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

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

Advances In The Management Of Cardiac Arrest Re-evaluation Disconnected to monitor Pulseless, unresponsive Unknown down-time Nurse is on break

Advances In The Management Of Cardiac Arrest Next Step: Chest compressions? Secure Airway? BVM? IV access? Hypothermia protocol? You decide to start compressions

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?”

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

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

Historical Perspective Cardiopulmonary Resuscitation (CPR) first published <50 years ago Young science Rapidly evolving

Historical Perspective Early 1900s: Shafer Method

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

Historical Perspective 1955: Paul Zoll: 1st successful closed chest defibrillation, external pacing

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

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

AHA 2005 Revisions OPALS Study NEJM 2004 17 Cities Multicenter, controlled clinical trial BLS + Rapid defibrillation ALS response intubation plus IV meds

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

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

AHA 2005 Revisions

AHA 2005 Revisions

AHA 2005 Revisions

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

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

AHA 2005 Revisions Optimizing circulation Recent research indicated inadequate chest compressions Frequent interruptions Inadequate pressure/compression

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

AHA 2005 Revisions Quality of cardiopulmonary arrest during out-of-hospital arrest JAMA 2005

AHA 2005 Revisions Quality of cardiopulmonary arrest during out-of-hospital arrest JAMA 2005

AHA 2005 Revisions Quality of cardiopulmonary arrest during out-of-hospital arrest JAMA 2005

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

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

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.

Automated Load Distributing Band 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

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

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%

Defibrillation

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

Defibrillation Delaying defibrillation to give basic CPR to patients with out-of-hospital VF, JAMA 2003 Norway Randomized study CPR before shock Standard

Defibrillation

Defibrillation

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

AHA 2005 Revisions Chest compressions immediately after defibrillation Don’t check monitor for rhythm Don’t check for a pulse

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

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%

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

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.

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

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.

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

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

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

European Study

European Study

European Study

European Study

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.”

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

Arctic Sun

Cincinnati Sub-0 Blanketrol II

Caircooler

Icy-Cath

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.

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

Where should hypothermia be initiated? No definitive recommendations by the AHA yet Increasing volume of literature Cold IVF Safe Effective Fast Further research needed

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

NYC Responds January 1, 2009 No methodology requirements 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

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.

Early Participating Hospitals NY Presbyterian Mt Sinai Bellevue St. Vincent’s Elmhurst Maimonidies Staten Island University

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

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

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

I think they can stop CPR. Questions? I think they can stop CPR.