in Cardiac Arrest
Management
Sean Kivlehan, MD, MPH, NREMT-P
September 2013
Plan
3 In Depth
• Medication Use
• Hypothermia
• Intubation
5 Quick Info
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Vascular Access
Cardiocerebral CPR
CPR Devices
Termination Rules
Current Trials
Please think about…..
1. Why do we do what we do?
2. How can we do it better?
What they already knew:
• Compressions affected ventilation
• If alone, only do compressions
• “Only the human hand is required”
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Clear Airway, esophageal airway or intubation
Push down 4-5cm and minimize interruptions to <5 sec (20 sec for intubation)
Defib at max dose (400J)
Epi, Isoproternal, Calcium, Bicarb, Lidocaine, intracardiac injections
Ontario Prehospital Advanced Life Support
(OPALS) Major Trauma Study
• Before/After study in 17 cities of BLS vs ALS
• 2867 patients with major trauma
• Overall survival: no difference
• GCS <9 survival:
– 50% with ALS
– 60% with BLS
Stiell IG, Nesbitt LP, Pickett K, et al. The OPALS Major Trauma Study: impact of
advanced life support on survival and morbidity. CMAJ 2008 Apr 22;178(9):1141-52
“The best available observational evidence indicates
that epinephrine may be harmful to
patients during cardiac arrest, and there are plausible
biological reasons to support this observation.”
Caveat:
“However, observational studies cannot establish causal
relationships in the way that randomized trials can.”
Callaway CW. Questioning the use of epinephrine
to treat cardiac arrest. JAMA 2012 Mar;307(11):1198-200
Norway 2003-2008
IV drugs vs no IV drugs
6 years, 851 patients
ROSC: 32% vs 21%: BETTER
Survival to discharge: NO CHANGE
Favorable Neuro Outcome: NO CHANGE
1 year survival: NO CHANGE
Overall, no improvement
Olasveengen TM, Sunde K, Brunborg C, et al. Intravenous drug administration during
out-of-hospital cardiac arrest: a randomized trial. JAMA. 2009;302(20):2222–2229
Western Australia 2006-2009
Epi vs Placebo
4 years, 534 patients
ROSC 23.5% vs 8.4%: BETTER
Survival to discharge 4.0% vs 1.9%: NO CHANGE
(OR 0.7-6.3)
No statistically significant
improvement
Jacobs IG, Fimm JC, Jelinek GA, et al. Effect of adrenaline on survival in out-of-hospital cardiac
arrest: A randomised double-blind placebo-controlled trial. Resuscitation 2011 Sep;82(9):1138-43
Hesitant to participate?
– 4/5 EMS services wouldn’t participate because of “withholding
standard of care.”
– Voluntary participation: only 40% of medics
– Negative press & ethics concerns affected funding
What is “Standard of Care?”
“To date the evidence base underpinning this “standard of
care” intervention has been restricted to animal and nonrandomised clinical studies that are characterised by
inconsistent findings. The extensive barriers … serve
only to ensure such interventions remain unproven.
March 2012
Epi vs Placebo
Japan, 4 years, 417,188 patients
ROSC: 18% vs 5%: BETTER
1 month survival: NO CHANGE
Good functional status: 1.4% vs 2.2%: WORSE
(OR 0.21 – 0.71)
prehospital epinephrine was significantly associated with increased
chance of ROSC but decreased chance of survival and good
functional outcomes 1 month after the event.
Why?
• Increased lactate, over-constriction of microcirculation,
metabolic debt overall
• Promotes dysrhythmias, activates platelets
Hagihara A, Hasegawa M, Abe T, et al. Prehospital epinephrine use and survival
among patients with out-of-hospital cardiac arrest. JAMA. 2012;307(11):1161–1168
The Debate Continues
Shockable rhythm: WORSE
Non-shockable: MAYBE BETTER
(if given in <20 min)
• Looked at:
– ROSC (better)
– 1 month survival (better)
– 1 month neuro outcome (same)
Goto, Critical Care, 2013
Is Speed the Issue?
“Early Epi” study
911 to epi <10 min or greater than 10 min
686 patients
– Avg 911 to Epi time = 14.3 min
– 155 (22.6%) received Early Epi
– Better ROSC
– No change in Admission or Discharge
Koscik, Resuscitation, 2013
What About Vasopressin?
2012 meta-analysis
Vasopressin vs epi in 6 RCT’s
No improvement in:
• Sustained ROSC
• Long term survival
• Favorable neuro outcome
Higher long term survival in asystole (slight)
Mentzelopoulos SD, Zakynthinos SG, Siempos I, et al. Vasopressin for cardiac arrest:
meta-analysis of randomized controlled trials. Resuscitation 2012 Jan;83(1):32-9.
