/
Resuscitation and Post Resuscitation Care Resuscitation and Post Resuscitation Care

Resuscitation and Post Resuscitation Care - PowerPoint Presentation

marina-yarberry
marina-yarberry . @marina-yarberry
Follow
603 views
Uploaded On 2016-07-03

Resuscitation and Post Resuscitation Care - PPT Presentation

Jose G Cabanas MD MPH FACEP Paul R Hinchey MD MBA FACEP Office of the Medical Director AustinTravis County EMS System AustinTravis County EMS Approximately 12 million citizens 1100 square miles ID: 389253

arrest cardiac post hypothermia cardiac arrest hypothermia post resuscitation hospital compressions ems patients rosc survival care cpr patient response discharge rate induced

Share:

Link:

Embed:

Download Presentation from below link

Download Presentation The PPT/PDF document "Resuscitation and Post Resuscitation Car..." is the property of its rightful owner. Permission is granted to download and print the materials on this web site for personal, non-commercial use only, and to display it on your personal computer provided you do not modify the materials and that you retain all copyright notices contained in the materials. By downloading content from our website, you accept the terms of this agreement.


Presentation Transcript

Slide1

Resuscitation and Post Resuscitation Care

Jose G. Cabanas, MD MPH FACEP

Paul R. Hinchey, MD MBA FACEP

Office of the Medical Director

Austin-Travis County EMS SystemSlide2

Austin/Travis County EMS

Approximately 1.2 million citizens, 1,100 square miles,

120

k

EMS calls

per year

1,000 cardiac

arrests

responses per

year

14 Fire Departments (1,500

FF’s

,)

EMS Transport Agency (400 Paramedics)

EMS

Systems are judged by their cardiac arrest resuscitation rates

Most large cities are 5-7%

King

Cnty

Wa

35-45%

Wake

Cnty

NC

38-42%

Austin 38%Slide3

Why are we talking about Cardiac Arrest Resuscitation?Slide4

Philosophy of Five

Time Dependent

Acute MI (STEMI)

Acute Stroke

Trauma / Surgical Emergency

Intervention Dependent

Cardiac Arrest

Respiratory Distress

Sophisticated providers/systems understand the differenceSlide5

Time Dependent

These conditions can not be definitively treated in the pre-hospital environment

Requires specialized intervention only available in the hospital

Outcomes are

improved by early access to definitive intervention

Goal is

recognition

and

short scene intervalSlide6

Intervention Dependent

Initial treatment can be delivered in

prehospital

environment

Outcomes linked to

prehospital

interventions

Goal is

identification

and

initiation of

treatment

Scene intervals are NOT criticalSlide7

Updates in Out-of-Hospital Resuscitation and Post Resuscitation CareSlide8

Objectives

Describe the importance of continuous compressions and controlled ventilations

Discuss what to do with the airway/drugs

Acknowledge the difficulty of performing continuous compressions and the need for a scripted process

Discuss importance of on-scene post ROSC stabilization

Describe role of resuscitation centers

Identify questions for the futureSlide9

Why do we worry about CA

Represents < 1% of our calls but…

> 70% of CA arrests occur outside the hospital

Definitive management of cardiac arrest is in the prehospital environment Slide10

“Stated succinctly, if ACLS care in the field cannot resuscitate the victim, ED care will not resuscitate the victim.”-

2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care (Part 7.2: Management of Cardiac Arrest)Slide11

Priorities in OOHCA Changed

Emphasis on compression

Limit interruptions from ANYTHING

Goal is to maximize % of time in compressions

Single D-fib every two minutes

Precharge monitor before break

Follow d-fib immediately by compressions

Decreased importance of ventilations

Fewer number of breaths

Each delivered more slowlySlide12

So if you had to push a car, would you push a few feet and stop….. only to start again a few minutes later?Slide13
Slide14

So how important are compressions?Slide15

Compression fraction article

Circulation 2009Slide16

If compressions are the most important therapy when do you move the patient…..Slide17

Prehospital

Emergency Care 2011;15(1):106Slide18

Results (Pre-Feedback)

N = 108 % (25

th

, 75

th

)

Scene Correct Rate%

Median:

44.8

(9.54, 59.6)

