cpr 2013 handout

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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

Chain of Survival

Basic Life Support

Advanced Cardiac Life Support

Summary of Key BLS Components "

>8 1-8

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Quality of CPRPush fast & hard

AHA: Depth>5cm & rate>100/minERC: Depth upto 6 cm & rate upto120/min

Decrease hand-off time

Near -infrared spectroscopy "

Monitoring of regional cerebral oxygenation during CPRusing portable near -infrared spectroscopy "

Airway

Lower Esophageal SphincterTone During Cardiac Arrest

20 mmHg 5mmHg

1/3 of OHCA have aspiration

Regurgitation of gastric content

Tracheal intubation

No study has shown a survival benet fortracheal intubation after cardiac arrest "

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

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Mechanical chest compressions devices "

AutoPulse Lucas

ACLSCardiac ArrestAlgorithm

Drugs in CPR

Epinephrine Alpha and beta adrenergic effect

myocardial & cerebral blood flow duringCPR

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 D 5W 100ml IV

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

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Vasopressin vs Epinephrine

Vasopressin for cardiac arrest: asystematic review and meta-analysis. ArchIntern Med. 2005;165:1724.

Aung K, Htay T. no statistically significant differences

between vasopressin & epinephrine for ROSC, 24-hour survival, or survival tohospital discharge.

CPR 2008 CPR 2008

Epinephrine 1mg +Vasopressin40iu vs Epinephrine 1 mg

the combination of vasopressin & epinephrine during ACLS for out-of-hospital cardiac arrest does not improve outcome

New Eng J Med 2008

Vasopressin, Epinephrine, and Corticosteroids for In-HospitalCardiac Arrest "

Combined vasopressin- epinephrine and methyl-prednisolone duringresuscitation and stress-dose hydrocortisone in post-resuscitation shockimproved survival in refractory in-hospital cardiac arrest "

Arch Intern Med. 2009;169(1):15-24 "

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 150mgiv

non-arrest : 150 mg in 10 min. Maintainance : then 1 mg/min x 6h and

0.5 mg/min later

Extracorporeal Life Support "

Observational studies showedhigher rate of survival discharge & 1year survival

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

Percent of patients alive at various time points

Time pointCPR + extracorporeal

life support (%) CPR alone (%)24 h 65.2 41.3

3 d 52.2 34.8

14 d 37.0 23.9

30 d 34.8 17.4

6 mo 32.6 15.2

1 y 19.6 13.0

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

CPR with assisted extracorporeal life-support versusconventional CPR in adults with in hospital cardiac arrest:

an observational study and propensity analysis.

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Care After CardiacArrest

The greatest drop-off in survivaloccur in hospital "

J AC C : C AR D I O V A S C U L AR 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 = Neurologicalinjury

In-hospital cardiac arrest = Cardiovascular +

multiple organ failure

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 precipitatingpathology

Pathophysiology Clinical Manifestation Potential Treatments

Cardiovascular disease(AMI/ACS,cardiomyopathy) Pulmonary disease(COPD, asthma) CNS disease (CVA) Thromboembolic disease(PE) Toxicological (overdose,poisoning) Infection (sepsis,pneumonia) Hypovolemia(hemorrhage,dehydration)

Specific to causebut complicatedby concomitant PCAS

Disease-specificinterventionsguided by patientconditionand concomitant PCAS

Post-Resuscitation Care

That Improve Outcome " Mild Therapeutic hypothermia after

cardiac arrest

Coronary angiography & PCI aftercardiac arrest

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Improvement in 1 year survival after implement of standardpost-resuscitation care emphasis on therapeutic hypothermiaand early coronary angiography for possible PCI "

J AC C : C AR D I O V A S C U L AR 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 "

Rate of Coronary Occlusion isfrequent in OHCA "

Studies " Rate of Coro occlusion "

Spaulding C et al " 67% "

Davies MJ et al. " 73.3 "

Farb A et al. " 57 "

Lo YS et al. " 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 "

January 2003-December 2008: 714OHCA with ROSC

No obvious extra-cardiac cause435

Obvious extra-cardiac cause279

ST segment elevation

134 (31%)

No ST segment elevation

301 (69%)

Successful PCI99 (74%)

No or failed PCI35 (26%)

Successful PCI78 (26%)

No or failed PCI223 (74%)

Dumas F et al , Circ Inter 2010: 3;

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

" " " "be treated by PCI !

