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July23,200

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Out-of-Hospital Cardiac ArrestOut-of-Hospital Cardiac Arrest

Brian Duffield, then 40, a salesman in

Tucson, collapsed in the shower after aswim. Luckily for him, he was on the

campus of the University of

Arizona . . . . . . .

NewsweekJuly 23, 2007


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Brian Duffield, then 40, a salesman in

Tucson, collapsed in the shower after aswim. Luckily for him, he was on theLuckily for him, he was on the

campus of the University ofcampus of the University of

Arizona . . . . . . .Arizona . . . . . . .



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A female off-duty paramedic just finished swimming atthe gym instructed someone to call 911 and to get an

AED. She then performed

Continuous Chest CompressionsContinuous Chest Compressions

AEDAED

Shocked twiceShocked twice


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University Medical CenterUniversity Medical CenterPost Resuscitation Care

Coma: Mild Hypothermia begun

ED

32-3432-34oo C for 24 hoursC for 24 hours


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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



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New Ways to Survive Cardiac Arrest

Dr. Sanjay Gupta

I am going to let you in on a secret: When a person's heartstops beating, it's not the end. Contrary to what you maythink, death is not a single event. Instead, it's a process thatcan be interrupted.


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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 new-style CPR, with compressions only

Their state, Arizona, has seen cardiac arrest

survival triple since adopting procedure


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Bentley J. Bobrow, MDBentley J. Bobrow, MDMedical DirectorMedical Director

Bureau of EMS & Trauma SystemBureau of EMS & Trauma System

Arizona Department of Health ServicesArizona Department of Health Services

Scottsdale Fire DepartmentScottsdale Fire Department

Assistant ProfessorAssistant Professor

Department of Emergency MedicineDepartment of Emergency MedicineMayo Clinic College of MedicineMayo Clinic College of Medicine

Cardiocerebral Resuscitation:

A New Approach to Cardiac Arrest


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Out-of-Hospital Cardiac Arrest:Out-of-Hospital Cardiac Arrest:

A Common DiseaseA Common Disease

~1000 OHCA victims today in the US~1000 OHCA victims today in the US

Likely someone in Massachusetts will sufferLikely someone in Massachusetts will suffer

OHCA during this talkOHCA during this talk


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Many Reasons for Low OHCAMany Reasons for Low OHCA

SurvivalSurvival::

Poor public knowledge of cardiac arrestPoor public knowledge of cardiac arrest

Delayed time to first defibrillationDelayed time to first defibrillation

Low rates of bystander CPRLow rates of bystander CPR

Inconsistent quality of professional CPRInconsistent quality of professional CPR

Inconsistent post cardiac arrest careInconsistent post cardiac arrest care

WE haventWE havent adequatelyadequately implemented whatimplemented what

we already knowwe already know


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Three-Phase Model of

Resuscitation

Three-Phase Model of

Resuscitation

0 2 4 6 8 10 12 14 16 18 20

Arrest Time (min)

Circulatory

PhaseElectrical

PhaseMetabolic

Phase

0

100%

MyocardialATP

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


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Phases of Cardiac Arrest

ElectricalElectrical

HemodynamicHemodynamicTraditionally we have treated theseTraditionally we have treated these

two different phases the sametwo different phases the same


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Circulatory Phase

Should CPR ever be doneShould CPR ever be doneBEFORE Defib?BEFORE Defib?

YESYES


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

0%

10%

20%

30%

40%

50%

60%

ROSC D/C Hosp 1yr Surv

CPR first

Standard

P=.82

P=.61 P=.44

Defibrillation vs. CPR first

(


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

0%

10%

20%

30%

40%

50%

60%

ROSC D/C Hosp 1yr Surv

CPR first

StandardP=.006 P=.01

P=.04

Defibrillation vs. CPR First

(>5 minute response time)


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0

5

10

15

20

25

30

35

40

Survival

0

5

10

15

20

25

30

35

40

Survival

Defib CPR Defib CPR

Response time < 4 min Response time > 4 min

p = 0.87 p


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Current CPR quality: summary

1. Frequent pauses

2. Shallow compressions

3. Hyperventilation


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Causes of Chest Compression

Interruptions

For EMS Providers

Assessing patient (i.e., repeatedly)Assessing patient (i.e., repeatedly)

Preparing and/or Over VentilationPreparing and/or Over Ventilation IV placementIV placement