Mean: 38.49 CI (33.2, 43.78)

Transport Correct Rate%

Median:

11.16

(5.83, 39.32)

Mean: 23.16 CI (18.35, 27.97)

Scene Correct Depth%

Median:

40.94

(15.96, 73.29)

Mean: 45.06 CI (38.76, 51.37)

Transport Correct Depth%

Median:

8.88

(2.62, 49.01)

Mean: 26.37 CI (20.12, 32.63)Slide19

Results (Post-Feedback)

N = 35 % (25

th

, 75

th

)

Scene Correct Rate%

Median:

48.16

(14.68, 62.36)

Mean: 43.6 CI (34.61, 52.59)

Transport Correct Rate%

Median:

19.0

(9.52, 60.22)

Mean: 32.78 CI (23.21, 42.33)

Scene Correct Depth%

Median:

75.73

(36.23, 95.07)

Mean: 66.86 CI (56.57, 77.16)

Transport Correct Depth%

Median:

14.0

(4.78, 90.78)

Mean: 42.04 CI (27.98, 56.11)Slide20

How about ventilations?Slide21

Importance of controlled Ventilation

Normal inspiration is negative pressure

Encourages blood return to the chest

Artificial ventilation is positive pressure

Reduces blood return to the chest

The faster the ventilation rate the higher the mean

intrathoracic

pressure

Higher MIP reduces cerebral emptying and reduces blood return to the heartSlide22

Survival in hyperventilationSlide23

STOP Hyperventilating

Telling providers not to hyperventilate is ineffective

High adrenaline situation

Tendency to ventilate faster and faster

Requires conscious effort to slow rates

Need constant reminder

Timing device

Goal directed ventilationSlide24

How to Deliver Ventilations

Goal is to oxygenate primarily and ventilate as a secondary consideration

Must provide continuous uninterrupted compressions

Traditional method is endotracheal intubation but increases interruption in compresions

So is this a paradigm that needs to be challenged?Slide25

Interrupt CPR…not ME

100 Cardiac Arrests

CPR interruptions 2* (1-9)

1

st

ETI interruption 46.5 s* (7-221 s)

Total all ETI interruption 109.5 s* (13-446 s)

1/3 > 1 min; ¼ > 3 min

ETI Interruptions 23% of all

* Indicates median values reported

Wang et

al Ann

Emerg

Med. 2009Slide26

But an advanced airway is a better airway…..Slide27

Advanced Airway Management

Advantages

No mask seal required

Easier to do

Less manpower

Allows continuous compressions

Disadvantage

Requires interruption of compressions

Easier to hyperventilate (rate and volume)

Doesn’t provide better ventilation/oxygenationSlide28

173 LMA vs 200 BVM by paramedics

No difference in median:

Pa

CO

2

52.9 v 55.3 (p=0.06)

Pa

O

2

64.6 v 71.9 (p=0.056)

There is no MAGIC to these devicesSlide29

Retrospective analysis of OOHCA

1,294 Cardiac Arrests

79% received intubation

10% BVM

4%

Combitube

/EOA

After adjusting for age, bystander CPR, witnessed arrest and initial rhythm

OR for BVM

vs

Advanced airway was 4.5Slide30

What is best vascular access?

Goal is vascular access by any means that does not interrupt compressions

Preferably rapid reliable access that does not detract from other tasks

Based on assumption that the drugs do anything….more on this later

IO access can be achieved in < 10 sec but which site should be used?Slide31

88 Cardiac arrest

56 (65.9%) used

tibial

site first

Initial success rate 89.7%

3 (5.8%) dislodged

18 (34%) used

humerus

first

Initial success rate 60%

6(33%) dislodged

Overall success rates

Tibia 84.5%

Humerus

40%Slide32

So what about the drugs?

