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Resuscitation and Post Resuscitation Care Jose G. Cabanas, MD MPH FACEP Paul R. Hinchey, MD MBA FACEP Office of the Medical Director Austin-Travis County.

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Presentation on theme: "Resuscitation and Post Resuscitation Care Jose G. Cabanas, MD MPH FACEP Paul R. Hinchey, MD MBA FACEP Office of the Medical Director Austin-Travis County."— Presentation transcript:

1 Resuscitation and Post Resuscitation Care Jose G. Cabanas, MD MPH FACEP Paul R. Hinchey, MD MBA FACEP Office of the Medical Director Austin-Travis County EMS System

2 Austin/Travis County EMS Approximately 1.2 million citizens, 1,100 square miles, 120k EMS calls per year Approximately 1.2 million citizens, 1,100 square miles, 120k EMS calls per year 1,000 cardiac arrests responses per year 1,000 cardiac arrests responses per year 14 Fire Departments (1,500 FF’s,) 14 Fire Departments (1,500 FF’s,) EMS Transport Agency (400 Paramedics) EMS Transport Agency (400 Paramedics) EMS Systems are judged by their cardiac arrest resuscitation rates EMS Systems are judged by their cardiac arrest resuscitation rates –Most large cities are 5-7% –King Cnty Wa 35-45% –Wake Cnty NC 38-42% –Austin 38%

3 Why are we talking about Cardiac Arrest Resuscitation?

4 Philosophy of Five Time Dependent Time Dependent –Acute MI (STEMI) –Acute Stroke –Trauma / Surgical Emergency Intervention Dependent Intervention Dependent –Cardiac Arrest –Respiratory Distress Sophisticated providers/systems understand the difference Sophisticated providers/systems understand the difference

5 Time Dependent These conditions can not be definitively treated in the pre-hospital environment These conditions can not be definitively treated in the pre-hospital environment Requires specialized intervention only available in the hospital Requires specialized intervention only available in the hospital Outcomes are improved by early access to definitive intervention Outcomes are improved by early access to definitive intervention Goal is recognition and short scene interval Goal is recognition and short scene interval

6 Intervention Dependent Initial treatment can be delivered in prehospital environment Initial treatment can be delivered in prehospital environment Outcomes linked to prehospital interventions Outcomes linked to prehospital interventions Goal is identification and initiation of treatment Goal is identification and initiation of treatment Scene intervals are NOT critical Scene intervals are NOT critical

7 Updates in Out-of- Hospital Resuscitation and Post Resuscitation Care

8 Objectives Describe the importance of continuous compressions and controlled ventilations Describe the importance of continuous compressions and controlled ventilations Discuss what to do with the airway/drugs Discuss what to do with the airway/drugs Acknowledge the difficulty of performing continuous compressions and the need for a scripted process Acknowledge the difficulty of performing continuous compressions and the need for a scripted process Discuss importance of on-scene post ROSC stabilization Discuss importance of on-scene post ROSC stabilization Describe role of resuscitation centers Describe role of resuscitation centers Identify questions for the future Identify questions for the future

9 Why do we worry about CA Represents < 1% of our calls but… Represents < 1% of our calls but… > 70% of CA arrests occur outside the hospital > 70% of CA arrests occur outside the hospital Definitive management of cardiac arrest is in the prehospital environment Definitive management of cardiac arrest is in the prehospital environment

10 “Stated succinctly, if ACLS care in the field cannot resuscitate the victim, ED care will not resuscitate the victim.” American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care (Part 7.2: Management of Cardiac Arrest)

11 Priorities in OOHCA Changed Emphasis on compression Emphasis on compression Limit interruptions from ANYTHING Limit interruptions from ANYTHING Goal is to maximize % of time in compressions Goal is to maximize % of time in compressions Single D-fib every two minutes Single D-fib every two minutes –Precharge monitor before break –Follow d-fib immediately by compressions Decreased importance of ventilations Decreased importance of ventilations –Fewer number of breaths –Each delivered more slowly

12 So if you had to push a car, would you push a few feet and stop….. only to start again a few minutes later?

13

14 So how important are compressions?

15 Compression fraction article Circulation 2009

16 If compressions are the most important therapy when do you move the patient…..

17 Prehospital Emergency Care 2011;15(1):106

18 Results (Pre-Feedback) N = 108 % (25 th, 75 th ) Scene Correct Rate% Median: 44.8 (9.54, 59.6) Mean: CI (33.2, 43.78) Transport Correct Rate% Median: (5.83, 39.32) Mean: CI (18.35, 27.97) Scene Correct Depth% Median: (15.96, 73.29) Mean: CI (38.76, 51.37) Transport Correct Depth% Median: 8.88 (2.62, 49.01) Mean: CI (20.12, 32.63)

19 Results (Post-Feedback) N = 35 % (25 th, 75 th ) Scene Correct Rate% Median: (14.68, 62.36) Mean: 43.6 CI (34.61, 52.59) Transport Correct Rate% Median: 19.0 (9.52, 60.22) Mean: CI (23.21, 42.33) Scene Correct Depth% Median: (36.23, 95.07) Mean: CI (56.57, 77.16) Transport Correct Depth% Median: 14.0 (4.78, 90.78) Mean: CI (27.98, 56.11)

