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Why Emergency Physicians Don ’ t Care about Cardiac Arrest and Should.

Why Emergency Physicians Don ’ t Care about Cardiac Arrest and Should. Robert Swor, DO Professor, Emergency Medicine Oakland University William Beaumont School of Medicine. Objectives. Epidemiology of Cardiac Arrest Survival Relative impact of interventions

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Why Emergency Physicians Don ’ t Care about Cardiac Arrest and Should.

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  1. Why Emergency Physicians Don’t Care about Cardiac Arrest and Should. • Robert Swor, DO • Professor, Emergency Medicine • Oakland University William Beaumont • School of Medicine

  2. Objectives • Epidemiology of Cardiac Arrest Survival • Relative impact of interventions • Relative impact of Phases of Care • Where do Emergency Physicians Make a Difference

  3. Emergency Physician Perspectives of Cardiac Arrest Resuscitation • It’s Futile • We just bring back patients to a vegetative state • The Only people that arrest are Gomers at the end of Life • This One’s comatose-He’s Toast • It’s a poor use of Health Care Dollars

  4. My Question • Are physician attitudes a self fulfilling prophecy? • i.e Do post arrest patients do poorly because we’re not aggressive with them in ED and hospital?

  5. Emergency Department Patient Scenarios • Field Cardiac Arrest • Post-Arrest- CPR in Progress • Post Arrest-DefibrillatedChest burns, alert • Post arrest-ResuscitatedSTEMI • Post Arrest- Comatose • Pre-Arrest-Crumps in the ED

  6. Cardiac Arrest Outcomes Out of Hospital Cardiac Arrest 225,000/yr In Hospital Cardiac Arrest 75,000/yr 17% Survive to Discharge ROSC 44% 20-25% survival To Admission (40-45% of Admitted Survive to Discharge) (38.6% of ROSC Survive to Discharge) Overall 5-10%Survival

  7. Neurologic Outcome Out of Hospital Arrest • Neurologic Death 25-30% • If survive to discharge • Excellent QOL if Early Defib • 5 Year survival Similar to age and health matched controls • OPALS-Good quality of life for survivors at 1 year* • Bunch TJ, NEJM 2003:348:2626-2633 • Steill, Circ 2003:108:1939

  8. Field Cardiac Arrest • CPR not Transported to Hospital • CPR in Progress on ED Arrival • Futile?

  9. 1

  10. What Happens to Field Cardiac Arrest • CARES Registry • 27,675 OHCA events • 18,541 (67.0%) with no field ROSC. • 12095 (65.2%) were pronounced in the field • 5618 (30.3%) had resuscitation terminated in the ED • 828 (4.5%) survived to admission

  11. Variation in Field Pronouncement after Failed Resuscitation-CARES

  12. Field Termination without ROSC-ROC Consortium

  13. Survivors To Admission • 828 (14.7% of transported) Survive to Admission • 128 survived to discharge (15.4%) • 81 (9.8%) survived with good cerebral performance.

  14. Termination of Resuscitation in Field-Decision Rules • ALS • No ROSC • No Bystander CPR • Not witnessed arrest • No shock Delivered • BLS • No ROSC • No witnessed • No AED shock

  15. Clinical Decision Rules for TOR-Evidence Based Review – Sherbino J. Em Med 2009:10:1016 • Literature Review • 4 Decision Rules • 3 BLS: 1 ALS • 6 Validation Studies • BLS Rule –PPV 99.5% (98.9%,99.8%) • Decreases transport 62.6% • ALS rule-no good quality validation study

  16. Cardiac Arrest Patients are All Gomers at the End of Life? • Need better work on who shouldn’t get CPR • Decreased Survival with Age • End of Life Planning and Care

  17. Unwanted or Not Indicated Resuscitation • King County 1994 (Dull) • 7% had undocumented DNR • 25% Severe Chronic Disease

  18. Possible Predictors of Outcomes After Cardiac Arrest • Clinical presentation • Arrest factors • Age • Diapers • Neuro exam • HCT • EEG • N-100 Enolase

  19. Impact of Therapeutic HypothermiaNielsonActa Anaes Scan 2009; 53:926-934 • Scandinavian Registry • 238 pts with Hypothermia - 7 Countries • Good Neurological Outcome • 22% Non VF • 56% VF

  20. Neurologic OutcomeOut of Hospital Arrest • Neurologic Death 25-30% • If survive to discharge • Excellent QOL if Early Defib • 5 Year survival Similar to age and health matched controls • OPALS-Good quality of life for survivors at 1 year* • Bunch TJ, NEJM 2003:348:2626-2633 • Steill, Circ 2003:108:1939

  21. Obstacle to initiating Aggressive Care No reliable data on predictors of outcome in first 3 days Consistent with AHA 2010 Guidelines Inability to Predict Outcomes

  22. Predicting Outcomes-Post Hypothermia

  23. ECMO To Support CPR in Adults • 1992-2007 • ELSO Database • Adults>18 years • Mean Age 52 • Survival in 27% • Brain Death in 29% • Ann Thoracic Surg 2009:87:778-785

  24. Case Study • Refractory Cardiac Arrest • 53 y/o male, severe 3 vessel ds • Post op CABG-refractory VF post op day 4 • 65 minutes CPR during attempted resuscitation-cannulation • ECMO for 4 days • Neuro intact, ICD placed, waiting for transplant

  25. Cost Effectiveness of Out of Hospital Cardiac Arrest Care • Cost Effective • Public Access Defibrillation • Nichol-$56,000 (IQR $44,000,$77,000) • Walker-$68,000 (Scotland) • Police AED • $2,000-$15,000/year of life saved • Advanced Life Support • Valenzuela-$8,800/year of Life saved (1990)

  26. Money Mechanics of L1CAC Survival 26 Lick et al. Crit Care Med 2011;39(1):26-33.

  27. Conclusion • CPR in progress Ominous prognosis • Resuscitated arrest • VF-Good outcome • Non-VF- Uncertain • Prognostication-Fool’s game • Time’s they’re a changin’ • Hypothermia • Aggressive therapy

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