July

07 , 20 23

Out-of-Hospital Cardiac Arrest
• “Brian Duffield, then 40, a salesman in Tucson, collapsed in the shower after a swim. Luckily for him, he was on the campus of the University of Arizona . . . . . . .”
Newsweek
July 23, 2007

Out-of-Hospital Cardiac Arrest
• “Brian Duffield, then 40, a salesman in Tucson, collapsed in the shower after a swim. Luckily for him, he was on the campus of the University of Arizona . . . . . . .”
Newsweek
July 23, 2007

A female off-duty paramedic just finished swimming at the gym instructed someone to call 911 and to get an AED. She then performed

Continuous Chest Compressions AED Shocked twice

University Medical Center
Post Resuscitation Care

Coma: Mild Hypothermia begun ED 32-34o C for 24 hours

Out-of-Hospital Cardiac Arrest
• • • • • B.D. Echo after PCI: LVEF = 20% Warmed after 24 hours Discharged 5 days later Business trip the following week Repeat Echo 6 weeks later:
– LVEF = 50% with minimal septal hypokinesis

Newsweek
July 23, 2007

New Ways to Survive Cardiac Arrest

I am going to let you in on a secret: When a person's heart stops beating, it's not the end. Contrary to what you may think, death is not a single event. Instead, it's a process that can be interrupted.

Dr. Sanjay Gupta

FLAGSTAFF, Arizona (CNN)
• For young mom, new CPR beat back death

Woman, 33, suffered sudden cardiac arrest; was without heartbeat 18 minutes Husband, a trained first responder, did newstyle CPR, with compressions only Their state, Arizona, has seen cardiac arrest survival triple since adopting procedure

 

Cardiocerebral Resuscitation: A New Approach to Cardiac Arrest
Bentley J. Bobrow, MD
Medical Director Bureau of EMS & Trauma System Arizona Department of Health Services Scottsdale Fire Department Assistant Professor Department of Emergency Medicine Mayo Clinic College of Medicine

Out-of-Hospital Cardiac Arrest: A Common Disease
• ~1000 OHCA victims today in the US • Likely someone in Massachusetts will suffer OHCA during this talk

Many Reasons for Low OHCA Survival:
• • • • • Poor public knowledge of cardiac arrest Delayed time to first defibrillation Low rates of bystander CPR Inconsistent quality of professional CPR Inconsistent post cardiac arrest care WE haven’t adequately implemented what we already know

100%

Three-Phase Model of Resuscitation
Myocardial ATP

0

Electrical Phase

Circulatory Phase

Metabolic Phase

0

2

4

6

8

10

12

14

16

18

20

Arrest Time (min)

Weisfeldt ML, Becker LB. JAMA 2002: 288:3035-8

Phases of Cardiac Arrest

Electrical Hemodynamic
“Traditionally we have treated these two different phases the same”

Circulatory Phase

• Should CPR ever be done BEFORE Defib? • YES

Defibrillation vs. CPR first (<5 minute response time)
60% 50% 40% 30% 20% 10% 0% ROSC D/C Hosp 1yr Surv CPR first Standard P=.44

P=.82

P=.61

Wik et al. JAMA 2003: 289:1389-95

Defibrillation vs. CPR First (>5 minute response time)
60% 50% 40% 30% 20% 10% 0% ROSC D/C Hosp 1yr Surv CPR first Standard

P=.04

P=.006

P=.01

Wik et al. JAMA 2003: 289:1389-95

Response time < 4 min
40 35 30 25 20 15 10 5 0 Survival

Response time > 4 min
40 35 30 25 20 15 10 5 0 Survival

p = 0.87

p <0.007

Defib

CPR

Defib

CPR

Current CPR quality: summary

1. Frequent pauses 2. Shallow compressions 3. Hyperventilation

Causes of Chest Compression Interruptions For EMS Providers
• • • • • • Assessing patient (i.e., repeatedly) Preparing and/or Over Ventilation IV placement Intubation Changing Rescuers Defibrillation, particularly use of AEDs

Interruptions in CPR from Paramedic Intubation
• Annals of Emergency Medicine Nov 2009 • Nov 1 through June 20, 2007, a prospective observational study involving a part of the Resuscitation Outcomes Consortium studies 182 consecutive adult cardiopulmonary arrest patients in Pittsburg • Median duration of interruption almost 2 minutes • 1/4 of all pauses

Interruptions to Chest Compressions During OHCA N = 60 • Proportion of time at scene:
– 43% of time with Chest Compressions – 57% of time without Chest Compressions

13 out-of-hospital cardiac arrest patients Ventilation rate measured during CPR
Average ventilation rate = 37 + 3 per minute (range 15-49)

Aufderheide et al. Circulation 2004; 109:1960-5

Hyperventilation during CPR
100% 80% % s u rv iv a6l 0 % 40% 20% 0%
12 30 13% 86% p = 0 .0 0 6

