New Frontiers in
Resuscitation
Science
Daniel Davis, MD
UCSD Center for Resuscitation Science
Key Concepts
• Compressions
• Ventilations
• Pressors
• PetCO2
• Post-resuscitative care
1. Optimal Compressions
The Primary Directive
Chest compressions should be performed
from the moment of arrest until return of
spontaneous circulation is assured.
Prime the Pump!
Kern (2002) Circulation
Stay on the chest!
5
* Adjusted for:
Adjusted OR
4
age, gender, bystander CPR,
public location, response time, compression rate
3
2
1
2.13
2.26
21-40
41-60
2.88
3.3
1
0
0-20
61-80
Chest Compression Fraction
Christenson (2009) Circulation
81-100
Compression Interruptions
• Initiating compressions
• Rhythm analysis
• Shock sequence
• Pulse check
• Intubation
• Vascular access
Bystander CPR
Percent (%)
100
90
Pre
80
Post
70
60
50
40
30
20
10
0
ICU
Non-ICU
ECG Filtration
Return of Spontaneous Circulation
Heart Rate (BPM) & PetCO2 (mmHg)
140
120
Electrical
(HR)
100
80
Mechanical
(PetCO2)
60
40
20
0
0
10
20
Time
30
40
50
Deeper Compressions
Stiell et al (2008) AHA Scientific Sessions
Good Recoil
Aufderheide (2005) Resuscitation
Rate vs Depth
Rate
Depth
38 mm
38-51 mm
>51 mm
0 to 80
(N=65)
49%
28%
23%
81 to 120 121+
(N=478) (N=122)
44%
44%
12%
Stiell et al (2008) AHA Scientific Sessions
69%
30%
2%
CPR Process
Code # 79265 (11/28/12)
Code Leader: Brendan Daly, MD
Recorded CPR time: 5 minutes
Type of arrest: VF/VT
Minute
Chest Compression
Fraction
(goal >90%)
Average Compression
Rate (goal 100)
Average
Compression
Depth (inches)
(goal 2-4 inches)
3.02
2.98
3.10
2.85
1
100%
118
2
73%
107
3
82%
115
4
85%
121
5
Defibrillations: 1
Pre-shock pause (goal <3 seconds) 14 seconds
Post-shock pause (goal < 6 seconds) 3 seconds
Use of End Tidal Carbon Dioxide: Yes
Other comments: Good compression rate and depth, great use of EtCO2.
Summary: (selected strips below)
Results
• Chest compression fraction
91%
• Compression rate
123/min
• Compression depth
2.6 inches
• Pre-shock pause
2.6 sec
• Post-shock pause
3.6 sec
• Perfusion check
4.3 sec
• Ventilation rate
9.7/min
• PetCO2
15.3 mmHg
What if we’re wrong?
2. Controlled ventilation
Prime the Pump!
Kern (2002) Circulation
Continuous Chest Compressions
with Synchronous Ventilations (10:1)
3. Pressor Therapy
Pressors
Mader (2008) Resuscitation
Hagihara (2012) JAMA
*
*
*
Vasopressin?
Fluids?
4. PetCO2 in resuscitation
Lung Perfusion in Shock
PaCO2
40 mmHg
PetCO2
37 mmHg
PetCO2
29 mmHg
PetCO2
21 mmHg
PetCO2 Monitoring
PetCO2 Associations
• Initial PetCO2 α ROSC
• Pre-shock PetCO2 α ROSC for VF
• Rise in PetCO2 α ROSC
• Initial PetCO2 α arrest etiology
• Compression depth/patient wt α PetCO2
5. Post-resuscitation care
Hyperventilation: Three Flavors
Cerebral Perfusion During Shock
mL/100 gm/min
45
40
35
30
25
20
15
P = .004 v 12
P = .004 v 12
10
5
0
RR6
RR12
ETCO2
Ventilation in Resuscitation
Rapid, Shallow Breaths?
95%
E s t
CI
f or
t he
r e g r e s s io n
e s t im a t e
4 0
6 0
T V
1 5 0 0
1 0 0 0
5 0 0
0
0
2 0
8 0
V R
Intrathoracic Pressure
Evidence for Hypothermia?
Hypothermia vs. Normothermia?
Hypothermia After Cardiac Arrest Study Group (2002) NEJM
When should we cool?
Post-Arrest Hypothermia
no cooling
HACA
36%
33oC
no cooling
33oC
53%
0
10
20
30
40
% 26%
survival
50
60
Bernard
49%
36oC
52%
33oC
50%
TTM
How should we cool?
How should we cool?
Re
sp
to
ry
Tr
ac
h
ira
He
m
or
rh
ag
e
Se
ps
is
ur
o
ck
VT
lo
Ne
Va
ga
l/b
VF
/
Survival (%)
100
90
80
70
60
50
40
30
20
10
0
Re
sp
to
ry
Tr
ac
h
ira
He
m
or
rh
ag
e
Se
ps
is
ur
o
ck
VT
lo
Ne
Va
ga
l/b
VF
/
Survival (%)
100
90
80
70
60
50
40
30
20
10
0
Re
sp
to
ry
Tr
ac
h
ira
He
m
or
rh
ag
e
Se
ps
is
ur
o
ck
VT
lo
Ne
Va
ga
l/b
VF
/
Survival (%)
100
90
80
70
60
50
40
30
20
10
0
Arrest Survival
50
Survival-to-Discharge (%)
45
40
35
30
25
20
15
Current U.S. Benchmark
10
5
0
2006-07
2007-08
2008-09
2009-10
2010-11
2011-12
2012-13
Conclusions
• The opportunity is staggering
• Compressions
• Technology
• Post-resuscitative care