5 th Congress of Cardiologists and Angiologists of Bosnia and Herzegovina and

1. CARDIOPULMONARY RESUSCITATIONAND CARDIAC ARREST IN ADULTS:From Physiological Concepts to Advances in CPR Performance 5th Congress of Cardiologists and Angiologists of Bosnia and Herzegovina and 1st Congress of Cardiovascular Nursing in Bosnia and Herzegovina May 28, 2010 A. Maziar Zafari, M.D., Ph.D. Associate Professor of Medicine Emory University School of Medicine

2. Early Attempts at Resuscitation Elisha's mouth to mouth resuscitation (Bible, 2 Kings, IV, 34): "...And he went up, and lay upon the child, and put his mouth upon his mouth, and his eyes upon his eyes, and his hands upon his hands; and he stretched himself upon the child; and the flesh of the child waxed warm." Early Ages -Inversion Method Early Ages -Heat Method Early Ages -Flagellation Method 1530-Bellows Method 1711-Fumigation Method 1770-Inversion Method 1803 -Russian Method 1812-Trotting Horse Method 1856-Roll Method 1892-Tongue stretching Hieronymus Bosch 1490, "The Ascent of the Blessed"

3. Scientific and Programmatic Highlights of the Modern History of CPR 1740 The Paris Academy of Sciences officially recommends mouth-to-mouth resuscitation for drowning victims. 1767 The Society for the Recovery of Drowned Persons becomes the first organized effort to deal with sudden death. 1891Dr. Friedrich Maass performs the first documented chest compression in humans. 1903 Dr. George Crile reports the first successful use of external chest compressions in human resuscitation. 1954 James Elam is the first to prove that expired air is sufficient to maintain adequate oxygenation. 1956 Peter Safar and James Elam invent mouth-to-mouth resuscitation. 1957 The United States military adopts the mouth-to-mouth resuscitation method  to revive unresponsive victims. 1960CPR is developed. The AHA starts a program to acquaint physicians with close-chest cardiac resuscitation. 1963Cardiologist Leonard Scherlis starts the AHA's CPR Committee, and the same year, the AHA formally endorses CPR. 1966Standardized training and performance standards for CPR are established. 1972Leonard Cobb holds the world's first mass citizen training in CPR in Seattle, Washington called Medic 2. 1981A program to provide telephone instructions in CPR begins in King County, Washington.  1984 A program with fire fighter EMTs using AEDs begins in King County, Washington 1991The chain of survival is introduced in 1991 as a model of efficiency and synergy in resuscitation efforts. 2000 The world’s first international conference is assembled specifically to produce international resuscitation guidelines. 2005ILCOR publishes the 2005 International Consensus on CPR and ECC Science with Treatment Recommendations. 2010The International Consensus on CPR and ECC Science with Treatment Recommendations is planned for publication in October.

4. Adult Chain of Survival The chain of survival was first introduced in 1991 as a model of efficiency and synergy in resuscitation efforts Circulation 2005.

5. I. The 3-phase model in VT/VF arrest integrating and characterizing specifically the time relationships of the value of rapid defibrillation, CPR performance, and the need for other measures. Weisfeldtand Becker. JAMA 2002.

6. Important Changes in the 2005 AHA Guidelines for CPR and Emergency Cardiovascular Care Ali and Zafari. Annals of Internal Medicine2007.

7. II. The introduction of inexpensive, easy-to-use Automatic External Defibrillators (AEDs).

8. Expected Survival According to the Interval between Collapse and the Administration of First Shock by the Defibrillator Weaver et al. NEJM 2002.

9. Percentage Arrest Victims Presenting with VT/VF Alive at Discharge as a Function of Year The percentage of the arrest victims presenting with pulseless ventricular tachycardia or ventricular fibrillation alive at discharge as a function of year. The percentage of patients presenting with life-threatening rhythms surviving to discharge was greater after a program encouraging early defibrillation was instituted in 2001. Zafari, et al. J Am Coll Cardiol 2004.

10. Public-Access Defibrillation and Survival after Out-of-Hospital Cardiac Arrest Kitamura T et al. N Engl J Med 2010. The Public Access Defibrillation Trial Investigators. N Engl J Med 2004.

11. III. The need to translate animal data on CPR performance and effectiveness from the laboratory into the clinical arena.

12. Coronary Perfusion Pressure During Chest Compressions Sanders, et al. J Am Coll Cardiol 1985. Kern, et al. Resuscitation 1998.

13. CPR Parameters and Resuscitation Outcomes In a Cardiac Arrest Cohort (2002-2004) Abella et al. JAMA 2005.

14. IV.Introduction of devices that may improve perfusion during cardiopulmonary resuscitation and thus may improve survival.

