VanderbiltEM.com. Cardiac Arrests. AAEM Practice Changing Articles Resuscitation Results Resuscitation 2014;85: /13/2015

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1 2/3/2 AAEM Practice Changing Articles Resuscitation 24-2 VanderbiltEM.com Corey M. Slovis, M.D. Vanderbilt University Medical Center Metro Nashville Fire Department Nashville International Airport Nashville, TN Cardiac Arrests Epi Calcium CPR Defibrillation Resuscitation 24;8:732-4 Does Epinephrine use have true benefits in CPR? Meta analysis, 4 RCTs, 2,246 patients Studies were: Epi vs placebo () n = 34 Epi vs high does Epi (6) n = 6,74 Epi vs Vasopression () n = 336 Epi vs Epi + Vasopressin (6) n =,22 Results Resuscitation 24;8:732-4 Epi vs placebo () n = 34 ROSC - No differences in survival or neuro outcome Epi vs High dose Epi (6) n = 6,74 - No differences in survival or neuro outcome Epi vs Epi + Vasopressin (6) n =,22 - No differences in ROSC, admit, survival or neuro Epi vs Vasopressin () n = No differences in ROSC, admit, survival or neuro

2 2/3/2 Benefits of Epinephrine in CPR Conclusions and Take Homes Very hard to prove efficacy Very hard to stop using it Epi + Vasopressin + steroids?? Future studies will hopefully help us define its role or lack there of JACC 24;64:236-7 Does prehospital epinephrine improve functional outcome post OOH cardiac arrest?,6 patients from 2 22,34 (73%) received epinephrine 422 (27%) did not receive epinephrine Evaluated frequency of CPC - 2 survival Epi vs No-Epi: CPC - 2 Matched Pairs Evaluation Study from Paris, France JACC 24;64: % All patients has ROSC All were admitted + Epi patients: older, less witnessed + Epi patients: longer resuscitation, less VF/VT Study compared 228 pairs of Epi vs non-epi matched samples % 68/228 Epi Used 38/228 No Epi P <. Epi vs No-Epi Additional Results Longer delay to epi = worse outcomes Negative effects of epi across subgroups Rhythm, TH, length of CPR, PCI JACC 24;64:236-7 The more the epi, the worse the outcome OR Epi Dosing and Survival CPC JACC 24;64: MG 2 - MGS > MGS 2

3 2/3/2 Epinephrine in Cardiac Arrest Take Homes JACC 24;64:236-7 Use appears to decrease functional neurological status in survivors More epi = worse outcomes May increase ischemic-reperfusion and postanoxic injury PCI and hypothermia do NOT attenuate Epi s negative effects As usual, more study needed, but epi alone is not the answer to improved neurologic intact survival Annal Emerg Med 24; 64:87-89 Is Calcium Beneficial in Cardiac Arrest? Systematic Review Snapshot 4 studies, reported ROSC/Survival Only 2 were blinded 7% were human trials There is no conclusive evidence that administration of calcium during CPR improves survival 3

4 2/3/2 Take Homes Calcium in CPR Do not use routinely Consider if hyperkalemia a possibility Wide QRS, Renal Failure Therapeutic Hypothermia And PCI s/p Arrest Heart Block/Bradycardia with peaked T waves 2 ACC/AHA Guidelines PCI and Hypothermia Therapeutic hypothermia should be started ASAP for all comatose STEMI patients and out of hospital arrests due to VF or VT (B) Immediate PCI is indicated in all STEMI arrest patients including those who are receiving therapeutic hypothermia (B) Resuscitation 24;8:88-9 Should all VF arrests go to the CCL even if comatose and no STEMI on post arrest 2 lead? 74 consecutive comatose patients s/p arrest 269 (3.7%) VF/VT and got TH 22 of these got early CCL vs late CCL 26.6% no MI had acute coronary occlusion Survival to Hospital Discharge Early CCL in Comatose non STEMI VF/VT Resuscitation 24;8: p = Early CCL Late CCL p = No CCL Resuscitation 24;8:67-63 How much does early PCI and TH affects neurologically intact survival s/p OOH cardiac arrest ROC Investigators 3,98 patients from hospitals ROSC > 6 minutes in-hospital 4

