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CPR 2013

CPR 2013!
Overview Guideline CPR 2010
What s new since 2010
Post resuscitation care
Coronary angiography & PCI in Cardiac arrest

Summary of Key BLS Components"

Chain of Survival

>8

1-8

<1

()

10
CPR
chest compression

Chest wall recoil
Airway
Compression-to-ventilation ratio
2 (5 )
C-A-B
100/
1/3 AP dia,
2 (5 )
1/3 AP dia,
1.5 (4 )

Full , 2,
Head tilt-chin lift (HCP suspected trauma; Jaw trust)
30:2 in 1 & 2 resuers
30:2 single resuer
15:2 2 HCP rescuers

Basic Life Support

Advanced Cardiac Life Support

Breathing
Debibrillation

1 breath every 6-8 seconds (8-10 breath/minute), 1 second per breath

AED , , resume chest compression after shock

Electrical therapies

"

Bystander CPR

1 shock protocol for VT/VF

" " "

150-200 J (biphasic); 360 J (mono)

J if not response
Resume chest compression immediately after shock

Atrial Fibrillation : cardioversion 120-200 J (200 J mono)
Atrial Flutter & other SVT : cardioversion 50-100 J (mono & biphasic)

Survival OHCA x 2-3

Compression only CPR or standard Dispatcher-assisted CPR

CPR?

"

New Shock energy

" "

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Quality of CPR

Push fast & hard
AHA: Depth>5cm & rate>100/min
ERC: Depth upto 6 cm & rate upto120/min

Decrease hand-off time

Near-infrared spectroscopy"

Monitoring ofportable regionalnear-infrared cerebral oxygenation during using spectroscopy " CPR

Airway

Lower Esophageal Sphincter Tone During Cardiac Arrest

Tracheal intubation

No study has shown a survival benet for

20 mmHg5mmHg
Regurgitation of gastric content

tracheal intubation after cardiac arrest "

1/3 of OHCA have aspiration

chest compression" Unrecognized esophageal intubation" Waveform capnography"

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Supraglottic Airway Devices"

Esophageal-tracheal " combitube" Laryngeal mask airway " (LMA)" i-Gel"

Waveform Capnography"
1. Proof a correct position of ET"
When tracheal intubation is undertaken <30 min after the onset of cardiac arrest, waveform capnography has 100% (95% CI 98100%) sensitivity and 100% (95% CI 97100%) specicity to verify placement of the tube in a major airway." "

2. Feedback quality of chest " compression during CPR"

Adequate chest compression 10-15 mmHg"

" 3. Detect ROSC"

Mobile telephone audio-visual guidance in CPR

CPR devices

CPR PRO (cpro) cradle and smartphone application running on an iPhone 3G mobile phone
Resuscitation Volume 82, Issue 6, June 2011,776779

App.

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Mechanical chest compressions devices"

AutoPulse

Lucas

ACLS
Cardiac Arrest
Algorithm

Drugs in CPR

Epinephrine
Alpha and beta adrenergic effect
myocardial & cerebral blood flow during CPR

Vasopressin
Anti-diuretic hormone High dose -> non-adrenergic peripheral vasoconstrictor T 10-20 min alternative for epinephrine in shock-refractory VF patient Dose 40 U iv push x 1

Used in - cardiac arrest - symptomatic bradycardia - severe hypotension - anaphylaxis Dose CPR : 1 mg q 3-5 min. bolus flush with 20 ml fluid or 10 mg+ Nss or D5W 100ml IV 100ml/h) IV drip : 2- 10 ug/min. Higher dose ROSC but not survival consider if 1mg dose fail or B-blocker or calcium channel blocker overdose

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Vasopressin vs Epinephrine
Vasopressin for cardiac arrest: a systematic review and meta-analysis. Arch Intern Med. 2005;165:1724. Aung K, Htay T. no statistically significant differences between vasopressin & epinephrine for ROSC, 24-hour survival, or survival to hospital discharge.
CPR 2008

Epinephrine 1mg +Vasopressin40iu vs Epinephrine 1 mg

the combination of vasopressin & epinephrine during ACLS for out-ofhospital cardiac arrest does not improve outcome New Eng J Med 2008
CPR 2008

Vasopressin, Epinephrine, and Corticosteroids for In-Hospital Cardiac Arrest"

Vasopressin (20 IU /CPR cycle) + epinephrine (1 mg per resuscitation cycle) +methylprednisolone sodium succinate (40 mg) On the rst resuscitation cycle"

Amiodarone
Used in : VT/VF +/- arrest (FIRST CHOICE) Dose Cardiac arrest : 300 mg in 20-30 ml DW iv repeat once if necess 150mg iv non-arrest : 150 mg in 10 min. Maintainance : then 1 mg/min x 6h and 0.5 mg/min later Increase survival to hospitalization but not to hospital discharge (ARREST N Eng J Med 1999;341,871-878)

