, 2 007

23
July
Out-of-Hospital Cardiac Arrest

• “Brian Duffield, then 40, a salesman in

Tucson, collapsed in the shower after a
swim. Luckily for him, he was on the
campus of the University of
Arizona . . . . . . .”

Newsweek
July 23, 2007
Out-of-Hospital Cardiac Arrest

• “Brian Duffield, then 40, a salesman in

Tucson, collapsed in the shower after a
swim. Luckily for him, he was on the
campus of the University of
Arizona . . . . . . .”

Newsweek
July 23, 2007
A female off-duty paramedic just finished swimming at
the gym instructed someone to call 911 and to get an
AED. She then performed
Continuous Chest Compressions

AED
Shocked twice
 University Medical Center
Post Resuscitation Care

Coma: Mild Hypothermia begun

ED

32-34o C for 24 hours

Out-of-Hospital Cardiac Arrest

• 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
Newsweek
July 23, 2007
New Ways to Survive Cardiac Arrest

I am going to let you in on a secret: When a person's heart

stops beating, it's not the end. Contrary to what you may
think, death is not a single event. Instead, it's a process that
can be interrupted.

Dr. Sanjay Gupta

 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
  
Cardiocerebral Resuscitation:
A New Approach to Cardiac Arrest
Bentley J. Bobrow, MD
Medical Director
Bureau of EMS & Trauma System
Arizona Department of Health Services

Scottsdale Fire Department

Assistant Professor
Department of Emergency Medicine
Mayo Clinic College of Medicine
 Out-of-Hospital Cardiac Arrest:
A Common Disease

• ~1000 OHCA victims today in the US

• Likely someone in Massachusetts will suffer

OHCA during this talk
Many Reasons for Low OHCA
Survival:
•Poor public knowledge of cardiac arrest
•Delayed time to first defibrillation
•Low rates of bystander CPR
•Inconsistent quality of professional CPR
•Inconsistent post cardiac arrest care
WE haven’t adequately implemented what
we already know
 Three-Phase Model of
100% Resuscitation
Myocardial ATP

Electrical Circulatory Metabolic

Phase Phase Phase

0 2 4 6 8 10 12 14 16 18 20
Arrest Time (min)

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

 Phases of Cardiac Arrest

Electrical
Hemodynamic
“Traditionally we have treated these
two different phases the same”
 Circulatory Phase

• Should CPR ever be done

BEFORE Defib?

• YES
Defibrillation vs. CPR first
(<5 minute response time)
60%
P=.82
50%

40%

30% CPR first

20% P=.61 P=.44Standard

10%

0%
ROSC D/C Hosp 1yr Surv

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

Defibrillation vs. CPR First
(>5 minute response time)

60%
P=.04
50%

40%

30% CPR first

Standard
20% P=.006 P=.01
10%

0%
ROSC D/C Hosp 1yr Surv

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

Response time < 4 min Response time > 4 min

40 40
35 35
p = 0.87 p <0.007
30 30
25 25
20 Survival 20 Survival
15 15
10 10
5 5
0 0

Defib CPR Defib CPR

Current CPR quality: summary

1. Frequent pauses
2. Shallow compressions
3. Hyperventilation
 Causes of Chest Compression
Interruptions
For EMS Providers
• Assessing patient (i.e., repeatedly)
• Preparing and/or Over Ventilation
• IV placement
• Intubation
• Changing Rescuers
• Defibrillation, particularly use of AEDs
 Interruptions in CPR from Paramedic
Intubation
• Annals of Emergency Medicine Nov 2009
• Nov 1 through June 20, 2007, a prospective
observational study involving a part of the
Resuscitation Outcomes Consortium studies 182
consecutive adult cardiopulmonary arrest
patients in Pittsburg
• Median duration of interruption almost 2 minutes
• 1/4 of all pauses
Interruptions to Chest Compressions
During OHCA

N = 60

• Proportion of time at scene:

– 43% of time with Chest Compressions

– 57% of time without Chest Compressions
13 out-of-hospital cardiac arrest patients
Ventilation rate measured during CPR