5 2/3/2 Patients Resuscitation 24;8:67-63 VF 4%, PEA 27%, AS 23% TH in 6% of VF; 2% AS Early PCI in 77% of VF; 9% AS LOC on arrival not available from data TH + PCI obviously only in comatose pts % Hypothermia + PCI Resuscitation 24;8: Survival Good Neuro Survival Good Neuro Survival Good Neuro No PCI No TH PCI + TH TH and PCI Take Home 2 Management of VF/VT Survivors Be careful that a non-stemi is not an acutely intervenable AMI - = 3% of VF/VT arrests without STEMI will have an acute, stentable lesion S/P VF/VT awake PCI S/P VF/VT coma PCI + TH Used data based on protocol that BLS was dispatched if ALS not available JAMA 24, online Nov 24, 24 Is ALS significantly better than BLS for out of hospital cardiac arrest? 3,292 ALS vs,643 BLS cases Medicare billing data records (2% of total) Harvard study 29 2, no rural serviced Propensity matching utilized ALS younger, more male, less likely to have chronic medical condition and picked up at a residence BLS more likely to be picked up at a skilled nursing facility

6 2/3/2 Survival to Hospital Discharge Propensity Matched JAMA 24, online Nov 24, 24 Poor Neurologic Outcome Admitted Pts Propensity Matched JAMA 24, online Nov 24, % % RR =.4 43% diff % 44.8% (9% CI = ) 4 2 BLS ALS BLS ALS 3 Day to Survival Propensity Matched Probability of Survival JAMA 24, online Nov 24, % % RR. 9% CI = (.2.7) BLS ALS BLS vs ALS Take Homes AEDs and O 2 by BVM are key How important is ALS? Not a randomized study Many potential confounders Resuscitation 24;3: What s the importance of the peri-shock pause? 2,6 patients with pre/post shock times Evaluated T pre-shock and post shock Compared survival to discharge 6

7 2/3/2 Resuscitation 23;3: % of pts had pre-shock pause > 2 seconds Median T to shock was seconds 6.% had a post-shock pause > 2 seconds Median T to resume CPR was 6 seconds Optimal pre-shock pause is < seconds < sec vs > 2 sec increases survival (OR =.) Pre Shock Pause Resuscitation 24;8:7- Does compressing during defibrillator charging (CDC) improve compression fraction and/or survival? 29 patients, Canadian study Resuscitation 24;8:7- Sec 3. Sec P <. 4.2% received compressions during charging No significant change in rate or depth noted STD CPR CDC CPR Conclusions on CDC Easy to teach and do Increases compression fraction by % Not yet clear if improves survival Larger study will evaluate mortality effects AEDs will all soon have this feature Peri-shock Pauses Take Homes Be ready to shock before stopping CPR Stop CPR and shock near simultaneously Hands on CPR? Post shock interval is not as important 7

8 2/3/2 Resuscitation 24; epub ahead of print Is hands-on defibrillation safe? Cadaver study; 6 cadavers used Used A-P defibrillator pad placement Defibrillated cadavers at 36 joules Dry Abrasion-Dry H 2O / NSS NSS Gel Conclusions Based on this study, hands-on defibrillation is dangerous and should not be done Or Resuscitation 24; epub ahead of print Based on this study, cadavers should not defibrillate themselves Study Issues Used cadavers without blood and perfused organs Measured current on cadaver body surface Did not directly measure current going to rescuer directly 8

9 2/3/2 Take Homes on Hands-On Defibrillation (HOD) Resuscitation 24; epub ahead of print This is the first hands-on defibrillation study not to use hands-on defibrillation The safety of hand-on defibrillation (HOD) is not fully known Use gloves if you do HOD Do not put your hands on the pad(s) Large real life study needed HOD or not, minimize pre-shock pause Resuscitation 23;84:69-96 How effective is a precordial thump in patients with VF or VT? 434 EMS patients with monitored VF or VT 7% shocked vs 2% initially thumped 6.% (7 patients) responded to thump 7.8% of defibrillated immediate ROSC Response to Precordial Thump (n = 3) % No Response 6. Response 4.9 ROSC Resuscitation 23;84: Deterioration.9 VF - VT Precordial Thump Take Homes Rarely works ( / 8 ) 2x deteriorate vs improve ROSC rare Dramatic, for TV, real life, not so much Circulation 24;epub Sept 24 Is the current AHA CPR guideline of >mm (2in.) compression depth correct? 9,36 ROC CPR patients Mean depth of compression 4.9mm Evaluated survival on compression depth 9