20 How about ventilations?

21 Importance of controlled Ventilation Normal inspiration is negative pressure Normal inspiration is negative pressure –Encourages blood return to the chest Artificial ventilation is positive pressure Artificial ventilation is positive pressure –Reduces blood return to the chest The faster the ventilation rate the higher the mean intrathoracic pressure The faster the ventilation rate the higher the mean intrathoracic pressure Higher MIP reduces cerebral emptying and reduces blood return to the heart Higher MIP reduces cerebral emptying and reduces blood return to the heart

22 Survival in hyperventilation

23 STOP Hyperventilating Telling providers not to hyperventilate is ineffective Telling providers not to hyperventilate is ineffective High adrenaline situation High adrenaline situation Tendency to ventilate faster and faster Tendency to ventilate faster and faster Requires conscious effort to slow rates Requires conscious effort to slow rates Need constant reminder Need constant reminder –Timing device –Goal directed ventilation

24 How to Deliver Ventilations Goal is to oxygenate primarily and ventilate as a secondary consideration Goal is to oxygenate primarily and ventilate as a secondary consideration Must provide continuous uninterrupted compressions Must provide continuous uninterrupted compressions Traditional method is endotracheal intubation but increases interruption in compresions Traditional method is endotracheal intubation but increases interruption in compresions So is this a paradigm that needs to be challenged? So is this a paradigm that needs to be challenged?

25 Interrupt CPR…not ME 100 Cardiac Arrests CPR interruptions 2* (1-9) 1 st ETI interruption 46.5 s* (7-221 s) Total all ETI interruption s* ( s) 1/3 > 1 min; ¼ > 3 min ETI Interruptions 23% of all * Indicates median values reported Wang et al Ann Emerg Med. 2009

26 But an advanced airway is a better airway…..

27 Advanced Airway Management Advantages Advantages –No mask seal required –Easier to do –Less manpower –Allows continuous compressions Disadvantage Disadvantage –Requires interruption of compressions –Easier to hyperventilate (rate and volume) –Doesn’t provide better ventilation/oxygenation

28 173 LMA vs 200 BVM by paramedics 173 LMA vs 200 BVM by paramedics No difference in median: No difference in median: –Pa CO v 55.3 (p=0.06) –Pa O v 71.9 (p=0.056) There is no MAGIC to these devices There is no MAGIC to these devices

29 Retrospective analysis of OOHCA Retrospective analysis of OOHCA 1,294 Cardiac Arrests 1,294 Cardiac Arrests – 79% received intubation –10% BVM –4% Combitube/EOA After adjusting for age, bystander CPR, witnessed arrest and initial rhythm After adjusting for age, bystander CPR, witnessed arrest and initial rhythm OR for BVM vs Advanced airway was 4.5 OR for BVM vs Advanced airway was 4.5

30 What is best vascular access? Goal is vascular access by any means that does not interrupt compressions Goal is vascular access by any means that does not interrupt compressions Preferably rapid reliable access that does not detract from other tasks Preferably rapid reliable access that does not detract from other tasks Based on assumption that the drugs do anything….more on this later Based on assumption that the drugs do anything….more on this later IO access can be achieved in < 10 sec but which site should be used? IO access can be achieved in < 10 sec but which site should be used?

31 88 Cardiac arrest 88 Cardiac arrest 56 (65.9%) used tibial site first 56 (65.9%) used tibial site first –Initial success rate 89.7% –3 (5.8%) dislodged 18 (34%) used humerus first 18 (34%) used humerus first –Initial success rate 60% –6(33%) dislodged Overall success rates Overall success rates –Tibia 84.5% –Humerus 40%

32 So what about the drugs? Most recent quandary Most recent quandary Standard of care is currently being challenged Standard of care is currently being challenged Will be a major change in management in your career Will be a major change in management in your career Who will make the first step… Who will make the first step…

33 851 patients with OOHCA randomized to: 851 patients with OOHCA randomized to: –418 given IV drugs –433 given no drugs Primary outcome hospital discharge Primary outcome hospital discharge Also looked at: Also looked at: –Hosp admission with ROSC –Neuro outcome at discharge –Survival at 1 year

34

35 Recent epi study

36 Running the Arrest CA is not the most diagnostically challenging condition so thought to be “EASY” CA is not the most diagnostically challenging condition so thought to be “EASY” EXECUTION is anything but… EXECUTION is anything but… Conflicting interests of multiple tasks and the need for continuous uninterrupted compressions and infrequent occurence Conflicting interests of multiple tasks and the need for continuous uninterrupted compressions and infrequent occurence

37 This is harder to do than you think

38 Task Interruptions Airway interventions and IVs Airway interventions and IVs Ventilations Ventilations Pulse checks Pulse checks Rhythm analysis Rhythm analysis Defibrillation Defibrillation Changing compressors Changing compressors Patient movement Patient movement

39 We have limited awareness of task time in complex processes….so these interruptions should be engineered and choreographed to minimize their impact…..

40 >20 second pause for defibrillation. Appears that a ventilation was given before the compressions resumed. Compressions resume 10 seconds after shock delivery.

41 Long pause for ventilations. Then short sequence of compressions during defib charging. Compressions resumed approximately 5 seconds after shock 1 delivered.

