1 / 34

UPDATE: IN-HOSPITAL

CARDIOPULMONARY RESUSCITATION. UPDATE: IN-HOSPITAL. Cardiac Arrests at JHH. 85 cardiac arrests in 2011: excluding ED, ICU and theatres 3 in the cath lab (1 survived) 26 in CCU (58% survived, 32% died) 9 in G3 (1 survived to get to ICU) Of the remaining 47 patients: 72% died

kenaz
Download Presentation

UPDATE: IN-HOSPITAL

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. CARDIOPULMONARY RESUSCITATION UPDATE: IN-HOSPITAL

  2. Cardiac Arrests at JHH • 85 cardiac arrests in 2011: • excluding ED, ICU and theatres • 3 in the cath lab (1 survived) • 26 in CCU (58% survived, 32% died) • 9 in G3 (1 survived to get to ICU) • Of the remaining 47 patients: • 72% died • 11% made it to discharge

  3. Australian Resuscitation Council 2010 DRS ABCD (S=send for help) • When to commence CPR • Unresponsiveness and abnormal breathing • Check for central pulse for 10 seconds [A, ECO] • Hand placement • Lower half of the sternum • Inter-nipple line • Depth of compression • 1/3 chest wall depth or greater than 5cm [A, animal] Cardiopulmonary resuscitation for advanced life support providers. ARC and NZRC Guidelines 2010, Emerg Med Aust, 2011,23:264-70

  4. Australian Resuscitation Council 2010 • Compression rate • 100 per minute, no evidence for faster rate [A, animal] • Compression:relaxation ratio • Equal time spent in compression and release • Aim to achieve complete recoil of chest between compressions • Provision of a firm surface • [A, manikin]

  5. Australian Resuscitation Council 2010 • Minimise interruptions to CPR [A, human] • Continue without interruption • unless evidence of return to breathing or specific task • Attempts at intubation should NOT interrupt • Planned pauses for rhythm/pulse analysis <10sec • Compression ventilation ratio • Before airway is secured, 30:2 [A, EO] • After secured, ventilate with 100% O2 • need to assess chest rise with EACH breath • 6-10 ventilations per minute with airway [A, EO] • Don’t interrupt compressions, but time with compressions • Don’t ventilate at same time as compression

  6. Australian Resuscitation Council 2010 • Fatigue • Chest compressions become shallower at one minute but providers only become aware at 5 minutes • Swap pumpers every two minutes • Perform CPR right up to the point of shock • Recommence CPR immediately after shock • If rhythm compatible with spont circulation, check pulse • Otherwise, keep pumping • Shock • Monophasic =360J, biphasic =200J

  7. Australian Resuscitation Council 2010 • Precordial thump • Doesn’t work in VF, might work in VT • Vasopressors • Increase return of spontaneous circulation • No improvement in longer term outcome • Adrenaline 1mg IV at time of commencement • Anti-arrhythmics • No evidence of improved mortality • Give amiodarone after 3rd unsuccessful defib

  8. Australian Resuscitation Council 2010 • Monitor adequacy of CPR • Technique • End-tidal CO2 - low CO2 = breathing too fast • ABG - only for electrolytes, NOT for acid base state • Real-time feedback devices • Harm to patient during CPR • Audit, feedback and quality improvement

  9. Australian Resuscitation Council 2010 • Guidelines also encompass: • Seek reversible causes • Special circumstances • Anaphylaxis, avalanches, pregnancy, tamponade, etc. • Managing acute dysarrhythmias • Evidence for equipment • Post resuscitation therapy • PCI in STEMI • Use of amiodarone prophylactic anti-arrhythmic [A, EO] • BP, BSL, O2 and CO2 ,neuro, temperature etc • Consider resuscitation related injuries • Prognosis • Organ donation

  10. American guidelines

  11. Differences • ABC becomes CAB • Atropine has been officially removed • Cricoid pressure has been removed • Consider all for cardiac catheterisation