IntubationIntubation

Changing RescuersChanging Rescuers

Defibrillation, particularly use of AEDsDefibrillation, particularly use of AEDs


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Interruptions in CPR from Paramedic

Intubation

Annals of Emergency Medicine Nov 2009

Nov 1 through June 20, 2007, a prospectiveobservational study involving a part of the

Resuscitation Outcomes Consortium studies 182consecutive adult cardiopulmonary arrestpatients in Pittsburg

Median duration of interruption almost 2 minutes

1/4 of all pauses


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Interruptions to Chest CompressionsInterruptions to Chest Compressions

During OHCADuring OHCA

N = 60N = 60

Proportion of time at scene:Proportion of time at scene:

43% of time with Chest Compressions

57% of time without Chest Compressions


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Average ventilation rate = 37 + 3 per minute(range 15-49)

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

13 out-of-hospital cardiac arrest patients

Ventilation rate measured during CPR


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Hyperventilation during CPRHyperventilation during CPR

8 6

1 3

0 %

2 0 %

4 0 %

6 0 %

8 0 %

1 0 0 %

% s u r v i

1 2 3 0

# v e n t ila t io n s p e r

p = 0 .0

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


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Disadvantages of Ventilation DuringDisadvantages of Ventilation During

CPR:CPR:

Delays/interrupts chest compressionsDelays/interrupts chest compressions

ComplicatedComplicated

Stops bystanders doing CPR?Stops bystanders doing CPR?

Gastric inflation aspirationGastric inflation aspiration

Increased intrathoracic pressureIncreased intrathoracic pressure Reduces coronary/cerebral perfusionReduces coronary/cerebral perfusion

Animal models show worse outcomeAnimal models show worse outcome


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Standard CPR (with breaths) vs. CC alone

Berg et al, 2001

Blood

pre

ssure

Time

= chest compression


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Standard CPR (with breaths) vs. CC alone

Berg et al, 2001

Blood

pre

ssure

Time

= chest compression


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CCR GoalCCR Goal

Optimal timing of defibrillationOptimal timing of defibrillation

Reducing all Hands-Off IntervalsReducing all Hands-Off Intervals

Avoidance of hyper-ventilationAvoidance of hyper-ventilation

Administer earlier epinephrineAdminister earlier epinephrine

Increase coronary perfusion pressureIncrease coronary perfusion pressure

Increase % of bystander CPRIncrease % of bystander CPR


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Discussion:Discussion:

Possible Beneficial Effects of CCRPossible Beneficial Effects of CCR

MinimizeMinimize interruptions of marginal forwardinterruptions of marginal forwardblood flow during resuscitation effortsblood flow during resuscitation efforts

MinimizeMinimize hyperventilation during resuscitationhyperventilation during resuscitation

DelayDelayin advanced airway interventionsin advanced airway interventions maymayenable providers to focus on compressionsenable providers to focus on compressionsand earlier epinephrine administrationand earlier epinephrine administration


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CCR vs. ACLSCCR vs. ACLS

FUNDAMENTAL DIFFERENCESFUNDAMENTAL DIFFERENCES

For Adult Non-Traumatic Cardiac ArrestFor Adult Non-Traumatic Cardiac Arrest

Order in which interventions are performedOrder in which interventions are performed

Specified Continuous Cardiac CompressionsSpecified Continuous Cardiac CompressionsFaster more forceful compressionsFaster more forceful compressions

Compressions Before and After DefibrillationCompressions Before and After Defibrillation

Early IV EpinephrineEarly IV Epinephrine

Delay intubation for first 3 roundsDelay intubation for first 3 rounds

Airway: Face Mask 02Airway: Face Mask 02

No Atropine for first 3 roundsNo Atropine for first 3 rounds


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9.29.2

28.128.1

3.63.6

10.910.9

ResultsResultsSurvival from Out of Hospital Cardiac ArrestSurvival from Out of Hospital Cardiac Arrest

Surviva

lto

Hospital

Disch

arge(%)

Survivalto

Ho

spital

Disch

arge(%

)30

25

20

15

10

5

0

30

25

20

15

10

5

0

All cardiac arrestsAll cardiac arrests Witnessed with VFWitnessed with VF

(55/598)(55/598)

(61/1686)(61/1686)

(36/128)(36/128)