15. Techniques and Mechanisms of Cardiac Massage Cooper, et al. Circulation 2006.

16. Correlations between Heart and Brain Flows for AutoPulse-CPR and Conventional CPR Halperin, et al. J Am Coll Cardiol 2004.

17. Comparison of the Thoracic-Vest System for CPR with Standard Manual CPR Halperin, et al. N Engl J Med 1993.

18. “Why is it that every time I press on his chest he opens his eyes, and every time I stop to breathe for him he goes back to sleep?” A lay rescuer who had been given 9-1-1 dispatch telephone instructions in CPR V. Cardiocerebral resuscitation may be useful in patients with out-of-hospital cardiac arrest. http://handsonlycpr.org/

19. Cardiocerebral Resuscitation Kern, et al. Circulation 2002. Ewy. Circulation 2005.

20. Continuous Chest Compressions-CPR:Hemodynamic Changes Ewy. Circulation 2005.

21. Survival to Hospital Discharge of Patients With Out-of-Hospital Cardiac Arrest Treated by Different Emergency Medical Services Protocols Ewy, et al. J Am CollCardiol2009.

22. VI. Change in the characteristics of the population suffering cardiac arrest and registry-based information on in-hospital and out-of-hospital CPR. Zheng, et al. Circulation 2001.

23. The National Registry of Cardiopulmonary Resuscitation Chan, et al. N Engl J Med 2008.

24. Factors Associated with Delayed Time to Defibrillation Chan, et al. NEJM 2008.

25. Outcomes of In-Hospital Pulseless Cardiac Arrest by First Documented Pulseless Arrest Rhythm Nadkarni, et al. JAMA 2006.

26. Characteristics of Survivors and Non-Survivors of Cardiac Arrest Bloom, et al. American Heart Journal 2007.

27. Comparison of Cardiac Arrest Survivors with and without Implantable Cardiac Defibrillators Bloom, et al. Am Heart J 2007.

28. VII. The Post-Cardiac Arrest Syndrome and new technologies that may impact on resuscitation. Neumar, et al. Resuscitation 2004. Neumar, et al. Circulation 2008.

29. Post–Cardiac Arrest Syndrome: Pathophysiology, Clinical Manifestations, and Potential Treatments Neumar, et al. Circulation 2008.

30. VIII. Moderate Hypothermia may be useful in patients who after out-of-hospital cardiac arrest have not awakened when they reach the emergency department.

31. Mechanisms of Action • In the normal brain, hypothermia reduces the cerebral metabolic rate for oxygen by 6% for every 1oC reduction in brain temperature >28oC, in part by reduction in normal electrical activity. • Mild hypothermia reduces free radical production, excitatory amino acid release, and calcium shifts, which can in turn lead to mitochondrial damage and programmed cell death. • Hypothermia can also produce adverse effects, including arrhythmias, infection, and coagulopathy. Perhaps the greatest risk comes not from cooling itself but from rewarming, which can sink blood pressure to life-threatening lows.

32. Four Trials of Mild Induced Hypothermia after Cardiac Arrest Foëx and Butler. Emerg Med J 2004.

33. Induced Hypothermia After Cardiac Arrest The Hypothermia after Cardiac Arrest Study Group. N Engl J Med 2002.

34. IX. New paradigms that may affect resuscitation. Lloyd, et al. Circulation 2008.

35. Measurements from 36 Shocks with Rescuer-Patient Contact during External Defibrillation Average Leakage Current During Hands-on Defibrillation in Relation to Electrical Safety Lloyd, et al. Circulation 2008.

36. Automatic External Cardiac Defibrillation This pilot study recorded time to defibrillation and investigated an operator-independent automatic external cardiac defibrillator (AECD) on resuscitation outcomes. Ali, et al. Trials 2008.

37. Case Patient The AECD correctly recognized sustained monomorphic ventricular tachycardia and delivered a 150 Joule shock after 47 seconds. The rhythm is converted to sinus rhythm but reverts to ventricular tachycardia after 10 seconds. Ali, et al. Trials 2008.

38. X. The state of consciousness during cardiac arrest. Flatliners, 1990 with Julia Roberts and Kiefer Sutherland. The AWAreness during Resuscitation Experiment (AWARE) is an ongoing study run by the Human Consciousness Project.