# v e n tila tio n s p e r m in u te

Aufderheide et al. Circulation 2004; 109:1960-5

Disadvantages of Ventilation During CPR:
• • • • • • • Delays/interrupts chest compressions Complicated Stops bystanders doing CPR? Gastric inflation – aspiration Increased intrathoracic pressure Reduces coronary/cerebral perfusion Animal models show worse outcome

Standard CPR (with breaths) vs. CC alone

Blood pressure

Time
= chest compression

Berg et al, 2001

Standard CPR (with breaths) vs. CC alone

Blood pressure

Time
= chest compression

Berg et al, 2001

CCR Goal
• • • • • • Optimal timing of defibrillation Reducing all “Hands-Off” Intervals Avoidance of hyper-ventilation Administer earlier epinephrine Increase coronary perfusion pressure Increase % of bystander CPR

Discussion:
Possible Beneficial Effects of CCR
• Minimize interruptions of marginal forward blood flow during resuscitation efforts • Minimize hyperventilation during resuscitation • Delay in advanced airway interventions may enable providers to focus on compressions and earlier epinephrine administration

CCR vs. ACLS FUNDAMENTAL DIFFERENCES
For Adult Non-Traumatic Cardiac Arrest

Order in which interventions are performed Specified Continuous Cardiac Compressions Faster more forceful compressions Compressions Before and After Defibrillation Early IV Epinephrine Delay intubation for first 3 rounds Airway: Face Mask 02 No Atropine for first 3 rounds

Results
Survival from Out of Hospital Cardiac Arrest
Survival to Hospital Discharge (%)
30 25 20 15 10 5 0
(61/1686) (55/598) (38/348)

CCR ALS

(36/128)

28.1

9.2

10.9 Witnessed with VF

3.6 All cardiac arrests

Results Survival to Hospital Discharge from OHCA
% Survival to Hospital Discharge
50% 40%

POI BVM

21/46

P=.001
30% 20% 24/206 10%

P=.144

45.7% 14/77

30/376 11.7% 8.0%

18.2%

0%

All Cardiac Arrests Witnessed with VF

Vadeboncoeur et al. Circulation. 2007;116:II_923

Witnessed VF Survival Passive Oxygen Insufflation vs. BVM Ventilation
50% 40%

Survival

30% 20% 10% 0%
(12/60) 20%

(17/35) 48%

BVM Ventilation

Passive Oxygen Insufflation

Comparison of Major Outcomes Odds Ratios
Outcomes Primary Survival to hospital discharge, % Odds ratio (95% CI) Survival with witnessed VF, % Odds ratio (95% CI) 14.2) POI vs. BVM 8.0 vs. 11.7 1.7 (0.9-3.1) 18.2 vs. 45.7 5.7 (2.3-

The model is adjusted for age, gender, location, bystander CPR, ventricular fibrillation, witnessed, and EMS dispatch to arrival interval

Cardiocerebral Resuscitation (CCR) in rural Wisconsin for witnessed VF
Neurologically normal survival

50% 40% 30% 20% 10% 0% CPR p = 0.001

48% 15%
Kellum, Kennedy, Ewy Amer J Med 2006;119:335

CCR

Circulation June 2009
Improved Patient Survival Using a Modified Resuscitation Protocol for Out-of-Hospital Cardiac Arrest Alex G. Garza, MD, MPH et al This retrospective observational cohort study reviewed all adult primary ventricular fibrillation and pulseless ventricular tachycardia cardiac arrests 36 months before and 12 months after the protocol change. Survival of out-ofhospital arrest of cardiac origin improved from 7.5% (82 of 1097) in the historical cohort to 13.9% (47 of 339) in the protocol cohort. Similar increases in return of spontaneous circulation were achieved for the subset of witnessed cardiac arrest patients with initial rhythm of ventricular fibrillation from 37.8% (54 of 143) to 59.6% (34 of 57). Survival to hospital discharge also improved from an unadjusted survival rate of 22.4% (32 of 143) to 43.9% (25 of 57) with the protocol. Of the 25 survivors, 88% (n=22) had favorable cerebral performance categories on discharge. Conclusions— The changes to our prehospital protocol for adult cardiac arrest that optimized chest compressions and reduced disruptions increased the return of spontaneous circulation and survival to discharge in our patient population.

Key Questions Remain:
• Perhaps witnessed VF but what about unwitnessed VF, asystole and PEA? • When is active ventilation necessary? • What part of the CCR protocol is most critical? • What is the optimal training method and retraining frequency? • Will CCC-CPR truly improve bystander CPR rates?

Recommendations
• Unconscious adult patients with return of spontaneous circulation (ROSC) after out-of hospital cardiac arrest should be cooled to 32°C to 34°C (89.6°F to 93.2°F) for 12 to 24 hours when the initial rhythm was ventricular fibrillation. Class IIa • Similar therapy may be beneficial for patients with non-VF arrest out of hospital or for in-hospital arrest. Class IIb

American Heart Association 2005 Guidelines

50

Aggressive Post Cardiac Arrest Care Saves Lives 60% 50% 40% 30%
Survival

p < 0.05

59% 34%
Before After

20% 10%

Pytte M, Jensen LP, Smedsrud C, Jacobsen D, Mangschau A, Sunde K.

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