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. 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 %
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

51. European Study

52. European Study

53. European Study

54. 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 hours when the initial rhythm was VF. Similar therapy may be beneficial to non VF arrest. Further research is needed.”

55. 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

56. Arctic Sun

57. Cincinnati Sub-0 Blanketrol II

58. Caircooler

59. Icy-Cath

60. 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.

61. 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

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

63. “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”

64. 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

65. 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.

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

67. 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

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

69. 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

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