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Whats New in Resuscitation Greg Christiansen DO, MEd, FACOEP VCU Department of Emergency Medicine Slide 2 Disclosure No Industry or Third Party Affiliation No Conflict of Interest Credits: Dr. Kevin Ward Dr. Joe Ornato Slide 3 Goals Recognize processes to follow in an emergent cardiac arrest as part of a resuscitation effort Be familiar with acute resuscitation concepts guiding acute cardiac care Slide 4 Perceptions and Reality Television drama demonstrate 75 % survival rate Correlates with public perception of CPR success Adams found 81% of elderly admitted to a hospital believed there was a > 50% chance of their own survival if they had CPR Derrick Adams How mispercetpions among elderly pt regarding survival outcomesJAOA 106 July 2006 Diem Cardiopulmonary resuscitation on TV: miracles & misinformation NEJM 1996:13 1578-1582. Slide 5 Myths & Reality Successful field resuscitation rates 2-5% Long held belief out of hospital cardiac arrest efforts are futile Slide 6 Some Myths Die Hard Slide 7 Flatliners..\..\..\Image File\recorded video\video\resuscitation\Flatlinev2.mpg Slide 8 Question: Which One of these Organs are Primarily Perfused During Diastole? Brain Heart Kidney Intestines Slide 9 Question: Which One of these Organs are Primarily Perfused During Diastole? Brain Heart Kidney Intestines Slide 10 Which Patient has the Highest Chance of ROSC During CPR? A.ABP: 120/20, CVP: 20 B.ABP: 160/10, CVP: 30 C.ABP: 60/30, CVP: 0 Slide 11 Which Patient has the Highest Chance of ROSC During CPR? A.ABP: 120/20, CVP: 20 B.ABP: 160/10, CVP: 30 C.ABP: 60/30, CVP: 0 CPP = end diastolic atrial pressure Right atrial pressure ( CVP) 30 0 = 30 CCP Slide 12 Which Patient has Highest Likelihood of ROSC During CPR? A.PetCO2: 6 mmHg: ABP 100/30 B.PetCO2: 9 mmHg: ABP 120/20 C.PetCO2: 20 mmHg: ABP 70/20 Slide 13 Which Patient has Highest Likelihood of ROSC During CPR? A.PetCO2: 6 mmHg: ABP 100/30 B.PetCO2: 9 mmHg: ABP 120/20 C.PetCO2: 20 mmHg: ABP 70/20 CPP > 15 tend to have higher ROSC Slide 14 What effect will Epinephrine or Vasopressin have during CPR? A.Lower PetCO2 levels B.Increase PetCO2 levels C.Increase Cardiac output D.Decrease Cardiac Output Slide 15 What effect will Epinephrine or Vasopressin have during CPR? A.Lower PetCO2 levels B.Increase PetCO2 levels C.Increase Cardiac output D.Decrease Cardiac Output Vasopressors after load, COCPP ETCO2 Slide 16 Rosamond et al., Heart Disease & Stroke Statistics, 2008 Update. Circulation 2008; 117:e1-e122 Slide 17 Case: MR Ve Thach 46 yo male collapsed on the tread mill Full arrest CPR ALS medication 10 minute down time Slide 18 My First Case Fluid resuscitation ROSC Coma Decorticate Posturing Sent to CT Instituted therapeutic hypothermia Slide 19 Were not making vegetables Slide 20 Lessons learned What it is & why it works sometimes Slide 21 Cardiac Arrest Final common pathway: Everyone has it once A symptom or finding of a disease process Myocardial ischemia, profound hypoxia, conduction defects, toxicologic, hemorrhage, etc The ultimate state of shock: Global ischemia Neurologic outcomes better than commonly believed Slide 22 Goals (when appropriate) Return of Spontaneous Circulation (ROSC) and reversal of underlying causes. What is the best therapy for the brain during CPR? Restart the Heart Slide 23 Methods Electrical Therapy Pharmacological Therapy Mechanical perfusion Slide 24 Ischemia: The Problem ATP ATP Failure Slide 25 Importance of Myocardial ATP Myocardial Cell 100% ATP Myocardial Cell RAA Field Hypothermia Induction Indications Initial VF or Witnessed arrest w/ PEA or asystole Initial core temperature >34 C No contraindications to cooling (e.g., terminal illness, DNAR, obvious signs of biological death) Slide 68 RAA Field Hypothermia Induction Protocol Summary EMS Supervisor carries iced saline Expose patient; icepacks to neck, axilla, groin 4 C saline 30 ml/kg (up to 2 L) IV with pressure bag 18F orogastric tube Novotemp orogastric probe Slide 69 Significant improvement with protocol change Citywide ROSC & Survival to Discharge Richmond, VA: 2001-3 vs. 2004-9 p=.002 p=.0001 N= 1,233 Slide 70 Richmond Ambulance Field Hypothermia Induction T delta = -1.9 [95% CI -4.3, 0.4] ROSC= 86% Slide 71 A dvanced R esuscitation C ooling T herapeutics I ntensive C are Slide 72 ARCTIC 24/7 post-resuscitation team that can initiate endovascular cooling w/in 30 min of ED arrival Trained, dedicated support team of ED and CCU physicians and nurses ED team responsible for primary patient care CCU/cath team responsible for cooling Catheters placed by interventional cardiologist Alert initiated by EMS, activated by EM attending physician Slide 73 Relative Contraindications to Continued Cooling After ED Arrival Persistent hypotension MAP