What’s New in Resuscitation VOMA VOMA What’s New in Resuscitation Greg Christiansen DO, MEd, FACOEP VCU Department of Emergency Medicine

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

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

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 1996:13 1578-1582.

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

Some Myths Die Hard

Flatliners ..\..\..\Image File\recorded video\video\resuscitation\Flatlinev2.mpg The future is changing

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

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

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

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

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

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

Increase Cardiac output Decrease Cardiac Output What effect will Epinephrine or Vasopressin have during CPR? Lower PetCO2 levels Increase PetCO2 levels Increase Cardiac output Decrease Cardiac Output

Increase Cardiac output Decrease Cardiac Output What effect will Epinephrine or Vasopressin have during CPR? Lower PetCO2 levels Increase PetCO2 levels Increase Cardiac output Decrease Cardiac Output Vasopressors ↑ after load, ↓CO↓CPP ↓ETCO2

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

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

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

Were not making vegetables

Lessons learned What it is & why it works … sometimes

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

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

Methods Electrical Therapy Pharmacological Therapy Mechanical perfusion

Ischemia: The Problem ATP ATP ATP Failure OER : Oxygen extraction VO2: oxygen consumption SVO2 mix venous saturation ATP Failure

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

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

Cardiac Resus image with CPR

Coronary Perfusion Pressure (CPP) Key to Successful Resuscitation Aod RAd CPP = Aod - RAd

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

The Higher the CPP the Better

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

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

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

Palpating Pulses to Monitor CPR Effectiveness ….. Driving Blindly: Rule #1: Palpating Pulses to Monitor CPR Effectiveness ….. Is for Those Who Don’t Know What to Do.

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

Effects of Epinephrine

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

Improving Blood Flow during Resuscitation

Quality of Chest Compressions in OOH-CA Wik et al Quality of Chest Compressions in OOH-CA Wik et al. JAMA 2005: 293:299-304 176 adult patients Sweden, Norway, England ROSC 35% These data come from new technology that allows measurement of the quality of CPR. Even with allowance for advanced procedures, analysis, etc…, the NFR was 42%. Elevated No Flow Ratios may be responsible for the dismal outcomes from cardiac arrest and the failure for multiple promising new therapies to demonstrate efficacy in human trials.

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 1158-1165.

Minimally Interrupted Cardiopulmonary Resuscitation (MICR) by EMS Bobrow et al. JAMA 2008; 299:1158-65 Peberdy MA, Ornato JP: JAMA 2008; 299:1188-90 62 EMS agencies in Arizona 75% of state population 200 CCs first Rhythm check Single DF 200 CCs post-DF Early epinephrine Delayed intubation

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

Compression Rate vs. ROSC Abella BS. Circulation 2005; 111:428-34 This study demonstrates that in very few of the 30-second time intervals was the optimal chest compression rate observed. Most of the time, the rates were low, probably due to time spent off the chest.

Effect of Incomplete Chest Decompression On Coronary and Cerebral Perfusion Pressures Yannopoulos D et al. Resuscitation 2005;64:363-72 ǂ n=9 instrumented swine 6 minutes untreated VF  standard CPR* x 3 min  CPR with 75% recoil (residual 1.2 cm sternal compression @ end decompression) x 1 min  standard CPR* x 1 min  defib x 3  ACLS Critical pressure for ROSC (Paradis, JAMA 1990;263:3257-8) % Chest Wall Decompression

Median Frequency (VF “Coarseness”) “Hands-Off” Interval vs. DF Success Eftestol T et al. Circulation 2002; 105:2270-3 156 OOH cardiac arrest 868 DF attempts 0% 20% 40% 60% % ROSC High Medium Low Median Frequency (VF “Coarseness”) 5 10 15 20 "Hands-off Interval" [sec] from Stop CPR to DF shock

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

Improving Blood Flow During Resuscitation Summary CPR necessary to provide coronary perfusion Must restart the heart for survival Conclusion – focus of the heart! What’s the evidence to support this focus?

Therapeutic hypothermia during or immediately after resuscitation

Today 500 of 5,000 hospitals use therapeutic hypothermia Capturing on 20% of all eligible patients If the patient can’t walk out of the hospital then… A hospital bed is a parked taxi with the meter running - Groucho Marx

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

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

Public blogs say…

Public Commentary

Metabolic Chain of Events in Cardiac Arrest Cell Damage No Blood Flow Cerebral Ischemia CPR / Pulse Free Radicals O2 Reperfusion Cell Death and Cerebral injury 54

Induced Hypothermia (32-34º C) The Hypothermia after Cardiac Arrest Study Group N Engl J Med 2002; 346 : 549-556 7 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

Induced Hypothermia (33º C) Bernard SA et al Induced Hypothermia (33º C) Bernard SA et al. N Engl J Med 2002; 346 : 557-63 Australian study 73 OOH-CA pts with ROSC Cooled to 33º C for 12 h

Cooling Techniques

Cooled IV Fluid Infusion

Pilot Randomized Trial of Prehospital Induction of Hypothermia in OOH-CA with Rapid Infusion of 4ºC Saline Kim et. al. Circ 2007;115:3064-3070 p= .15 p= .13

Specialized Post-Resuscitation Centers

Resuscitation Care ROSC 63

In-Hospital Factors Associated with Improved Outcome from OOH-CA Langhelle A et al. Resuscitation 2003; 56:247-63 4 regions in Norway

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

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

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)

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

Significant improvement with protocol change Citywide ROSC & Survival to Discharge Richmond, VA: 2001-3 vs. 2004-9 N= 1,233 p= .0001 Significant improvement with protocol change p= .002

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

Advanced Resuscitation Cooling Therapeutics Intensive Care

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

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

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

Continuous EEG Monitoring Rossetti AO et al. Neurology 2007; 69:255-60 EEG monitoring in 166 adult comatose cardiac arrest pts 59% therapeutic hypothermia 33% survival Status epilepticus associated with poor survival

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

ARTIC Program Survival 2008

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

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

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