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Advances In The Management Of Cardiac Arrest

Advances In The Management Of Cardiac Arrest

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Advances In The Management Of Cardiac Arrest

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  1. Advances In The Management Of Cardiac Arrest Victor Maroun MD EMS/Disaster Medicine Fellowship Director Department of Emergency Medicine Saint Joseph’s Regional Medical Center Paterson, NJ

  2. Advances In The Management Of Cardiac Arrest • Conflicts to report: • None

  3. Advances In The Management Of Cardiac Arrest • Case: • 47 year old male presents to the ED with chest pain for 3 days • HTN, smoking • EKG: LVH • Cardiac markers are negative • CXR: normal

  4. Advances In The Management Of Cardiac Arrest • Re-evaluation • Disconnected to monitor • Pulseless, unresponsive • Unknown down-time • Nurse is on break

  5. Advances In The Management Of Cardiac Arrest • Next Step: • Chest compressions? • Secure Airway? • BVM? • IV access? • Hypothermia protocol? You decide to start compressions

  6. Advances In The Management Of Cardiac Arrest • Crash Cart Arrives • Biphasic Defibrillator • Voltage? • Stack Shocks? • Nurse arrives • “Do you want to stop CPR to establish IV access, what meds do you want?”

  7. Current Statistics • 350,000 cardiac arrest in USA/year • 1 in every 90 seconds • 36% In-hospital • 18% of which survive to discharge • 64% out of Hospital • 2-9% of which survive to discharge • 3-7% of survivors return to normal neurologic functioning

  8. Current Statistics • Majority of resuscitative efforts fail • Anoxia • Reperfusion injury • Neurologic injury • Airway/Breathing • Circulation • Other complications

  9. Historical Perspective • Cardiopulmonary Resuscitation (CPR) first published <50 years ago • Young science • Rapidly evolving

  10. Historical Perspective • Early 1900s: Shafer Method

  11. Historical Perspective • 1960s – Peter Safar • Prone position inadequate • Expired air did provide sufficient O2. • Head tilt, chin lift kept patent airway

  12. Historical Perspective • 1955: Paul Zoll: 1st successful closed chest defibrillation, external pacing

  13. Historical Perspective • 1930s: In hospital resuscitation team • 1960s: MICU with physicians • 1970: Education in Seattle • 100,000 laypersons CPR • 911 dispatch education • Paramedic training • 1974: Training of laypersons formally sanctioned • 1979: 1st AED developed • Sensing electrode in pharynx • Shocking electrode on tongue and abdomen • 1981: AICD developed

  14. 2005: • American Heart Association Revisions • Minimal interruption of chest compressions • Push hard and fast • 8-10 breaths per minute • Delivered over one second duration • 30/2 compression ventilation ratio • Compressions immediately after defibrillation • Hypothermia

  15. AHA 2005 Revisions • OPALS Study NEJM 2004 • 17 Cities • Multicenter, controlled clinical trial • BLS + Rapid defibrillation • ALS response intubation plus IV meds

  16. AHA 2005 Revisions • OPALS – NEJM 2004 • 5638 patients with out-of-hospital arrest • 1391 BLS + Defibrillation • 4247 ALS Intubation, IV meds • Admission: 10.9% vs. 14.6%, P <0.001 • Discharge: 5.0% vs. 5.1%, P 0.83

  17. AHA 2005 Revisions • Hyperventilation-induced hypotension in cardiopulmonary resuscitation: Circulation 2004 • Clinical observational study Milwaukee • 13 adults in cardiac arrest avg. 63yrs • Device electronically recorded ventilation rates after intubation • Half-way through study, retraining of personnel to deliver 12 breaths per minute • Group 1 Initial group • Group 2 retrained group • Group 3 combination • Animal study

  18. AHA 2005 Revisions

  19. AHA 2005 Revisions

  20. AHA 2005 Revisions

  21. AHA 2005 Revisions • Cardiopulmonary resuscitation by chest compression alone or with mouth to mouth ventilation N Engl J Med 2000 • Seattle 911 telephone staff instructed bystanders to perform • CPR alone (241) 81% delivered • CPR + mouth to mouth (279) 62% delivered • Outcome: discharge home • Similar outcomes: 14.6% CPR alone, 10.4% + MTM • Likely benefit from continuous chest compressions • Airway obstruction, ineffective MTM

  22. AHA 2005 Revisions • AHA revision of ventilation rate • 8 to 10 breaths per minute • Breaths should be delivered quickly • One second duration • Timing device should be encouraged

  23. AHA 2005 Revisions • Optimizing circulation • Recent research indicated inadequate chest compressions • Frequent interruptions • Inadequate pressure/compression

  24. AHA 2005 Revisions • Quality of cardiopulmonary arrest during out-of-hospital arrest JAMA 2005 • European study 3/02 – 10/03 • Case series 176 patients • Accelerometer on defibrillators • Measured compression depth and rate • Measured ventilation rates • Compared to AHA guidelines • Duplicated for inpatients, similar results, reported as separate study

