Cardiopulmonary ressuscitation Dr Guillaume Thiery, Medical ICU Klinicki Centar Univerziteta Sarajevo St Louis Hospita, Paris

Out-of-hospital cardiopulmonary arrest by aetiology

Importance of each link Stiell et al. NEJM, 2004

Why is it every time I press on his chest he opens his eyes, and every time I stop to breathe for him he goes back to sleep?"

Discharged alive: Compression + mouth to mouth29/278 (10,4%) Compression alone35/240 (14,6%)

Why is it every time I press on his chest he opens his eyes, and every time I stop to breathe for him he goes back to sleep?" Cardio Pulmonary Ressuscitation

Cardio Cerebral Ressuscitation Why is it every time I press on his chest he opens his eyes, and every time I stop to breathe for him he goes back to sleep?" Cardio Pulmonary Ressuscitation

2006 Overall survival increased from 19% to 57% Survival neurologically intact increased from 15% to 48%

2009 Overall survival increased from 22% to 44% 88% of these survivors were discharged with good neurological outcome

Cardio Cerebral Ressuscitation Reduce or avoid positive pressure ventilation, Airway management is limited to a pharyngal devince (airway) and O2 supplementation, Avoid or delay intubation (3 cycles of 2 min) No more than 10 sec without compression,

3 rules of airway management Head tilt (hyperextention) and chin lift Pharyngeal device (airway) O2 non mask with reserve 15 L/min

3 rules of airway management Head tilt (hyperextention) and chin lift Pharyngeal device (airway) O2 non mask with reserve 15 L/min

3 rules of airway management Head tilt (hyperextention) and chin lift Pharyngeal device (airway) O2 non mask with reserve 15 L/min

2004

Deleterious effect of hyperventilation Mean Intrathoracic pressure Coronary Perfusion Pressure

The 4th rule of airway management If Positive Pressure Ventilation, by mask of intubation:  Maximun 12/min

Cardio Cerebral Ressuscitation ALL TO IMPROVE COMPRESSIONS Mandatory pre-shock compression during 2 min, 100 compressions/minute, 2 min of compression after each shock before pulse check No more than 10 sec without compression, Reduce or avoid positive pressure ventilation, Airway management is limited to a pharyngal device (airway) and O2 supplementation, Avoid or delay intubation (3 cycles of 2 min), When intubated, maximun resp frequency 12/min.

Clincal case Patients 45 years old presents in the ER for chest pain 10 after arrival, – Acute chest pain – Unresponsive

What would you do first? Chest compressions 100/min Mask ventilation 12/min + oxygen Rapid intubation Rapid defibrillation – Maximum joules – One time – Resume ventilation and compressions during 2 min +/- drugs: adrenalin Check pulse after 2 min of compressions/ventilation New defibrillation after 2 min if not Return of Spontaneous Circulation.

What could have been done differently? Chest compressions 100/min Mask ventilation 12/min + oxygen Rapid intubation Rapid defibrillation – Maximum joules – One time – Resume ventilation and compressions during 2 min +/- drugs: adrenalin Check pulse after 2 min of compressions/ventilation New defibrillation after 2 min if not Return of Spontaneous Circulation. Etc…

What could have been done differently? Chest compressions 100/min Head tilt and Chin lift Pharyngeal device (airway) placement Oxygen mask 15L/min Rapid defibrillation – Maximum joules – One time – Resume ventilation and compressions during 2 min +/- drugs: adrenalin Check pulse after 2 min of compressions/ventilation New defibrillation after 2 min if not Return of Spontaneous Circulation.

Case (suite) Patients gets return to spontaneous circulation But remains unconscious

Case (suite) If the patient has this ECG

Therapeutic hypothermia Goal: temp 32 – 34°C during 12 to 18h after return of spontaneous circulation, External cooling: –Axillar and Femoral ice –Blowing cold air Internal cooling: –Infusion of 30 ml/kg of cold NaCl 4°C

Therapeutic hypothermia

Experience in the medical ICU in KCU Sarajevo (Jedinica Internisticke Intenzivne Terapije) 5 patients admitted in the ICU for cardiac arrest remaining unconscious after successfull ressuscitation VT/VF initial or after adrenalin All myocardial infarction Mean age 59

MedianMin-max Time from end CPR to temp < 36°C 6,2h0 – 7h Time < 36°C55 – 20h Time < 34°C50 – 17h Nadir temperature33,2°C32,5° - 35°C Characteristic of the hypothermia

MedianMin-max Minium glycemia5,54,4 – 15,8 Maximum glycemia10,77,2 – 27,7 Mininum K32,5 – 4,6 Maximum K4,63,7 – 6,4 CK Complications

Shock state2/5 ARDS1/5 DIC1/5 Acute renal failure2/5 Seizures of myoclonies2/5 Complications

Survival4/5 Neurological intact3/5 Duration of MVMedian 8 days (min 1 - max 40) Lenght of stay in the ICUMedial 14 dayx (min 1 – max 47) Outcome