Average ventilation rate = 37 + 3 per minute

(range 15-49)

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

Hyperventilation during CPR
86%
100% p = 0 .0 0 6

80%

% s u rv iv a6l 0 %

40% 13%

20%

0%
12 30

# v e n tila tio n s p e r m in u te

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

Disadvantages of Ventilation During
CPR:

• Delays/interrupts chest compressions

• Complicated
• Stops bystanders doing CPR?
• Gastric inflation – aspiration
• Increased intrathoracic pressure
• Reduces coronary/cerebral perfusion
• Animal models show worse outcome
Standard CPR (with breaths) vs. CC alone
Blood pressure

Time
= chest compression
Berg et al, 2001
Standard CPR (with breaths) vs. CC alone
Blood pressure

Time
= chest compression
Berg et al, 2001
 CCR Goal

• Optimal timing of defibrillation

• Reducing all “Hands-Off” Intervals
• Avoidance of hyper-ventilation
• Administer earlier epinephrine
• Increase coronary perfusion pressure
• Increase % of bystander CPR
 Discussion:
Possible Beneficial Effects of CCR

• Minimize interruptions of marginal forward

blood flow during resuscitation efforts

• Minimize hyperventilation during resuscitation

• Delay in advanced airway interventions may

enable providers to focus on compressions
and earlier epinephrine administration
 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
 Results
Survival from Out of Hospital Cardiac Arrest

CCR (36/128)
30
Survival to Hospital Discharge (%)

ALS
25

20

15 28.1
(38/348)
(55/598)
10

5 (61/1686) 10.9
9.2
3.6
0
All cardiac arrests Witnessed with VF
 Results
Survival to Hospital Discharge
from OHCA
% Survival to Hospital Discharge

50% POI 21/46

BVM
40%

P=.001
30% P=.144
45.7%

20%
14/77
24/206

10% 30/376
18.2%
11.7%
8.0%
0%
All Cardiac Arrests Witnessed with VF
Vadeboncoeur et al. Circulation. 2007;116:II_923
 Witnessed VF Survival
Passive Oxygen Insufflation vs.
BVM Ventilation
50%

40%
Survival

30%
(17/35)
48%
20%
(12/60)
10% 20%

0%
BVM Passive
Ventilation Oxygen Insufflation
 Comparison of Major Outcomes
Odds Ratios

Outcomes POI vs. BVM

Primary
Survival to hospital discharge, % 8.0 vs. 11.7
Odds ratio (95% CI) 1.7 (0.9-3.1)

Survival with witnessed VF, % 18.2 vs. 45.7

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

The model is adjusted for age, gender, location, bystander CPR, ventricular fibrillation, witnessed, and EMS dispatch to arrival interval
 Cardiocerebral Resuscitation (CCR)
in rural Wisconsin for witnessed VF
50%
Neurologically normal survival

40%
p = 0.001
30%
48%
20%

10%
15%
0%
CPR CCR
Kellum, Kennedy, Ewy Amer J Med
2006;119:335
 Circulation June 2009
Improved 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 cardiac
arrest 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.
 Key Questions Remain:
• Perhaps witnessed VF but what about unwitnessed VF, asystole and
PEA?

• When is active ventilation necessary?

• What part of the CCR protocol is most critical?

• What is the optimal training method and retraining frequency?

• Will CCC-CPR truly improve bystander CPR rates?

 Recommendations
• Unconscious adult patients with return of
spontaneous circulation (ROSC) after out-of
hospital cardiac arrest should be cooled to
32°C to 34°C (89.6°F to 93.2°F) for 12 to 24
hours when the initial rhythm was
ventricular fibrillation. Class IIa
• Similar therapy may be beneficial for
patients with non-VF arrest out of hospital or
for in-hospital arrest. Class IIb

American Heart Association 2005 Guidelines 50

 Aggressive Post Cardiac Arrest Care Saves
Lives
60%

50%
p < 0.05
40%
59%
30%
Survival

20% 34%

10%
Before After
Pytte M, Jensen LP, Smedsrud C, Jacobsen D, Mangschau A,
Sunde K.