What’s New in Resuscitation

1. VOMA VOMA What’s New in Resuscitation Greg Christiansen DO, MEd, FACOEP VCU Department of Emergency Medicine

2. Disclosure • No Industry or Third Party Affiliation • No Conflict of Interest • Credits: Dr. Kevin Ward • Dr. Joe Ornato • VOMA VOMA

3. Goals • Recognize processes to follow in an emergent cardiac arrest as part of a resuscitation effort • Be familiar with acute resuscitation concepts guiding acute cardiac care

4. Perceptionsand Reality • Television drama demonstrate 75 % survival rate • Correlates with public perception of CPR success • Adams found 81% of elderly admitted to a hospital believed there was a > 50% chance of their own survival if they had CPR Derrick Adams How mispercetpions among elderly pt regarding survival outcomes…JAOA 106 July 2006 Diem Cardiopulmonary resuscitation on TV: miracles & misinformation NEJM 1996:13 1578-1582.

5. Myths & Reality • Successful field resuscitation rates • 2-5% • Long held belief… • out of hospital cardiac arrest efforts are futile

6. Some Myths Die Hard

7. Flatliners • ..\..\..\Image File\recorded video\video\resuscitation\Flatlinev2.mpg

8. Question: • Which One of these Organs are Primarily Perfused During Diastole? • Brain • Heart • Kidney • Intestines

9. Question: • Which One of these Organs are Primarily Perfused During Diastole? • Brain • Heart • Kidney • Intestines

10. Which Patient has the Highest Chance of ROSC During CPR? • ABP: 120/20, CVP: 20 • ABP: 160/10, CVP: 30 • ABP: 60/30, CVP: 0

11. Which Patient has the Highest Chance of ROSC During CPR? • ABP: 120/20, CVP: 20 • ABP: 160/10, CVP: 30 • ABP: 60/30, CVP: 0 • CPP = end diastolic atrial pressure – Right atrial pressure ( CVP) • 30 – 0 = 30 CCP

12. Which Patient has Highest Likelihood of ROSC During CPR? • PetCO2: 6 mmHg: ABP 100/30 • PetCO2: 9 mmHg: ABP 120/20 • PetCO2: 20 mmHg: ABP 70/20

13. Which Patient has Highest Likelihood of ROSC During CPR? • PetCO2: 6 mmHg: ABP 100/30 • PetCO2: 9 mmHg: ABP 120/20 • PetCO2: 20 mmHg: ABP 70/20 • CPP > 15 tend to have higher ROSC

14. What effect will Epinephrine or Vasopressin have during CPR? • Lower PetCO2 levels • Increase PetCO2 levels • Increase Cardiac output • Decrease Cardiac Output

15. What effect will Epinephrine or Vasopressin have during CPR? • Lower PetCO2 levels • Increase PetCO2 levels • Increase Cardiac output • Decrease Cardiac Output • Vasopressors ↑after load, • ↓CO↓CPP ↓ETCO2

16. Rosamond et al., Heart Disease & Stroke Statistics, 2008 Update. Circulation 2008; 117:e1-e122

17. Case: MR VeThach – • 46 yo male collapsed on the tread mill • Full arrest • CPR • ALS medication • 10 minute down time

18. My First Case • Fluid resuscitation • ROSC • Coma • Decorticate Posturing • Sent to CT • Instituted therapeutic hypothermia

19. Were not making vegetables

20. Lessons learned What it is & why it works … sometimes

21. Cardiac Arrest • Final common pathway: Everyone has it once • A symptom or finding of a disease process • Myocardial ischemia, profound hypoxia, conduction defects, toxicologic, hemorrhage, etc • The ultimate state of shock: Global ischemia • Neurologic outcomes better than commonly believed

22. Goals (when appropriate) • Return of Spontaneous Circulation (ROSC) and reversal of underlying causes. • What is the best therapy for the brain during CPR? Restart the Heart

