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Advances In The Management Of Cardiac Arrest

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Saint Joseph's Regional Medical Center. Paterson, NJ ... 47 year old male presents to the ED with chest pain for 3 days. HTN, smoking. EKG: LVH ... – PowerPoint PPT presentation

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Title: Advances In The Management Of Cardiac Arrest


1
Advances In The Management Of Cardiac Arrest
  • Victor Maroun MD
  • EMS/Disaster Medicine Fellowship Director
  • Department of Emergency Medicine
  • Saint Josephs 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 lt50 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 lt0.001
  • 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 302
  • 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 dont 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 plumbers 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
  • Dont check monitor for rhythm
  • Dont 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 gt 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
51
European Study
52
European Study
53
European Study
54
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.

55
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

56
Arctic Sun
57
Cincinnati Sub-0Blanketrol II
58
Caircooler
59
Icy-Cath
60
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.

61
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

62
Where should hypothermia be initiated?
  • No definitive recommendations by the AHA yet
  • Increasing volume of literature
  • Cold IVF
  • Safe
  • Effective
  • Fast
  • Further research needed

63
A cooling treatment is credited with helping Dr.
Syed Hassan Naqvi recover from Cardiac arrest.
City Pushes Cooling Therapy for Cardiac Arrest
64
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

65
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.

66
Early Participating Hospitals
  • NY Presbyterian
  • Mt Sinai
  • Bellevue
  • St. Vincents
  • Elmhurst
  • Maimonidies
  • Staten Island University

67
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

68
NJ Responds
  • Cooper University Hospital
  • Morristown Memorial Hospital
  • Hackensack University Medical Center
  • Newark Beth Israel
  • Many others developing protocols

69
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

70
Questions?
I think they can stop CPR.
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