Advances In The Management Of
Cardiac Arrest
Victor Maroun MD
EMS/Disaster Medicine Fellowship Director
Department of Emergency Medicine
Saint Joseph’s Regional Medical Center
Paterson, NJ
Advances In The Management Of
Cardiac Arrest
Conflicts to report:
 None

Advances In The Management Of
Cardiac Arrest

Case:
– 47 year old male presents to the ED with
chest pain for 3 days
– HTN, smoking
– EKG: LVH
– Cardiac markers are negative
– CXR: normal
Advances In The Management Of
Cardiac Arrest

Re-evaluation
– Disconnected to monitor
– Pulseless, unresponsive
– Unknown down-time
– Nurse is on break
Advances In The Management Of
Cardiac Arrest

Next Step:
– Chest compressions?
– Secure Airway?
– BVM?
– IV access?
– Hypothermia protocol?
You decide to start compressions
Advances In The Management Of
Cardiac Arrest

Crash Cart Arrives
– Biphasic Defibrillator
• Voltage?
• Stack Shocks?

Nurse arrives
– “Do you want to stop CPR to establish IV
access, what meds do you want?”
Current Statistics
350,000 cardiac arrest in USA/year
 1 in every 90 seconds

– 36% In-hospital
• 18% of which survive to discharge
– 64% out of Hospital
• 2-9% of which survive to discharge
– 3-7% of survivors return to normal
neurologic functioning
Current Statistics

Majority of resuscitative efforts fail
– Anoxia
– Reperfusion injury
– Neurologic injury
– Airway/Breathing
– Circulation
– Other complications
Historical Perspective
Cardiopulmonary Resuscitation (CPR)
first published <50 years ago
 Young science
 Rapidly evolving
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Historical Perspective
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Early 1900s: Shafer Method
Historical Perspective

1960s – Peter Safar
– Prone position inadequate
– Expired air did provide sufficient O2.
– Head tilt, chin lift kept patent airway
Historical Perspective

1955: Paul Zoll: 1st successful closed
chest defibrillation, external pacing
Historical Perspective
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1930s: In hospital resuscitation team
1960s: MICU with physicians
1970: Education in Seattle
– 100,000 laypersons CPR
– 911 dispatch education
– Paramedic training
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1974: Training of laypersons formally sanctioned
1979: 1st AED developed
– Sensing electrode in pharynx
– Shocking electrode on tongue and abdomen
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1981: AICD developed
2005:
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American Heart Association Revisions
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Minimal interruption of chest compressions
Push hard and fast
8-10 breaths per minute
Delivered over one second duration
30/2 compression ventilation ratio
Compressions immediately after defibrillation
Hypothermia
AHA 2005 Revisions

OPALS Study NEJM 2004
– 17 Cities
– Multicenter, controlled clinical trial
– BLS + Rapid defibrillation
– ALS response intubation plus IV meds
AHA 2005 Revisions

OPALS – NEJM 2004
– 5638 patients with out-of-hospital arrest
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1391 BLS + Defibrillation
4247 ALS Intubation, IV meds
Admission: 10.9% vs. 14.6%, P <0.001
Discharge: 5.0% vs. 5.1%, P 0.83
AHA 2005 Revisions

Hyperventilation-induced hypotension in cardiopulmonary
resuscitation: Circulation 2004
– Clinical observational study Milwaukee
• 13 adults in cardiac arrest avg. 63yrs
• Device electronically recorded ventilation rates after intubation
• Half-way through study, retraining of personnel to deliver 12
breaths per minute
• Group 1 Initial group
• Group 2 retrained group
• Group 3 combination
– Animal study
AHA 2005 Revisions
AHA 2005 Revisions
AHA 2005 Revisions
AHA 2005 Revisions

Cardiopulmonary resuscitation by chest compression
alone or with mouth to mouth ventilation
N Engl J Med 2000
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Seattle 911 telephone staff instructed bystanders to perform
CPR alone (241) 81% delivered
CPR + mouth to mouth (279) 62% delivered
Outcome: discharge home
Similar outcomes: 14.6% CPR alone, 10.4% + MTM
• Likely benefit from continuous chest compressions
• Airway obstruction, ineffective MTM
AHA 2005 Revisions

AHA revision of ventilation rate
– 8 to 10 breaths per minute
– Breaths should be delivered quickly
– One second duration
– Timing device should be encouraged
AHA 2005 Revisions

