Damn Good CPR J. Scott Wieters MD Asst Prof EM Texas A&M COM Dept. EM Baylor Scott and White TCEP 2015

1. Go Beyond the algorithm. You are a Resuscitationist and better than a weekend class. Burn

the ACLS card and Become the leader. a. Directed roles b. Calm the storm c. Debrief and always do better

2. High-Quality CPR a. Compressor is the most important member of the team! b. Hard- Straight arms over pt with forceful contractions, full recoil don’t lean. c. Fast- >100 maybe >120? d. Uninterrupted- Chest compression fraction (CCF) goal 80%

i. We can’t feel good pulse 1. Deakin, C D, and J L Low. 2000. Accuracy of the advanced trauma

life support guidelines for predicting systolic blood pressure using carotid, femoral, and radial pulses: observational study.BMJ (Clinical research ed.),no.7262(16). http://www.ncbi.nlm.nih.gov/pubmed/ 10987771. Poulton, T J. 1988. ATLS paradigm fails. Annals of emergency medicine, no. 1.http://www.ncbi.nlm.nih.gov/ pubmed/3337405.

2. consider art line/ETCO2 ii. Don’t stop Compressions for:

1. Intubation 2. Central line 3. Pulse checks 4. New technology for rhythm analysis 5. Cunningham LM, Mattu A, O'Connor RE, Brady WJ.

Cardiopulmonary resuscitation for cardiac arrest: the importance of uninterrupted chest compressions in cardiac arrest resuscitation. Am J Emerg Med. 2012 Oct;30(8):1630-8. doi: 10.1016/j.ajem.2012.02.015. Epub 2012 May 23.

6. Most important pauses are PERISHOCK pauses 7. Cheskes S, Schmicker RH, Christenson J, Salcido DD, Rea T, Powell J,

Edelson DP, Sell R, May S, Menegazzi JJ, Van Ottingham L, Olsufka M,

Pennington S, Simonini J, Berg RA, Stiell I, Idris A, Bigham B, Morrison

L; Resuscitation Outcomes Consortium (ROC) Investigators. Perishock

pause: an independent predictor of survival from out-of-hospital

shockable cardiac arrest. Circulation. 2011 Jul 5;124(1):58-66. doi:

10.1161/CIRCULATIONAHA.110.010736. Epub 2011 Jun 20. PubMed

PMID: 21690495; PubMed Central PMCID: PMC3138806.

a. Survival significantly lower for patients with preshock pause > 20 secs compared to preshock pause < 10 secs

b. 18% reduction in survival for every 5 sec increase in preshock pause

iii. Reduce perishock pauses: 1. Charge during compressions 2. Hands-on defibrillation. Probably safe. 3. Restart compressions immediately after shock

3. Man vs Machine? CPR Devices

a. Brooks et al. Cochrane database: feb 2014 i. Multiple RCT have not shown difference, widespread use not supported

b. Westfall M, et al. Critial Care Med 2013 i. Meta-analysis of machines vs standard ii. 12 studies (6,538 patients; 1,824 with ROSC) iii. Results

1. No benefit piston-driven devices 2. Only one load-distributing device showed a positive difference

c. Perkins GD, et al. Lancet 2014 i. Randomized 4471 English pts with OHCA ii. Primary outcome: 30-day survival

1. 30-day survival a. LUCAS-2 group: 6% b. Control group: 7% no difference

d. THERE IS NO DIFFERENCE BETWEEN MAN AND MACHINE 4. Defibrillation

a. Biphasic early for vib or pulseless vtach b. Shock during a Short Perishock Pause c. HOD?

i. No injuries reported just tingling ii. Recorded injuries mostly defective equipment horseplay

1. Gibbs W, Eisenberg M, Damon SK. Dangers of defibrillation: injuries to emergency personnel during patient resuscitation. Am J Emerg Med. 1990 Mar;8(2):101-4. PubMed PMID: 2302275.

2. Hoke RS, Heinroth K, Trappe HJ, Werdan K. Is external defibrillation an electric threat for bystanders? Resuscitation. 2009 Apr;80(4):395-401. doi: 10.1016/j.resuscitation.2009.01.002. Epub 2009 Feb 10. Review. PubMed PMID: 19211180.

iii. Concerns that gloves break down 1. Sullivan JL, Chapman FW. Will medical examination gloves protect

rescuers from defibrillation voltages during hands-on defibrillation? Resuscitation. 2012 Dec;83(12):1467-72. doi: 10.1016/j.resuscitation.2012.07.031. Epub 2012 Aug 25. PubMed PMID: 22925991.

iv. Most exam gloves leak after CPR 1. Deakin CD, Lee-Shrewsbury V, Hogg K, Petley GW. Do clinical

examination gloves provide adequate electrical insulation for safe hands-on defibrillation? I: Resistive properties of nitrile gloves. Resuscitation. 2013 Jul;84(7):895-9. doi: 10.1016/j.resuscitation.2013.03.011. Epub 2013 Mar 16. PubMed PMID: 23507464.

