1. What’s New in Resuscitation
VOMA
VOMA
What’s 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
VOMA
VOMA

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
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The future is changing

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

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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. Rosamond et al. , Heart Disease & Stroke Statistics, 2008 Update
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 ATP Failure OER : Oxygen extraction
VO2: oxygen consumption
SVO2 mix venous saturation
ATP Failure

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

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

27. Cardiac Resus image with CPR

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

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

34. 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.

35. Vasopressors: Epinephrine vs. Vasopressin
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
Quality of Chest Compressions in OOH-CA Wik et al. JAMA 2005: 293:
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.

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:
62 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
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.

44. 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 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

45. 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

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
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?

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 can’t 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
When heart stops, hypothermia helps- Sunday Gazette Charleston WV
More Hospitals Offering Therapeutic Hypothermia For Comatose Survivors Of Cardiac Arrest.

52. Public blogs say…

53. Public Commentary

54. 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

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

56. Induced Hypothermia (33º C) Bernard SA et al
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

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 63

64. In-Hospital Factors Associated with Improved Outcome from OOH-CA Langhelle A et al. Resuscitation 2003; 56:247-63
4 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: % 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
N= 1,233
p= .0001
Significant improvement with protocol change
p= .002

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

71. Advanced Resuscitation Cooling Therapeutics Intensive Care

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; 69:255-60
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 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

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