42 Why engineer the process? Creates uniformity: Creates uniformity: –Accurate assessment of outcomes –Linking specific interventions to outcomes –Baseline for future modification In the process it: In the process it: –Improves outcomes –Improves efficiency –Reduces errors

43 Regional Variation in Incidence / Outcome ,898 cardiac arrests 11,898 cardiac arrests 2729 had initial rhythm of V-Fib / V-Tach had initial rhythm of V-Fib / V-Tach. 954 (4.6% of total) were discharged alive. 954 (4.6% of total) were discharged alive. Incidence of EMS-treated CA was 52.1 per Incidence of EMS-treated CA was 52.1 per survival ranged from 3.0% to 16.3% (median of 8.4%) survival ranged from 3.0% to 16.3% (median of 8.4%) Median ventricular fibrillation 12.6 per Median ventricular fibrillation 12.6 per survival ranged from 7.7% to 39.9%, survival ranged from 7.7% to 39.9%,

44 So how do you control variability

45

46 Professional CA resuscitation is to CPR …. ….what a pit crew is to changing tires

47 Pit Crew Model Same name…many versions Same name…many versions CPR CPR –Maximize compression fraction –Effective compression(rate/depth) –Provider fatigue Controlled ventilations Controlled ventilations Defib Defib –Emphasis on Shock/Don’t’ shock

48 Current Goal: Less than 10 second break in every 2 minute cycle of CPR

49 Staying Alive or Another One Bites the Dust? Staying alive 103 bpm Staying alive 103 bpm 30:2 30:2 –100 compressions/min =18s for compressions –5 s break for ventilations every 30 compressions? –18 of every 23s in active compression is 78% –NOT counting other breaks in CPR Pit Crew Pit Crew –Continuous compressions w/asynchronous ventilation –10s break every 2 min is 92% –5s break every 2 min is 96%

50 Typical example (actually 40:2) ©2010 Paul R. Hinchey

51 Good example of ventilations at a rate of about 8-10 per minute. ©2010 Paul R. Hinchey

52

53 So we went to the simulation lab and now it’s ALL choreographed….

54

55 BLS & ALS

56

57

58 ©2010 Paul R. Hinchey Need cpr checklist

59 Some Scenarios

60 Scenario 1 78 y/o Wal-Mart greeter suffers cardiac arrest in the front of a store: 1. Where do you work the cardiac arrest? Would this be different if it were in his house? 2. When do you begin transport to the hospital? 3. If unsuccessful when do you terminate the resuscitation?

61 Scenario 2 78 y/o Wal-Mart greeter has been resuscitated from CA and is being transported when he re-arrests: 1. What would you instruct your crews to do if they were 20 min out from the hospital? 2. What if they were 5 min out?

62 Scenario 3 78 y/o suffers CA at home. Wife does 2 min dispatcher directed CPR. Pt has ROSC and wakes up. Walks to couch. Crews find in CHF and treat appropriately w/meds and CPAP. FF ride w/crew to hosp. While pulling into ED bay pt goes into CA: 1. What do you want your crews to do?

63 Take Home Message CA is not as easy as once thought CA is not as easy as once thought Pre-hospital providers must be the experts Pre-hospital providers must be the experts Its all about compressions Its all about compressions Airway, drugs, etc are a big ? Airway, drugs, etc are a big ? If you want to do this well you must have universally understood goals and plan If you want to do this well you must have universally understood goals and plan

64 Post Resuscitation Care

65 Post-Cardiac Arrest Syndrome Post-cardiac arrest brain injury Post-cardiac arrest brain injury –Responsible for 68% of deaths of patients who survived to ICU admission (Lever, 2004) Post-cardiac arrest myocardial dysfunction Post-cardiac arrest myocardial dysfunction –LV dysfunction, myocardial stunning, cardiogenic shock Systemic ischemia/reperfusion injury Systemic ischemia/reperfusion injury –Inflammatory response, impaired vasoregulation, oxygen delivery and utilization, resulting in hypotension / MSOF Persistent precipitating pathology Persistent precipitating pathology –STEMI, Toxic Ingestion, Hypoxia, Hemorrhage, etc.

66 Phases of Post-Cardiac Arrest Syndrome

67 Post-Resuscitation Care Goals of Post-Arrest Care Goals of Post-Arrest Care –Maintain Hemodynamic Stability –Preserve the Brain –Avoid hyperventilation –Prevent re-arrest Elements of Post-Care include Elements of Post-Care include –Vasopressor titration –Therapeutic Hypothermia –Early Cardiac Catheterization –Sedation –Glucose and Electrolyte Management

68 Post Cardiac Arrest Care The first 20 minutes after ROSC is the Immediate Phase of Post Cardiac Arrest Syndrome The first 20 minutes after ROSC is the Immediate Phase of Post Cardiac Arrest Syndrome Patients in these phases may be critically ill and benefit by immediate treatment AT SCENE: Patients in these phases may be critically ill and benefit by immediate treatment AT SCENE: –This is a better strategy for patient survival than rapid movement to the vehicle and rapid transport delaying or deferring key interventions –Failure to initiate immediate aggressive treatment may result in re arrest of patient or increased morbidity

69 1,199 Cardiac Arrests 1,199 Cardiac Arrests ROSC in 27.4% ROSC in 27.4% Rearrest in 36% Rearrest in 36% Time to rearrest Time to rearrest –Median 3.1 min ( )

