Why Emergency Physicians Don’t
Care about Cardiac Arrest and Should.
 Robert Swor, DO
 Professor, Emergency Medicine
 Oakland University William Beaumont
 School of Medicine
Objectives
 Epidemiology of Cardiac Arrest Survival
 Relative impact of interventions
 Relative impact of Phases of Care
 Where do Emergency Physicians Make a Difference
Emergency Physician Perspectives
of Cardiac Arrest Resuscitation
 It’s Futile
 We just bring back patients to a vegetative
state
 The Only people that arrest are Gomers at
the end of Life
 This One’s comatose-He’s Toast
 It’s a poor use of Health Care Dollars
My Question
 Are 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
Scenarios
 Field Cardiac Arrest
 Post-Arrest- CPR in Progress
 Post Arrest-DefibrillatedChest burns, alert
 Post arrest-ResuscitatedSTEMI
 Post Arrest- Comatose
 Pre-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%
(38.6% of ROSC
Survive to Discharge)
17%
Survive to Discharge
Neurologic Outcome
Out 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
Field Cardiac Arrest
 CPR not Transported to Hospital
 CPR in Progress on ED Arrival
 Futile?
1
What Happens to Field Cardiac
Arrest
 CARES Registry
 27,675 OHCA events
 18,541 (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
80
% Field Pronouncement
70
60
50
40
30
20
10
0
3
12
17
19
27
30
34
EMS Agency
36
40
55
58
Median
Field Termination without
ROSC-ROC Consortium
100%
90%
% Termination
80%
70%
60%
50%
40%
30%
20%
10%
0%
Alab
Iowa
Ottawa
Pitt
Port
Site
Seattle Toronto
Vanc
Mean
Survivors To Admission
 828 (14.7% of transported) Survive to
Admission
 128 survived to discharge (15.4%)
 81 (9.8%) survived with good cerebral
performance.
Termination of Resuscitation in
Field-Decision Rules
 ALS
 No ROSC
 No Bystander CPR
 Not witnessed arrest
 No shock Delivered
 BLS
 No ROSC
 No witnessed
 No AED shock
Clinical Decision Rules for TOREvidence Based Review –
Sherbino J. Em Med 2009:10:1016
 Literature Review
 4 Decision Rules
 3 BLS: 1 ALS
 6 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 Age
End of Life Planning and Care
Unwanted or Not Indicated
Resuscitation
 King County 1994 (Dull)
 7% had undocumented DNR
 25% Severe Chronic Disease
Possible Predictors of Outcomes
After Cardiac Arrest
 Clinical presentation
 Arrest factors
 Age
 Diapers
 Neuro exam
 HCT
 EEG
 N-100 Enolase
Impact of Therapeutic
Hypothermia
Nielson Acta Anaes Scan 2009; 53:926-934
 Scandinavian Registry
 238 pts with Hypothermia - 7 Countries
 Good Neurological Outcome


22% Non VF
56% VF
Neurologic Outcome
Out 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 Outcomes
 Obstacle to initiating
Aggressive Care
 No reliable data on
predictors of outcome in
first 3 days
 Consistent with AHA 2010
Guidelines
Predicting Outcomes-Post
Hypothermia
ECMO To Support CPR in Adults
 1992-2007
 ELSO Database
 Adults>18 years
 Mean Age 52
 Survival in 27%
 Brain Death in 29%
 Ann Thoracic Surg 2009:87:778-785
Case Study
 Refractory Cardiac Arrest
 53 y/o male, severe 3 vessel ds
 Post op CABG-refractory VF post op day 4
 65 minutes CPR during attempted resuscitationcannulation
 ECMO for 4 days
 Neuro 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
Lick et al. Crit Care Med 2011;39(1):26-33.
26
Conclusion
 CPR in progress Ominous prognosis
 Resuscitated arrest
 VF-Good outcome
 Non-VF- Uncertain
 Prognostication-Fool’s game
 Time’s they’re a changin’
 Hypothermia
 Aggressive therapy