Combined vasopressin- epinephrine and methyl-prednisolone during resuscitation and stress-dose hydrocortisone in post-resuscitation shock improved survival in refractory in-hospital cardiac arrest" Arch Intern Med. 2009;169(1):15-24"

Extracorporeal Life Support"

CPR with assisted extracorporeal life-support versus conventional CPR in adults with in hospital cardiac arrest: an observational study and propensity analysis. Percent of patients alive at various time points Time point 24 h 3d 14 d CPR + extracorporeal life support (%) 65.2 52.2 37.0 34.8 32.6 19.6 CPR alone (%) 41.3 34.8 23.9 17.4 15.2 13.0

Observational studies showed

higher rate of survival discharge & 1 year survival

Chen, Y. S. et al. Cardiopulmonary resuscitation with assisted extracorporeal life-support versus conventional cardiopulmonary resuscitation in adults with in-hospital cardiac arrest: an observational study and propensity analysis. Lancet 372, 554561 (2008)."

30 d 6 mo 1y

Chen Y-S et al. Lancet; published online before print July 7, 2008.

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The greatest drop-off in survival occur in hospital"

Care After Cardiac Arrest

J A C C : C A R D I O V A S C U L A R I N T E R V E N T I O N S , V O L . 5 , N O . 6 , 2 0 1 2 J U N E 2 0 1 2 : 5 9 7 6 0 5"

Cause of Death

Out-of-hospital cardiac arrest = Neurological In-hospital cardiac arrest = Cardiovascular +
multiple organ failure
injury

Post cardiac arrest syndrome"

1.Precipitating pathology! 2.Neurologic dysfunction secondary to

anoxic brain injury!

3.Myocardial stunning and

dysfunction,!
4.Systemic ischemia/ reperfusion

response!

(1) Persistent precipitating pathology

Pathophysiology Cardiovascular disease (AMI/ACS, cardiomyopathy) Pulmonary disease (COPD, asthma) CNS disease (CVA) Thromboembolic disease (PE) Toxicological (overdose, poisoning) Infection (sepsis, pneumonia) Hypovolemia (hemorrhage, dehydration) Clinical Manifestation Potential Treatments Specific to cause Disease-specific but complicated interventions by concomitant PCAS guided by patient condition and concomitant PCAS

Post-Resuscitation Care That Improve Outcome"

Mild Therapeutic hypothermia after Coronary angiography & PCI after

cardiac arrest
cardiac arrest

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Improvement in 1 year survival after implement of standard post-resuscitation care emphasis on therapeutic hypothermia and early coronary angiography for possible PCI"

Rate of Coronary Occlusion is frequent in OHCA"

Studies" Spaulding C et al" Davies MJ et al." Farb A et al." Lo YS et al." Rate of Coro occlusion" 67%" 73.3" 57" 33"
Spaulding C et al, N Engl J Med, 1997; 336: 1629-33" Davies MJ et al, Circulation 1992;85:119-24" Farb A et al, Circulation 1995;92:1701-9" Lo YS et al AHJ 1988; 115:781-5"

J A C C : C A R D I O V A S C U L A R I N T E R V E N T I O N S , V O L . 5 , N O . 6 , 2 0 1 2 J U N E 2 0 1 2 : 5 9 7 6 0 5"

January 2003-December 2008: 714 OHCA with ROSC

No obvious extra-cardiac cause 435 Obvious extra-cardiac cause 279

Ravascularization after successful" resuscitation for OHCA"

" " " What is the value of post-ROSC clinical and ECG data" " "for predicting coronary artery occlusion as a cause of" " "OHCA?" " " " ECG is often difcult to analyze in this setting," " " " "predictive ! ! ! !segment ! ! ! " " "

ST segment elevation 134 (31%)

No ST segment elevation 301 (69%)

value of ECG is poor and lack of ST! elevation does not exclude acute! !coronary occlusion or unstable lesions which can" "be treated by PCI!

Successful PCI 99 (74%)

No or failed PCI 35 (26%)

Successful PCI 78 (26%)

No or failed PCI 223 (74%)

When should a coronary angiogram be performed?!

Dumas F et al , Circ Inter 2010: 3;

ILCOR Consensus Statement

In summary, patients resuscitated from cardiac arrest who have electrocardiographic criteria for ST- elevation myocardial infarction should undergo immediate coronary angiography, with subsequent PCI if indicated. Furthermore, given the high incidence of ACS in patients with out-of-hospital cardiac arrest and limitations of electrocardiography- based diagnosis, it is appropriate to consider immediate coronary angiography in all post cardiac arrest patients in whom ACS is suspected.

