UPDATE:
IN-HOSPITAL
CARDIOPULMONARY
RESUSCITATION
Cardiac Arrests at JHH
• 85 cardiac arrests in 2011:
–
–
–
–
excluding ED, ICU and theatres
3 in the cath lab (1 survived)
26 in CCU (58% survived, 32% died)
9 in G3 (1 survived to get to ICU)
• Of the remaining 47 patients:
– 72% died
– 11% made it to discharge
Australian Resuscitation Council 2010
DRS ABCD
(S=send for help)
• When to commence CPR
– Unresponsiveness and abnormal breathing
– Check for central pulse for 10 seconds [A, ECO]
• Hand placement
– Lower half of the sternum
– Inter-nipple line
• Depth of compression
– 1/3 chest wall depth or greater than 5cm [A, animal]
Cardiopulmonary resuscitation for advanced life support providers. ARC and NZRC Guidelines 2010, Emerg Med Aust, 2011,23:264-70
Australian Resuscitation Council 2010
• Compression rate
– 100 per minute, no evidence for faster rate [A, animal]
• Compression:relaxation ratio
– Equal time spent in compression and release
– Aim to achieve complete recoil of chest between
compressions
• Provision of a firm surface
– [A, manikin]
Australian Resuscitation Council 2010
• Minimise interruptions to CPR [A, human]
–
–
–
–
Continue without interruption
unless evidence of return to breathing or specific task
Attempts at intubation should NOT interrupt
Planned pauses for rhythm/pulse analysis <10sec
• Compression ventilation ratio
–
–
–
–
–
–
Before airway is secured, 30:2 [A, EO]
After secured, ventilate with 100% O2
need to assess chest rise with EACH breath
6-10 ventilations per minute with airway [A, EO]
Don’t interrupt compressions, but time with compressions
Don’t ventilate at same time as compression
Australian Resuscitation Council 2010
• Fatigue
– Chest compressions become shallower at one minute
but providers only become aware at 5 minutes
– Swap pumpers every two minutes
• Perform CPR right up to the point of shock
• Recommence CPR immediately after shock
– If rhythm compatible with spont circulation, check pulse
– Otherwise, keep pumping
• Shock
– Monophasic =360J, biphasic =200J
Australian Resuscitation Council 2010
• Precordial thump
– Doesn’t work in VF, might work in VT
• Vasopressors
– Increase return of spontaneous circulation
– No improvement in longer term outcome
– Adrenaline 1mg IV at time of commencement
• Anti-arrhythmics
– No evidence of improved mortality
– Give amiodarone after 3rd unsuccessful defib
Australian Resuscitation Council 2010
• Monitor adequacy of CPR
–
–
–
–
Technique
End-tidal CO2 - low CO2 = breathing too fast
ABG - only for electrolytes, NOT for acid base state
Real-time feedback devices
• Harm to patient during CPR
• Audit, feedback and quality improvement
Australian Resuscitation Council 2010
• Guidelines also encompass:
– Seek reversible causes
– Special circumstances
• Anaphylaxis, avalanches, pregnancy, tamponade, etc.
– Managing acute dysarrhythmias
– Evidence for equipment
– Post resuscitation therapy
•
•
•
•
•
•
PCI in STEMI
Use of amiodarone prophylactic anti-arrhythmic [A, EO]
BP, BSL, O2 and CO2 ,neuro, temperature etc
Consider resuscitation related injuries
Prognosis
Organ donation
American
guidelines
Differences
•
•
•
•
ABC becomes CAB
Atropine has been officially removed
Cricoid pressure has been removed
Consider all for cardiac catheterisation
Evidence
• Evolution in understanding over the past
decade
– The longer someone is in VF, the harder to cardiovert
– The better perfused the myocardium is prior to a
shock, the more likely cardioversion is to work
– A single dose of adrenaline is the only drug which can
help return of spontaneous circulation, except for
MgSO4 in torsades
– Over-ventilation is harmful, “lazarus syndrome”
Evidence for training
to improve
technique and outcomes
• Teaching hand placement improves
technique1
• Teaching ALS results in improved
technique for at least 6 months2
1.
