Cardiac Arrest 2014 Beyond ACLS

1. Cardiac Arrest 2014Beyond ACLS Jason Mansour, MD, FACEP Broward General Medical Center Emergency Medicine

2. Objectives • Definition • Epidemiology • Pathophysiology • ACLS: past, present, and future • Cardiocerebral Resuscitation • Reversible causes (5H’s, 5T’s) • Post-resuscitation care • Therapeutic Hypothermia

3. Case 165 yo male found to be pulseless and apneic, unwitnessed CODE BLUE has been called. You are the first to arrive. You should first: • Start compressions • Attach AED +/- Shock • Intubate • Establish IV access • Give 2 rescue breaths

4. Cardiac Arrest Definition • The cessation of effective cardiac output as a result of either asystole, VT, or VF. • The end result is sudden cardiac death (SCD) • SCD is defined as the unexpected natural death from cardiac cause within 1 hour of onset of symptoms in a person without any prior condition that appears fatal

5. Epidemiology Sudden Cardiac Death (SCD) • 300,000–400,000 deaths per year in the US • Incidence of SCD 55 /100,000 • Most occur in the home • Most commonly male ages 50-75 • Most have underlying heart disease • Most tend to happen in the morning • Prognosis of survivors has not improved (50-71% in-house mortality)

6. Epidemiology Sudden Cardiac Death: Circadian Pattern • Most SCD occur in AM • Increased sympathetic tone? • Neurohormonal factors? Thaker RK, et al: Circadian variation in sudden cardiac death: Effects of age, sex, and initial cardiac rhythm. Ann Emerg Med 27: 29-34, 1996.

7. Pathophysiology Structural Heart Abnormalities Functional Electrophysiological Disturbances • Myocardial Scar • Aortic Stenosis • Congenital Heart Dz • LVH • BBB • WPW • Brugada • Long QTc • Ischemia • Hypoxia • Electrolyte Abn. • PE • Drug Effects • Acidosis Arrhythmia • Asystole/PEA • VT/VF

8. ACLSReturn of spontaneous circulation (ROSC) does not necessarily mean survival ROSC Hospital Discharge Intervention A Standard Therapy

9. ACLSAHA Updates 2005 More focus on good quality uninterrupted CPR Focus on Defibrillation vs. Focus on CPR GOAL: ROSC GOAL: Perfuse Brain

10. ACLS 2000 • Focus was more on early defibrillation • Several studies showed greater survival when defibrillation was delivered early • One study showed 74% survival to dc when shock was delivered within 3 min* *Valenzuela TD, Roe DJ, Nichol G, Clark LL, Spaite DW, Hardman RG. Outcomes of rapid defibrillation by security officers after cardiac arrest in casinos. N Engl J Med. 2000;343:1206-9.

11. CPR vs. DefibrillationWhich is first priority? • Animal studies show defib first approach only beneficial in first few minutes • Yakaitis et al. Crit Care Med. 1980 – 3 min • Niemann et al. Circulation. 1992 – 5 min • Menegazzi et al. Ann Emerg Med. 1992 – 8 min

12. Pathophysiology3-phased time-sensitive model • Phase 1: Electrical • 0-4 minutes • Defibrillation is key • Phase 2: Circulatory \ • 4-10 minutes • CPR gains importance • Phase 3: Metabolic • 10+ minutes • Global ischemia • Sepsis-like immuno. changes (IL, TNF, etc) • Hypothermia may be beneficial Defibrillation Quality CPR

13. CPR Does interrupting CPR decrease its success ? • Animal studies suggest interruptions increase mortality Yu et al. Circulation. 2002

14. Uninterrupted CPR saves livesShould we even pause for rescue breaths? • Bohm, et al. Circulation. 2007 • Retrospective review • Cardiac Arrest Registry 1990-2005 73% Bohm K, et al. Survival is similar after standard treatment and chest compression only in out-of-hospital bystander CPR. Circulation. 2007;116:2908-2912.

15. Uninterrupted CPR saves livesShould we even pause for rescue breaths? • Bohm, et al. Circulation. 2007 • No difference in outcome: CPR vs. Compression only Bohm K, et al. Survival is similar after standard treatment and chest compression only in out-of-hospital bystander CPR. Circulation. 2007;116:2900-2907.

16. Cardiac Only Resusc. vs. CPR • Iwani T, et al. Circulation. 2007. • Prospective, observational • 4902 witnessed arrests May 98- Apr 03 Bystander intervention Iwani T, Kawamura T, Hiraide A, et al. Effectiveness of bystander initiated cardiac-only resuscitation for patients with out-of-hospital cardiac arrests. Circulation. 2007;116:2900-2907.