10 2/3/2 Survival increased per each mm increase in compression depth BUT Maximum survival benefits achieved by 4.6mm (.8 inches) Depth & Compressions Take Homes Circulation 24;epub Sept 24 The Authors Conclude: Maximize survival was in the depth interval of 4.3.3mm (peak 4.6) suggesting that the 2 AHA CPR guideline target may be too high.8 inches 2 inches NOT more NOT less Beta Blockers AMI CPR Circulation 23;28:49-3 Annals of Emerg Med 24, epub ahead of print Is immediate Beta-Blocker again indicated in acute STEMI care?

11 2/3/2 Circulation 23;28: STEMI patients; STEMI < 6 hours Killip Class I or II; no III or IV mg Q min IV metoprolol (n = 3) Oral metoprolol s/p PCI MRI evaluation at -7 days (n = 22) g Infarct Size (Grams of Infarct) 32 Control Circulation 23;28: Metoprolol p =.2 Other Findings Circulation 23;28:49-3 LV EF by 2.67% with BB No increase in adverse effects No in heart failure or heart block with BB No in mortality with BB Composite Index (Death, VF/VT, Shock, AV Block, Re-AMI) % % Control Circulation 23;28: % Metoprolol p =.2 Annals of Emerg Med 24, epub ahead of print Anterior AMI subset analysis 47 patients from METOCARD-CNIC Trial Prehospital IV metoprolol mg Q x 3 doses g Infarct Size (Grams of Infarct) 34 Control Annals of Emerg Med 24, epub ahead of print 23.4 Metoprolol - 3% infarct size p =.9

12 2/3/2 Composite Index (Death, VF/VT, Shock, AV Block, Re-AMI) % % Control Annals of Emerg Med 24, epub ahead of print 6.8% Metoprolol -.% absolute p =.3 Acute IV Beta Blockade in STEMI Take Homes Clinically Significant reduction in infarct size and composite endpoints but not statistically significant MDs administered in EMS units Was Killip I and II by MD exam Not yet a practice changer But coming?? Esmolol for Refractory VF/VT Sustained ROSC and Good Neuro D/C Resuscitation 24;8: Resuscitation 24;8: Is Esmolol effective in refractory VF/VT? Retrospective ED study % 66% % All EMS to ED arrivals All s/p 3 shocks, 3 doses Epi, 3mg Amio Compares Esmolol vs no Esmolol 3 2 No Esmolol Sustained ROSC.% No Esmolol Good Neuro D/C BB For Refractory VF/VT Does Esmolol help terminate the Electrical Storm of VF? Very small study But impressive results Certainly not harmful Has been suggested for years I think worth a try Small study Resuscitation 24;8: patients: 9 received Esmolol Loaded with.mg/kg Maintained at -.mg/kg/min 4/6 had ROSC Cath lab Two of theses 4 had STEMI 2

13 2/3/2 Vomiting With and Without Morphine Circ Cardiovasc Inter 2;8 epub Jan % Circ Cardiovasc Inter 2;8 epub Jan 3 PCI patients with STEMI P =. 9 patients (32%) received morphine Evaluated incidence of vomiting Measured platelet inhibition Morphine 2% No Morphine High Residual Platelet Activity (P2Y 2 > 28) Morphine in AMI Take Homes 3% Morphine 29% No Morphine P =. Morphine increases vomiting in AMI Decreases platelet inhibitor absorption Platelet aggregation affected by morphine Try to use fentanyl and antiemetics If you use morphine less and antiemetics TXA J Trauma and Acute Care 24;76: Level trauma patients All required immediate OR or blood TXA gram IV then G over 8 hours 4% penetrating trauma, 2% TBI Evaluated mortality in TXA matched pts 3

14 2/3/2 Mortality TXA vs Standard Care J Trauma and Acute Care 24;76:373 27% J Trauma and Acute Care 24;76:373 August 29 January 23 8% SBP < 2 mm Hg 3% SBP < 7mm Hg ¾ required surgery and transfusion Evaluated mortality in TXA matched pts 7% No TXA TXA P =.24 Use new drugs as soon as possible Before they develop side effects or loose efficacy J Trauma and Acute Care 24;76:373 Groups perfectly matched TXA group received more fluids, RBCs and FFP in OR If the death within 2 hours patients excluded then: Changes 8 deaths to 6 total deaths TXA vs No TXA Deaths in 2 hrs exlcuded J Trauma and Acute Care 24;76:373 TXA Summary % Role in US Level I Centers Unclear 7% P =.24 Seems to work if transport to definitive care will be delayed significantly No TXA TXA Studies over next 2-8 months will be more definitive 4

