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Daniel Davis, MD UCSD Center for Resuscitation Science

New Frontiers in Resuscitation Science. Daniel Davis, MD UCSD Center for Resuscitation Science. Key Concepts. Compressions Ventilations Pressors PetCO2 Post-resuscitative care. 1. Optimal Compressions. The Primary Directive.

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Daniel Davis, MD UCSD Center for Resuscitation Science

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  1. New Frontiers in Resuscitation Science Daniel Davis, MD UCSD Center for Resuscitation Science

  2. Key Concepts • Compressions • Ventilations • Pressors • PetCO2 • Post-resuscitative care

  3. 1. Optimal Compressions

  4. The Primary Directive Chest compressions should be performed from the moment of arrest until return of spontaneous circulation is assured.

  5. Prime the Pump! Kern (2002) Circulation

  6. Stay on the chest! * Adjusted for: age, gender, bystander CPR, public location, response time, compression rate Christenson (2009) Circulation

  7. Compression Interruptions • Initiating compressions • Rhythm analysis • Shock sequence • Pulse check • Intubation • Vascular access

  8. Bystander CPR Percent (%)

  9. ECG Filtration

  10. Return of Spontaneous Circulation Electrical (HR) Mechanical (PetCO2)

  11. Deeper Compressions Stiell et al (2008) AHA Scientific Sessions

  12. Good Recoil Aufderheide (2005) Resuscitation

  13. Rate vs Depth Rate 0 to 80 81 to 120 121+ (N=65) (N=478) (N=122) 38 mm 49% 44% 69% 38-51 mm 28% 44% 30% >51 mm 23% 12% 2% Depth Stiell et al (2008) AHA Scientific Sessions

  14. CPR Process

  15. Results • Chest compression fraction 91% • Compression rate 123/min • Compression depth 2.6 inches • Pre-shock pause 2.6 sec • Post-shock pause 3.6 sec • Perfusion check 4.3 sec • Ventilation rate 9.7/min • PetCO2 15.3 mmHg

  16. What if we’re wrong?

  17. 2. Controlled ventilation

  18. Prime the Pump! Kern (2002) Circulation

  19. Continuous Chest Compressions with Synchronous Ventilations (10:1)

  20. 3. Pressor Therapy

  21. Pressors Mader (2008) Resuscitation

  22. Hagihara (2012) JAMA

  23. * * *

  24. Vasopressin?

  25. Fluids?

  26. 4. PetCO2 in resuscitation

  27. Lung Perfusion in Shock PaCO2 40 mmHg PetCO2 37 mmHg PetCO2 29 mmHg PetCO2 21 mmHg

  28. PetCO2 Monitoring

  29. PetCO2 Associations • Initial PetCO2 α ROSC • Pre-shock PetCO2 α ROSC for VF • Rise in PetCO2 α ROSC • Initial PetCO2 α arrest etiology • Compression depth/patient wt α PetCO2

  30. 5. Post-resuscitation care

  31. Hyperventilation: Three Flavors

  32. mL/100 gm/min P = .004 v 12 P = .004 v 12 Cerebral Perfusion During Shock

  33. Ventilation in Resuscitation

  34. Rapid, Shallow Breaths?

  35. Intrathoracic Pressure

  36. Evidence for Hypothermia?

  37. Hypothermia vs. Normothermia? Hypothermia After Cardiac Arrest Study Group (2002) NEJM

  38. When should we cool?

  39. Post-Arrest Hypothermia HACA no cooling 33oC 36% 53% 0 10 20 30 40 50 60 % survival Bernard no cooling 33oC 26% 49% TTM 36oC 33oC 52% 50%

  40. How should we cool?

  41. How should we cool?

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