23. Methods • Electrical Therapy • Pharmacological Therapy • Mechanical perfusion

24. Ischemia: The Problem ATP ATP ATP Failure

25. Myocardial Cell<10% ATP Myocardial Cell30-40% ATP Myocardial Cell100% ATP Importance of Myocardial ATP

26. Cardiac Image No CPR Courtesy of Dr. Stig Steen University Hospital Lund, Sweden

27. Cardiac Resus image with CPR

28. Aod RAd Coronary Perfusion Pressure (CPP) Key to Successful Resuscitation CPP = Aod- RAd

29. Effect of Chest Compression Pauses on Coronary Perfusion Pressure Aorta CPP RA

30. The Higher the CPP the Better

31. Mechanism for Cardiac Compression • Direct Compression of Chambers • Functional Aortic Valve • Trend for higher CPP

32. Thoracic Pump Mechanism • Global changes in intrathoracic pressure • Heart is passive conduit • Harder to achieve CPP • Maybe better CePP • Beware of Chest tubes

33. Which Pump? • Not mutually exclusive • Body habitus dependent? • Both markedly deteriorate over time as valves become less functional.

34. Driving Blindly: • Rule #1: • Palpating Pulses to Monitor CPR Effectiveness ….. • Is for Those Who Don’t Know What to Do.

35. How to Improve CPP? • Pharmacologically • Vasopressors: Epinephrine vs. Vasopressin • Mechanically • Type of CPR: Regular, new and improved, delux

36. Effects of Epinephrine

37. Summary • Many critical components to Successful Resuscitation (Neurological Recovery) • Limiting Total Arrest time is Key!!! • Obtain ROSC ASAP (5-10 minutes) • After ROSC….Real work begins • Similar to Trauma Care…Should be one with Cardiology/Pulmonary Critical Care

38. Improving Blood Flow during Resuscitation

39. Quality of Chest Compressionsin OOH-CA Wik et al. JAMA 2005: 293:299-304 • 176 adult patients • Sweden, Norway, England • ROSC 35%

40. Minimally Interrupted CPR Experience Wisconsin & Arizona: • Emphasis on compression quality and quantity • New protocol • 200 pre shock compression before defibrillation • 200 post shock compression. • Delays endotracheal intubation and eliminates pulse checks. Bobrow, B.J. et.al., Minimally Interrupted Cardiac Resuscitation by Emergency Medical Services for Out-of-Hospital Cardiac Arrest. JAMA; 2008; 299: pp 1158-1165.

41. Minimally Interrupted Cardiopulmonary Resuscitation (MICR) by EMSBobrow et al. JAMA 2008; 299:1158-65Peberdy MA, Ornato JP: JAMA 2008; 299:1188-90 • 62 EMS agencies in Arizona • 75% of state population • 200 CCs first • Rhythm check • Single DF • 200 CCs post-DF • Early epinephrine • Delayed intubation

42. CPR Prior to DefibrillationChristenson J et al. AHA ReSS 2007 • ROC Epistry • N= 7,963 • Male 81% • Byst CPR 51%

43. Compression Rate vs. ROSCAbella BS. Circulation 2005; 111:428-34

44. Critical pressure for ROSC (Paradis, JAMA 1990;263:3257-8) % Chest Wall Decompression % Chest Wall Decompression Effect of Incomplete Chest Decompression On Coronary and Cerebral Perfusion PressuresYannopoulos D et al. Resuscitation 2005;64:363-72 ǂ • n=9 instrumented swine • 6 minutes untreated VF  standard CPR* x 3 min  CPR with 75% recoil (residual 1.2 cm sternal compression @ end decompression) x 1 min  standard CPR* x 1 min  defib x 3  ACLS

45. 156 OOH cardiac arrest • 868 DF attempts 60% "Hands-off Interval" [sec] from Stop CPR to DF shock 0 5 10 15 20 40% % ROSC 20% 0% High Medium Low Median Frequency (VF “Coarseness”) “Hands-Off” Interval vs. DF SuccessEftestol T et al. Circulation 2002; 105:2270-3

46. CPR Fraction prior to DFChristenson J et al. AHA ReSS 2007 • ROC Epistry • N= 7,963 • Male 81% • Byst CPR 51%

47. Improving Blood Flow During Resuscitation Summary • CPR necessary to provide coronary perfusion • Must restart the heart for survival • Conclusion – focus of the heart! What’s the evidence to support this focus?

48. Therapeutic hypothermia during or immediately after resuscitation

49. Today • 500 of 5,000 hospitals use therapeutic hypothermia • Capturing on 20% of all eligible patients If the patient can’t walk out of the hospital then… A hospital bed is a parked taxi with the meter running - Groucho Marx

50. BRAIN INJURYis the most common cause of death after initial resuscitation from sudden cardiac arrest HIPPA