Circulation. 2008 ;118:2452-83 Circulation. 2008 ;118:2452-83

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PROCAT

Does PCI improve the prognosis of"
"

survivors of OHCA?!

Dumas F et al , Circ Interv 2010; 3:

PROCAT Predictor of survival"

Time from BLS to ROSC Time from Collapse to BLS Diabetes Mellitus Age>59 yrs Initial arrest rhythm: Asystole/PEA Blood lactate ST segment elevation Successful PCI
Better Prognosis"

19 Clinical Reports of Coronary Angiography After Resuscitation" From Cardiac Arrest"

Dumas F et al , Circ Interv 2010; 3:

JAC C : CAR D I O VAS C U LAR I N T E RVENTIONS,VOL.5,NO.6,201 2 J U N E 2 0 1 2 : 5 9 7 6 0 5"

Post Cardiac Arrest Coma cath?"

2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science!

In OHCA patients with STEMI or new LBBB on ECG after ROSC, early angiography and PPCI should be considered. Out-ofhospital cardiac arrest patients are often initially comatose but this should not be a contraindication to consider immediate angiography and PCI. It may be reasonable to include cardiac catheterization in a standardized post-cardiac-arrest protocol as part of an overall strategy to improve neurologically intact survival in this patient group "

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No differences in survival-to-discharge or favorable neurological function among survivors were seen between those with or without ST-segment elevation on their post-resuscitation electrocardiograms"

J Am Coll Cardiol Intv 2013;6:11525!

Thammasat Data 2007-2012"

45 OHCA /IHCA & angiography"
Normal/" minor coro ds" 18" (1PE)"

Thammasat Data 2007-2012"

45 OHCA /IHCA & angiography"

Signicant Coronary stenosis = 27" LMCA +2VV" 2" LMCA" +3VV" 7"
(1postCABG)"

1vessel" 5"

2vessel" 8"

3vessel" 5"

18
27

Revascularization = 26" " 6" 4PCI" 2CABG"

"

" 3 PCI"

" 8 PCI"

3 PCI" 2 CABG"

" 2 PCI"

(2) Post cardiac arrest brain injury

Pathophysiology Impaired cerebrovascular autoregulation Cerebral edema (limited) Postischemic neurodegeneration Clinical Manifestation Coma Seizures Myoclonus Cognitive dysfunction Persistent vegetative state Cortical stroke Spinal stroke Brain death Potential Treatments Therapeutic hypothermia Early hemodynamic optimization Airway protection and mechanical ventilation Seizure control (SaO2 94% to 96%) Supportive care

Secondary Parkinsonism Controlled reoxygenation

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Therapeutic HyPothermia

Out-of-hospital VF
cool to 32-34 C
for 12-24 hr
start minutes-hors after ROSC

The Hypothermia after Cardiac Arrest Study Group. Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest. NEJM 2002;346:549-556

Maximize Recovery of Brain Function

Hypothermia
Optimize cerebral perfusion
Control seizure
Control metabolic-blood glucose

(3) Postcardiac arrest myocardial dysfunction

Pathophysiology Global hypokinesis (myocardial stunning) ACS Clinical Manifestation Reduced cardiac output Hypotension Dysrhythmias Cardiovascular collapse Potential Treatments Early revascularization of AMI Early hemodynamic optimization Intravenous fluid Inotropes IABP LVAD ECMO

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(4) Systemic ischemia/reperfusion response

Pathophysiology Systemic inflammatory response syndrome Increased coagulation Adrenal suppression Impaired tissue oxygen delivery and utilization Impaired resistance to infection Clinical Manifestation Ongoing tissue hypoxia/ischemia Cardiovascular collapse Pyrexia (fever) Hyperglycemia Multiorgan failure Infection Potential Treatments Early hemodynamic optimization Intravenous fluid Vasopressors High-volume hemofiltration Temperature control Glucose control Antibiotics for documented infection

Impaired vasoregulation Hypotension

General Goal-directed therapy

MAP of 65 to 100 mm Hg Central venous pressure of 8 to 12 mm Hg ScvO2 70% urine output 0.5-1 mL / kg/ h1 normal or decreasing serum or blood lactate level hemoglobin concentration?- 30% O2 Sat 94-96%
CPR 2008

Prognostication

Multimodal approach
Neurological examination
Electrophysiological investigation
Delay until 72 hr after return to
normothermia

Prevention of Cardiac Arrest"

In-Hospital" Out-Hospital"
OHCA: warning sign" Typical angina was present for a median duration of 2 h in 25% of 274 patients with witnessed OHCA"

IHCA: 80% Vital

sign " system"

Rapid response

Kause, J. et al. the ACADEMIA study. Resuscitation 62, 275282 (2004)." Muller, D et al. How sudden is sudden cardiac death? Circulation 114, 11461150 (2006)."

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