Most recent quandary

Standard of care is currently being challenged

Will be a major change in management in your career

Who will make the first step…Slide33

851 patients with OOHCA randomized to:

418 given IV drugs

433 given no drugs

Primary outcome hospital discharge

Also looked at:

Hosp admission with ROSC

Neuro outcome at discharge

Survival at 1 yearSlide34
Slide35

Recent epi

studySlide36

Running the Arrest

CA is not the most diagnostically challenging condition so thought to be “EASY”

EXECUTION is anything but…

Conflicting interests of multiple tasks and the need for continuous uninterrupted compressions and infrequent occurenceSlide37

This is harder to do than you thinkSlide38

Task Interruptions

Airway interventions and IVs

Ventilations

Pulse checks

Rhythm analysis

Defibrillation

Changing compressors

Patient movementSlide39

We have limited awareness of task time in complex processes….so these interruptions should be engineered and choreographed to minimize their impact…..Slide40

>20 second pause for defibrillation. Appears that a ventilation was given before the compressions resumed. Compressions resume 10 seconds after shock delivery.Slide41

Long pause for ventilations. Then short sequence of compressions during defib charging. Compressions resumed approximately 5 seconds after shock 1 delivered.Slide42

Why engineer the process?

Creates uniformity:

Accurate assessment of outcomes

Linking specific interventions to outcomes

Baseline for future modification

In the process it:

Improves outcomes

Improves efficiency

Reduces errorsSlide43

Regional Variation in Incidence / Outcome

2008

11,898 cardiac arrests

2729 had initial rhythm of V-Fib / V-

Tach

.

954 (4.6% of total) were discharged alive.

Incidence of EMS-treated CA was 52.1 per 100 000

survival ranged from 3.0% to 16.3% (median of 8.4%)

Median ventricular fibrillation 12.6 per 100 000

survival ranged

from 7.7% to 39.9%, Slide44

So how do you control variabilitySlide45
Slide46

Professional CA resuscitation

is to CPR ….

….what a pit crew

is to changing tiresSlide47

Pit Crew Model

Same name…many versions

CPR

Maximize compression fraction

Effective compression(rate/depth)

Provider fatigue

Controlled ventilations

Defib

Pre-charge @1:45

Emphasis on Shock/Don

t

shockSlide48

Current Goal:

Less than 10 second break

in every

2 minute cycle of CPRSlide49

Staying Alive or

Another One Bites the Dust?

Staying alive 103 bpm

30:2

100 compressions/min =18s for compressions

5 s break for ventilations every 30 compressions?

18 of every 23s in active compression is 78%

NOT counting other breaks in CPR

Pit Crew

Continuous compressions w/asynchronous ventilation

10s break every 2 min is 92%

5s break every 2 min is 96%Slide50

Typical example

(actually 40:2)

©2010 Paul R. HincheySlide51

Good example of ventilations at a rate of about 8-10 per minute.

©2010 Paul R. HincheySlide52

©2010 Paul R. HincheySlide53

So we went to the simulation lab and now it

s ALL choreographed….Slide54
Slide55

BLS

&

ALSSlide56
Slide57
Slide58

©2010 Paul R. Hinchey

Need cpr checklistSlide59

Some ScenariosSlide60

Scenario 1

78 y/o Wal-Mart greeter suffers cardiac arrest in the front of a store:

Where do you work the cardiac arrest? Would this be different if it were in his house?

When do you begin transport to the hospital?

If unsuccessful when do you terminate the resuscitation?Slide61

Scenario 2

78 y/o Wal-Mart greeter has been resuscitated from CA and is being transported when he re-arrests:

What would you instruct your crews to do if they were 20 min out from the hospital?

What if they were 5 min out?Slide62

Scenario 3

78 y/o suffers CA at home. Wife does 2 min dispatcher directed CPR. Pt has ROSC and wakes up. Walks to couch. Crews find in CHF and treat appropriately w/meds and CPAP. FF ride w/crew to hosp. While pulling into ED bay pt goes into CA:

What do you want your crews to do?Slide63

Take Home Message

CA is not as easy as once thought

Pre-hospital providers must be the experts

Its all about compressions

Airway, drugs, etc are a big ?