v. Most exam gloves leak worse after exposed to electrical currents 1. Petley GW, Deakin CD. Do clinical examination gloves provide

adequate electrical insulation for safe hands-on defibrillation? II: Material integrity following exposure to defibrillation waveforms. Resuscitation. 2013 Jul;84(7):900-3. doi: 10.1016/j.resuscitation.2013.03.012. Epub 2013 Mar 16. PubMed PMID: 23507465.

vi. The leak is not causing significant harm

1. Lloyd MS, Heeke B, Walter PF, Langberg JJ. Hands-on defibrillation: an analysis of electrical current flow through rescuers in direct contact with patients during biphasic external defibrillation. Circulation. 2008 May Epub 2008 May 5. PubMed PMID: 18458166.

2. Johnson T. Et al. Performing HOD in OOHCA Can result in mild subjective perception of current to providers. Resuscitation Conf 2012 Abstract 107

3. Weingart SD. A note of caution on the performance of hands-on biphasic defibrillation. Resuscitation. 2013 Mar;84(3):e53. doi: 10.1016/j.resuscitation.2012.12.014. Epub 2012 Dec 22. PubMed PMID: 23266533.

vii. Protect providers with an electrical blanket 1. Yu T, Ristagno G, Li Y, Bisera J, Weil MH, Tang W. The

resuscitation blanket: a useful tool for "hands-on" defibrillation. Resuscitation. 2010 Feb;81(2):230-5.doi:0.1016 /j.resuscitation.2009.09.029. Epub 2009 Dec 4. PubMed PMID: 19962817.

viii. Protect providers with electrical gloves 1. Deakin CD, Thomsen JE, Løfgren B, Petley GW. Achieving safe

hands-on defibrillation using electrical safety gloves - A clinical evaluation. Resuscitation. 2015 Feb 26. pii: S0300-9572(15)00010-6. doi: 10.1016/j.resuscitation.2014.12.028. [Epub ahead of print] PubMed PMID: 25725295.

5. Epinephrine: a. Olasveengen TM, Sunde K, Brunborg C, Thowsen J, Steen PA, Wik L. Intravenous

drug administration during out-of-hospital cardiac arrest: a randomized trial. JAMA. 2009 Nov 25;302(20):2222-9. doi: 10.1001/jama.2009.1729. PubMed PMID: 19934423.

i. Prospective, RCT OHCA Norway looking at removing IV drug administration from ACLS would improve survival to hospital DC after OHCA in 851 patients

ii. Results-no difference b. Jacobs IG, Finn JC, Jelinek GA, Oxer HF, Thompson PL. Effect of adrenaline on

survival in out-of-hospital cardiac arrest: A randomised double-blind placebo-controlled trial. Resuscitation. 2011 Sep;82(9):1138-43. doi: 10.1016/j.resuscitation.2011.06.029. Epub 2011 Jul 2. PubMed PMID: 217

i. Double-blind, RCT of epinephrine in OHCA 600 pts. Looked at effect of Epi on DC fm hospital

ii. Results-no difference c. Hagihara A, Hasegawa M, Abe T, Nagata T, Wakata Y, Miyazaki S. Prehospital

epinephrine use and survival among patients with out-of-hospital cardiac arrest. JAMA. 2012 Mar 21;307(11):1161-8. doi: 10.1001/jama.2012.294. PubMed PMID: 22436956.

i. Japan observational study 417,000pts. to evaluate the association between epinephrine use on short- and long-term survival

1. Results- Among patients with OHCA in Japan, use of prehospital epinephrine was significantly associated with increased chance of return of spontaneous circulation before hospital arrival but decreased chance of survival and good functional outcomes 1 month after the event.

d. Larabee TM, Liu KY, Campbell JA, Little CM. Vasopressors in cardiac arrest: a systematic review. Resuscitation. 2012 Aug;83(8):932-9. doi: 10.1016/j.resuscitation.2012.02.029. Epub 2012 Mar 15. Review. PubMed PMID: 22425731.

i. Systematic review of 53 articles ii. Results There is a short-term, but no long-term, survival benefit when using

high dose vs. standard dose epinephrine during resuscitation from cardiac arrest.

iii. There are no other vasopressors that provide a long-term survival benefit when compared to epinephrine.

e. Dumas F, Bougouin W, Geri G, Lamhaut L, Bougle A, Daviaud F, Morichau-Beauchant T, Rosencher J, Marijon E, Carli P, Jouven X, Rea TD, Cariou A. Is epinephrine during cardiac arrest associated with worse outcomes in resuscitated patients? J Am Coll Cardiol. 2014 Dec 9;64(22):2360-7. doi: 10.1016/j.jacc.2014.09.036. Epub 2014 Dec 1. PubMed PMID: 25465423

i. Observational cohort study- epinephrine on 1556 patients with OOHCA and measuring survival.