  25. AHA 2005 Revisions • Quality of cardiopulmonary arrest during out-of-hospital arrest JAMA 2005

  26. AHA 2005 Revisions • Quality of cardiopulmonary arrest during out-of-hospital arrest JAMA 2005

  27. AHA 2005 Revisions • Quality of cardiopulmonary arrest during out-of-hospital arrest JAMA 2005

  28. AHA 2005 Revisions • AHA recommendations • 100 beats per minute • “push hard and fast” • Very few interruptions • Very brief interruptions • Compression/Ventilation 30:2 • CPR prior to Shock

  29. Compressions • Art pressures 60/20 • Clinical assessment of heart chamber size and valve motion during CPR using 2D ECHO, AM Heart J 1981 (4 patients) • LV dimensions don’t change • Aortic and Mitral valves are both open during compression • Increased flow in RV during relaxation • Conclusions: improved cardiocirculatory dynamics secondary to thoracic pressure, not compression of LV

  30. Compressions • Haemodynamics of cardiac arrest and resuscitation, • Curr Opin Crit Care, 2006 (Review Article) • In V-fib blood continues to flow until p-aorta = p-RV • Aorta flow during compression • Coronary flow during relaxation • Carotid flow reaches a plateau after a few minutes of CPR, and dramatically drops with short pauses, with a recovery time of a few minutes.

  31. Compressions Automated Load Distributing Band • Ong et al. JAMA June 2006 (747 pts) • ROSC 34% vs.. 20% • Hospital discharge 9.7% vs.. 2.9% • Hallstrom et al. JAMA June 2006 (1061 pts) • Survival to 4 hours after CPR 29.5% vs.. 28.5% • Survival to discharge 5.8% vs.. 9.9%, P .06 • Cerebral performance 1 or 2 3.1%, vs.. 7.5% P 0.006

  32. Compressions • CPR: the P stands for plumber’s helper JAMA 1990 • Lafuente et al, Cochrane Database of Systematic Reviews 2004 • 10 randomized clinical trials ACDR vs.. CPR • No no difference in survival outcomes • Trend toward worse neurologic outcomes in ACDR

  33. Compressions • Survival from in-hospital cardiac arrest with interposed abdominal counterpulsation during CPR JAMA 1992 • Randomized to IAC-CPR or conventional CPR n135 • ROSC 57% vs.. 27% P 0.007 • Discharge 25% vs.. 7% P 0.02 • Neurologically intact 17% vs. 6% • Pre-hospital IAC-CPR versus standard CPR (Milwaukee Paramedics) n291 • Randomized after intubation • Successful resuscitation 28% vs. 31%

  34. Defibrillation

  35. Defibrillation • Most Rapid response in casinos • Dedicated trained responders • Confined environment • Security cameras • Collapse to shock 4.4 minutes • Hospital discharge 75% if within 3 minutes

  36. Defibrillation Delaying defibrillation to give basic CPR to patients with out-of-hospital VF, JAMA 2003 • Norway • Randomized study • CPR before shock • Standard

  37. Defibrillation

  38. Defibrillation

  39. Defibrillation • American Heart Association Recommendations • CPR initiated while AED is being set up • Defibrillation immediately when equipment is ready

  40. AHA 2005 Revisions • Chest compressions immediately after defibrillation • Don’t check monitor for rhythm • Don’t check for a pulse

  41. AHA 2005 Revisions • Carpenter et al. Resuscitation 2003 • Seattle study • Out of Hospital Cardiac Arrest • Reviewed post shock rhythms of 366 pts at various times 5, 10, 20, 30, 60 seconds • Compared Monophasic vs Biphasic defibrillators

  42. Carpenter et al. Resuscitation 2003 • No difference in post-shock rhythms at 5-30 seconds (25% organized rhythm) • At 60 seconds • Biphasic defibrillation 40% • Monophasic Defibrillation 25%

  43. Therapeutic Hypothermia • Hippocrates advocated packing bleeding patients in snow • Profound hypothermia Lancet 1959 • Ronald Belsey (Cardiac surgery) performed cardiac surgery in cooled patients with no perfusion > 60 minutes • Research was inconsistent • Predisposition to infection • Fell out of favor • Safar et al Crit Care Medicine 1988 • FV in dogs better outcome if hypothermic

  44. Therapeutic Hypothermia • New England Journal of Medicine 2002 • 2 large randomized clinical studies in humans were published • Induced hypothermia after cardiac arrest • Control group • Favorable neurologic outcomes in treatment groups.

  45. Australian Study • Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia • Successful V-fib patients, who were comatose • Randomized • 43 Hypothermia • 34 Normothermia

  46. Australian Study • Medics applied cold packs in the field • Continued in the ED to temp of 33C • 12-hours of Hypothermia • Shivering – (Versed, Vecuronium) • Similar protocols used in Normothermic group, temp maintained at 37C.

  47. 21/43 (49%) Treated patients had good outcomes vs.. 9/34 patients (26%), NNT = 4 Mortality: 22/43 (51%) treated patients died vs.. 23/34 (68%), NNT = 6

  48. European Study • Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest • Larger Study • 273 Patients • Successful V-fib out-of-hospital arrest • Comatose state • Randomized to Hypothermia and Normothermia groups

  49. European Study • Cooling induced in the ED • Cooling mattress and blanket (Cool air) • 32 to 34 degrees C. for 24 hours • Hypothermia 137 patients • Normothermia 138 patients • Shivering (Versed, Vecuronium) • Compared outcomes

  50. European Study