15 2/3/2 TXA 2 Emerg Med Australia 24;26:94-7 Prehospital antifibinolytic coagulopathy and hemorrhage study PATCH Study Australian study Currently underway Evaluates TXA for EMS use A randomized TXA study in high morbidity high mortality Australian and New Zealand patients TXA Summary Prehosp Emerg Care 24; early online STAAMP Trial TXA During Air Medical Prehospital Transport US Department of Defense trial Will use TXA during air evacuations Placebo-controlled, randomized Rochester NY, Pittsburg, Utah and San Antonio < 2 hrs of injury, < 9 SBP, HR > 3 dosing regiments Proven on battlefield Proven in 3 rd world countries Role is soon to be clarified Data appears somewhat convincing Don t be too sure either way Chest 2; online Jan 29 Lytic Therapy for PE Evaluates BOVA Score for predicting complications from symptomatic PE,83 PE patients divided into 3 groups Used prior 2874 pts derivation cohort findings 3 day follow-up; Spanish study Hypotensive patients excluded

16 2/3/2 BOVA Score PE Related Complications and Mortality Chest 2; online Jan 29 Variable Points Systolic BP 9 mmhg 2 Cardiac Troponin elevation 2 RV dysfunction (CT or US) 2 HR > Stage = -2 Stage II = 3-4 Stage 3 = >4 % PE Complications PE Mortality JAMA 24;3: Meta-analysis, 6 trials, 2, pts, % Low risk, 7% Intermed,.% High risk,499 Intermediate risk patients evaluated Assessed morbidity and major bleeding Urokinase, streptokinase, TPA, TNK used Intermediate Risk defines as a Hemodynamically stable PE with RV dysfunction 6

17 2/3/2 Mortality Heparin vs Lytics in PE JAMA 24;3: Recurrent PE JAMA 24;3: % Heparin 2.7% Thrombolytic P = % Heparin.7% Thrombolytic P =.3 PE Major Bleeding JAMA 24;3: Risk of ICH JAMA 24;3: % % Heparin Thrombolytic P < % Heparin.46% Lytic P =.2 Age 6 and Older Mortality and Major Bleeding JAMA 24;3: Age Younger Than 6 Mortality and Major Bleeding JAMA 24;3: % 3.6% Mortality Bleed Heparin 2.8% Mortality Lytic 2.93% Bleed p =.7 p < % 2.27% Mortality Bleed Heparin 2.32% Mortality Lytic 2.84% Bleed p =.9 p =.89 7

18 2/3/2 Intermediate Risk Patients NEJM 24;37:42- NEJM 24;37:42-, patients, 76 sites, 3 countries Randomized, double blind, placebo controlled Full dose TNK + UFH vs UFH only Intermediate risk PE patients Death or hemodynamic collapse at 7 days PE by CTA (94.9%) All patients normotensive All had RV dysfunction All had Troponin elevation Efficacy: TNK vs Placebo in PE NEJM 24;37:42- Safety: TNK vs Placebo in PE NEJM 24;37: %. P =.2 P =.2 P < P = NS P =.3.2 TNK Placebo TNK Placebo Death Hemodynamic Collapse TNK Placebo TNK Placebo Death Only Cause Major Bleeding TNK Placebo Hemorrhagic Shock Thrombolytics for Intermediate Risk PE Take Homes Hemodynamically stable PE pts with RV dysfunction have decreased mortality with thrombolytic therapy Lytic therapy, however, dramatically increases major bleeding and ICH, especially in pts 6 yo and older All PE pts should have RV dysfunction and troponin evaluated If CTA shows significant clot, plus there is RV dysfunction, plus troponin is positive: patients should be considered for lytic therapy based on age, comorbidities and bleeding risks Half dose TNK should always be considered Circulation 24;29: Is ultrasound-assisted catheter directed thrombolysis superior to IV heparin for intermediate-risk PE? Multicenter, randomized trial 9 patients with PE by CT, RV > LV IV UFH vs - 2mg TPA by EKOS 8

