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Cardiac resuscitation - fresh views and changes!

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  • 1. From CPR to CCR- why the change ? Dr. Imran Ahmed DM. (Cardiology) Kolkata, India
  • 2. Major Determinants of Survival From Cardiac Arrest Early / Effective CPR Early Defibrillation
  • 3. Three-Phase Model of Resuscitation 0 2 4 6 8 10 12 14 16 18 20 Arrest Time (min) Circulatory Phase Electrical Phase Metabolic Phase 0 100% Myocardial ATP Weisfeldt ML, Becker LB. JAMA 2002: 288:3035-8
  • 4. Outcomes of Rapid Defibrillation by Security Officers after Cardiac Arrest in Casinos Survival rate 74 % in patients who received first shock within 3 minutes Survival rate 49 % in patients who received first shock after 3 minutes Intervals of no more than 3 minutes from collapse to defibrillation are necessary to achieve the highest survival rates Valenzuela et al NEJM 2000; 343: 1206
  • 5. How Compressions move blood
  • 6. 5 sec 80 160 mmHg Time (sec) 40 120 0 Standard CPR: 30:2 Interruption of chest compression/relaxation directly effects the level of CPP
  • 7. From CPR to CCR- why the change ? Simultaneous aortic (red) and right atrial (blue) pressure tracings are shown. With the initiation of chest compressions, it takes some time for the coronary perfusion pressures (aortic diastolic minus the right atrial diastolic pressure) to increase. The chest compression rate is 100/min. Standard CPR: 30:2 Ewy GA, Circulation 2005;111:2131-2142
  • 8. Pausing Chest Compressions (CC) to Shock Impacts survival (Yu - Circulation 106:368; 2002) Increasing the pause Reduces success rate Of resuscitation –Edelson(2005) 87% - 9.7 sec – 20% - 22.5 sec •More deaths •Longer time to Return of Spontaneous Circulation (ROSC)
  • 9. Drawbacks of mouth to mouth ventilations • Bystanders not willing to perform mouth to mouth • Long interruptions of chest compression • Intrathoracic pressure is increased • Can lead to gastric regurgitations • Not necessary in those who are gasping initially – CC suffices Virkunnen I. J Int Med. 2010, 260:39-42
  • 10. Summary of pathophysiology of Resuscitation  Chest compressions are the single most important intervention !!!! Optimal QUALITY is essential Interruptions are deadly → continuous  Ventilation can be deadly Don’t do when not needed Do it without error when needed  Interventions MUST be prioritized. Learn What to do it When to do it How to do it as well as possible Defibb is better than chest compressions only in the <4 mins
  • 11. Survival in Tucson AZ with Cardiocerebral Resuscitation(2.8x) HospitalDischargeSurvival 40% 30% 20% 10% 0% CPR CCR 9% 28/314 25% 34/136 Terry Valenzuela MD AHA Resuscitation Science Symposium 2006 11/03-8/06 1997-1999
  • 12. Survival in Kansas City Pre-Hospital Return of Spontaneous Circulation (ROSC) Pre-HospitalROSC 100% 80% 60% 40% 20% 0% CPR CCR 15% 52% Bobrow and SHARE study group
  • 13. Survival in WISCONSIN with Normal Brains Three Year Results (2.7x) Cardiocerebral Resuscitation Witnessed collapse with shockable rhythm Neurologicallyintactsurvival 50% 40% 30% 20% 10% 0% CPR CCR 15% 40% p = 0.001 14/92 36/89
  • 14. Why Learn Cardiocerebral Resuscitation (CCR)?  Because IT WORKS!!  It saves lives = SURVIVAL  Until now standard BLS + ALS has failed  Survival has been dismal  And essentially unchanged  Despite 40 years of “improvements” & updates  CCR on the other hand  Dramatically increases survival  Including neurologically normal survival
  • 15. Why is Cardiocerebral Resuscitation (CCR) better than Cardiopulmonary Resuscitation (CPR)?  “CPR” evolved as a single treatment for two totally different disease processes: Respiratory and Cardiac arrests  They differ dramatically in how much oxygen exists in their blood at the onset of arrest Drowning or choking victims use up all available oxygen before arresting. They DO need early ventilation  Cardiac arrest victims have normal oxygenation Initially they do NOT need additional oxygen Instead they need existing O2 pumped to the two organs that determine survival – the heart and brain
  • 16. CCR is REALLY SIMPLE stuff ! Continuous Chest Compressions Quality Chest Compressions Uninterrupted Chest Compressions  Quality is crucial – MUST be monitored by the other pumper  Rate (use metronome) of 100 / min  Depth adequate  Recoil absolutely crucial You can ONLY stop Chest Compressions (CC) for Switching pumpers (every minute) 2-3 seconds  Analysis - Is shock indicated (every 200 CC)? 2-3 seconds Shocking 5-7 sec
  • 17. 2005 AHA Guidelines “For adult OHCA that is not witnessed, rescuers may give a period of CPR before checking the rhythm and attempting defibrillation” (Class IIb)
  • 18. CCR vs. ACLS FUNDAMENTAL DIFFERENCES For Adult Non-Traumatic Cardiac Arrest Order in which interventions are performed Specified Continuous Cardiac Compressions Faster more forceful compressions Compressions Before and After Defibrillation Early IV Epinephrine Delay intubation for first 3 rounds Airway: Face Mask 02 No Atropine for first 3 rounds
