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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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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 theLuckily for him, he was on the
campus of the University ofcampus of the University of
Arizona . . . . . . .Arizona . . . . . . .
NewsweekJuly 23, 2007
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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
Out-of-Hospital Cardiac ArrestOut-of-Hospital Cardiac Arrest
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NewsweekJuly 23, 2007
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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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50
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
Recommended