Stephen Bernard MD FACEM FCICM FCCM

Refractory Cardiac Arrest

The CHEER Protocol

The Victorian setting

• 000 call system

• Computer aided dispatch

• Post dispatch instructions (ECM only)

• “3-tier” system

– PAD/ Firefighters/ CERT

– ALS paramedics

– Intensive Care Paramedics

• ACLS at scene

• Transport to ED if ROSC

The Victorian setting

• If no ROSC at ~30 minutes- declared deceased

– All ACLS provided at scene

– Asystole as final rhythm

– No compelling other factors (hypothermia/ OD)

• EMS transport with effective CPR not practical

• Hazardous for EMS crew

• No new therapy in ED

• Considered futile

The Victorian setting

• Data from Victorian Ambulance Cardiac Arrest Register for Melbourne

– 12 month period (2012)

– Age < 65 years

– VF as initial cardiac rhythm

• 222 patients

• 149 ROSC (Survival of these = 55%)

• 68 no ROSC

• 5/68 transported with CPR (Autopulse)

• 63 declared deceased at scene

The Victorian setting

• Data from Victorian Ambulance Cardiac Arrest Register for Melbourne

– 12 month period (2012)

– Age < 65 years

– VF as initial cardiac rhythm

• 222 patients

• 149 ROSC (Survival of these = 50%)

• 68 no ROSC

• 5/68 transported with CPR (Autopulse)

• 63 declared deceased at scene

ECMO

• 2008 Swine flu

• Increasing experience in VV ECMO

• Intensivists at Alfred undertake training program

– 2 day program

– Cannulation in dogs

– Circuit management

E-CPR

Reports from Japan in 2000-2012

J Am Coll Cardiol 2000; 36(3):776-83.

E-CPR

• January 2004 and May 2011

• E-CPR in 86 patients with ACS

• Median age 63 years/ 81% were male

• Intra-arrest PCI was performed in 61 patients (71%).

• ROSC 88%

• 30-day survival 29%

• Favorable neurological outcome 24%

Kagawa E, et al. Should we emergently revascularize occluded coronaries for cardiac arrest?: Rapid-response extracorporeal membrane oxygenation and intra-arrest percutaneous coronary intervention. Circulation 2012 Sep 25;126(13):1605-13

The CHEER Trial

– Pilot observational trial

– Post-VF arrest

– <70 years old

– No ROSC at 30 minutes

• CPR to ED with Autopulse

• Hypothermia

• ECMO

• Emergency

• Reperfusion

The CHEER Trial

– Mechanical CPR to ED

The CHEER Trial

– Notification by AV

– Equipment

immediately available in ICU

– Brought to ED by ICU team

Autopulse Primed circuit

Cold fluidCannulae

Drapes etc

In the ED

• Clearly defined roles to prevent chaos

– ED Consultant manages airway/ventilator

– No shocks or cannulation during ECPR

– ED nurses (x 2) equipment and scribe

– ICU SR pumps ice cold saline x 3L

– ICU Consultants x 2 cannulate

– ICU/ED manage U/S upper abdo for wires

– ICU nurse manages Autopulse and ECMO circuit

– Cardiology review need for PCI

– All others stand back

In the ED

– Percutaneous

cannulation by Intensivists x 2

– 15F arterial/ 17F venous

– Ultrasound of femoral vessels

– Ultrasound of IVC

– No defibs/ CVC during cannulation

VENO-ARTERIAL ECMO

V-A ecmo for CPR

Low flow configuration

(3-4L/min)

Oxygen vs Air?

The CHEER Trial

– Cold IV saline

– 3 L bolus IV

– Cools rapidly

Bernard SA, et al. Therapeutic hypothermia induced during

cardiopulmonary resuscitation using large-volume, ice-cold intravenous

fluid. Resuscitation 2008; 76:311-3

In the cath lab:

•Coronary angiogram

•Stent any blockages

•Then the heart will start!

To the ICU:

•Cooling for 24 hours

•33°C

•Slow rewarming over 12 hours @ 0.25°C/hr

In-hospital cardiac arrest

– Refractory cardiac arrest following in-hospital arrest

– No ROSC at 30 minutes

– The “CHEER” approach

– Reversible cause

• Age <70

• ACS in ED

• Reperfusion arrest in Cath lab

• Pulmonary embolism

Experience to date

Definitions for this presentation

• OHCA- CPR into the ED and > 30 minutes

• IHCA- CPR > 30 minutes

• Excludes

– VA-ECMO for shock with arrest < 30 minutes

– IHT from other centre

Experience to date

Site ECMO Survival

OHCA 7/9 3/7

IHCA 13/13 8/13

E-CPR Good neurological outcome 11/20 (55%)

IHCA-1

IHCA-11

“Jenny thanks 'miracle workers'

who saved her life”

What we are doing now…

– Extra 10 Autopulses donated to AV by Zoll

– Covers most of Melbourne

– 24/7 ICU Consultant roster

– Strategy to move patients within 20 minutes of arrest- ECMO < 60 minutes

– Scenario training for the team

Summary

– Every large city should have E-CPR available

– Safe transfer to hospital with CPR now possible

– Intensivist rapid percutaneous cannulation in ED feasible

– Cooling during CPR is recommended (40mL/kg cold fluid bolus)

– Normal neurological outcomes possible with up to 125 minutes of CPR

– 55% good outcomes at The Alfred (11/20)