If you want to do this well you must have universally understood goals and plan Slide64

Post Resuscitation CareSlide65

Post-Cardiac Arrest Syndrome

Post-cardiac arrest brain injury

Responsible for 68% of deaths of patients who survived to ICU admission (Lever, 2004)

Post-cardiac arrest myocardial dysfunction

LV dysfunction, myocardial stunning, cardiogenic shock

Systemic ischemia/reperfusion injury

Inflammatory response, impaired vasoregulation, oxygen delivery and utilization, resulting in hypotension / MSOF

Persistent precipitating pathology

STEMI, Toxic Ingestion, Hypoxia, Hemorrhage, etc. Slide66

Phases of Post-Cardiac Arrest SyndromeSlide67

Post-Resuscitation Care

Goals of Post-Arrest Care

Maintain Hemodynamic Stability

Preserve the Brain

Avoid hyperventilation

Prevent re-arrest

Elements of Post-Care include

Vasopressor titration

Therapeutic Hypothermia

Early Cardiac Catheterization

Sedation

Glucose and Electrolyte ManagementSlide68

Post Cardiac Arrest Care

The first 20 minutes after ROSC is the Immediate Phase of Post Cardiac Arrest Syndrome

Patients in these phases may be critically ill and benefit by immediate treatment AT SCENE:

This is a better strategy for patient survival than rapid movement to the vehicle and rapid transport delaying or deferring key interventions

Failure to initiate immediate aggressive treatment may result in re arrest of patient or increased morbidity Slide69

1,199 Cardiac Arrests

ROSC in 27.4%

Rearrest in 36%

Time to rearrest

Median 3.1 min (1.6-6.3)Slide70

Post-Resuscitation Care

Focus should be on restoring perfusion

Perfuse the myocardium

Perfuse the brain

Fluids and pressors for MAP >90

Remove the ITD

Initiate hypothermia

Obtain 12 lead EKG

THEN move the patientSlide71
Slide72

Barriers in Post-Cardiac Arrest Care

Post– cardiac arrest patients are treated by multiple teams of providers

Variation in post-cardiac arrest treatment and patient outcome between institutions.

Limited reliability of early prognostication (<72 hours after arrest)Slide73

The science behind the cooling

Han Solo frozen in Carbonite – Star Wars Episode V (1980)Slide74

Journal Iowa Medical Society,

November

1964 Slide75

Therapeutic Hypothermia

HACA

2002

Bernard 2002

Idrissi 2001Slide76

ILCOR Advisory Statement

Unconscious adult patients with ROSC after out-of-hospital VF cardiac arrest should be cooled to 32°C - 34°C for 12 - 24 hours

Possible benefit for other rhythms or in-hospital cardiac arrestSlide77

Editorial Comments

“The reason hypothermia has not become the standard of care for post-resuscitation is simple. Emergency and EMS physicians have failed to make it so.”

Mennegazzi and Callaway, PEC 2005Slide78

“The Future”

720j Defibrillation?

Hands on Defibrillation?

Intra-arrest cooling?

Mechanical CPR and AC/DC CPR?

Regional Receiving Facilities?Slide79

Knowledge Gaps

Impact of Prehospital Cooling in Outcomes?

Continuous temperature in the Field?

Rate of Cooling?

Target? How Long?

Urban vs. Rural EMS?

ALS Vs BLS?

How do we train Providers?Slide80

Take Home Message

Resuscitation is not over with ROSC

Post-Cardiac Arrest Patients need to be treated with a high sense of urgency.

Patients should receive hypothermia specially if initial rhythm was VF/VT.

Hypothermia is not a substitute for other key components in the Chain of SurvivalSlide81

Take Home Message

Post

-resuscitation/cardiac specialty hospitals

should

receive patients directly from the field or in prompt

transfer

Coordination between EMS, EM, ICU, and Cardiology is a must!!

Engage all stakeholders in your system

Management of Cardiac Arrest is evolving rapidly!! EMS Medical Directors must keep upSlide82
Slide83

Questions?Slide84

Out-of-Hospital Initiation of Therapeutic Hypothermia with Cold Saline Improves Survival in Patients with Return of Spontaneous Circulation in the Field.