  12. Evidence • Evolution in understanding over the past decade • The longer someone is in VF, the harder to cardiovert • The better perfused the myocardium is prior to a shock, the more likely cardioversion is to work • A single dose of adrenaline is the only drug which can help return of spontaneous circulation, except for MgSO4 in torsades • Over-ventilation is harmful, “lazarus syndrome”

  13. Evidence for training to improve technique and outcomes • Teaching hand placement improves technique1 • Teaching ALS results in improved technique for at least 6 months2 Owen et al, A randomised control trial comparing two techniques for locating chest compression hand position in adult basic life support, Resuscitation 2011, 82:944-6 Ettl et al, Updated teaching techniques improve CPR performance measures: a cluster randomised control trial, Resuscitation2011, 82:730-5

  14. Technique • Important not to “lean” on patient between compressions as reduces chest expansion1 • Supraglotic airways are adequate in an emergency and reduce “hands off time”2 • Pause for ECG analysis <10 seconds3 Editorial, Leaning is common in chest compressions but remains a relatively unknown entity, Resuscitation 2011, 82:971-2 Hands-off time during insertion of six airways devices during cardiopulmonary resuscitation: a randomised manikin trial, Resuscitation 2011, 82:1060-3 Editorial, Pauses during CPR are breaks hinering our efforts? Resuscitation 2011, 82:1379-80

  15. Longer pauses between compressions and defib decrease survival 815 out of hospital arrests treated by paramedics • Longer pre-shock periods were associated with decreased survival1 • Longer than 20 seconds vs <10sec OR=0.47 • For peri-shock pause: • >40 seconds, 45% decrease in survival compared to • peri-shock pause <20sec Cheskes et al, Circulation2011, 124:58-66

  16. Evidence for Drugs in Resus • Adrenaline doubles chance of return to spont. circulation but no mortality benefit: • Survival to hospital d/c - 10.5% vs 9.2% • Survival with favourable neuro - 9.8% vs 8.1% • Vasopressin and terlipressin are as good as adrenaline • Short-term benefit of amiodarone • MgSO4 for torsades works Morley, Drugs during cardiopulmonary resuscitation, Cardiopulm Resus, 2011, 17:214-18

  17. Evidence of damage secondary to CPR • 65% of patients have rib fractures • 30% of patients have sternum fractures • Patients >60yrs old much greater risk Kim et al, Multidetector CT findings of skeletal chest injuries secondary to cardiopulmonary resuscitation, Resuscitation 2011, 82:1285-88

  18. Evidence of damage secondary to CPR • 1987 study of 705 autopsies after CPR • 18% had mediastinal hemorrhage • 3% had abdo visceral / oesophageal rupture • 10% had pericardial bleeding or lacerations of the great vessels or myocardium Bardy, A ciritcs assessment of our approach to cardiac arrest, NEJM 2011, 364:374-5 Krischer et al, Complications of cardiac resuscitation, Chest 1987, 92:287-91

  19. Evidence of damage secondary to CPR • Recognition of gastric rupture secondary to use of laryngeal mask in CPR Haslam et al, Gastric rupture associated with use of the laryngeal mask during cardiopulmonary resuscitation, BMJ 2004, 329:1225-6

  20. Evidence of damage secondary to CPR • Extreme oxygen tension associated with increased mortality • Hypothesized to be global ischaemia / reperfusion injury Kilgannon et al, Relationship between supranomral oxygen tension and outcome after resuscitation from cardiac arrest, Circulation2011, 123:2717-22

  21. Treatment protocols for post arrest improve outcomes • Out-of-hospital arrest, favourable outcome can be achieved (25% vs 56%) by following stardard protocol1 including • PCI for all ST elevation ECG • Mild therapeutic hypothermia (MTH) • Standard ICU protocols 1. Tomte et al, Strong and weak aspects of an established post-resuscitation treatment protocol - a five year observational study, Resuscitation 2011, 82:1186-93