70 Post-Resuscitation Care Focus should be on restoring perfusion Focus should be on restoring perfusion –Perfuse the myocardium –Perfuse the brain Fluids and pressors for MAP >90 Fluids and pressors for MAP >90 Remove the ITD Remove the ITD Initiate hypothermia Initiate hypothermia Obtain 12 lead EKG Obtain 12 lead EKG THEN move the patient THEN move the patient

71

72 Barriers in Post-Cardiac Arrest Care Post– cardiac arrest patients are treated by multiple teams of providers Post– cardiac arrest patients are treated by multiple teams of providers Variation in post-cardiac arrest treatment and patient outcome between institutions. Variation in post-cardiac arrest treatment and patient outcome between institutions. Limited reliability of early prognostication (<72 hours after arrest) Limited reliability of early prognostication (<72 hours after arrest)

73 The science behind the cooling Han Solo frozen in Carbonite – Star Wars Episode V (1980)

74 Journal Iowa Medical Society, November 1964

75 Therapeutic Hypothermia HACA 2002 Bernard 2002 Idrissi 2001

76 ILCOR Advisory Statement Unconscious adult patients with ROSC after out-of-hospital VF cardiac arrest should be cooled to 32°C - 34°C for hours Possible benefit for other rhythms or in-hospital cardiac arrest

77 Editorial Comments “The reason hypothermia has not become the standard of care for post- resuscitation is simple. Emergency and EMS physicians have failed to make it so.” “The reason hypothermia has not become the standard of care for post- resuscitation is simple. Emergency and EMS physicians have failed to make it so.” –Mennegazzi and Callaway, PEC 2005

78 “The Future” 720j Defibrillation? 720j Defibrillation? Hands on Defibrillation? Hands on Defibrillation? Intra-arrest cooling? Intra-arrest cooling? Mechanical CPR and AC/DC CPR? Mechanical CPR and AC/DC CPR? Regional Receiving Facilities? Regional Receiving Facilities?

79 Knowledge Gaps Impact of Prehospital Cooling in Outcomes? Impact of Prehospital Cooling in Outcomes? –Continuous temperature in the Field? –Rate of Cooling? –Target? How Long? Urban vs. Rural EMS? Urban vs. Rural EMS? ALS Vs BLS? ALS Vs BLS? How do we train Providers? How do we train Providers?

80 Take Home Message Resuscitation is not over with ROSC Resuscitation is not over with ROSC Post-Cardiac Arrest Patients need to be treated with a high sense of urgency. Post-Cardiac Arrest Patients need to be treated with a high sense of urgency. Patients should receive hypothermia specially if initial rhythm was VF/VT. Patients should receive hypothermia specially if initial rhythm was VF/VT. Hypothermia is not a substitute for other key components in the Chain of Survival Hypothermia is not a substitute for other key components in the Chain of Survival

81 Take Home Message Post-resuscitation/cardiac specialty hospitals should receive patients directly from the field or in prompt transfer Post-resuscitation/cardiac specialty hospitals should receive patients directly from the field or in prompt transfer Coordination between EMS, EM, ICU, and Cardiology is a must!! Coordination between EMS, EM, ICU, and Cardiology is a must!! Engage all stakeholders in your system Engage all stakeholders in your system Management of Cardiac Arrest is evolving rapidly!! EMS Medical Directors must keep up Management of Cardiac Arrest is evolving rapidly!! EMS Medical Directors must keep up

82

83 Questions?

84 Out-of-Hospital Initiation of Therapeutic Hypothermia with Cold Saline Improves Survival in Patients with Return of Spontaneous Circulation in the Field. Jose G. Cabanas MD, MPH / Brent Myers MD, MPH Wake County EMS System

85 Authors Brent Myers MD, MPH, Wake EMS/WakeMed Brent Myers MD, MPH, Wake EMS/WakeMed Jose G. Cabanas, MD, Wake EMS/WakeMed Jose G. Cabanas, MD, Wake EMS/WakeMed Ryan Lewis, MS, EMT-P, Wake EMS Ryan Lewis, MS, EMT-P, Wake EMS Valerie De Maio, MD MSc, WakeMed Valerie De Maio, MD MSc, WakeMed Graham Synder, MD, WakeMed Graham Synder, MD, WakeMed Gay Beneveides, MD, WakeMed Gay Beneveides, MD, WakeMed Robert Denton, MD, Rex Healthcare Robert Denton, MD, Rex Healthcare Daniel Licastese, RN, Rex Healthcare Daniel Licastese, RN, Rex Healthcare Robert Lee, MS MA, WakeMed Robert Lee, MS MA, WakeMed

86 Disclosure This Project was supported by the SAEMS EMS Physio-Control Award (2008) This Project was supported by the SAEMS EMS Physio-Control Award (2008)

87 Objective To determine the impact on survival of a standard post- resuscitation care protocol that includes prehospital initiation of therapeutic hypothermia in patients with return of spontaneous circulation (ROSC) in the field.