Optimizing circulation
– Recent research indicated inadequate
chest compressions
– Frequent interruptions
– Inadequate pressure/compression
AHA 2005 Revisions
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Quality of cardiopulmonary arrest during out-ofhospital arrest JAMA 2005
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European study 3/02 – 10/03
Case series 176 patients
Accelerometer on defibrillators
Measured compression depth and rate
Measured ventilation rates
Compared to AHA guidelines
Duplicated for inpatients, similar results, reported as
separate study
AHA 2005 Revisions
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Quality of cardiopulmonary arrest during out-ofhospital arrest JAMA 2005
AHA 2005 Revisions
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Quality of cardiopulmonary arrest during out-ofhospital arrest JAMA 2005
AHA 2005 Revisions
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Quality of cardiopulmonary arrest during out-ofhospital arrest JAMA 2005
AHA 2005 Revisions
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AHA recommendations
– 100 beats per minute
– “push hard and fast”
– Very few interruptions
– Very brief interruptions
– Compression/Ventilation 30:2
– CPR prior to Shock
Compressions
•Art pressures 60/20
•Clinical assessment of heart chamber size and valve motion during
CPR using 2D ECHO, AM Heart J 1981 (4 patients)
•LV dimensions don’t change
•Aortic and Mitral valves are both open during compression
•Increased flow in RV during relaxation
•Conclusions: improved cardiocirculatory dynamics secondary to
thoracic pressure, not compression of LV
Compressions
• Haemodynamics of cardiac arrest and resuscitation,
Curr Opin Crit Care, 2006 (Review Article)
•In V-fib blood continues to flow until p-aorta = p-RV
•Aorta flow during compression
•Coronary flow during relaxation
•Carotid flow reaches a plateau after a few minutes of CPR, and
dramatically drops with short pauses, with a recovery time of a few
minutes.
Compressions
Automated Load
Distributing Band
•Ong et al. JAMA June 2006 (747 pts)
•ROSC 34% vs.. 20%
•Hospital discharge 9.7% vs.. 2.9%
•Hallstrom et al. JAMA June 2006 (1061 pts)
•Survival to 4 hours after CPR 29.5% vs.. 28.5%
•Survival to discharge 5.8% vs.. 9.9%, P .06
•Cerebral performance 1 or 2 3.1%, vs.. 7.5% P 0.006
Compressions
•CPR: the P stands for plumber’s helper JAMA 1990
•Lafuente et al, Cochrane Database of Systematic Reviews
2004
•10 randomized clinical trials ACDR vs.. CPR
•No no difference in survival outcomes
•Trend toward worse neurologic outcomes in ACDR
Compressions
•Survival from in-hospital cardiac arrest with interposed abdominal
counterpulsation during CPR JAMA 1992
•Randomized to IAC-CPR or conventional CPR n135
•ROSC 57% vs.. 27% P 0.007
•Discharge 25% vs.. 7% P 0.02
•Neurologically intact 17% vs. 6%
•Pre-hospital IAC-CPR versus standard CPR (Milwaukee Paramedics) n291
•Randomized after intubation
•Successful resuscitation 28% vs. 31%
Defibrillation
Defibrillation

Most Rapid response in casinos
– Dedicated trained responders
– Confined environment
– Security cameras
– Collapse to shock 4.4 minutes
– Hospital discharge 75% if within 3 minutes
Defibrillation
Delaying defibrillation to give basic CPR to patients with
out-of-hospital VF, JAMA 2003
•Norway
•Randomized study
•CPR before shock
•Standard
Defibrillation
Defibrillation
Defibrillation

American Heart Association
Recommendations
– CPR initiated while AED is being set up
– Defibrillation immediately when equipment
is ready
AHA 2005 Revisions
Chest compressions immediately after
defibrillation
 Don’t check monitor for rhythm
 Don’t check for a pulse
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AHA 2005 Revisions
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Carpenter et al. Resuscitation 2003
– Seattle study
– Out of Hospital Cardiac Arrest
– Reviewed post shock rhythms of 366 pts at
various times 5, 10, 20, 30, 60 seconds
– Compared Monophasic vs Biphasic
defibrillators
Carpenter et al. Resuscitation 2003
No difference in post-shock rhythms at
5-30 seconds (25% organized rhythm)
 At 60 seconds
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– Biphasic defibrillation 40%
– Monophasic Defibrillation 25%
Therapeutic Hypothermia
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
Hippocrates advocated packing bleeding patients in
snow
Profound hypothermia Lancet 1959
– Ronald Belsey (Cardiac surgery) performed cardiac surgery
in cooled patients with no perfusion > 60 minutes
– Research was inconsistent
– Predisposition to infection
– Fell out of favor

Safar et al Crit Care Medicine 1988
– FV in dogs better outcome if hypothermic
Therapeutic Hypothermia

New England Journal of Medicine 2002
– 2 large randomized clinical studies in
humans were published
– Induced hypothermia after cardiac
arrest
– Control group
– Favorable neurologic outcomes in
treatment groups.
Australian Study

Treatment of comatose survivors of
out-of-hospital cardiac arrest with
induced hypothermia
– Successful V-fib patients, who were
comatose
– Randomized
– 43 Hypothermia
– 34 Normothermia
Australian Study
Medics applied cold packs in the field
 Continued in the ED to temp of 33C
 12-hours of Hypothermia
 Shivering – (Versed, Vecuronium)
 Similar protocols used in Normothermic
group, temp maintained at 37C.

