Why Emergency Physicians Don’t Care about Cardiac Arrest and Should.

Robert Swor, DOProfessor, Emergency MedicineOakland University William BeaumontSchool of Medicine

Epidemiology of Cardiac Arrest SurvivalRelative impact of interventionsRelative impact of Phases of CareWhere do Emergency Physicians Make a

Difference

Objectives

Emergency Physician Perspectives of Cardiac Arrest ResuscitationIt’s FutileWe just bring back patients to a

vegetative stateThe Only people that arrest are

Gomers at the end of LifeThis One’s comatose-He’s ToastIt’s a poor use of Health Care Dollars

My QuestionAre physician attitudes a self

fulfilling prophecy?i.e Do post arrest patients do poorly

because we’re not aggressive with them in ED and hospital?

Emergency Department Patient ScenariosField Cardiac ArrestPost-Arrest- CPR in ProgressPost Arrest-DefibrillatedChest burns, alertPost arrest-ResuscitatedSTEMIPost Arrest- ComatosePre-Arrest-Crumps in the ED

Cardiac Arrest Outcomes

Out of Hospital Cardiac Arrest

225,000/yr

20-25% survival To Admission

(40-45% of Admitted Survive to Discharge)

Overall 5-10%Survival

In Hospital Cardiac Arrest

75,000/yr

ROSC 44%

17% Survive to Discharge

(38.6% of ROSC Survive to Discharge)

Neurologic Outcome Out of Hospital Arrest

Neurologic Death 25-30%If survive to discharge

Excellent QOL if Early Defib5 Year survival Similar to age and health matched controls

OPALS-Good quality of life for survivors at 1 year*

Bunch TJ, NEJM 2003:348:2626-2633 Steill, Circ 2003:108:1939

Field Cardiac Arrest CPR not Transported to HospitalCPR in Progress on ED Arrival

Futile?

1

What Happens to Field Cardiac Arrest

CARES Registry27,675 OHCA events18,541 (67.0%) with no field ROSC.

12095 (65.2%) were pronounced in the field 5618 (30.3%) had resuscitation terminated in

the ED

828 (4.5%) survived to admission

Variation in Field Pronouncement after Failed Resuscitation-CARES

0

10

20

30

40

50

60

70

80

% F

ield

Pro

noun

cem

ent

3 12 17 19 27 30 34 36 40 55 58 Median

EMS Agency

Field Termination without ROSC-ROC Consortium

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Alab Iowa Ottawa Pitt Port Seattle Toronto Vanc Mean

Site

% T

erm

ina

tio

n

Survivors To Admission828 (14.7% of transported) Survive

to Admission128 survived to discharge (15.4%)81 (9.8%) survived with good cerebral performance.

Termination of Resuscitation in Field-Decision RulesALS

No ROSC No Bystander CPR Not witnessed arrest No shock Delivered

BLS No ROSC No witnessed No AED shock

Clinical Decision Rules for TOR-Evidence Based Review – Sherbino J. Em Med 2009:10:1016

Literature Review4 Decision Rules

3 BLS: 1 ALS6 Validation Studies

BLS Rule –PPV 99.5% (98.9%,99.8%) Decreases transport 62.6%

ALS rule-no good quality validation study

Cardiac Arrest Patients are All Gomers at the End of Life?Need better work on who shouldn’t get CPR

Decreased Survival with AgeEnd of Life Planning and Care

Unwanted or Not Indicated ResuscitationKing County 1994 (Dull)

7% had undocumented DNR25% Severe Chronic Disease

Possible Predictors of Outcomes After Cardiac ArrestClinical presentation

Arrest factorsAgeDiapersNeuro exam

HCTEEGN-100 Enolase

Impact of Therapeutic HypothermiaNielson Acta Anaes Scan 2009; 53:926-934

Scandinavian Registry238 pts with Hypothermia - 7 Countries

Good Neurological Outcome 22% Non VF 56% VF

Neurologic OutcomeOut of Hospital Arrest

Neurologic Death 25-30% If survive to discharge

Excellent QOL if Early Defib 5 Year survival Similar to age and health matched controls

OPALS-Good quality of life for survivors at 1 year*

Bunch TJ, NEJM 2003:348:2626-2633 Steill, Circ 2003:108:1939

Inability to Predict OutcomesObstacle to initiating

Aggressive CareNo reliable data on

predictors of outcome in first 3 days

Consistent with AHA 2010 Guidelines

Predicting Outcomes-Post Hypothermia

ECMO To Support CPR in Adults1992-2007ELSO DatabaseAdults>18 yearsMean Age 52Survival in 27%Brain Death in 29%

Ann Thoracic Surg 2009:87:778-785

Case StudyRefractory Cardiac Arrest53 y/o male, severe 3 vessel dsPost op CABG-refractory VF post op day 465 minutes CPR during attempted

resuscitation-cannulationECMO for 4 daysNeuro intact, ICD placed, waiting for

transplant

Cost Effectiveness of Out of Hospital Cardiac Arrest Care

Cost Effective Public Access Defibrillation

Nichol-$56,000 (IQR $44,000,$77,000) Walker-$68,000 (Scotland)

Police AED $2,000-$15,000/year of life saved

Advanced Life Support Valenzuela-$8,800/year of Life saved (1990)

Money Mechanics of L1CAC Survival

Average Revenue

Per Patient

Direct Cost Per

Patient

Direct Margin

Per Patient

Discharged Alive

$57,783 $37,099 $20,684

Died in Hospital

$12,014 $8,686 $3,329

26Lick et al. Crit Care Med 2011;39(1):26-33.

ConclusionCPR in progress Ominous prognosisResuscitated arrest

VF-Good outcomeNon-VF- Uncertain

Prognostication-Fool’s gameTime’s they’re a changin’

HypothermiaAggressive therapy