But unfortunately, the first sign of cardiovascular disease is often the last. Chest-Compression-Only Resuscitation Gordon A.

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1 THE UNIVERSITY OF ARIZONA Sarver Heart Center 1 THE UNIVERSITY OF ARIZONA Sarver Heart Center 2 But unfortunately, the first sign of cardiovascular disease is often the last 3 4 1

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3 Risk of Cardiac Arrest

4 Cardiocerebral Resuscitation Recognition Call 911 CO-CPR AED Initiating Resuscitation Revised ACLS Protocol Definitive Resuscitation Cardiac Receiving Centers Post-Resuscitation Care The New CPR for Primary Cardiac Arrest What is wrong with Cardiopulmonary Resuscitation?

5 What you really want to know is: The survival of patients in your community with OHCA secondary to Ventricular Fibrillation? Utstein 1 vs. Utstein 2 and later

6 Early Access Early CPR Early Defib Early ACLS Early Access Early CPR Early Defib Early ACLS Cummings et al Circulation 1991;83: Cummings et al Circulation 1991;83:

7 A major reason for the low rate of bystander CPR was the ABCs --the requirement for mouth-tomouth ventilations as an initial step! Cardiocerebral Resuscitation Recognition Call 911 CO-CPR Revised ACLS Protocol Cardiac Resuscitation Centers Initiating Resuscitation Definitive Resuscitation Post-Resuscitation Care Secondary Cardiac Arrest

8 Primary Cardiac Arrest Unexpected, witnessed (seen or heard) collapse in an individual who is not responsive Secondary Cardiac Arrest Secondary to Respiratory Failure: e.g. Drowning, Drug Overdose, Respiratory Failure Primary CARDIAC ARREST A witnessed (seen or heard) unexpected collapse in an individual who is not responsive Gasping is Common 55% of witnessed VF arrests VF persists with CO-CPR At the time of a primary cardiac arrest due to VF, the arterial blood is oxygenated

9 Primary Cardiac Arrest Ventricular Fibrillation (VF) Ventricular Tachycardia (VT) Asystole Pulseless Electrical Activity (PEA) Primary Cardiac Arrest Ventricular Fibrillation (VF) Ventricular Tachycardia (VT) Asystole Pulseless Electrical Activity (PEA) Electrical Phase Circulatory Phase Metabolic Phase Weisfeldt ML, Becker LB. JAMA 2002: 288:

10 Can the Electrical Phase of VF arrest be prolonged? How does Chest Compressions perfuse the heart? DK UMC y/o transplant rejection; BIVAD: VF 4/27/90 5/7/

11 The heart is perfused during diastole! Perfusing the Heart during Cardiac Arrest Coronary Perfusion Pressure = Ao RA diastolic pressure HeartMate II (both ventricles) No pulse, BP, ECG, nor Heart Sounds! Aortic and RA pressures during VF and 15:2 Compressions:Ventilations During Cardiac Arrest, the heart is also, only perfused during diastole The release phase of chest compression

12 Coronary Perfusion Pressure (mm Hg) hour Survivors Resuscitated But Expired Could Not Resuscitate Kern, Ewy, Voorhees, Babbs, Tacker Resuscitation 1988; 16: Percent Hour Neurologically Normal Survival 100% 80% 60% 40% 20% 0% 73% CO-CPR 13% No CPR University of Arizona Sarver Heart Center CPR Research Group Percent Hour Neurologically Normal Survival 100% 80% 60% 40% 20% 0% 73% 70% CO-CPR Ideal Std-CPR University of Arizona Sarver Heart Center CPR Research Group 48 12

13 We then learned that lay individuals interrupt chest an average of 16 seconds to deliver the recommended 2 quick rescue breaths CO-CPR equivalent to ideal CPR: 4 sec interruption of each set of chest for MTM ventilations What about realistic CPR: 16 sec interruption of each set of chest for MTM ventilation? 71% 19% ventilations 42% 58% ventilations 24-Hour Neurological Normal Survival (percent) Outcomes During Simulated Single Lay Rescuer Scenario of OHCA from VF (3 minutes VF, 12 minutes CPR, then ACLS) 100% 80% 60% 40% 20% 0% 80% CO-CPR P < % Realistic 2:15 CPR 51 Kern, Hilwig, Berg, Sanders, Ewy. Circulation 2002; 105:

14 53 Cardiocerebral Resuscitation Recognition Call 911 CO-CPR AED if available CHECK CALL COMPRESS Cardiac Resuscitation Centers Post-Resuscitation Care

15 Bystander CPR for OHCA in Arizona (2005 to 2010) Survival after Bystander CPR for OHCA in Arizona (2005 to 2010) Compression Only CPR Advocated and Taught 5,272 adult presumed cardiac arrests not observed by EMS 4,493 adult not observed by EMS 2,941 no bystander resuscitation 1,550 bystander resuscitation 1,532 Bystander CPR 675 Conventional CPR 779 excluded; non-lay or occurred in medical facility 2 excluded; missing bystander data 18 excluded unidentified bystander CPR technique 857 CO-CPR A. All OHCA B. AOR 1.6 (95% CI, ) 7.8% 13.3% Witnessed/Shockable 17.7% 33.7% 4,415 comparison to survival to hospital discharge after cardiac arrest (10 missing outcomes, 1 missing rhythm data, 47 missing response intervals % 3.8% 2.7%

