1. Daniel Davis, MD UCSD Center for Resuscitation Science New Frontiers in Resuscitation Science

2. Key Concepts Compressions Ventilations Pressors PetCO2 Post-resuscitative care

3. 1. Optimal Compressions

4. The Primary Directive Chest compressions should be performed from the moment of arrest until return of spontaneous circulation is assured.

5. Kern (2002) Circulation Prime the Pump!

6. Christenson (2009) Circulation Stay on the chest! * Adjusted for: age, gender, bystander CPR, public location, response time, compression rate

8. Compression Interruptions Initiating compressions Rhythm analysis Shock sequence Pulse check Intubation Vascular access

9. Bystander CPR Percent (%)

10. ECG Filtration

11. Return of Spontaneous Circulation Electrical (HR) Mechanical (PetCO2)

12. Stiell et al (2008) AHA Scientific Sessions Deeper Compressions

13. Aufderheide (2005) Resuscitation Good Recoil

14. Rate 0 to 80 81 to 120 121+ (N=65) (N=478) (N=122)  38 mm 49% 44% 69% 38-51 mm 28% 44% 30% >51 mm 23% 12% 2% Depth Stiell et al (2008) AHA Scientific Sessions Rate vs Depth

15. CPR Process

17. Results Chest compression fraction91% Compression rate 123/min Compression depth 2.6 inches Pre-shock pause2.6 sec Post-shock pause3.6 sec Perfusion check4.3 sec Ventilation rate9.7/min PetCO215.3 mmHg

18. What if we’re wrong?

22. 2. Controlled ventilation

23. Kern (2002) Circulation Prime the Pump!

24. Continuous Chest Compressions with Synchronous Ventilations (10:1)

25. 3. Pressor Therapy

26. Pressors Mader (2008) Resuscitation

27. Hagihara (2012) JAMA

28. * * *

29. Vasopressin?

30. Fluids?

35. 4. PetCO2 in resuscitation

36. Lung Perfusion in Shock PaCO2 40 mmHg PaCO2 40 mmHg PetCO2 37 mmHg PetCO2 37 mmHg PetCO2 29 mmHg PetCO2 29 mmHg PetCO2 21 mmHg PetCO2 21 mmHg

37. PetCO2 Monitoring

38. PetCO2 Associations Initial PetCO2 α ROSC Pre-shock PetCO2 α ROSC for VF Rise in PetCO2 α ROSC Initial PetCO2 α arrest etiology Compression depth/patient wt α PetCO2

39. 5. Post-resuscitation care

40. Hyperventilation: Three Flavors

41. Cerebral Perfusion During Shock P =.004 v 12 mL/100 gm/min

42. Ventilation in Resuscitation

43. Rapid, Shallow Breaths?

44. Intrathoracic Pressure

45. Evidence for Hypothermia?

46. Hypothermia After Cardiac Arrest Study Group (2002) NEJM Hypothermia vs. Normothermia?

47. When should we cool?

48. no cooling 33 o C 0 10 20 30 40 50 60 % survival 36% 53% no cooling 33 o C 26% 49% 36 o C 33 o C 52% 50% Post-Arrest Hypothermia HACA Bernard TTM

49. How should we cool?

52. Survival (%)

55. Survival-to-Discharge (%) Current U.S. Benchmark

56. Conclusions The opportunity is staggering Compressions Technology Post-resuscitative care