19 2/3/2 Circulation 24;29: Study Outcomes Change in RV size (RV/LV ratio) Death Major Bleeding Minor Bleeding RV/LV RV/LV Ratio at 24 Hours EKOS vs UFH in PE.2 UFH.7 p =.3 p < = 24 hrs + = 24 hrs EKOS EKOS For PE Take Homes Circulation 24;29: Additional Results No death from PE in either group No major bleeding in either group 3 minor EKOS bleeds vs with UFH No large study yet Appears safe in small study Appears to improve RV/LV dysfunction Unclear if truly superior long term EKOS vs / 2 dose TNK one day New Engl J Med 2;372:28-3 STROKE Is magnesium neuroprotective in stroke?,7 randomized prehospital patients MgSO 4 within 2 hours of stroke 4 grams MgSO 4 in min; 6grams/24hrs Magnesium offers NO benefits 9

20 2/3/2 New Engl J Med 24;372:-2 Can a mechanical therapy improve outcome in CVA patients who have distal carotid or proximal MCA or ACA occlusion? patients from the Netherlands Mechanical therapy vs control 89% Rxd with TPA pre-randomization Used retrievable stents (8.%) New Engl J Med 24;372:-2 All patients had distal internal carotid, MCA (M, M 2 ) or ACA (A, A 2 ) lesions Modified Rankin Score at 9 days = no sx, no clinical disability New Engl J Med 24;372:-2 Modified Rankin Score 2 at 9 days 2 = slight disability, can look after self, not at baseline New Engl J Med 24;372: % Control Group.6% Mechanical Rx OR = 2.6 ( ) % Control Group 32.6% Mechanical Rx OR = 2. ( ) There was a 3.% absolute increase in the likelihood of having a 2 modified Rankin Score at 9 days 2

21 2/3/2 Mr. Clean Trial Comments Authors note that second generation retrievable stents are superior to first generation Merci device one that failed to improve outcomes when added to TPA 9% of interventional group embolized 3% underwent carotid stenting Adding Intraarterial Treatment to TPA Take Homes Results are encouraging and suggest this therapy may become mainstream Single study from the Netherlands Control group in this study did not do as well as in other TPA studies If you can walk and care for yourself with a 3.% increased chance, lets study it more New Eng J Med 2; epub ahead of print Does mechanical thrombectomy improve outcomes in acute stroke patients who have also received TPA The ESCAPE Trial Treatment within 2 hours of symptoms Proximal anterior occlusion, small infarct core Moderate to good collateral circulation IV TPA post CT/CTA perfusion study New Eng J Med 2; epub ahead of print 36 patients, 22 centers Canada, US, S. Korea, Ireland, UK Thrombectomy via available devices Retrievable stents recommended Suction through catheter in carotid Rankin Score New Eng J Med 2; epub ahead of print All patients received TPA with or without use of mechanical device Study stopped before planned patients due to MR. CLEAN findings and efficacy in first 3 ESCAPE subjects No symptoms No clinically significant disability 2 Slight disabilities Moderate disabilities 4 Moderately severe disabilities Severe disabilities 6 Death 2

22 2/3/2 9 Day Good Neurologic Outcomes (Rankin -2) New Eng J Med 2; epub ahead of print % 6 3.% % P <. 3 2 TPA PTA + Mechanical Mechanical Device in Stroke Take Homes Based now on 2 different studies, it appears this will become the standard of care unless Oxygen Therapy a new trial shows harm 22

23 2/3/2 Is too much oxygen bad? Is % O 2 sat wrong? Intens Care Med 2;4: post CPR patients treated with O2 Hyperoxia vs Prob Hyper, vs Normal vs Hypoxia ( >3 vs 299 vs 6 vs <6mm Hg) Used Utsein co-variates and multiple repressions UPMC Presbyterian Hospital Intens Care Med 2;4:4-9 Measured hours of hyperoxia (O 2 > 3mm Hg) Overall survival to discharge 46% 36% of patients had hyperoxia; x =.4hrs (+ 2.2h) Results Intens Care Med 2;4:4-9 Hyperoxia = Sequential Organ Failure Each Hyperoxia hr Survival by an OR of.84 Probable Hyperoxia not Deleterious Odds of Survival to Discharge Intens Care Med 2;4:4-9 Oxygen Take Homes p =.2 Hyperoxia for any length of time in bad Avoid % O 2 sats ASAP Damage appears time dependent Hyperoxia increases mortality and MOSF Hyperoxia ( >3) Mod Prob ( 299) Normal (6 ) Hypoxia ( <6) 23

