Advances In The Management Of Cardiac Arrest

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Advances In The Management Of Cardiac Arrest

• Victor Maroun MD
• EMS/Disaster Medicine Fellowship Director
• Department of Emergency Medicine
• Saint Josephs Regional Medical Center
• Paterson, NJ

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Advances In The Management Of Cardiac Arrest

• Conflicts to report
• None

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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

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Advances In The Management Of Cardiac Arrest

• Re-evaluation
• Disconnected to monitor
• Pulseless, unresponsive
• Unknown down-time
• Nurse is on break

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Advances In The Management Of Cardiac Arrest

• Next Step
• Chest compressions?
• Secure Airway?
• BVM?
• IV access?
• Hypothermia protocol?
• You decide to start compressions

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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?

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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

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Current Statistics

• Majority of resuscitative efforts fail
• Anoxia
• Reperfusion injury
• Neurologic injury
• Airway/Breathing
• Circulation
• Other complications

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Historical Perspective

• Cardiopulmonary Resuscitation (CPR) first
  published lt50 years ago
• Young science
• Rapidly evolving

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Historical Perspective

• Early 1900s Shafer Method

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Historical Perspective

• 1960s Peter Safar
• Prone position inadequate
• Expired air did provide sufficient O2.
• Head tilt, chin lift kept patent airway

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Historical Perspective

• 1955 Paul Zoll 1st successful closed chest
  defibrillation, external pacing

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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

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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

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AHA 2005 Revisions

• OPALS Study NEJM 2004
• 17 Cities
• Multicenter, controlled clinical trial
• BLS Rapid defibrillation
• ALS response intubation plus IV meds

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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 lt0.001
• Discharge 5.0 vs. 5.1, P 0.83

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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

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AHA 2005 Revisions
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AHA 2005 Revisions
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AHA 2005 Revisions
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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

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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

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AHA 2005 Revisions

• Optimizing circulation
• Recent research indicated inadequate chest
  compressions
• Frequent interruptions
• Inadequate pressure/compression

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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

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AHA 2005 Revisions

• Quality of cardiopulmonary arrest during
  out-of-hospital arrest JAMA 2005

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AHA 2005 Revisions

• Quality of cardiopulmonary arrest during
  out-of-hospital arrest JAMA 2005

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AHA 2005 Revisions

• Quality of cardiopulmonary arrest during
  out-of-hospital arrest JAMA 2005

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AHA 2005 Revisions

• AHA recommendations
• 100 beats per minute
• push hard and fast
• Very few interruptions
• Very brief interruptions
• Compression/Ventilation 302
• CPR prior to Shock

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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 dont 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

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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.

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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

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Compressions

• CPR the P stands for plumbers 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

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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

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Defibrillation
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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

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Defibrillation
Delaying defibrillation to give basic CPR to
patients with out-of-hospital VF, JAMA 2003

• Norway
• Randomized study
• CPR before shock
• Standard

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Defibrillation
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Defibrillation
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Defibrillation

• American Heart Association Recommendations
• CPR initiated while AED is being set up
• Defibrillation immediately when equipment is
  ready

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AHA 2005 Revisions

• Chest compressions immediately after
  defibrillation
• Dont check monitor for rhythm
• Dont check for a pulse

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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

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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

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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 gt 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

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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.

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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

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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.

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• 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

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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

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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

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European Study
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European Study
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European Study
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European Study
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Therapeutic Hypothermia

• AHA recommendations
• 2003 Mild hypothermia may be beneficial to
  neurological outcome and is likely to be well
  tolerated
• 2005 Unconscious adult patients with ROSC after
  out-of-hospital cardiac arrest should be cooled
  to 32-34C for 12-24 hours when the initial rhythm
  was VF. Similar therapy may be beneficial to non
  VF arrest. Further research is needed.

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Methods of Achieving Hypothermia

• External
• Selective regional cooling (Head and neck)
• Generalized Entire body (cooling blanket)
• Internal
• IV (Cold IV Fluids)
• Bladder Lavage with cold fluid
• Invasive central vein devices.
• External / Internal combinations

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Arctic Sun
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Cincinnati Sub-0Blanketrol II
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Caircooler
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Icy-Cath
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Cold IV Fluid

• Bernard et al. Resuscitation 2003
• 30ml/kg 4C RL reduced temp 35.5 to 33.8C.
• Initiated in ED.
• Kim et al. Circulation 2005
• 2L 4C NS reduced temp by 1.4C in 30 min.
• Polder man et al. Crit Care Med 2005
• 2 Liters 4C NS bolus () Cooling blanket
• Reduced temp from 36.9 to 32.9 in one hour
• No complications in either study were reported.

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Pre-hospital Cooling

• Kim et al. Circulation 2007
• 125 patients
• Randomized to standard care, vs.. Pre-hospital
  cooling with 2 liters cold IVF.
• 63 (Hypothermia group)
• Decrease temp by 1.25C
• No complications
• 62 (Standard)
• Increase in temp by 1C

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Where should hypothermia be initiated?

• No definitive recommendations by the AHA yet
• Increasing volume of literature
• Cold IVF
• Safe
• Effective
• Fast
• Further research needed

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A cooling treatment is credited with helping Dr.
Syed Hassan Naqvi recover from Cardiac arrest.
City Pushes Cooling Therapy for Cardiac Arrest
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NYC Responds

• January 1, 2009
• NYC EMS will transport cardiac arrest patient to
  only those hospitals that provide therapeutic
  hypothermia
• Bypass closer hospitals
• Bloomberg endorsement
• 20 of 59 NYC hospitals expected provide treatment
• Seattle, Boston, Miami will have similar
  protocols
• Vienna, London
• No methodology requirements

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NYC Responds

• Criteria
• CPR, with pulse regained within 30 min of
  resuscitation, neurologically compromised
• Bypass non-participating hospital if you can get
  to a participating hospital by 20 min.
• Avg. 10 min transport time.

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Early Participating Hospitals

• NY Presbyterian
• Mt Sinai
• Bellevue
• St. Vincents
• Elmhurst
• Maimonidies
• Staten Island University

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SJRMC Responds

• 66 Year Old Female
• Pre-hospital cardiac arrest with ROSC
• Comatose state
• Therapeutic Hypothermia protocol initiated, 24
  hours
• Rewarming 6 hours
• Patient now awake and alert in MICU

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NJ Responds

• Cooper University Hospital
• Morristown Memorial Hospital
• Hackensack University Medical Center
• Newark Beth Israel
• Many others developing protocols

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Conclusions

• The science of cardiopulmonary resuscitation is
  developing rapidly
• We as physicians and first responders must stay
  updated
• We must also adjust our practice of medicine
  accordingly

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Questions?
I think they can stop CPR.