Owen et al, A randomised control trial comparing two techniques for locating chest compression
hand position in adult basic life support, Resuscitation 2011, 82:944-6
2.
Ettl et al, Updated teaching techniques improve CPR performance measures: a cluster
randomised control trial, Resuscitation 2011, 82:730-5
Technique
• Important not to “lean” on patient between
compressions as reduces chest expansion1
• Supraglotic airways are adequate in an
emergency and reduce “hands off time”2
• Pause for ECG analysis <10 seconds3
1.
Editorial, Leaning is common in chest compressions but remains a relatively unknown entity, Resuscitation 2011, 82:971-2
2.
Hands-off time during insertion of six airways devices during cardiopulmonary resuscitation: a randomised manikin trial,
Resuscitation 2011, 82:1060-3
3.
Editorial, Pauses during CPR are breaks hinering our efforts? Resuscitation 2011, 82:1379-80
Longer pauses between
compressions and defib
decrease survival
815 out of hospital arrests treated by paramedics
• Longer pre-shock periods were associated with
decreased survival1
• Longer than 20 seconds vs <10sec OR=0.47
• For peri-shock pause:
– >40 seconds, 45% decrease in survival compared to
– peri-shock pause <20sec
Cheskes et al, Circulation 2011, 124:58-66
Evidence for Drugs in Resus
• Adrenaline doubles chance of return to spont.
circulation but no mortality benefit:
– Survival to hospital d/c - 10.5% vs 9.2%
– Survival with favourable neuro - 9.8% vs 8.1%
• Vasopressin and terlipressin are as good as
adrenaline
• Short-term benefit of amiodarone
• MgSO4 for torsades works
Morley, Drugs during cardiopulmonary resuscitation, Cardiopulm Resus, 2011, 17:214-18
Evidence of damage
secondary to CPR
• 65% of patients have rib fractures
• 30% of patients have sternum fractures
• Patients >60yrs old much greater risk
Kim et al, Multidetector CT findings of skeletal chest injuries secondary to cardiopulmonary resuscitation,
Resuscitation 2011, 82:1285-88
Evidence of damage
secondary to CPR
• 1987 study of 705 autopsies after CPR
– 18% had mediastinal hemorrhage
– 3% had abdo visceral / oesophageal rupture
– 10% had pericardial bleeding or lacerations of
the great vessels or myocardium
Bardy, A ciritcs assessment of our approach to cardiac arrest, NEJM 2011, 364:374-5
Krischer et al, Complications of cardiac resuscitation, Chest 1987, 92:287-91
Evidence of damage
secondary to CPR
• Recognition of gastric rupture secondary
to use of laryngeal mask in CPR
Haslam et al, Gastric rupture associated with use of the laryngeal mask during cardiopulmonary resuscitation, BMJ 2004, 329:1225-6
Evidence of damage
secondary to CPR
• Extreme oxygen tension
associated with
increased mortality
• Hypothesized to be
global ischaemia /
reperfusion injury
Kilgannon et al, Relationship between supranomral oxygen tension and outcome after resuscitation from
cardiac arrest, Circulation 2011, 123:2717-22
Treatment protocols for post
arrest improve outcomes
• Out-of-hospital arrest, favourable outcome
can be achieved (25% vs 56%) by
following stardard protocol1 including
– PCI for all ST elevation ECG
– Mild therapeutic hypothermia (MTH)
– Standard ICU protocols
1. Tomte et al, Strong and weak aspects of an established post-resuscitation treatment protocol - a five year observational
study, Resuscitation 2011, 82:1186-93
Rhythms and outcomes
• American Heart Association National Registry for
Cardiopulmonary Resuscitation
• 51,919 pts with pulsless cardiac arrest between 1999
and 2005
–
–
–
–
VT 7%
VF 17%
PEA 37%
Asystole 39%
• Survival to hospital discharge was
– 37% in VF/VT and
– 12% PEA,
– 11% asystole
Evidence for CCU and
Monitoring
• Good evidence that monitoring improves
outcomes in cardiac arrest
• Cerebral performance caregory 1 or 2 at
discharge compared to non-witnessed:
• OR 2.4 if monitored and witnessed
• OR 2.12. if monitored only
• OR 2.42 if witnessed only
Brady et al, In-hospital cardiac arrest: impact of monitoring and witnessed event on patient
survival and neurologic status at hospital discharge, Resuscitation 2011, 82:845-52
Resuscitation in
elderly hospital inpatients?