Jose G. Cabanas MD, MPH / Brent Myers MD, MPH

Wake County EMS SystemSlide85

Authors

Brent Myers MD, MPH, Wake EMS/

WakeMed

Jose G. Cabanas, MD, Wake EMS/

WakeMed

Ryan Lewis, MS, EMT-P, Wake EMS

Valerie De

Maio

, MD

MSc

,

WakeMed

Graham

Synder

, MD,

WakeMed

Gay

Beneveides

, MD,

WakeMed

Robert Denton, MD, Rex Healthcare

Daniel

Licastese

, RN, Rex Healthcare

Robert Lee, MS MA,

WakeMedSlide86

Disclosure

This Project was supported by the SAEMS EMS

Physio

-Control Award (2008)Slide87

Objective

To determine the impact on survival of a standard post-resuscitation care protocol that includes

prehospital

initiation of therapeutic hypothermia in patients with return of spontaneous circulation (ROSC) in the field.Slide88

Methods

Observational cohort

“Before and after” – Introduction of Therapeutic Hypothermia for patients with

prehospital

ROSC

Post-resuscitation patients are selectively transported to one of 2 high volume PCI centers

Wake County NC - pop. 897,000

April 2005 through December 2008Slide89

Cardiac Arrest Response

All calls receive EMD from a single, high-volume center

Fire first response with AED and compressions

Paramedic response with transport ambulances (2)

Supervisory response at paramedic levelSlide90

Protocol Revision

[Apr 2005-Oct 2006]: Continuous compressions, controlled ventilations

[Oct 2006-Dec 2008]: Induced Hypothermia after ROSCSlide91

Criteria for Induced Hypothermia

ROSC after cardiac arrest not related to trauma or hemorrhage

Age 16 years or greater

Female without obviously gravid uterus

Initial temperature >34 C

Patient with advanced airway (no RSI)

Patient remains comatose without purposeful response to painSlide92

Data Collection

All EMS records are maintained in an electronic database

Records with any of the following characteristics are reviewed to determine if cardiac arrest occurred:

EMS Patient Disposition = cardiac arrest

CPR procedure is recorded

Defibrillation is recorded

Induced Hypothermia ProcedureSlide93

Inclusion Criteria

All adult patients resuscitated from out of hospital cardiac arrest (OHCA) prior to hospital arrival, regardless of initial rhythm, were included if they had ROSC in the field.Slide94

Age less than 16

Obvious traumatic origin of arrest

EMS witnessed arrest

Arrest not in EMS control

Prison facilities

Out-of-system intercept

Arrests under direction of non-EMS physician

Exclusion CriteriaSlide95

Outcome Measures

Discharge from hospital (

primary

)

Neurologically intact survival was defined as CPC 1 or 2 at time of hospital discharge.

2 blinded physician reviewers from each hospital independently assigned CPC scores based on patient discharge recordsSlide96

Included Patients / Phase

All Phases

N=640

Before (17 Months)

227

After (26 Months)

413Slide97

Before After

(n=227) (n=413)

Mean age (yrs)

66

64

Male sex

62%

60%

Bystander witnessed arrest

45%

32%

Bystander CPR

38%

39%

Mean Response (

mins

)

5.6

5.6

Initial rhythm VF/VT

35%

38%

NOTE: no statistically significant difference between study periods

Patient and EMS CharacteristicsSlide98

Multivariate Odds of

Neuro

Intact Survival

Factor

Odds

95% CI

Age

0.97

0.96-0.98

Bystander CPR

1.44

.94-2.19

Vfib

8.58

5.5-13.1

Hypothermia (After)

1.95

1.23-3.09Slide99

Survival to Hospital Discharge for All Rhythms

NOTE: statistically significant difference p value <0.0163Slide100

Survival to Hospital Discharge for All Rhythms

*Difference in overall survival was significant with a p-value of 0.0163Slide101

Percent of Survivors Neurologically Intact

NOTE: no statistically significant difference between study periodsSlide102

Limitations

Protocol-driven pre- and post-resuscitation cardiac arrest care

Hawthorne effect

Intention-to-treat analysisSlide103

Conclusion

Out-of-hospital standard post-resuscitation care protocol that includes induced hypothermia for all patients with ROSC significantly improved survival to hospital discharge in this EMS systemSlide104

www.wakeems.comSlide105

Wake County EMS

Annually 70,000+ 911 calls (700 OHCA)

Providers: 1,500

BLS

, 225 ALS, 17

APPs

Tiered response incl. dispatch assisted CPR, first responder apparatus and paramedic supervisor to high acuity calls