88 Methods Observational cohort Observational cohort “Before and after” – Introduction of Therapeutic Hypothermia for patients with prehospital ROSC “Before and after” – Introduction of Therapeutic Hypothermia for patients with prehospital ROSC Post-resuscitation patients are selectively transported to one of 2 high volume PCI centers Post-resuscitation patients are selectively transported to one of 2 high volume PCI centers Wake County NC - pop. 897,000 Wake County NC - pop. 897,000 April 2005 through December 2008 April 2005 through December 2008

89 Cardiac Arrest Response All calls receive EMD from a single, high-volume center All calls receive EMD from a single, high-volume center Fire first response with AED and compressions Fire first response with AED and compressions Paramedic response with transport ambulances (2) Paramedic response with transport ambulances (2) Supervisory response at paramedic level Supervisory response at paramedic level

90 Protocol Revision [Apr 2005-Oct 2006]: Continuous compressions, controlled ventilations [Apr 2005-Oct 2006]: Continuous compressions, controlled ventilations [Oct 2006-Dec 2008]: Induced Hypothermia after ROSC [Oct 2006-Dec 2008]: Induced Hypothermia after ROSC

91 Criteria for Induced Hypothermia ROSC after cardiac arrest not related to trauma or hemorrhage ROSC after cardiac arrest not related to trauma or hemorrhage Age 16 years or greater Age 16 years or greater Female without obviously gravid uterus Female without obviously gravid uterus Initial temperature >34 C Initial temperature >34 C Patient with advanced airway (no RSI) Patient with advanced airway (no RSI) Patient remains comatose without purposeful response to pain Patient remains comatose without purposeful response to pain

92 Data Collection All EMS records are maintained in an electronic database All EMS records are maintained in an electronic database Records with any of the following characteristics are reviewed to determine if cardiac arrest occurred: Records with any of the following characteristics are reviewed to determine if cardiac arrest occurred: EMS Patient Disposition = cardiac arrest EMS Patient Disposition = cardiac arrest CPR procedure is recorded CPR procedure is recorded Defibrillation is recorded Defibrillation is recorded Induced Hypothermia Procedure Induced Hypothermia Procedure

93 Inclusion Criteria All adult patients resuscitated from out of hospital cardiac arrest (OHCA) prior to hospital arrival, regardless of initial rhythm, were included if they had ROSC in the field. All adult patients resuscitated from out of hospital cardiac arrest (OHCA) prior to hospital arrival, regardless of initial rhythm, were included if they had ROSC in the field.

94 Age less than 16 Age less than 16 Obvious traumatic origin of arrest Obvious traumatic origin of arrest EMS witnessed arrest EMS witnessed arrest Arrest not in EMS control Arrest not in EMS control Prison facilities Prison facilities Out-of-system intercept Out-of-system intercept Arrests under direction of non-EMS physician Arrests under direction of non-EMS physician Exclusion Criteria

95 Outcome Measures Discharge from hospital (primary) Discharge from hospital (primary) Neurologically intact survival was defined as CPC 1 or 2 at time of hospital discharge. Neurologically intact survival was defined as CPC 1 or 2 at time of hospital discharge. 2 blinded physician reviewers from each hospital independently assigned CPC scores based on patient discharge records 2 blinded physician reviewers from each hospital independently assigned CPC scores based on patient discharge records

96 Included Patients / Phase All PhasesN=640 Before (17 Months)227 After (26 Months)413

97 Before After (n=227) (n=413) Mean age (yrs)6664 Male sex62%60% Bystander witnessed arrest45%32% Bystander CPR38%39% Mean Response (mins)5.6 Initial rhythm VF/VT35%38% NOTE: no statistically significant difference between study periods Patient and EMS Characteristics

98 Multivariate Odds of Neuro Intact Survival FactorOdds95% CI Age Bystander CPR Vfib Hypothermia (After)

99 Survival to Hospital Discharge for All Rhythms NOTE: statistically significant difference p value <0.0163

100 Survival to Hospital Discharge for All Rhythms *Difference in overall survival was significant with a p-value of

101 Percent of Survivors Neurologically Intact NOTE: no statistically significant difference between study periods

102 Limitations Protocol-driven pre- and post- resuscitation cardiac arrest care Protocol-driven pre- and post- resuscitation cardiac arrest care Hawthorne effect Hawthorne effect Intention-to-treat analysis Intention-to-treat analysis

103 Conclusion Out-of-hospital standard post- resuscitation care protocol that includes induced hypothermia for all patients with ROSC significantly improved survival to hospital discharge in this EMS system Out-of-hospital standard post- resuscitation care protocol that includes induced hypothermia for all patients with ROSC significantly improved survival to hospital discharge in this EMS system

104

105 Wake County EMS Annually 70, calls (700 OHCA) Annually 70, calls (700 OHCA) Providers: 1,500 BLS, 225 ALS, 17 APPs Providers: 1,500 BLS, 225 ALS, 17 APPs Tiered response incl. dispatch assisted CPR, first responder apparatus and paramedic supervisor to high acuity calls Tiered response incl. dispatch assisted CPR, first responder apparatus and paramedic supervisor to high acuity calls Serve 7 hospitals of 3 health care systems, incl. 2 PCI capable facilities Serve 7 hospitals of 3 health care systems, incl. 2 PCI capable facilities Annual protocol updates in April Annual protocol updates in April Utstein style data collection template Utstein style data collection template

