1 / 70

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 Arrest. Conflicts to report: None.

dalton-little
Download Presentation

Advances In The Management Of Cardiac Arrest

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. 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

  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 <50 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 <0.001 • 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 30:2 • 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 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

  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 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

  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 • Don’t check monitor for rhythm • Don’t 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 > 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

More Related