Serve 7 hospitals of 3 health care systems, incl. 2 PCI capable facilities

Annual protocol updates in April

Utstein

style data collection templateSlide106

Survival to Discharge – VF/VT

NOTE: no statistically significant difference between study periodsSlide107

Optimizing Neurologic Resuscitation

Mild Induced Hypothermia (IH)

Decrease metabolic demand

4,5,6,7

Inhibits inflammatory cascade

12,14,15

IH is time sensitive

8,11,14,15

Hemodilution

12,13

Normal saline dilution as part of hypertensive reperfusion strategy

Hypertensive reperfusion

Use of vasopressors to target MAP of 90Slide108

Circulation 2007Slide109

Standardized post resuscitation bundle:

Cardiac catheterization

Therapeutic hypothermia

Hemodynamic maintenance

Ventilator management

Electrolyte/glucose control

PrognosticationSlide110

Outcome –CPC 1 or 2

Control period 15/58 (26%)

Treatment period 34/61(56%)

OR 3.61 (CI 1.66-7.84, p=0.001)Slide111

Induced Hypothermia

Do NOT delay starting IH

If patient meets inclusion criteria start cooling

Do not worry about rewarming Slide112
Slide113

?Slide114

So if compressions are the MOST important intervention for a successful resuscitation what is our airway management device of choice in a cardiac arrest?

….more on this laterSlide115

Ventilation vs Oxygenation

Oxygenation is delivery of oxygen to RBC and tissues

Oxygenation determined by two things:

FiO

2

(

% inspired O

2

)

Pressure of gas (CPAP or PEEP)

Ventilation is the elimination of CO

2

Ventilation is determined by two things:

Tidal volume

Ventilatory rateSlide116

Why is this important?

Cells require oxygen to make energy

Inability to oxygenate the tissue is quickly fatal

Exchanging carbon dioxide is NOT!

If forced to make the choice between oxygenation and CO2 exchange

CHOOSE OXYGENATION!Slide117

So why does that matter?

If oxygenation has nothing to do with ventilation why do we ventilate patients at rates > 30 breaths per minute?

Who cares…..if breathing 12 times a minute is good 30 times a minute MUST be better right?Slide118

….what is our airway management device of choice in a cardiac arrest?Slide119

The device that allows us to

oxygenate

the patients brain and myocardium and causes the…

LEAST interruption in compressionsSlide120

Objective

Describe the importance of:

Prehospital resuscitation

Continuous compression

Controlled ventilatory rates

Describe the value and limitations of advanced airway management adjuncts

List the critical components of cardiac arrest managementSlide121

Pit Crew CPR

Went to simulation to design highly scripted process that allows intervention without interruption

Tasks assigned to positions rather than individuals because individuals changeSlide122

OOHCA What matters!

For first 2 cycles concentrate on

compressions

Get on the chest as quick as possible

Compress hard and fast (do NOT exceed 120)

Minimize interruptions

If on monitor compress up to delivery of shock

Resume compressions immediately regardless of pulse or rhythm

BVM

ONLY

Control ventilation (use your blinky light)Slide123

OOHCA What matters!

After 2 cycles (4 min) place King Airway

Don’t stop compressions!

ETI only if unsuccessful with BIAD

Place gastric tube via KING or OG/NG

Control your ventilations

Recheck tube with each patient movementSlide124

OOHCA What matters!

Continue resuscitation

Rhythm/Pulse check

only

at 2 min

Change compressor q 1 min regardless of fatigue

Run checklist to assure overlooked errors

Careful consideration of causes

Do NOT move the patient unless:

You are in potential danger

You are in a public place

Other situation not suitable to leave the bodySlide125

Pre-hospital providers must be the experts in cardiac arrest resuscitation!Slide126

0

2

4

6

8

10

12

14

16

18

20

Arrest Time (min)

SHOCK

CCC

HYPO?

Electric

Circulatory

Phase

Etapa metabólica

What we know?

Metabolic PhaseSlide127

BackgroundSlide128

Inertia…..

it’s not just for cars anymore!

Blood

Inertia?

Berg et al. Resuscitation 2001Slide129

What is Post-Cardiac Arrest Syndrome?

Unique / complex combination of pathophysiological processes, which include:

Post–cardiac arrest brain injury,

Post–cardiac arrest myocardial dysfunction

Systemic ischemia/reperfusion response.