106 Survival to Discharge – VF/VT NOTE: no statistically significant difference between study periods

107 Optimizing Neurologic Resuscitation Mild Induced Hypothermia (IH) Mild Induced Hypothermia (IH) –Decrease metabolic demand 4,5,6,7 –Inhibits inflammatory cascade 12,14,15 –IH is time sensitive 8,11,14,15 Hemodilution 12,13 Hemodilution 12,13 –Normal saline dilution as part of hypertensive reperfusion strategy Hypertensive reperfusion Hypertensive reperfusion –Use of vasopressors to target MAP of 90

108 Circulation 2007

109 Standardized post resuscitation bundle: Standardized post resuscitation bundle: –Cardiac catheterization –Therapeutic hypothermia –Hemodynamic maintenance –Ventilator management –Electrolyte/glucose control –Prognostication

110 Outcome –CPC 1 or 2 Outcome –CPC 1 or 2 Control period 15/58 (26%) Control period 15/58 (26%) Treatment period 34/61(56%) Treatment period 34/61(56%) OR 3.61 (CI , p=0.001) OR 3.61 (CI , p=0.001)

111 Induced Hypothermia Do NOT delay starting IH If patient meets inclusion criteria start cooling Do not worry about rewarming

112

113 ?

114 So if compressions are the MOST important intervention for a successful resuscitation what is our airway management device of choice in a cardiac arrest? ….more on this later

115 Ventilation vs Oxygenation Oxygenation is delivery of oxygen to RBC and tissues Oxygenation is delivery of oxygen to RBC and tissues Oxygenation determined by two things: Oxygenation determined by two things: –FiO 2 ( % inspired O 2 ) –Pressure of gas (CPAP or PEEP) Ventilation is the elimination of CO 2 Ventilation is the elimination of CO 2 Ventilation is determined by two things: Ventilation is determined by two things: –Tidal volume –Ventilatory rate

116 Why is this important? Cells require oxygen to make energy Cells require oxygen to make energy Inability to oxygenate the tissue is quickly fatal Inability to oxygenate the tissue is quickly fatal Exchanging carbon dioxide is NOT! Exchanging carbon dioxide is NOT! If forced to make the choice between oxygenation and CO2 exchange If forced to make the choice between oxygenation and CO2 exchange CHOOSE OXYGENATION!

117 So why does that matter? If oxygenation has nothing to do with ventilation why do we ventilate patients at rates > 30 breaths per minute? If oxygenation has nothing to do with ventilation why do we ventilate patients at rates > 30 breaths per minute? Who cares…..if breathing 12 times a minute is good 30 times a minute MUST be better right? Who cares…..if breathing 12 times a minute is good 30 times a minute MUST be better right?

118 ….what is our airway management device of choice in a cardiac arrest?

119 The device that allows us to oxygenate the patients brain and myocardium and causes the… The device that allows us to oxygenate the patients brain and myocardium and causes the… LEAST interruption in compressions

120 Objective Describe the importance of: Describe the importance of: –Prehospital resuscitation –Continuous compression –Controlled ventilatory rates Describe the value and limitations of advanced airway management adjuncts Describe the value and limitations of advanced airway management adjuncts List the critical components of cardiac arrest management List the critical components of cardiac arrest management

121 Pit Crew CPR Went to simulation to design highly scripted process that allows intervention without interruption Went to simulation to design highly scripted process that allows intervention without interruption Tasks assigned to positions rather than individuals because individuals change Tasks assigned to positions rather than individuals because individuals change

122 OOHCA What matters! For first 2 cycles concentrate on compressions For first 2 cycles concentrate on compressions –Get on the chest as quick as possible –Compress hard and fast (do NOT exceed 120) –Minimize interruptions If on monitor compress up to delivery of shock If on monitor compress up to delivery of shock Resume compressions immediately regardless of pulse or rhythm Resume compressions immediately regardless of pulse or rhythm –BVM ONLY –Control ventilation (use your blinky light)

123 OOHCA What matters! After 2 cycles (4 min) place King Airway After 2 cycles (4 min) place King Airway –Don’t stop compressions! –ETI only if unsuccessful with BIAD –Place gastric tube via KING or OG/NG –Control your ventilations Recheck tube with each patient movement Recheck tube with each patient movement

124 OOHCA What matters! Continue resuscitation Continue resuscitation –Rhythm/Pulse check only at 2 min –Change compressor q 1 min regardless of fatigue –Run checklist to assure overlooked errors –Careful consideration of causes Do NOT move the patient unless: Do NOT move the patient unless: –You are in potential danger –You are in a public place –Other situation not suitable to leave the body

125 Pre-hospital providers must be the experts in cardiac arrest resuscitation!

126 Arrest Time (min) SHOCK CCCHYPO? ElectricCirculatory Phase Etapa metabólica What we know? Metabolic Phase

127 Background

128 Inertia….. it’s not just for cars anymore! Blood Inertia? Berg et al. Resuscitation 2001

129 What is Post-Cardiac Arrest Syndrome? Unique / complex combination of pathophysiological processes, which include: Unique / complex combination of pathophysiological processes, which include: –Post–cardiac arrest brain injury, –Post–cardiac arrest myocardial dysfunction –Systemic ischemia/reperfusion response. –DON’T FORGET!! the unresolved pathological process that caused the cardiac arrest.