  • 19. EPINEPHRINE Attempt to administer early IV epinephrine Intraosseous administration fastest Tobias JD, Ross AK (2010). "Intraosseous infusion". ANALGESIA 110 (2): 391–401
  • 20. Fundamentals Think 3 cycles: each = 200 CC + analysis ± shock Compressions started immediately upon arrival All victims are initially presumed shockable Therefore all get the same Rx during first 2 minutes (McMAID) All get 200 Chest Compressions (CC) before analysis First rhythm (after 200 CC) is either shockable or not Resume Chest Compressions (CC) Immediately after analysis ± shock – DO NOT pay attention to
  • 21. Cardiocerebral Resuscitation (CCR) 200 chest compressions 200 chest compressions Single shock without pulse Check or rhythm analysis BVM or Passive Insufflation 15L 02 Begin IV Analysis 200 chest compressions Single shock if Indicated without pulse check or rhythm analysis Analysis Single shock if Indicated without pulse check or rhythm analysis Resume Standard ACLS Consider Endotracheal Intubation 200 chest compressions CCC Only• EMS arrival Administer 1 mg IV Epinephrine Analysis • If adequate bystander chest compressions are provided, EMS providers perform immediate rhythm analysis
  • 22. Protocol Oral Pharyngeal (OP) airway Non-rebreather face mask @15 L/min 200 compressions IV access Epinephrine 1mg IVP One shock, 3-5 seconds, no pulse checks.
  • 23. Begin second round of 200 compressions Amiodarone 300mg IVP (anti- arrhythmic) Shock x1 at max joules No pulse checks, not off chest more than 5 seconds. Protocol
  • 24. Begin third round of 200 compressions Epinephrine 1mg IVP Shock x1 Rapid Sequence Intubation (RSI). Ventilate at 6 breaths/minute (BPM) Insert ET tube during the fourth round of 200 chest compressions after the 3rd round shock Protocol
  • 25. First 2 minutes Monitor Airway IV Drugs Mc MAID Metronome Chest Compressions
  • 26. First 2 minutes M c MAID - Metronome / Chest Compressions  Get the Metronome – know how to start it  Chest Compression (CC) Rate is critical  CC rates < 90 → inadequate output  CC rates > 120 → inadequate output  Without a metronome pumpers compression rates of 130-150 are common
  • 27. First 2 minutes Mc M AID - Monitor  Delegate someone to do these (usually the code commander)  Turn the Monitor ON first (clock useful)  Place the pads without interrupting compressions.  Change to DEFIB mode (not monitor)  Shock energy will be preset to maximum Joules (360 J)  Place pads without interrupting compressions
  • 28. First 2 minutes McM A ID - Airway (initial)  Delegate someone to do this  Insert Oral Pharyngeal Airway  O2 via Non-rebreather mask  Ensure airway patency
  • 29. First 2 minutes McMA I D - IV - vascular access Use Interosseous (IO) whenever a delay is anticipated
  • 30. First 2 minutes - McMAI D - Drugs  Delegate one person for this task  Responsible for  Giving drug  Recording when given  Anticipating when next dose is due  Be ready to give ASAP after analysis ± shock  Vasopressors: EPI first – then vasopressin  Exception may be patient expected to respond with ROSC after first shock – use vasopressin 1st instead  Be sure repeat EPI doses given every 2 cycles (~ 4 min)  Amiodarone if first rhythm is shockable  Must remember to give for recurrent or persisting VF
  • 31. First 2 minutes Metronome Monitor Airway IV Drugs McMAID Practice this until one can, as a team, routinely do it in 2 minutes With 2 and more persons on scene CC
  • 32. Even seconds without Chest Compressions are deadly
  • 33. First 2 minutes How to analyze ± Shock Practice this – – – ONLY the Code Commander looks at the rhythm. Be sure to switch Pumpers after shock Epi
  • 34. Invasive Airway + Ventilations  1 rescuer MUST be available to devote full-time attention to this task  Endotracheal (ET) insertion will always reduce the quality of Chest Compressions (CC)  Paramedics are directed to use a Combitube if they do not get ET on the FIRST try  Anticipate this and have a Combitube ready!  Consider using Combitube in ALL initially shockable patients  A 2nd person must ensure proper ventilation  Time each individual ventilation (1 second)  8-10 seconds between vents (6-8 ventilations / minute)  Volume ~ 500 CC (about 1/2 of an Adult Bag Valve Mask)  ** Volume given over 1 second **  Attach EtCO2
  • 35. When to Stop Chest Compressions (CC)?  If the patient shows signs of brain function AND the rhythm is non-shockable  Clues to ROSC (Return of Spontaneous Circulation)  Waking up  Visualized carotid pulses  Agonal gasps → regular respirations  End tidal CO2 jumps to normal or supra-normal  Pulse check ONLY during pause for analysis  Correlate with rhythm  DO NOT stop Chest Compressions for a good looking rhythm without other clues that ROSC has occurred.