• Individuals with certain characteristics automatically
opted out1
• Better education for healthcare workers re decision
to resuscitate and the right of medic to withhold2
• If a patient enters hospital and there is a plausible
risk of cardiac arrest, physician should recommend
against it when there is a low likelihood of benefit3
1.
2.
3.
Opt in not out. BMJ 2011, 343:5251
Progress towards fewer inappropriate attempts at cardiopulmonary resuscitation. BMJ 2011, 343:5942
Blinderman et al, Time to revise the approach to determining CPR status, JAMA 2012, 307:917-18
Opt in not out
• Vocal criticism of “the slow code”
although
• Some ethicists state that the “slow code” may be
a method of meeting the needs of family and
patient1
Lantos et al, Should the slow code be resuscitated? Am J Bioeth 2011, 11:8-12
Resuscitation in the elderly
Predictors of survival following in-hospital cardiopulmonary resuscitation, CMAJ 2002, 167:343-8
Resuscitation in the elderly
In a 1989 study, 503 inpatients over 70:
•22% survived initially, 9.6% survived to discharge
•Unwitnessed arrest – 1/116 survived
•PEA or asystole – 1/237 survived
•CPR > 15 minutes – 1/360 survived
•Acute care hospital inpatients – 17/259 survived
•Most survivors had VT or VF that was witnessed
Outcomes of cardiopulmonary resuscitation in the elderly, Annals of Internal Medicine, 1989, 111:199-205
When is it futile?
Cardiac arrest
Respiratory arrest
Predictors of survival after cardiac or respiratory arrest, CMAJ, 2011, 183:1589-94
Greek Cardiologist’s
Knowledge of CPR
Pantazopolous et al, Carrdiologists’ knowledge of the 2005 American Heart
Association Guidelines, Heart and Lung 2011, 40:278-84
The Quilty Take – GIVE UP
• No CPR on unwitnessed arrest in patients > 80
• All inpatients not monitored and >80 are NFR
• Discussion with susceptible patients who are unlikely to
benefit from CPR before arrest situation
– Should the patient be give an option?
• If over 70 and >10 minutes, call it quits
• If PEA or asystole and over 70, call it quits
The Quilty Take – GIVE ‘EM A GO
• Early defibrillation if witnessed
• High quality chest compressions of:
– adequate depth
– rate
– complete chest wall release b/n compressions
– minimal hands off time
• Keep pumping until defib ready to go
• Go slowly with resps, aim for SaO2 88-95%
• ED form documenting resus status for all over 70?
• Always consider the damage that might have occurred
The Quilty Take
• Formalise resuscitation processes in the
hospital, including expanded register to
include outcomes
• Train all medical registrars
• In-hospital protocol for cardiac arrest, ie
immediate revascularization, immediate
ECHO, use of ultrasound etc?
Quilty Take
• Average age of 99 resuscitated in 2005?
– 71
• Average age of the 85 resuscitated 2011?
– 71
• Age of the oldest survivor in 2011?
– 90 (G1)
• How many were over 90 in 2011?
–4