130 Post-Cardiac Arrest Syndrome High mortality of cardiac arrest patients after ROSC is due to multiple organ system dysfunction High mortality of cardiac arrest patients after ROSC is due to multiple organ system dysfunction –Cardiac Arrest etiology –Duration of cardiac arrest and no flow –Reperfusion injury after ROSC

131 Post-Cardiac Arrest Brain Injury Pathophysiology Pathophysiology –Impaired Cerebral Autoregulation –Cerebral Edema Clinical Manifestations Clinical Manifestations –Coma, Seizures, Myoclonus –Vegetative State, Brain Death, Strokes Potential Treatments Potential Treatments –Therapeutic Hypothermia –Early Hemodynamic Optimization –Ventilation/ Oxygenation

132 Did Rate Change with Feedback? Independent Variables (Not Paired) Scene Kruskal-Wallis Test P = 0.25 Transport Kruskal-Wallis Test P = 0.39*

133 Post-Cardiac Arrest Myocardial Dysfunction Pathophysiology Pathophysiology –Global Hypokinesis –ACS Clinical Manifestations Clinical Manifestations –Reduced Cardiac Output (Low BP) –Dysrhythmias –Cardivascular Collapse Potential Treatments Potential Treatments –Early Revascularization (AMI) –Hemodynamic Optimization

134 Systemic Ischemia/ Reperfusion Response Pathophysiology Pathophysiology –Systemic Inflammatory Response –Increased Coagulation –Adrenal Suppression Key Potential Treatments Key Potential Treatments –Temperature Control –Hemodynamic Optimization –Glucose Control –Treat Cause of Arrest

135 Aha statement Post-Resuscitation Recommendations Induced hypothermia Induced hypothermia Prevention of hyperthermia Prevention of hyperthermia Tight glucose control Tight glucose control Prevent hypocapnia Prevent hypocapnia Maintain elevated MAP Maintain elevated MAP

136 Therapeutic Hypothermia The protective effects of hypothermia induction have been suggested since the time of Hippocrates, who advocated packing bleeding patients in snow. The protective effects of hypothermia induction have been suggested since the time of Hippocrates, who advocated packing bleeding patients in snow. Baron Larrey, Napoleon’s Battle surgeon during the invasion of Russia had noted that soldiers that were left in the snow had improved survival than those treated with blankets and warm drinks. Baron Larrey, Napoleon’s Battle surgeon during the invasion of Russia had noted that soldiers that were left in the snow had improved survival than those treated with blankets and warm drinks.

137 History of Hypothermia and Cardiac Arrest Williams et al -Annals of Surgery, Volume 4 #3 September 1958

138 Why Induced Hypothermia? Pre-hospital ROSC 1 Pre-hospital ROSC 1 –45%(38%) of v-fib arrests –37% (22%)of all cardiac arrests Discharge 1 Discharge 1 –12%(10%) Post Resuscitation Deaths 3 Post Resuscitation Deaths 3 –10% die due to recurrent dysrhythmias –30% die to due to cardiovascular collapse –40% die due to PRE

139 Mechanisms of Hypothermia In the normal brain, hypothermia reduces the cerebral metabolic rate for oxygen (CMRO2) by 6% for every 1°C reduction in brain temperature In the normal brain, hypothermia reduces the cerebral metabolic rate for oxygen (CMRO2) by 6% for every 1°C reduction in brain temperature It is thought to suppress many of the chemical reactions associated with reperfusion injury. (free radical, excitatory amino acid release, and calcium shifts, which can in turn lead to mitochondrial damage and apoptosis It is thought to suppress many of the chemical reactions associated with reperfusion injury. (free radical, excitatory amino acid release, and calcium shifts, which can in turn lead to mitochondrial damage and apoptosis Steen PA, Newberg L, Milde JH, et al. Hypothermia and barbiturates: individual and combined effects on canine cerebral oxygen consumption. Anesthesiology. 1983;58:527–532.

140 P ost R esuscitation E ncephalopathy Initial insult from cardiac arrest Initial insult from cardiac arrest Period of luxuriant hyperperfusion 3 Period of luxuriant hyperperfusion 3 Cell injury 8,11 Cell injury 8,11 –Oxygen free radical formation –Inflammatory cascade –Glutamate mediated cell death Loss of autoregulation Loss of autoregulation –Sludging and hypoperfusion 3,8,11 –Perfusion/demand mismatch 8,11

141 Wake EMS Experience…

142 Objective To determine the impact on survival of a standard post- resuscitation care protocol that includes prehospital initiation of therapeutic hypothermia in patients with return of spontaneous circulation (ROSC) in the field.

143 Methods Observational cohort Observational cohort “Before and after” – Introduction of Therapeutic Hypothermia for patients with prehospital ROSC “Before and after” – Introduction of Therapeutic Hypothermia for patients with prehospital ROSC Post-resuscitation patients are selectively transported to one of 2 high volume PCI centers Post-resuscitation patients are selectively transported to one of 2 high volume PCI centers Wake County NC - pop. 897,000 Wake County NC - pop. 897,000 April 2005 through December 2008 April 2005 through December 2008

144 Cardiac Arrest Response All calls receive EMD from a single, high-volume center All calls receive EMD from a single, high-volume center Fire first response with AED and compressions Fire first response with AED and compressions Paramedic response with transport ambulances (2) Paramedic response with transport ambulances (2) Supervisory response at paramedic level Supervisory response at paramedic level

