Daniel Davis, MD UCSD Center for Resuscitation Science New Frontiers in Resuscitation Science.
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Transcript of Daniel Davis, MD UCSD Center for Resuscitation Science New Frontiers in Resuscitation Science.
![Page 1: Daniel Davis, MD UCSD Center for Resuscitation Science New Frontiers in Resuscitation Science.](https://reader035.fdocuments.net/reader035/viewer/2022070409/56649e755503460f94b76e37/html5/thumbnails/1.jpg)
Daniel Davis, MD
UCSD Center for Resuscitation Science
New Frontiers inResuscitation
Science
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Key Concepts
• Compressions
• Ventilations
• Pressors
• PetCO2
• Post-resuscitative care
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1. Optimal Compressions
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The Primary Directive
Chest compressions should be performed
from the moment of arrest until return of
spontaneous circulation is assured.
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Kern (2002) Circulation
Prime the Pump!
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Christenson (2009) Circulation
Stay on the chest!
* Adjusted for: age, gender, bystander CPR, public location, response time, compression rate
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Compression Interruptions
• Initiating compressions
• Rhythm analysis
• Shock sequence
• Pulse check
• Intubation
• Vascular access
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Bystander CPR
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ECG Filtration
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Return of Spontaneous Circulation
Electrical(HR)
Mechanical(PetCO2)
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Stiell et al (2008) AHA Scientific Sessions
Deeper Compressions
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Aufderheide (2005) Resuscitation
Good Recoil
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Rate
0 to 80 81 to 120 121+ (N=65) (N=478) (N=122)
38 mm 49% 44% 69%
38-51 mm 28% 44% 30%
>51 mm 23% 12% 2%
Depth
Stiell et al (2008) AHA Scientific Sessions
Rate vs Depth
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CPR Process
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Code # 79265 (11/28/12) Code Leader: Brendan Daly, MD Recorded CPR time: 5 minutes Type of arrest: VF/VT Minute Chest Compression
Fraction (goal >90%)
Average Compression Rate (goal 100)
Average Compression
Depth (inches) (goal 2-4 inches)
1 100% 118 3.02 2 73% 107 2.98 3 82% 115 3.10 4 85% 121 2.85 5
Defibrillations: 1 Pre-shock pause (goal <3 seconds) 14 seconds Post-shock pause (goal < 6 seconds) 3 seconds Use of End Tidal Carbon Dioxide: Yes Other comments: Good compression rate and depth, great use of EtCO2. Summary: (selected strips below)
Defibrillation:
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Results• Chest compression fraction 91%
• Compression rate 123/min
• Compression depth 2.6 inches
• Pre-shock pause 2.6 sec
• Post-shock pause 3.6 sec
• Perfusion check 4.3 sec
• Ventilation rate 9.7/min
• PetCO2 15.3 mmHg
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What if we’re wrong?
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2. Controlled ventilation
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Kern (2002) Circulation
Prime the Pump!
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Continuous Chest Compressions with Synchronous Ventilations (10:1)
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3. Pressor Therapy
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Pressors
Mader (2008) Resuscitation
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Hagihara (2012) JAMA
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*
*
*
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Vasopressin?
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Fluids?
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4. PetCO2 in resuscitation
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Lung Perfusion in ShockPaCO2
40 mmHgPaCO2
40 mmHg
PetCO237 mmHgPetCO2
37 mmHgPetCO2
29 mmHgPetCO2
29 mmHgPetCO2
21 mmHgPetCO2
21 mmHg
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PetCO2 MonitoringPetCO2 Monitoring
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PetCO2 Associations
• Initial PetCO2 α ROSC
• Pre-shock PetCO2 α ROSC for VF
• Rise in PetCO2 α ROSC
• Initial PetCO2 α arrest etiology
• Compression depth/patient wt α PetCO2
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5. Post-resuscitation care
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Hyperventilation: Three Flavors
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Cerebral Perfusion During Shock
0
5
10
15
20
25
30
35
40
45
RR6 RR12 ETCO2
P = .004 v 12P = .004 v 12
mL/100 gm/min
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Ventilation in Resuscitation
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Rapid, Shallow Breaths?95% CI for the regression estimate
0 20 40 60 800
500
1000
1500
Est TV
VR
95% CI for the regression estimate
0 20 40 60 800
500
1000
1500
Est TV
VR
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Intrathoracic Pressure
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Evidence for Hypothermia?
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Hypothermia After Cardiac Arrest Study Group (2002) NEJM
Hypothermia vs. Normothermia?
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When should we cool?
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no cooling
33oC
0 10 20 30 40 50 60 % survival
36%
53%
no cooling
33oC
26%
49%
36oC
33oC
52%
50%
Post-Arrest Hypothermia HACA
Bernard
TTM
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How should we cool?
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How should we cool?
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Current U.S. Benchmark
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Conclusions
• The opportunity is staggering
• Compressions
• Technology
• Post-resuscitative care
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