21/43 (49%) Treated patients had good outcomes
vs.. 9/34 patients (26%), NNT = 4
Mortality: 22/43 (51%) treated patients died
vs.. 23/34 (68%), NNT = 6
European Study
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Mild therapeutic hypothermia to improve the
neurologic outcome after cardiac arrest
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Larger Study
273 Patients
Successful V-fib out-of-hospital arrest
Comatose state
Randomized to Hypothermia and Normothermia
groups
European Study
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Cooling induced in the ED
– Cooling mattress and blanket (Cool air)
– 32 to 34 degrees C. for 24 hours
Hypothermia 137 patients
Normothermia 138 patients
Shivering (Versed, Vecuronium)
Compared outcomes
European Study
European Study
European Study
European Study
Therapeutic Hypothermia
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AHA recommendations
– 2003: “Mild hypothermia may be beneficial to
neurological outcome and is likely to be well
tolerated”
– 2005: “Unconscious adult patients with ROSC
after out-of-hospital cardiac arrest should be
cooled to 32-34C for 12-24 hours when the initial
rhythm was VF. Similar therapy may be beneficial
to non VF arrest. Further research is needed.”
Methods of Achieving
Hypothermia
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External
– Selective regional cooling: (Head and neck)
– Generalized: Entire body (cooling blanket)
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Internal
– IV (Cold IV Fluids)
– Bladder Lavage with cold fluid
– Invasive central vein devices.
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External / Internal combinations
Arctic Sun
Cincinnati Sub-0
Blanketrol II
Caircooler
Icy-Cath
Cold IV Fluid
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Bernard et al. Resuscitation 2003
– 30ml/kg 4C RL reduced temp 35.5 to 33.8C.
– Initiated in ED.
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Kim et al. Circulation 2005
– 2L 4C NS reduced temp by 1.4C in 30 min.
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Polder man et al. Crit Care Med 2005
– 2 Liters 4C NS bolus (+) Cooling blanket
– Reduced temp from 36.9 to 32.9 in one hour
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No complications in either study were
reported.
Pre-hospital Cooling

Kim et al. Circulation 2007
– 125 patients
– Randomized to standard care, vs.. Prehospital cooling with 2 liters cold IVF.
– 63 (Hypothermia group)
• Decrease temp by 1.25C
• No complications
– 62 (Standard)
• Increase in temp by 1C
Where should hypothermia be
initiated?
No definitive recommendations by the
AHA yet
 Increasing volume of literature

– Cold IVF
– Safe
– Effective
– Fast

Further research needed
A cooling treatment is credited with helping Dr. Syed Hassan Naqvi recover from Cardiac arrest.
“City Pushes Cooling Therapy for Cardiac Arrest”
NYC Responds

January 1, 2009
– NYC EMS will transport cardiac arrest patient to
only those hospitals that provide therapeutic
hypothermia
– Bypass closer hospitals
– Bloomberg endorsement
– 20 of 59 NYC hospitals expected provide
treatment
– Seattle, Boston, Miami will have similar protocols
– Vienna, London

No methodology requirements
NYC Responds
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Criteria
– CPR, with pulse regained within 30 min of
resuscitation, neurologically compromised
– Bypass non-participating hospital if you
can get to a participating hospital by 20
min.
– Avg. 10 min transport time.
Early Participating Hospitals
– NY Presbyterian
– Mt Sinai
– Bellevue
– St. Vincent’s
– Elmhurst
– Maimonidies
– Staten Island University
SJRMC Responds
66 Year Old Female
 Pre-hospital cardiac arrest with ROSC
 Comatose state
 Therapeutic Hypothermia protocol
initiated, 24 hours
 Rewarming 6 hours
 Patient now awake and alert in MICU

NJ Responds
Cooper University Hospital
 Morristown Memorial Hospital
 Hackensack University Medical Center
 Newark Beth Israel
 Many others developing protocols
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Conclusions
The science of cardiopulmonary
resuscitation is developing rapidly
 We as physicians and first responders
must stay updated
 We must also adjust our practice of
medicine accordingly

Questions?
I think they can stop CPR.