When should a coronary angiogram be performed? !

Circulation. 2008 ;118:2452-83

ILCOR Consensus Statement

In summary, patients resuscitated from cardiacarrest who have electrocardiographic criteria for ST-elevation myocardial infarction should undergoimmediate coronary angiography, with subsequentPCI if indicated. Furthermore, given the highincidence of ACS in patients with out-of-hospitalcardiac arrest and limitations of electrocardiography-

based diagnosis , it is appropriate to consider immediate coronary angiography in all post cardiacarrest patients in whom ACS is suspected .

Circulation. 2008 ;118:2452-83

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Does PCI improve the prognosis of "

"survivors of OHCA? !

PROCAT

Dumas F et al , Circ Interv 2010; 3:

PROCAT Predictor of survival "

Dumas F et al , Circ Interv 2010; 3:

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 Reportsof CoronaryAngiography AfterResuscitation "From CardiacArrest "

J AC C : C AR D I O V A S C U L AR I N T ER V E N T I O N S , V O L . 5 , N O . 6 , 2 0 12 J U N E 2 0 1 2 : 5 9 7 6 0 5 "

Post Cardiac Arrest Coma

cath ? " In OHCA patients with STEMI or new LBBB onECG after ROSC, early angiography and PPCIshould be considered. Out-ofhospital cardiac arrestpatients are often initially comatose but this should not be a contraindication to consider immediate angiography and PCI . It may bereasonable to include cardiac catheterization in astandardized post-cardiac-arrest protocol as part ofan overall strategy to improve neurologically intactsurvival in this patient group "

2010 American Heart Association Guidelinesfor Cardiopulmonary Resuscitation and

Emergency Cardiovascular Care Science !

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No differences in survival-to-discharge or favorableneurological function among survivors were seenbetween those with or without ST-segment elevationon 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) "

Signicant Coronary stenosis = 27 "

1vessel "5"

2vessel "8"

3vessel "5"

LMCA+2VV"

2"

LMCA"+3VV"

7"(1postCABG) "

Revascularization = 26 "

"3 PCI "

"8 PCI "

3 PCI "2 CABG "

"2 PCI "

"6"

4PCI "2CABG "

"

Thammasat Data 2007-2012 "

45 OHCA /IHCA & angiography "

1827

(2) Post cardiac arrest braininjury


Impaired

cerebrovascular

autoregulation

Cerebral edema

(limited)

Postischemic

neurodegeneration

Coma

Seizures

Myoclonus

Cognitive dysfunction

Persistent vegetative

state

Secondary Parkinsonism

Cortical stroke

Spinal stroke

Brain death

Therapeutic hypothermia

Early hemodynamic

optimization

Airway protection and

mechanical ventilation

Seizure control

Controlled reoxygenation

(SaO2 94% to 96%)

Supportive care

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Therapeutic HyPothermia

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

Out-of-hospital VFcool to 32-34 C

for 12-24 hrstart minutes-hors

after ROSC

Maximize Recovery of Brain Function

Hypothermia Optimize cerebral perfusion

Control seizure Control metabolic-blood glucose

(3) Postcardiac arrestmyocardial dysfunction


Global hypokinesis

(myocardial stunning)

ACS

Reduced cardiac

output

Hypotension

Dysrhythmias

Cardiovascular

collapse

Early revascularization

of AMI

Early hemodynamic

optimization

Intravenous fluid

Inotropes

IABP

LVAD

ECMO

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(4) Systemic ischemia/reperfusionresponsePathophysiology Clinical Manifestation Potential Treatments

Systemic inflammatory

response syndrome

Impaired vasoregulation

Increased coagulation

Adrenal suppression

Impaired tissue oxygen

delivery and utilization

Impaired resistance to

infection

Ongoing tissue

hypoxia/ischemia

Hypotension

Cardiovascular

collapse

Pyrexia (fever)

Hyperglycemia

Multiorgan failure

Infection

Early hemodynamic

optimization

Intravenous fluid

Vasopressors

High-volume

hemofiltration

Temperature control

Glucose control

Antibiotics for

documented

infection

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 tonormothermia

Prevention of Cardiac Arrest "

IHCA: 80% Vital

sign

"

Rapid responsesystem "

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). "

OHCA: warningsign "

Typical angina was presentfor a median duration of 2 hin 25% of 274 patients withwitnessed OHCA "

In-Hospital " Out-Hospital "

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