DON’T FORGET!! the unresolved pathological process that caused the cardiac arrest.Slide130

Post-Cardiac Arrest Syndrome

High mortality of cardiac arrest patients after ROSC is due to multiple organ system dysfunction

Cardiac Arrest etiology

Duration of cardiac arrest and no flow

Reperfusion injury after ROSC Slide131

Post-Cardiac Arrest Brain Injury

Pathophysiology

Impaired Cerebral Autoregulation

Cerebral Edema

Clinical Manifestations

Coma, Seizures, Myoclonus

Vegetative State, Brain Death, Strokes

Potential Treatments

Therapeutic Hypothermia

Early Hemodynamic Optimization

Ventilation/ Oxygenation Slide132

Did Rate Change with Feedback?

Independent Variables (Not Paired)

Scene

Kruskal-Wallis Test

P = 0.25

Transport

Kruskal-Wallis Test

P = 0.39*Slide133

Post-Cardiac Arrest Myocardial Dysfunction

Pathophysiology

Global Hypokinesis

ACS

Clinical Manifestations

Reduced Cardiac Output (Low BP)

Dysrhythmias

Cardivascular Collapse

Potential Treatments

Early Revascularization (AMI)

Hemodynamic OptimizationSlide134

Systemic Ischemia/ Reperfusion Response

Pathophysiology

Systemic Inflammatory Response

Increased Coagulation

Adrenal Suppression

Key Potential Treatments

Temperature Control

Hemodynamic Optimization

Glucose Control

Treat Cause of ArrestSlide135

Aha statement

Post-Resuscitation Recommendations

Induced hypothermia

Prevention of hyperthermia

Tight glucose control

Prevent hypocapnia

Maintain elevated MAPSlide136

Therapeutic Hypothermia

The protective effects of hypothermia

induction have been suggested since

the time of Hippocrates, who

advocated packing bleeding patients

in

snow.

Baron Larrey, Napoleon’s Battle surgeon during the invasion of Russia had noted that soldiers that were left in the snow had improved survival than those treated with blankets and warm drinks.

Slide137

History of Hypothermia and Cardiac Arrest

Williams et al -Annals of Surgery, Volume 4 #3 September 1958 Slide138

Why Induced Hypothermia?

Pre-hospital ROSC

1

45%(38%) of v-fib arrests

37% (22%)of all cardiac arrests

Discharge

1

12%(10%)

Post Resuscitation Deaths

3

10% die due to recurrent dysrhythmias

30% die to due to cardiovascular collapse

40% die due to PRESlide139

Mechanisms of Hypothermia

In the normal brain, hypothermia reduces the cerebral metabolic rate for oxygen (CMRO2) by 6% for every 1°C reduction in brain temperature

It is thought to suppress many of the chemical reactions associated with reperfusion injury. (free radical

, excitatory

amino acid release, and calcium shifts, which can in turn lead to mitochondrial damage and apoptosis

Steen PA, Newberg L, Milde JH, et al. Hypothermia and barbiturates: individual and combined effects on canine cerebral

oxygen consumption.

Anesthesiology. 1983;58:527–532.Slide140

Post

R

esuscitation

E

ncephalopathy

Initial insult from cardiac arrest

Period of luxuriant hyperperfusion

3

Cell injury

8,11

Oxygen free radical formation

Inflammatory cascade

Glutamate mediated cell death

Loss of autoregulation

Sludging and hypoperfusion

3,8,11

Perfusion/demand mismatch

8,11

Slide141

Wake EMS Experience…Slide142

Objective

To determine the impact on survival of a standard post-resuscitation care protocol that includes prehospital initiation of therapeutic hypothermia in patients with return of spontaneous circulation (ROSC) in the field.Slide143

Methods

Observational cohort

“Before and after” – Introduction of Therapeutic Hypothermia for patients with prehospital ROSC

Post-resuscitation patients are selectively transported to one of 2 high volume PCI centers

Wake County NC - pop. 897,000

April 2005 through December 2008Slide144

Cardiac Arrest Response

All calls receive EMD from a single, high-volume center

Fire first response with AED and compressions

Paramedic response with transport ambulances (2)