17. Cardiac Only Resusc. vs. CPR • Outcome 1 yr • No difference • VF– no difference • EMS arrival > 15 min • Favors CPR Iwani T, Kawamura T, Hiraide A, et al. Effectiveness of bystander initiated cardiac-only resuscitation for patients with out-of-hospital cardiac arrests. Circulation. 2007;116:2900-2907.

18. Cardiac Only Resuscitation Iwani T, Kawamura T, Hiraide A, et al. Effectiveness of bystander initiated cardiac-only resuscitation for patients with out-of-hospital cardiac arrests. Circulation. 2007;116:2900-2907.

19. What about Pediatric pts?Conventional CPR seems to be superior to CC alone • Outcome: favorable neurological outcome at 30 days • Non cardiac cause 3675 pts • CPR 7.2% [45/624] vs CC only 1.6% [6/380] • OR 5.54 [2.52-16.99] • Cardiac cause 1495 pts • CPR 9.9% [28/282] vs CC only 8.9% [14/158] • OR 1.20, 0.55-2.66 • In children, conventional CPR seems to be be superior to CC alone1 Kitamura T, Iwami T, et al. Conventional and chest-compression-only CPR by bystanders for children who have out-of-hospital cardiac arrest: a prospective, nationwide, population based cohort study. Lancet. 2010;375;1347-1354.

20. SummaryWhat is the new evidence telling us ? • Prompt and uninterrupted CPR improves outcome • After ~4mins of downtime (circulatory phase), “compression before defibrillation” approach may be better • Interrupting CPR decreases survival • Minimize the “pre-shock pause”! • In most adult arrests, conventional CPR do not seem to be superior to CC alone

21. Cardiocerebral ResuscitationMinimally Interrupted Cardiac Resuscitation (MICR) • Bobrow B, et al. JAMA. 2008.

22. Cardiocerebral ResuscitationMinimally Interrupted Cardiac Resuscitation (MICR) • Bobrow B, et al. JAMA. 2008. B C A Passive O2 via NRB or BVM Compressions Compressions Compressions Over 2 mins Over 2 mins Over 2 mins Epinephrine given as soon as possible and with each round of compressions Bobrow BJ, Clark L, Ewy G, et al. Minimally Interrupted Cardiac Resuscitation by EMS for Out-of-Hospital Cardiac Arrest. JAMA. 2008;299(10)1158-1165.

23. Cardiocerebral ResuscitationMinimally Interrupted Cardiac Resuscitation (MICR) • 886 patients, 2 AZ hospitals, 2005-2007 • 218 before MICR, 668 MICR trained • Outcome: survival to hospital discharge Bobrow BJ, Clark L, Ewy G, et al. Minimally Interrupted Cardiac Resuscitation by EMS for Out-of-Hospital Cardiac Arrest. JAMA. 2008;299(10)1158-1165.

24. Cardiocerebral ResuscitationMinimally Interrupted Cardiac Resuscitation (MICR) • Improved rate of hospital discharge Bobrow BJ, Clark L, Ewy G, et al. Minimally Interrupted Cardiac Resuscitation by EMS for Out-of-Hospital Cardiac Arrest. JAMA. 2008;299(10)1158-1165.

25. Cardiocerebral ResuscitationMinimally Interrupted Cardiac Resuscitation (MICR) • 80% of patients in both groups had favorable neurological outcomes Bobrow BJ, Clark L, Ewy G, et al. Minimally Interrupted Cardiac Resuscitation by EMS for Out-of-Hospital Cardiac Arrest. JAMA. 2008;299(10)1158-1165.

26. Summary CPR Saves Brain

27. 2010 AHA GuidelinesBLS Providers - Changes • “Look, Listen, and Feel” • Inconsistent and time consuming • Replaced by immediate activation of EMS system and chest compressions • Layperson encouraged mouth-to-mouth • “Hands-only” CPR is now encouraged for untrained layperson • A-B-C approach • Position head, attain seal or assemble BVM, 2 breaths too time consuming • Start CPR with 30 compressions (C-A-B approach)

28. 2010 AHA GuidelinesBLS Providers – Points of Emphasis • Emphasize qualitychest compressions • Emphasize recognition of atypical presentations of cardiac arrest • Cardiac arrest victims can appear to be gasping or having a seizure • Minimize interruptions in compressions • Minimize importance of pulse checks • Pulse detection can be difficult and time consuming • Take no longer than 10 seconds to check for pulse • Chest compressions delivered to pts with a pulse rarely are harmful