39. Death: What Happens to Mind and Consciousness? • Reports of Near Death Experiences in 1970’s • What is meant by near death? • Outcome of mind at point of death • Cardiac arrest - closest model of dying process

40. AWARE Study • Prospective international multicenter study of mind, brain and consciousness during cardiac arrest • Aim: To determine what happens to human mind during clinical death • First large scale study to examine claims to “see” and “hear” andprove or disprove “out of body experiences” • Use of sophisticated technology to study the relationship between brain oxygenation during cardiac arrest and consciousness

41. Cerebral Oximetry Possible tool to study flow during cardiac arrest The INVOS® Cerebral/Somatic oximeter is a noninvasive, safe and effective oxygen monitor. Near-infraredspectroscopy (NIRS) is used to provide real-time monitoring of changes in regional oxygen saturation (rSO2) of blood in the brain or other body tissues beneath the sensor. It measures site-specific oxygen levels, rather than systemic, whole body measures such as blood pressure and pulse oximetry. Brain oximetry will be studied as a potential real time marker of cerebral resuscitation during in-hospital cardiac arrest. Higher cerebral oxygen levels are associated with better outcomes (60%) and lower values (40%) are associated with worse survival in out-of-hospital cardiac arrest. Newman, et al. Resuscitation 2004.

42. 1. The occurrence of cognitive function and awareness during cardiac arrest arises due to improved cerebral resuscitation and is associated with reduced brain damage.2. Although seeming “real” to patients themselves, the reports of consciousness and thought processes including the ability to “see” and “hear” does not correspond with an objective reality related to the period of cardiac arrest but are rather experiences that are associated with an individual’s previous social and cultural background. Hypotheses

43. Study Objectives 1. Determine the relationship between consciousness and activity of the mind with cerebral perfusion as measured by cerebral oximetry together with its impact on short and long term neurological and cognitive outcomes in cardiac arrest survivors. 2. Determine the clinical usefulness of measuring brain perfusion by cerebral oximetry during cardiac arrest in terms of predicting cognitive and neurological outcomes. 3. Identify physiological factors and clinical measures that lead to improved cerebral resuscitation and their relationship with short and long term cognitive and neurological outcomes. 4. Determine the association of cognitive function during cardiac arrest with physiological, clinical and sociocultural variables as well as their impact on psychological and neurological outcomes. 5. Qualitatively investigate consciousness, memories and perception during in-hospital cardiac arrest. 6. Objectively test memory and recall from the period of cardiac arrest. This study includes an objective test that may demonstrate whether patients’ reported memories of ‘seeing and hearing’ are false memories formed after the event or an actual awareness from the period of cardiac arrest.

44. Ethical Issues in Resuscitation ResearchAssess the views of cardiac arrest survivors on research conducted in emergency settings using the federal exception from informed consent.Serum Markers of Neuronal DamageIn almost all cardiac arrest cases patients will have routine blood samples sent to the laboratory by the medical and nursing staff. Where serum samples have been routinely sent to the laboratory, the excess serum that is not being used by the laboratory will be used to test for the levels of the two brain parenchyma markers of damage (NSE and S100). DNA/RNA StorageExcess blood samples and/or blood samples drawn for the purpose of this study will be stored for later analysis of DNA and/or RNA. At present, there is no knowledge about possible genetic variations that might be associated with better cognitive or neurological outcomes or the occurrence of reported memories for the cardiac arrest period. Additional Aims

45. Summary and Conclusions • Advances in resuscitative medicine are founded on the basic science understanding of physiology and pathophysiology as well as advances in understanding of the causal mechanisms involved in successful or unsuccessful resuscitation. • Survival is correlated with the speed and quality with which definitive therapies such as chest compressions and defibrillation are begun after cardiac arrest. Push hard, push fast, minimize interruptions. • Automated detection algorithms and technological advances in early defibrillation, chest compression, and post cardiac arrest care have the potential to increase survival to discharge in patients with out-of-hospital and in-hospital cardiac arrest.

46. Atlanta VAMC Andrea G. Backscheider, PhD Heather Bloom, MD Matthew Certain, MD Neal Dickert, MD, PhD Samuel C. Dudley, MD, PhD Vicki Heggen, RN Akram Ibrahim, MD Michael S. Lloyd, MD Heather Miller, RN Emeka Onuorah, PhD Roger Phillips , RN Kiran Reddy, BA Maya Sternberg, PhD Regina A. Taylor, RN Lisa Williams, RN Patricia Wilson, RN, MSN Susan K Zarter, RN and the CPR Committee Sam Parnia, MD, PhD Weill Cornell Medical Center, NY and the Collaborators Grady Memorial Hospital Prasad Abraham, PharmD Eric Honig, MD Tze-chun V. Liao, PharmD Antoine Trammell, MD

47. How technology changed us …!

48. Neurological Prognosis and Withdrawal of Life support After resuscitation from Cardiac Arrest Roine, et al. Arch Neurol 1991. Geocadin, et al. Neurology 2006.

49. XII. The role for advance directives and living wills on end-of-life care. Silveira, et al. N Engl J Med 2010. Gillick. N Engl J Med 2010.

50. Communication Tips for an Effective Code Status Discussion Loertscher, et al. Am J Med 2010.