Supervisory response at paramedic levelSlide145

Protocol Revision

[

Apr 2005-Oct 2006]: Continuous compressions, controlled ventilations

[Oct 2006-Dec 2008]: Induced Hypothermia after ROSCSlide146

Criteria for Induced Hypothermia

ROSC after cardiac arrest not related to trauma or hemorrhage

Age 16 years or greater

Female without obviously gravid uterus

Initial temperature >34 C

Patient with advanced airway (no RSI)

Patient remains comatose without purposeful response to painSlide147

Data Collection

All EMS records are maintained in an electronic database

Records with any of the following characteristics are reviewed to determine if cardiac arrest occurred:

EMS Patient Disposition = cardiac arrest

CPR procedure is recorded

Defibrillation is recorded

Induced Hypothermia ProcedureSlide148

Inclusion Criteria

All adult patients resuscitated from out of hospital cardiac arrest (OHCA) prior to hospital arrival, regardless of initial rhythm, were included if they had ROSC in the field.Slide149

Age less than 16

Obvious traumatic origin of arrest

EMS witnessed arrest

Arrest not in EMS control

Prison facilities

Out-of-system intercept

Arrests under direction of non-EMS physician

Exclusion CriteriaSlide150

Outcome Measures

Discharge from hospital (

primary

)

Neurologically intact survival was defined as CPC 1 or 2 at time of hospital discharge.

2 blinded physician reviewers from each hospital independently assigned CPC scores based on patient discharge recordsSlide151

Included Patients / Phase

All Phases

N=640

Before (17 Months)

227

After (26 Months)

413Slide152

Before After

(n=227) (n=413)

Mean age (yrs)

66

64

Male sex

62%

60%

Bystander witnessed arrest

45%

32%

Bystander CPR

38%

39%

Mean Response (mins)

5.6

5.6

Initial rhythm VF/VT

35%

38%

NOTE: no statistically significant difference between study periods

Patient and EMS CharacteristicsSlide153

Survival to Hospital Discharge for All Rhythms

NOTE: statistically significant difference p value <0.0163Slide154

Survival to Hospital Discharge for All Rhythms

*Difference in overall survival was significant with a p-value of 0.0163Slide155

Percent of Survivors Neurologically Intact

NOTE: no statistically significant difference between study periodsSlide156

Limitations

Protocol-driven pre- and post-resuscitation cardiac arrest care

Hawthorne effect

Intention-to-treat analysisSlide157

Conclusion

Out-of-hospital standard post-resuscitation care protocol that includes induced hypothermia for all patients with ROSC significantly improved survival to hospital discharge in this EMS systemSlide158

Optimizing Neurologic Resuscitation

Mild Induced Hypothermia (IH)

Decrease metabolic demand

4,5,6,7

Inhibits inflammatory cascade

12,14,15

IH is time sensitive

8,11,14,15

Hemodilution

12,13

Normal saline dilution as part of hypertensive reperfusion strategy

Hypertensive reperfusion

Use of vasopressors to target MAP of 90Slide159

Is Earlier Better??

Nordmark

2005

20 Pigs Subjected to 8 minutes of V-fib followed by CPR

Randomized into 2 groups (hypothermia/control)

Hypothermic group received cold saline after 1 min in CPR

Conclusion:

“Inducing Therapeutic Hypothermia with a cold infusion seems to be an effective method that can be started during ongoing CPR”Slide160

Is Earlier Better??

Bernard

2008

Resuscitation

60 year-old female in cardiac arrest (37 minutes) due to pericardial tamponade

D/H Alert and Oriented

Conclusion:

“Treatment with a rapid Intravenous Infusion of large volume (40ml/kg), Ice-cold (4˚C) fluid during CPR induces mild hypothermia and may provide neurological protection

”Slide161

Is Pre-Hospital Cooling Safe??

Bruel

2008

The study was aimed to determine the safety and effectiveness of cooling patients while in ALS Support

The Median time

to reach mil hypothermia (<34˚C) after ROSC

was

16 minutes

Conclusion:

“The

infusion of 2 liters of Normal Saline at 4˚C in the field during ALS to induce mild hypothermia in resuscitated OHCA patients is safe, feasible and effective”