• Vasopressin
• Epi
• Methylprednisolone
40mg
Mentzelopoulos, JAMA 2013
Saline
Epi
Saline
Therapeutic Hypothermia
In Hospital – 2002
Study #1
– 77 patients randomized to 33°C x12 hours
– Favorable neuro outcome:
• 49% chilled
• 26% not
Study #2
– VF post arrest, 136 patients randomized to 32-34°C x24 hours
– Favorable neuro outcome:
• 55% chilled
• 39% not
6 month mortality down 14%
No difference in complication rate
Bernard SA, Gray TW, Buist MD, et al: Treatment of comatose survivors of out-of-hospital
cardiac arrest with induced hypothermia. N Engl J Med 2002, 346:557-563
Hypothermia after Cardiac Arrest Study Group: Mild therapeutic hypothermia to improve
the neurologic outcome after cardiac arrest. N Engl J Med 2002, 346:549-556
EMS Use: Post-Arrest
Australia 2010: ROSC after VF
PRCT: Rapid infusion of 2L ice-cold NS by EMS after ROSC vs
hospital cooling
Favorable neuro outcome: 47.5% vs 52.6% (p = 0.43)
[No difference]
Australia 2011: ROSC after Asystole/PEA
Same approach, same results
Bernard SA, Smith K, Cameron P, et al. Induction of prehospital therapeutic hypothermia by
paramedics after resuscitation from out-of-hospital ventricular fibrillation cardiac arrest: a randomized,
controlled trial. Circulation 2010 Aug 17;122(7):737-42
Bernard SA, Smith K, Cameron P, et al. Induction of prehospital therapeutic hypothermia
after resuscitation from nonventricular fibrillation cardiac arrest. Crit Care Med 2012 Mar;40(3):747-53
Intra-Arrest
– Before/after study in North Carolina
– 551 patients, 2L 4°C NS intra-arrest vs None
– ROSC: 36.5% vs 26.9% (OR 1.19-2.81)
– Hospital discharge not statistically significant
Garrett JS, Studnek JR, Blackwell T, et al. The association between intra-arrest
therapeutic hypothermia and return of spontaneous circulation among individuals
experiencing out of hospital cardiac arrest. Resuscitation 2011 Jan;82(1):21-5
NYC Project Hypothermia
Before/after study (2009-2011); 10,309 arrests
• 30 cc/kg up to 2L @ 4ºC via large-bore IV/IO
• after defibrillation and airway management, but before any drugs
Working? avg cooled by 1.6ºC (35.6 to 34)
Harming? 8% get pulmonary edema
Helping? 32.5% (38% with >1500cc) vs 27.9%
NYC Project Hypothermia Working Group, Freese J. Intra-arrest induction of therapeutic
hypothermia via large-volume-ice-cold saline infusion improves immediate outcomes for
out-of-hospital cardiac arrest. Circulation 2011;124:A2 (Resuscitation Science Symposium 2011 Presentation)
Outstanding Issues
Route: IV, Intra-nasal evaporative, Ice packs/lavage
Induction: Intra-arrest vs post-arrest & if so how long after
ROSC
Rhythm: VF/VT only or all
Trauma patients? (J Trauma case series 2011)
Optimal temperature?
When to rewarm?
Summary: IATH improves survival and neurological
outcome
Scolletta S, Taccone FS, Nordberg P, et al. Intra-arrest hypothermia during cardiac
arrest: a systematic review. Crit Care 2012 Mar 7;16(2):R41
ETI vs SGA
Witnessed nontraumatic OHCA x4 years in Japan
5,377 patients
Favorable neuro outcome 3.6% vs 3.6%
Longer time to placement for ETI: 17.2 vs 15.8 min
(p<0.001)
Kajino K, Iwami T, Kitamura T, et al. Comparison of supraglottic airway versus
endotracheal intubation for the pre-hospital treatment of out-of-hospital cardiac arrest.
Crit Care 2011;15(5):R236
“Out of Hospital Airway
Management in the United States”
NEMSIS data from 16 states in 2008
4.3 million EMS calls
10,356 ETI: success 77%
(Hubble, 2010 showed 86.3% in meta-analysis of 30 studies)
1,794 alternate airways: success 87%
[Combitube, EOA, LMA, King LT]
Wang HE, Mann NC, Mears G, et al. Out-of-hospital airway management in the United States. Resuscitation
2011 Apr;82(4):378-85
Hubble MW, Brown L, Wilfong DA, et al. A meta-analysis of prehospital airway control techniques part I:
orotracheal and nasotracheal intubation success rates. Prehosp Emerg Care 14(2010):377-401
Harming > Helping?