24 2/3/2 Resuscitation 24;8:42-48 Do we need to be vigilant about preventing both Hypoxia and Hyperoxia? Reviews 4 studies, 8 full, 6 abstracts 49,9 patients Hyperoxia defined as Pa O 2 > 3mm Resuscitation 24;8:42-48 Hyperoxia was associated with a 4% increase ( OR =.4) in hospital mortality Hyperoxia Take Homes No study has shown a benefit from hyperoxia Increasing number of small studies, and now this meta-analysis show harm Never be at % O 2 by pulse ox Early Resuscitation For Sepsis Aim for 93 9% 89 92% or COPD EGDT Protocol Care New Engl J Med 24;37: New Engl J Med 24;37: ,39 patients from 3 US EDs Protocol based PROCESS trial; 3 groups 439 EGDT, 446 Protocol, 46 Usual Evaluated 9 day and year mortalities Evaluated multiple other parameters cc bolus till CVP > 8 CVP catheter to CVP > 8 Vasopressors if SVO 2 < 7% Dobutamine RBCs 24

25 2/3/2 Protocol Care CVP not required Up to 2,cc if SBP < Pressors if SBP < s/p 2L New Engl J Med 24;37: Standard Therapy New Engl J Med 24;37: Fluids until MD felt perfusion adequate Pressors as needed by MD RBCs only if Hgb < 7.g/dl Fluid Resuscitation New Engl J Med 24;37: Vasopressor Use New Engl J Med 24;37: P < % 2.2% 44.% P = EGDT Protocol Usual EGDT Protocol Usual Survival in PROCESS Trial In Hospital and 9 Day New Engl J Med 24;37: P = NS New Engl J Med 24;37:496-6,6 patients ARISE Trial Australasian Resuscitation in Sepsis Eval In-Hosp 9 D In-Hosp 9 D EGDT Protocol In-Hosp 9 D Usual 76 EGDT, 84 Usual Care Volume, Pressors, RBCs Compared 9 day outcomes Evaluated 2

26 2/3/2 EGDT vs STD Therapy EGDT vs STD Therapy 9 Day Mortality New Engl J Med 24;37:496-6 % cc cc EGDT STD Volume P <. for all EGDT STP Pressor EGDT STD RBCs % % EGDT 8.8% STD RX P = NS Protocol Care in Sepsis Take Homes New Engl J Med 24;37:496-6 Additional Results No difference in 9 day survival No difference in in-hospital mortality No difference in LOS No difference in organ support No benefits to routine CVP No benefits to aggressive pressors No benefits from early transfusions Be aggressive with fluid and early ABX Transfer for Hgb < 7.g/dl Living Forever Eat more fish, less red meat Living Forever Drink 2 glasses of wine or ETOH Consume less saturated fats and fried foods Eat more nuts Exercise? 26

27 2/3/2 JACC 24;64:472-8 Does running affect mortality? How far to get what benefit?,37 patients, years follow-up Used medical hx questions of leisure activities Divided runners in quintiles < min/wk - >76 min/wk JACC 24;64:472-8 Used Cooper Clinic of Dallas, TX patients Most college educated, white, socio economic Ages 8-, M/F, mean age 44 at baseline Excluded prior MI, CVA, cancer Runners vs Non-Runners Death Rate (Deaths/yr/, patients) Take Homes JACC 24;64:472-8 Running reduces all cause mortality by 3% Running reduces cardiac mortality by 4% All Cause Card Non-Runners 8. All Cause Card Runners Findings consistent even if running just min/week Can run -2x/week slowly for benefits ( < min miles) Benefits overcame smoking, HT, HL, obesity Average in lifespan = 3 years Running increasing distances and/or at faster pace does not increase life more! Do something physical! Walking is safe and is highly beneficial 27

28 2/3/2 Summary BLS > ALS in cardiac arrest Take all VF/VTs to PCI Minimize CPR pauses Hands on chest - maybe Beta Blockers: more Summary TXA: maybe Lytics work in PE, but Mechanical stroke Rx: yes Oxygen: not too much Be aggressive in sepsis 28