Resuscitation Science

Stephen Bernard MD FACEM FCICM FCCM

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Disclosures- grants

�NHMRC

�Paramedics Australia

�TAC

�Faulk Foundation

CHARACTERISTIC Odd ratio 95% CI P value

Age 0.957 0.950 - 0.964 <0.001

EMS arrival to ROSC time

0.998 0.896 - 0.920 <0.001

EMS Response time 0.968 0.940 - 0.997 0.03

No EMS Intubation Patient GCS > 8

4.96* 2.60 – 9.59 <0.001

No EMS intubationPatient GCS < 8

1.64* 1.10 – 2.43 0.015

Initial rhythm VF/VT 4.31 3.41 – 5.45 <0.001

Witnessed arrest 1.50 1.16 – 1.93 0.002

Bystander CPR 1.31 1.06 – 1.61 0.011

Transport to Cardiac Centre

1.40 1.12 – 1.74 0.003

Admission in hours (0800-1700)

1.34 1.10 – 1.64 0.004

Male Gender 1.30 1.03 – 1.64 0.025

Stub D, Bernard SA, Duffy S, et al. Hospital characteristics are associated with

patient outcomes following out-of-hospital cardiac arrest. Heart 2011; 97:1489-1494

Post Arrest Team

�Therapeutic temperature management

�Decrease inspired oxygen

�Aim systolic BP 120mmHg

�Transfer to cardiac catheter lab

�ECMO

�IAOC

Resuscitation. 2012 Apr;83(4):417-22

Animal studies

Post Arrest Management in 2014

What systolic BP ?

�Victorian Ambulance Cardiac Arrest Register (VACAR)

�3620 OHCA cases

�Median age was 69 years, 70% were male, and

60% were in a shockable rhythm on ambulance arrival

�For VF/VT patients, survival was maximal at 120-129mmHg (54%)

Bray J, Bernard S, Cantwell K, et al. Resuscitation 2014; Apr;85(4):509-15

Post Arrest Management in 2014

Transfer to cardiac catheter lab (angio+/-IABP)

�714 patients with OHCA at a tertiary centre in Paris

�435 patients with cardiac cause of arrest underwent

coronary angiogram

�304 (70%) patients had a significant lesion

�128 (96%) of 134 patients with STEMI and in 176 (58%)

of 301 patients without STEMI had a relevant lesion

Dumas F,et al. Immediate percutaneous coronary intervention is associated with better

survival after out-of-hospital cardiac arrest: insights from the PROCAT (Parisian Region

Out of hospital Cardiac ArresT) registry. Circ Cardiovasc Interv. 2010 Jun 1;3(3):200-7

Number 65 31

Year 2011-12 2013 (Nov)

Arrest duration 20 min 15min

Decrease FIO2 34% 77%

TTM 82% 100%

Cath Lab 40% 52%

ICU 1st SBP 90mmHg 100mmHg

ICU 1st pO2 151mmHg 104mmHg

Hospital survival 62% 81%

Bring on the PAT team

Temperature Management (after 17/11/13)

TTM

TTM

TTM

TTM

�This study should change practice !

�Maintaining 36°C for 24 hours is easier than 33°C

�Control with sedation/ paralysis and a cooling

device

�Prognostication - day 5 (24+12+72=108 hours)

Refractory Arrest: What more can be done?

�Just keep going

�VA ECMO during CPR (ECPR)

�Mechanical CPR to cardiac

catheter laboratory

Cold IV saline

3L bolus IV

Cools rapidly

Bernard SA, et al. Therapeutic hypothermia induced during cardiopulmonary resuscitation using

large-volume, ice-cold intravenous fluid. Resuscitation 2008; 76:311-3

To the ICU:

�Cooling for 24 hours

�33°C

�Slow rewarming over 24 hours @ 0.25°C/hr

�ECMO out when ROSC or CNS hopeless

THE CHEER TRIAL

�February 2012 to January 2014

�21 patients had attempted E-CPR

�9/21 with out-of-hospital cardiac arrest

�The site of cannulationo 13/21 (62%) in the ED

o 7/21 (33%) in the ICU

o 1/21 (5%) in the cath lab

�The average age 47 years (21-62)

�16/21 (76%) male

THE CHEER TRIAL

�Percutaneous cannulation was successful in 19/21 (90.5%)

�The average duration of ECMO support

in the 19 cannulated patients was 4.2 days

�13/21 (62%) patients awoke and 12/21 (57%) patients were discharged home

I have a dream….

� Post arrest patient go to a 24/7 cath lab hospital with interested staff

� Post arrest team?

� ECPR available in selected centres (at least one in each capital city)

� ED or ICU driven

� IAOC for arrest due to bleeding subdiaphragm