29. Differential Diagnosis • Hypoxia • Hypovolemia • Hypothermia • H+ ion (acidosis) • Hyper/Hypokalemia • Tension Pneumothorax • Tamponade • Thrombosis (MI) • Thrombosis (PE) • Toxins (drugs) 5 H’s 5T’s

30. Hypoxia • Typically bradycardia prior to arrest • Look for clues in history • Airway issues • Drowning • Carbon Monoxide • Treated with Oxygenation and Ventilation

31. Hypovolemia • Typically tachycardia prior to arrest • Look for clues with in history • AAA • GI Bleeding • Trauma • Look for clues on exam • Flat neck veins • Bedside Ultrasound is very valuable • Treatment is Volume

32. Hypovolemia (AAA) Using Ultrasound at the Bedside

33. Bedside Ultrasound for AAA

34. Bedside Ultrasound for AAA

35. Hypothermia • History and Temp will reveal diagnosis • EKG may show Osborne waves • Passive Rewarming • Remove from environment, blanket • Active External Rewarming • Heating Blankets, warm water immersion • Active Core Rewarming • Heated vent, IVF, ECMO • Lavage (GI, Foley, Peritoneal, Pleural)

36. H+ Ion (Acidosis) • Low voltage QRS prior to arrest • History of Diabetes, Renal Failure, or any hypoperfusion state • Other ACLS therapies may not work in acidotic environment (controversial) • Treatment is Bicarb +/- Hyperventilation

37. Hyper/Hypokalemia

38. Hyperkalemia Pearls • History of renal failure or dialysis graft on exam TREAT HYPERKALEMIA • Wide Complex Bradycardia or sine wave on EKG TREAT HYPERKALEMIA

39. Hypokalemia Pearls • Suspect in diuretic use or severe diarrhea • Difficult to empirically treat hypokalemia • If you know arrest is due to hypokalemia, give Mg with K replacement

40. Tension Pneumothorax • History may give a clue (COPD, trauma) • Exam may show classical signs (tracheal deviation, no BS, JVD) • Treatment is needle decompression

41. Cardiac Tamponade • Typically tachycardia prior to arrest • History may provide clues (CA, post-MI, Uremia, SLE) • Ultrasound is key to rapid diagnosis • Treatment is Pericardiocentesis

42. Cardiac TamponadeUsing Ultrasound at the Bedside • Subxiphoid approach

43. Cardiac Tamponade Using Ultrasound at the Bedside

44. Cardiac Tamponade Using Ultrasound at the Bedside

45. Thrombosis (MI) • History may give clues • EKG (ischemia or STEMI) • In out-of-hospital arrests studies, 50% have documented MI1 • Treatment is PCI or lytics Bulut S, et al. Successful out-of-hospital CPR: What is the optimal in-hospital treatment strategy? Resuscitation. 2000;47:155-161

46. Thrombosis (PE) • Typically tachycardia prior to arrest • Usually must rely on history alone during resuscitation • Should I use Thrombolytics?? • No study has shown a mortality benefit1 • Indiscriminate use can lead to devastating consequences • Cochrane review done on stable pts with confirmed PE 1Dong BR, Yue J, et al. Thrombolytic therapy for pulmonary embolism (review). Cochrane Database of Systematic Reviews. August 2008.

47. Thrombosis (PE)What about the pt with suspected PE and unstable? • Thrombolytics • One study on unstable pts1 • Randomized controlled trial • 8 pts with high clinical suspicion of PE • Thrombolytics+heparin vs. heparin alone • 4 pts who got lytics improved and survived • 4 pts who got heparin died • Bottom Line: Must have a high clinical suspicion and unstable patient to consider using thrombolytics 1Jerjes-Sanchez C, Ramirez-Rivera A, et al.Streptokinase and heparin versus heparin alone in massive pulmonary embolism: A randomized controlled trial. Journal of Thrombosis & Thrombolysis 1995;2 (3):227–9.

48. Toxins (Drugs) • History is key • Rapid detection and antidote is key

49. Differential Diagnosis • Hypoxia • Hypovolemia • Hypothermia • H+ ion (acidosis) • Hyper/Hypokalemia • Tension Pneumothorax • Tamponade • Thrombosis (MI) • Thrombosis (PE) • Toxins (drugs) 5 H’s 5T’s

50. Return to Case 1: ….after careful consideration of H’s and T’s, 22 minutes of minimally interrupted CPR, Defibrillation , epinephrine, and amiodorone… I Feel a Pulse! Now what???