehospital, multicenter study (PRINCE: Pre-ROSC IntraNasal Cooling Effectiveness). Castrén M, Nordberg P, Svensson L, Taccone F, Vincent JL, Desruelles D, Eichwede F, Mols P, Schwab T, Vergnion M, Storm C, Pesenti A, Pachl J, Guérisse F, Elste T, Roessler M, Fritz H, Durnez P, Busch HJ, Inderbitzen B, Barbut D. Castrén MNordberg PSvensson LTaccone FVincent JLDesruelles DEichwede FMols PSchwab TVergnion MStorm CPesenti APachl J Guérisse FElste TRoessler MFritz HDurnez PBusch HJInderbitzen BBarbut D transnasal cooling is safe and feasible and is associated with a significant improvement in the time intervals required to cool patients.
What about ECMO? ROSC- not really a problem RONF – BIG PROBLEM We need to focus on the brain!
Someone who doesn’t have ECMO already thought of this Cardiocerebral Resuscitation University of Arizona CCR consists of 3 major parts: (1) continuous chest compressions with no early ventilations preshock and postshock; (2) delayed intubation; and (3) early use of epinephrine (EPI). Both survival (47.2% vs 19.6%) and percentage of survivors with good neurologic outcome (83.3% vs 77.8%) were significantly improved in those who underwent CCR.
U of A 1. Compression-only CPR by anyone who witnessed the event. 2. CCR by emergency medical service personnel, assumed to be arriving > 5 minutes postarrest. 200 chest compressions (at 100/minute), delay intubation; second person to apply defibrillation pads and initiate passive oxygen insufflation (eg, 100% oxygen via facemask) Single shock if indicated, immediately followed by 200 more chest compressions (no pulse check after shock) Check for pulse and rhythm; note that this pulse check occurs 4 minutes after the CCR has begun EPI intravenously or intraosseously as soon as possible to improve central circulation, coronary circulation, and diastolic blood pressure Repeat (b) and (c) 3 times; intubate if no return of spontaneous circulation after 3 cycles; note that neither bag-valve-mask ventilation nor intubation occurs until 12 minutes after the CCR has begun Continue resuscitation efforts with minimal interruptions of chest compressions until resuscitation is successful or the person is pronounced dead
The Major Benefit What’s going to save lives? – It’s probably not the Epi – Or the IO – Or the Chest compressions – It’s probably the fact that we make this a priority
What will change! No monitor initially IO is only line (unless good working line in field) Epi for code/Vasopressin if on B-blocker? Get patient from ambulance bay with autopulse ready Teach 2 HCPs and 2 nurses their role and do it One Nurse has laundry list of what needs to happen Resus Cart has everything easily available Sharp Shot Clock – compression timing, when epi due
Arrests at Sharp Out of Hospital No monitor initially IO is only line Epi for code/Vasopressin if on B-blocker? Get patient from ambulance bay with autopulse ready Teach 2 HCPs and 2 nurses their role and do it One Nurse has laundry list of what needs to happen Resus Cart has everything easily available In Hospital Yes, monitor and shock as soon as possible Use established IV, if not working use IO 2 HCPs/Nurses Use same laundry list Use Resus Cart
Bed US Crash Cart Beta Nurse RT HCP #1 and #2 Computer Theoretic Room line with Open Doors Alpha Nurse Resus Cart Mayo Alpha Doc Beta Doc Arrest Schematic Gamma Doc Vent Pharmacist
Resus Cart Upper Circulation Shelf IO Gun/Extra pieces Extra Sterile Gloves Cook Arterial Catheters Cordis Catheters Ultrasound Gel Sterile US Covers Lower Airway Shelf LMAs Crich Kit Waveform ETCO2 Detector Bougie Refrigerator with Iced Saline Autopulse
The Alpha Nurse (aka Task Nurse) Minute 0: Ensure Good CPR Minute ½: Give Epi/Vasopressin; 500 cc bolus NS (preferably iced) Check Temperature Minute 1: Ensure monitor applied to patient Minute 2: Change HCP/Check Monitor/ Shock if indicated Minute 2 ½: Start Ice packs to Axilla Minute 3: Direct establishment of peripheral IV Get Istat, Glucose, Remind doc to correct abnormal values
Beta Nurse Administer Epi/Vaso/Bicarb/Fluids as directed Standing order for 500 cc bolus IV NS upon presentation through IO/IV Start peripheral IV once initial round of CPR finished (3 minute mark)
Alpha Doc Minute 0: LMA insertion if no airway document ETCO2 and waveform ______ Minute ½: Give Epi/Vaso/Iced Saline Minute 1: If ETCO2 jumps, check pulses; Decide if ECMO candidate (See checklist); Oversee cannula placement Minute 1 ½: Heating measures for hypothermia Minute 2: Check pulses, rhythm; Shock if indicated Minute 2 ½: Ice packs to axilla Minute 3: Ensure good CPR Bicarb for Hyperkalemia, D50 for hypoglycemia, ROSC – Therapeutic Hypothermia ECMO Call IR or Cards to place femoral artery line to perfuse distal extremity Call Perfusionist Ensure Exit Strategy proceeding (Cath Lab, Dialysis, Antidote, other) Ensure Temperature is at 32 degrees (ice in ECMO tray as needed)
Beta Doc Start Arterial Line with Cook 6 Fr Art Line Start Art ECMO Line if Alpha Doc says go Proceed to Venous Line if Gamma doc having difficulties
Gamma Doc Start IO if no IV or unsure IV Start Venous Line using 9 Fr Cordis Insert 21 French ECMO Catheter if Alpha doc says go
ECMO Checklist Age less than 70 Does patient have good pre-arrest neurologic status? Does the patient have a reasonable exit strategy? Is the arrest less than one hour in total CPR? Was CPR started within 10 minutes of a known arrest time?
http://www.resuscitationcentral.com/ circulation/content.aspx?id=2246 Low amplitude after cardiac arrest x 4 min– decreased chance of conversion Higher amplitude after 3 minutes of CPR– increased chance of conversion High amplitude immediately after cardiac arrest