1. use of epinephrine was consistently associated with a lower chance of survival, an association that showed a dose effect and persisted despite post-resuscitation interventions.

6. Combinations a. Mentzelopoulos SD, Malachias S, Chamos C, Konstantopoulos D, Ntaidou T,

Papastylianou A, Kolliantzaki I, Theodoridi M, Ischaki H, Makris D, Zakynthinos E, Zintzaras E, Sourlas S, Aloizos S, Zakynthinos SG. Vasopressin, steroids, and epinephrine and neurologically favorable survival after in-hospital cardiac arrest: a randomized clinical trial. JAMA. 2013 Jul 17;310(3):270-9. doi: 10.1001/jama.2013.7832. PubMed PMID: 23860985.

i. RCT 269 pts with IHCA compared vasopressin-epinephrine-corticosteroids during and after CPR to epi and salie measured survival to dc.

ii. Among patients with cardiac arrest requiring vasopressors, combined vasopressin-epinephrine and methylprednisolone during CPR and stress-dose hydrocortisone in postresuscitation shock, compared with epinephrine/saline placebo, resulted in improved survival to hospital discharge with favorable neurological status.

b. EPI conclusion- muddy waters? 7. Airway

a. Don’t stop compressions for intubation! i. Shin DH, Han SK, Choi PC, Sim MS, Lee JH, Park SO. Tracheal intubation

during chest compressions performed by qualified emergency physicians unfamiliar with the Pentax-Airwayscope. Eur J Emerg Med. 2013 Jun;20(3):187-92. doi: 10.1097/MEJ.0b013e328354f6c4. PubMed PMID: 22609723.

b. Supraglottic airways are reasonable if intubation is easily done. c. ETCO2 best way to confirm placement

8. Ventilations 6-8/min a. Hyperventilation is Harmful! b. High intrathoracic pressures fight lower CVP c. Use a ventilator? Take out human error?

9. Narrow PEA a. Consider obstruction or shock b. Treat accordingly

10. Wide PEA

a. Electrolytes/toxin b. Ca or Bicarb?

11. End-tidal CO2 a. Pokorná M, Necas E, Kratochvíl J, Skripský R, Andrlík M, Franek O. A sudden

increase in partial pressure end-tidal carbon dioxide (P(ET)CO(2)) at the moment of return of spontaneous circulation. J Emerg Med. 2010 Jun;38(5):614-21. doi: 10.1016/j.jemermed.2009.04.064. Epub 2009 Jul 1. PubMed PMID: 19570645.

b. Hartmann SM, Farris RW, Di Gennaro JL, Roberts JS. Systematic Review and Meta-Analysis of End-Tidal Carbon Dioxide Values Associated With Return of Spontaneous Circulation During Cardiopulmonary Resuscitation. J Intensive Care Med. 2014 Apr 22. [Epub ahead of print] PubMed PMID: 24756307

i. Participants with ROSC after CPR have statistically higher levels of ETCO2. The average ETCO2 level of 25 mm Hg in participants with ROSC is notably higher than the threshold of 10 to 20 mm Hg to improve delivery of chest compressions. The ETCO2 goals during resuscitation may be higher than previously suggested and further investigation into appropriate targets during resuscitation is needed to diminish morbidity and mortality after cardiorespiratory arrest.

c. Heradstveit B, et al. PQRST-A unique aide-memoire for capnography interpretation during cardiac arrest. Resuscitation 2014; 85:1619-20.

i. Position- the best way to determine proper ETT placement ii. Quality- levels >10 show adequate CPR levels <30 may indicate need for

epi. iii. ROSC - Jump of 10-20 or back to normal co2 levels correlate with ROSC iv. Strategy – Lower levels in PE/PTX, and hemorrhage v. Termination consistently low levels <10 may indicate non responders

12. ECLS a. Mostly case series

i. Kagawa, et al. Circulation 2012: 42 pts, 21% survival ii. Bellezzo JM, Shinar Z, et al. Resuscitation 2012: 18 pts 28% survival

neurologically intact iii. Maekawa, et al. Crit Care Med 2013: 53 pts; 32% survival iv. Leick, et al. Clin Res Cardiol 2013: 28 pts; 39% survival v. Extracorporeal Life Support Organization Registry

1. 5600 patients 28% survival to hospital DC vi. SAVE-J Study Group, et al. Resuscitation 2014

1. 454 patients 11% survival vii. Stub D, et al. The CHEER trial. Resuscitation 2014

1. 26 patients Survival to hospital DC: 56% viii. Johnson NJ, et al. Resuscitation 2014

1. 26 patients (15%) survived to DC; 3 neurologically intact b. ECLS Take Home Points

i. No RCT or agreed upon protocol ii. Who gets it and who doesn’t? iii. Expensive lots of resources iv. Good Outcome factors:

1. Witnessed arrest 2. Early bystander CPR 3. Shockable rhythm 4. quick transport time 5. ECMO done fast 6. More and quicker catheterization.

v. Survivors have increased complications