  • 36. 9.2 28.1 3.6 10.9 Results Survival from Out of Hospital Cardiac ArrestSurvivaltoHospitalDischarge(%) 30 25 20 15 10 5 0 All cardiac arrests Witnessed with VF (55/598) (61/1686) (36/128) (38/348) CCR ALS
  • 37. Witnessed VF Survival Passive Oxygen Insufflation vs. BVM Ventilation (17/35) 48% (12/60) 20% 50% 40% 30% 20% 10% 0% Survival BVM Ventilation Passive Oxygen Insufflation
  • 38. Possible Reasons for Beneficial Effects of CCR Minimize interruptions of marginal forward blood flow during resuscitation efforts Minimize hyperventilation during resuscitation Delay of advanced airway interventions may enable providers to focus on compressions and earlier epinephrine administration
  • 39. Our Goal Should be what is seen in animals (60-70+ survival) 24-HourGoodNeuroSurvival 100 80 60 40 20 0 80% 13% Standard CPR CCC CPR Kern, Hilwig, Berg, Sanders, Ewy. Circulation 2002
  • 40. Adult Basic Life Support • Minimize the frequency and duration of interruptions in compressions (Class IIa). • Once chest compressions have been started, a trained rescuer should deliver rescue breaths by mouth-to-mouth or bag- mask to provide oxygenation and ventilation.
  • 41. Adult Basic Life Support • Rescuer fatigue may lead to inadequate compression rates or depth. • When 2 or more rescuers are available it is reasonable to switch chest compressors approximately every 2 minutes (or after about 5 cycles of compressions and ventilations at a ratio of 30:2) to prevent decreases in the quality of compressions (Class IIa). • Every effort should be made to accomplish this switch in 5 seconds.
  • 42. Adult Basic Life Support • As long as the patient does not have an advanced airway in place, the rescuers should deliver cycles of 30 compressions and 2 breaths during CPR. • The rescuer delivers ventilations during pauses in compressions and delivers each breath over 1 second (Class IIa). • The healthcare provider should use supplementary oxygen (O2 concentration 40%, at a minimum flow rate of 10 to 12 L/min) when available.
  • 43. Adult Basic Life Support • Excessive ventilation is unnecessary and can cause gastric inflation and its resultant complications, such as regurgitation and aspiration (Class III). • Rescuers should avoid excessive ventilation (too many breaths or too large a volume) during CPR (Class III).
  • 44. Adult Basic Life Support Cricoid Pressure • Cricoid pressure might be used in a few special circumstances (eg, to aid in viewing the vocal cords during tracheal intubation). • Routine use of cricoid pressure in adult cardiac arrest is not recommended (Class III).
  • 45. Example of cardiopulmonary resuscitation prearrival instructions for an adult who has suddenly collapsed. Lerner E B et al. Circulation 2012;125:648-655 Copyright © American Heart Association
  • 46. Therapeutic Hypothermia
  • 47. No More Mouth to Mouth Breathing!
  • 48. Conclusions • CCR provides uninterrupted perfusion to heart and brain essential for neurologically intact survival • CCR has led to dramatic improvements in survival vs CPR • More aggressive post resuscitation care with hypothermia / emergent cath-PCI is required to save even more victims of cardiac arrest