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

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advances in the management of cardiac arrest

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

advances in the management of cardiac arrest3
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
advances in the management of cardiac arrest4
Advances In The Management Of Cardiac Arrest
  • Re-evaluation
    • Disconnected to monitor
    • Pulseless, unresponsive
    • Unknown down-time
    • Nurse is on break
advances in the management of cardiac arrest5
Advances In The Management Of Cardiac Arrest
  • Next Step:
    • Chest compressions?
    • Secure Airway?
    • BVM?
    • IV access?
    • Hypothermia protocol?

You decide to start compressions

advances in the management of cardiac arrest6
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?”
current statistics
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
current statistics8
Current Statistics
  • Majority of resuscitative efforts fail
    • Anoxia
    • Reperfusion injury
    • Neurologic injury
    • Airway/Breathing
    • Circulation
    • Other complications
historical perspective
Historical Perspective
  • Cardiopulmonary Resuscitation (CPR) first published <50 years ago
  • Young science
  • Rapidly evolving
historical perspective10
Historical Perspective
  • Early 1900s: Shafer Method
historical perspective11
Historical Perspective
  • 1960s – Peter Safar
    • Prone position inadequate
    • Expired air did provide sufficient O2.
    • Head tilt, chin lift kept patent airway
historical perspective12
Historical Perspective
  • 1955: Paul Zoll: 1st successful closed chest defibrillation, external pacing
historical perspective13
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
slide14
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
aha 2005 revisions
AHA 2005 Revisions
  • OPALS Study NEJM 2004
    • 17 Cities
    • Multicenter, controlled clinical trial
    • BLS + Rapid defibrillation
    • ALS response intubation plus IV meds
aha 2005 revisions16
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
aha 2005 revisions17
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
aha 2005 revisions21
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
aha 2005 revisions22
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
aha 2005 revisions23
AHA 2005 Revisions
  • Optimizing circulation
    • Recent research indicated inadequate chest compressions
    • Frequent interruptions
    • Inadequate pressure/compression
aha 2005 revisions24
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
aha 2005 revisions25
AHA 2005 Revisions
  • Quality of cardiopulmonary arrest during out-of-hospital arrest JAMA 2005
aha 2005 revisions26
AHA 2005 Revisions
  • Quality of cardiopulmonary arrest during out-of-hospital arrest JAMA 2005
aha 2005 revisions27
AHA 2005 Revisions
  • Quality of cardiopulmonary arrest during out-of-hospital arrest JAMA 2005
aha 2005 revisions28
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
compressions
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
compressions30
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.
compressions31
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
compressions32
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
compressions33
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%
defibrillation35
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
defibrillation36
Defibrillation

Delaying defibrillation to give basic CPR to patients with out-of-hospital VF, JAMA 2003

  • Norway
  • Randomized study
  • CPR before shock
  • Standard
defibrillation39
Defibrillation
  • American Heart Association Recommendations
    • CPR initiated while AED is being set up
    • Defibrillation immediately when equipment is ready
aha 2005 revisions40
AHA 2005 Revisions
  • Chest compressions immediately after defibrillation
  • Don’t check monitor for rhythm
  • Don’t check for a pulse
aha 2005 revisions41
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
carpenter et al resuscitation 2003
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%
therapeutic hypothermia
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
therapeutic hypothermia44
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.
australian study
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
australian study46
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.
slide47
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

european study
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
european study49
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
therapeutic hypothermia54
Therapeutic Hypothermia
  • AHA recommendations
    • 2003: “Mild hypothermia may be beneficial to neurological outcome and is likely to be well tolerated”
    • 2005: “Unconscious adult patients with ROSC after out-of-hospital cardiac arrest should be cooled to 32-34C for 12-24 hours when the initial rhythm was VF. Similar therapy may be beneficial to non VF arrest. Further research is needed.”
methods of achieving hypothermia
Methods of Achieving Hypothermia
  • External
    • Selective regional cooling: (Head and neck)
    • Generalized: Entire body (cooling blanket)
  • Internal
    • IV (Cold IV Fluids)
    • Bladder Lavage with cold fluid
    • Invasive central vein devices.
  • External / Internal combinations
cold iv fluid
Cold IV Fluid
  • Bernard et al. Resuscitation 2003
    • 30ml/kg 4C RL reduced temp 35.5 to 33.8C.
    • Initiated in ED.
  • Kim et al. Circulation 2005
    • 2L 4C NS reduced temp by 1.4C in 30 min.
  • Polder man et al. Crit Care Med 2005
    • 2 Liters 4C NS bolus (+) Cooling blanket
    • Reduced temp from 36.9 to 32.9 in one hour
  • No complications in either study were reported.
pre hospital cooling
Pre-hospital Cooling
  • Kim et al. Circulation 2007
    • 125 patients
    • Randomized to standard care, vs.. Pre-hospital cooling with 2 liters cold IVF.
    • 63 (Hypothermia group)
      • Decrease temp by 1.25C
      • No complications
    • 62 (Standard)
      • Increase in temp by 1C
where should hypothermia be initiated
Where should hypothermia be initiated?
  • No definitive recommendations by the AHA yet
  • Increasing volume of literature
    • Cold IVF
    • Safe
    • Effective
    • Fast
  • Further research needed
slide63

A cooling treatment is credited with helping Dr. Syed Hassan Naqvi recover from Cardiac arrest.

“City Pushes Cooling Therapy for Cardiac Arrest”

nyc responds
NYC Responds
  • January 1, 2009
    • NYC EMS will transport cardiac arrest patient to only those hospitals that provide therapeutic hypothermia
    • Bypass closer hospitals
    • Bloomberg endorsement
    • 20 of 59 NYC hospitals expected provide treatment
    • Seattle, Boston, Miami will have similar protocols
    • Vienna, London
  • No methodology requirements
nyc responds65
NYC Responds
  • Criteria
    • CPR, with pulse regained within 30 min of resuscitation, neurologically compromised
    • Bypass non-participating hospital if you can get to a participating hospital by 20 min.
    • Avg. 10 min transport time.
early participating hospitals
Early Participating Hospitals
  • NY Presbyterian
  • Mt Sinai
  • Bellevue
  • St. Vincent’s
  • Elmhurst
  • Maimonidies
  • Staten Island University
sjrmc responds
SJRMC Responds
  • 66 Year Old Female
  • Pre-hospital cardiac arrest with ROSC
  • Comatose state
  • Therapeutic Hypothermia protocol initiated, 24 hours
  • Rewarming 6 hours
  • Patient now awake and alert in MICU
nj responds
NJ Responds
  • Cooper University Hospital
  • Morristown Memorial Hospital
  • Hackensack University Medical Center
  • Newark Beth Israel
  • Many others developing protocols
conclusions
Conclusions
  • The science of cardiopulmonary resuscitation is developing rapidly
  • We as physicians and first responders must stay updated
  • We must also adjust our practice of medicine accordingly
slide70

Questions?

I think they can stop CPR.