(38/348)(38/348)

CCRCCR

ALSALS

ResultsResults


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ResultsResultsSurvival to Hospital DischargeSurvival to Hospital Discharge

from OHCAfrom OHCA

%

Surviv

alt o

Hospita

lD

ischa

rge

50%

40%

30%

20%

10%

0%

All Cardiac Arrests Witnessed with VF

11.7%

POI

BVM

24/206

8.0%

30/376

45.7%

21/46

18.2%

14/77

P=.144P=.001

Vadeboncoeur et al. Circulation. 2007;116:II_923

Wit d VF S i lWit d VF S i l


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Witnessed VF SurvivalWitnessed VF Survival

Passive Oxygen Insufflation vs.Passive Oxygen Insufflation vs.

BVM VentilationBVM Ventilation

(17/35)

48%

(12/60)

20%

50%

40%

30%

20%

10%

0%

Surv

ival

BVM

Ventilation

Passive

Oxygen Insufflation


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Comparison of Major OutcomesComparison of Major Outcomes

Odds RatiosOdds Ratios

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

OutcomesOutcomes POI vs. BVMPOI vs. BVM

PrimaryPrimary

Survival to hospital discharge, %Survival to hospital discharge, % 8.0 vs. 11.78.0 vs. 11.7

Odds ratio (95% CI)Odds ratio (95% CI) 1.7 (0.9-3.1)1.7 (0.9-3.1)

Survival with witnessed VF, %Survival with witnessed VF, % 18.2 vs. 45.718.2 vs. 45.7

Odds ratio (95% CI)Odds ratio (95% CI) 5.7 (2.3-5.7 (2.3-14.2)14.2)

OutcomesOutcomes POI vs. BVMPOI vs. BVM

PrimaryPrimary

Survival to hospital discharge, %Survival to hospital discharge, % 8.0 vs. 11.78.0 vs. 11.7

Odds ratio (95% CI)Odds ratio (95% CI) 1.7 (0.9-3.1)1.7 (0.9-3.1)

Survival with witnessed VF, %Survival with witnessed VF, % 18.2 vs. 45.718.2 vs. 45.7

Odds ratio (95% CI)Odds ratio (95% CI) 5.7 (2.3-5.7 (2.3-14.2)14.2)

Cardiocerebral Resuscitation (CCR)


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Cardiocerebral Resuscitation (CCR)

in rural Wisconsin for witnessed VF

Neurologi c

allynorm

alsu

rvival 50%

40%

30%

20%

10%

0%

CPR CCR

15%

48%

Kellum, Kennedy, Ewy Amer J Med2006;119:335

p = 0.001


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Circulation June 2009Improved 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-of-

hospital 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 cardiacarrest 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.


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Key Questions Remain:Key Questions Remain:

Perhaps witnessed VF but what about unwitnessed VF, asystole andPerhaps witnessed VF but what about unwitnessed VF, asystole andPEA?PEA?

When is active ventilation necessary?When is active ventilation necessary?

What part of the CCR protocol is most critical?What part of the CCR protocol is most critical?

What is the optimal training method and retraining frequency?What is the optimal training method and retraining frequency?

Will CCC-CPR truly improve bystander CPR rates?Will CCC-CPR truly improve bystander CPR rates?


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RecommendationsRecommendations

Unconscious adult patients with return ofUnconscious adult patients with return ofspontaneous circulation (ROSC) after out-ofspontaneous circulation (ROSC) after out-ofhospital cardiac arrest should be cooled tohospital cardiac arrest should be cooled to32C to 34C (89.6F to 93.2F) for 12 to 2432C to 34C (89.6F to 93.2F) for 12 to 24

hours when the initial rhythm washours when the initial rhythm wasventricular fibrillation.ventricular fibrillation. Class IIaClass IIa

Similar therapy may be beneficial forSimilar therapy may be beneficial forpatients with non-VF arrest out of hospital orpatients with non-VF arrest out of hospital or

for in-hospital arrest.for in-hospital arrest. Class IIbClass IIb

American Heart Association 2005 Guidelines

A i P C di A C SA i P t C di A t C S


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Aggressive Post Cardiac Arrest Care SavesAggressive Post Cardiac Arrest Care Saves

LivesLives

Surv

i val

60%

50%

40%

30%

20%

10%Before After

34%

59%

p < 0.05

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