145 Protocol Revision [Apr 2005-Oct 2006]: Continuous compressions, controlled ventilations [Apr 2005-Oct 2006]: Continuous compressions, controlled ventilations [Oct 2006-Dec 2008]: Induced Hypothermia after ROSC [Oct 2006-Dec 2008]: Induced Hypothermia after ROSC

146 Criteria for Induced Hypothermia ROSC after cardiac arrest not related to trauma or hemorrhage ROSC after cardiac arrest not related to trauma or hemorrhage Age 16 years or greater Age 16 years or greater Female without obviously gravid uterus Female without obviously gravid uterus Initial temperature >34 C Initial temperature >34 C Patient with advanced airway (no RSI) Patient with advanced airway (no RSI) Patient remains comatose without purposeful response to pain Patient remains comatose without purposeful response to pain

147 Data Collection All EMS records are maintained in an electronic database All EMS records are maintained in an electronic database Records with any of the following characteristics are reviewed to determine if cardiac arrest occurred: Records with any of the following characteristics are reviewed to determine if cardiac arrest occurred: EMS Patient Disposition = cardiac arrest EMS Patient Disposition = cardiac arrest CPR procedure is recorded CPR procedure is recorded Defibrillation is recorded Defibrillation is recorded Induced Hypothermia Procedure Induced Hypothermia Procedure

148 Inclusion Criteria All adult patients resuscitated from out of hospital cardiac arrest (OHCA) prior to hospital arrival, regardless of initial rhythm, were included if they had ROSC in the field. All adult patients resuscitated from out of hospital cardiac arrest (OHCA) prior to hospital arrival, regardless of initial rhythm, were included if they had ROSC in the field.

149 Age less than 16 Age less than 16 Obvious traumatic origin of arrest Obvious traumatic origin of arrest EMS witnessed arrest EMS witnessed arrest Arrest not in EMS control Arrest not in EMS control Prison facilities Prison facilities Out-of-system intercept Out-of-system intercept Arrests under direction of non-EMS physician Arrests under direction of non-EMS physician Exclusion Criteria

150 Outcome Measures Discharge from hospital (primary) Discharge from hospital (primary) Neurologically intact survival was defined as CPC 1 or 2 at time of hospital discharge. Neurologically intact survival was defined as CPC 1 or 2 at time of hospital discharge. 2 blinded physician reviewers from each hospital independently assigned CPC scores based on patient discharge records 2 blinded physician reviewers from each hospital independently assigned CPC scores based on patient discharge records

151 Included Patients / Phase All PhasesN=640 Before (17 Months)227 After (26 Months)413

152 Before After (n=227) (n=413) Mean age (yrs)6664 Male sex62%60% Bystander witnessed arrest45%32% Bystander CPR38%39% Mean Response (mins)5.6 Initial rhythm VF/VT35%38% NOTE: no statistically significant difference between study periods Patient and EMS Characteristics

153 Survival to Hospital Discharge for All Rhythms NOTE: statistically significant difference p value <0.0163

154 Survival to Hospital Discharge for All Rhythms *Difference in overall survival was significant with a p-value of

155 Percent of Survivors Neurologically Intact NOTE: no statistically significant difference between study periods

156 Limitations Protocol-driven pre- and post- resuscitation cardiac arrest care Protocol-driven pre- and post- resuscitation cardiac arrest care Hawthorne effect Hawthorne effect Intention-to-treat analysis Intention-to-treat analysis

157 Conclusion Out-of-hospital standard post- resuscitation care protocol that includes induced hypothermia for all patients with ROSC significantly improved survival to hospital discharge in this EMS system Out-of-hospital standard post- resuscitation care protocol that includes induced hypothermia for all patients with ROSC significantly improved survival to hospital discharge in this EMS system

158 Optimizing Neurologic Resuscitation Mild Induced Hypothermia (IH) Mild Induced Hypothermia (IH) –Decrease metabolic demand 4,5,6,7 –Inhibits inflammatory cascade 12,14,15 –IH is time sensitive 8,11,14,15 Hemodilution 12,13 Hemodilution 12,13 –Normal saline dilution as part of hypertensive reperfusion strategy Hypertensive reperfusion Hypertensive reperfusion –Use of vasopressors to target MAP of 90

159 Is Earlier Better?? Nordmark Pigs Subjected to 8 minutes of V-fib followed by CPR Randomized into 2 groups (hypothermia/control) Hypothermic group received cold saline after 1 min in CPR Conclusion: Conclusion: “Inducing Therapeutic Hypothermia with a cold infusion seems to be an effective method that can be started during ongoing CPR”

160 Is Earlier Better?? Bernard2008Resuscitation 60 year-old female in cardiac arrest (37 minutes) due to pericardial tamponade D/H Alert and Oriented Conclusion: Conclusion: “Treatment with a rapid Intravenous Infusion of large volume (40ml/kg), Ice-cold (4˚C) fluid during CPR induces mild hypothermia and may provide neurological protection”

161 Is Pre-Hospital Cooling Safe?? Bruel2008 The study was aimed to determine the safety and effectiveness of cooling patients while in ALS Support The Median time to reach mil hypothermia (<34˚C) after ROSC was 16 minutes Conclusion: Conclusion: “The infusion of 2 liters of Normal Saline at 4˚C in the field during ALS to induce mild hypothermia in resuscitated OHCA patients is safe, feasible and effective”


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