  22. Rhythms and outcomes • American Heart Association National Registry for Cardiopulmonary Resuscitation • 51,919 pts with pulsless cardiac arrest between 1999 and 2005 • VT 7% • VF 17% • PEA 37% • Asystole 39% • Survival to hospital discharge was • 37% in VF/VT and • 12% PEA, • 11% asystole

  23. Evidence for CCU and Monitoring • Good evidence that monitoring improves outcomes in cardiac arrest • Cerebral performance caregory 1 or 2 at discharge compared to non-witnessed: • OR 2.4 if monitored and witnessed • OR 2.12. if monitored only • OR 2.42 if witnessed only Brady et al, In-hospital cardiac arrest: impact of monitoring and witnessed event on patient survival and neurologic status at hospital discharge, Resuscitation 2011, 82:845-52

  24. Resuscitation in elderly hospital inpatients? • Individuals with certain characteristics automatically opted out1 • Better education for healthcare workers re decision to resuscitate and the right of medic to withhold2 • If a patient enters hospital and there is a plausible risk of cardiac arrest, physician should recommend against it when there is a low likelihood of benefit3 • Opt in not out. BMJ 2011, 343:5251 • Progress towards fewer inappropriate attempts at cardiopulmonary resuscitation. BMJ 2011, 343:5942 • Blinderman et al, Time to revise the approach to determining CPR status, JAMA 2012, 307:917-18

  25. Opt in not out • Vocal criticism of “the slow code” although • Some ethicists state that the “slow code” may be a method of meeting the needs of family and patient1 Lantos et al, Should the slow code be resuscitated? Am J Bioeth 2011, 11:8-12

  26. Resuscitation in the elderly Predictors of survival following in-hospital cardiopulmonary resuscitation, CMAJ 2002, 167:343-8

  27. Resuscitation in the elderly • In a 1989 study, 503 inpatients over 70: • 22% survived initially, 9.6% survived to discharge • Unwitnessed arrest– 1/116 survived • PEA or asystole– 1/237 survived • CPR > 15 minutes– 1/360 survived • Acute care hospital inpatients – 17/259 survived • Most survivors had VT or VF that was witnessed • Outcomes of cardiopulmonary resuscitation in the elderly, Annals of Internal Medicine, 1989, 111:199-205

  28. When is it futile? Cardiac arrest Respiratory arrest Predictors of survival after cardiac or respiratory arrest, CMAJ, 2011, 183:1589-94

  29. Greek Cardiologist’s Knowledge of CPR Pantazopolous et al, Carrdiologists’ knowledge of the 2005 American Heart Association Guidelines, Heart and Lung 2011, 40:278-84

  30. The Quilty Take – GIVE UP • No CPR on unwitnessed arrest in patients > 80 • All inpatients not monitored and >80 are NFR • Discussion with susceptible patients who are unlikely to benefit from CPR before arrest situation • Should the patient be give an option? • If over 70 and >10 minutes, call it quits • If PEA or asystole and over 70, call it quits

  31. The Quilty Take – GIVE ‘EM A GO • Early defibrillation if witnessed • High quality chest compressions of: • adequate depth • rate • complete chest wall release b/n compressions • minimal hands off time • Keep pumping until defib ready to go • Go slowly with resps, aim for SaO2 88-95% • ED form documenting resus status for all over 70? • Always consider the damage that might have occurred

  32. The Quilty Take • Formalise resuscitation processes in the hospital, including expanded register to include outcomes • Train all medical registrars • In-hospital protocol for cardiac arrest, ie immediate revascularization, immediate ECHO, use of ultrasound etc?

  33. Quilty Take • Average age of 99 resuscitated in 2005? • 71 • Average age of the 85 resuscitated 2011? • 71 • Age of the oldest survivor in 2011? • 90 (G1) • How many were over 90 in 2011? • 4

More Related