Michigan retrospective study 1995-2006
1,515 arrests, 86.2% intubated
Overall survival to discharge: 6.5% vs 10.0% (intubated vs not)
VF/VT survival to discharge decreased with intubation
California retrospective study 1994-2008
1,294 arrests, 79.4% intubated
Survival to discharge: BVM 4.5x more than intubation
North Carolina retrospective study 2006-2008
1,142 arrests, ROSC 5.4x more likely in nonintubated pts
Egly J, Custodio D, Bishop N, et al. Assessing the impact of prehospital intubation on survival
in out-of-hospital cardiac arrest. Prehosp Emerg Care 2011 Jan-Mar;15(1):44-9
Hanif MA, Kaji AH, Niemann JT, et al. Advanced airway management does not improve outcome
of out-of-hospital cardiac arrest. Acad Emerg Med 2010 Sep;17(9):926-31
Studnek JR, Thestrup L, Vandeventer S, et al. The association between prehospital endotracheal intubation attempts and
survival to hospital discharge among out-of-hospital cardiac arrest patients. Acad Emerg Med 2010 Sep;17(9):918-25
Japan Again
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5 year observational study
649,359 patients
43% with airway
WORSE neuro outcome
– 1.1% vs 2.9% (OR 0.38)
Hasegawa, JAMA, 2013
Hasegawa, JAMA, 2013
IO as first line in
arrest?
[182 arrest patients]
1st attempt success:
Tibial IO: 91%
Humeral IO: 51%
PIV: 43%
Time to initial success:
Tibial IO: 4.6 min
Humeral IO: 7.0 min
PIV: 5.8 min
Reades R, Studnek JR, Vandeventer S, et al. Intraosseous versus intravenous vascular access during
out-of-hospital cardiac arrest: a randomized controlled trial. Ann Emerg Med 2011 Dec;58(6):509-16
CPR vs CCR
Continuous Chest Compression (CCC) CPR
Preferred by bystanders
Equivalent or better resuscitation rates
Cardiocerebral CPR
– 200 uninterrupted chest compressions @100/min
– Rhythm analysis with a single shock if indicated
– Immediately followed by 200 postshock chest compressions
before any pulse check or rhythm reanalysis.
– ETI delayed until after 3 cycles
– IV epi administered as soon as possible during the protocol and
again with each cycle
More Info:
SHARE Program @ Univ. of Arizona Sarver Heart Center
Ewy GA, Sanders AB. Continuous chest compression CPR preferred for primary
cardiac arrest. Resuscitation 2010 Jun;81(6);639-40
Bobrow BJ, Clark LL, Ewy GA, et al. Minimally Interrupted Cardiac Resuscitation by
Emergency Medical Services for Out-of-Hospital Cardiac Arrest JAMA 2008;299(10):1158-1165
Systolic Blood Pressure
Compressions
Time (Seconds)
Increasing Bystander CPR
Hallstrom, NEJM 2000
CPR Adjuncts
Load Distributing Band CPR (AutoPulse)
2004-5 ASPIRE Trial, US multicenter RCT
Lower survival & worse neurological outcomes
Halted early (dangerous)
Mechanical Piston Device (LUCAS)
2005-2007 Pilot Study in Sweden, 148 arrests
No difference in early survival
Impedance Threshold Device (ITD)
2007-2009 US multicenter RCT, 8,718 arrests
No difference in survival
Halted early (futility)
Smekal D, Johansson J, Huzevka T, et al. A pilot study of mechanical chest compressions with the LUCAS device
in cardiopulmonary resuscitation. Resuscitation 2011 Jun;82(6):702-6
Hallstrom A, Rea TD, Sayre MR, et al. Manual chest compression vs use of an automated chest compression device
during resuscitation following out-of-hospital cardiac arrest: a randomized trial. JAMA 2006 Jun 14;295(22):2620-8
Aufderheide TP, Nichol G, Rea TD, et al. A trial of an impedance threshold device in out-of-hospital cardiac arrest.
NEJM 2011 Sep 1;365(9):798-806
What went wrong?
4 hour survival same
Hospital discharge 5.8% vs 9.9%
“Results are unexpected and there is no
obvious explanation”
– Hawthorne Effect for CPR & Learning curve
for device
– Delay to use?
– Enrollment bias?
“no alternative technique or device in routine use
has consistently been shown to be superior to
conventional CPR for out-of-hospital basic life
support”
(2010 AHA Guidelines)
“The experts are aware of several clinical trials of
the devices listed below that are under way
and/or recently concluded, so readers are
encouraged to monitor for the publication of
additional trial results in peer-reviewed journals
and AHA scientific advisory statements.”
Significantly Associated with ROSC:
– Witnessed Arrest (OR = 1.51)
– Initial EtCO2 >10 (OR = 4.79)
– EtCO2 falling <25% of baseline (OR = 2.82)
Alternatively:
– Male, no bystander CPR, unwitnessed
collapse, non-VF arrest, initial EtCO2 <10,
and EtCO2 falling >25%
– 97% predictive of no ROSC
Eckstein, 2011
Termination Rules
Morrison, Resuscitation 2009
sean.kivlehan@gmail.com