16 Cardiocerebral Resuscitation Cardiocerebral Resuscitation Recognition Call 911 CO-CPR AED Initiating Resuscitation Revised ACLS Protocol Definitive Resuscitation Cardiac Resuscitation Centers Post-Resuscitation Care EMS arrival Oral Pharyngeal al Airway Passive Ventilation (100% O2) Administer IV/IO 1 mg epinephrine every 3 to 5 minutes Consider endotracheal Intubation (follow Guidelines) The battle for life or death in patients with OHCA is won or lost in the field Cardiocerebral Resuscitation Why not intubate?

17 What if you could always intubate in a few seconds? or Why not use Bag Valve Mask ventilation? Early in cardiac arrest, any form of positive pressure ventilation is potentially harmful Death by Hyperventilation! 67 Sigurdsson et al (Aufderheide, Lurie) Circulation 2003; 108: IV

18 Use of passive oxygen insufflation (POI) (passive ventilation) EMS arrival Cardiocerebral Resuscitation Oral Pharyngeal al Airway Passive Ventilation (100% O2) Administer IV/IO 1 mg epinephrine every 3 to 5 minutes Consider endotracheal Intubation (follow Guidelines) Why before defibrillation?

19 Aortic Pressure CVP Coronary Perfusion Pressure Blood volume shifts from the arterial to the venous system Pressure (mmhg) Coronary Perfusion Pressure Ao mean RA mean RA mean Arthur Guyton s Mean Circulatory Filling Pressure :00 00:15 00:30 00:45 01:00 01:15 01:30 01:45 02:00 02:15 02:30 02:45 03:00 03:15 03:30 03:45 04:00 04:15 04:30 04:45 05:00 05:15 05:30 05:45 06:00 06:15 06:30 06:45 07:00 07:15 07:30 07:45 08:00 08:15 08:30 08:45 09:00 09:15 09:30 09:45 10:00 10:15 10:30 10:45 11:00 11:15 Time (mm:ss)

20 Defibrillation 1 st vs. CPR 1 st after prolonged VF Sinus Rhythm CO-CPR Pulseless Electrical Activity (PEA) Perfusing rhythm more likely 77 VFmf (Hz) Initial 8 min 9.5 min * DEFIB CPR DEFIB 1 st CPR 1 st Berg, Kern, Hilwig, Ewy Annals of Emergency Medicine 2002:40: Following the Guidelines Tucson paramedic/firefighters were compressing the chest less than ½ of the time What else was wrong with the 2000 AHA ECC Guidelines? A B C

21 Cardiocerebral Resuscitation Tucson, AZ November We explained our rationale Circulation 2005; 111: Resuscitation; 2003; 58: 271 Resuscitation; 2005; 64:

22 When do you have to begin mild positive pressure ventilation? Arterial Oxygen Saturation 10 minutes of un-treated VF, 7 minutes of CO-CPR Arterial Oxygen Saturation Summit of Mount Everest Arterial Oxygen Saturation of 34% is consistent with survival! Grocott MPW et al. NEJM

23 It is blood flow that keeps us alive not oxygen content! EMS arrival Cardiocerebral Resuscitation for pre-hospital phase of primary cardiac arrest Oral Pharyngeal al Airway Passive Ventilation (100% O2) Administer IV/IO 1 mg epinephrine every 3 to 5 minutes Consider endotracheal Intubation (follow Guidelines) EMS arrival Cardiocerebral Resuscitation for pre-hospital phase of primary cardiac arrest Oral Pharyngeal al Airway Passive Ventilation (100% O2) Administer IV/IO 1 mg epinephrine every 3 to 5 minutes Why not check the rhythm after the shock? Consider endotracheal Intubation (follow Guidelines)

24 Cardiocerebral Resuscitation for primary cardiac arrest EMS arrival Oral Pharyngeal al Airway Passive Ventilation (100% O2) Administer IV/IO 1 mg epinephrine every 3 to 5 minutes Consider endotracheal Intubation (follow Guidelines) Great! Cardiocerebral Resuscitation Witnessed collapse and shockable rhythm Neurologic Intact Survival 96 24

25 Neurological Intact Survival from OHCA Rx CCR Witnessed collapse and shockable rhythm 97 EMS arrival Cardiocerebral Resuscitation for primary cardiac arrest Oral Pharyngeal al Airway Passive Ventilation (100% O2) Administer IV/IO 1 mg epinephrine every 3 to 5 minutes Consider endotracheal Intubation (follow Guidelines) 98 Epinephrine in Cardiac Arrest Not needed during the electrical phase Improves survival during the circulatory phase Not effective during the metabolic phase 99 Epinephrine Out-of-Hospital Cardiac Arrest

26 Necessary For ROSC Sarver Heart Center Study Epinephrine OHCA Ewy, G.A. et al (UA-SHC Resus Research Group 103 Ewy, G.A. et al (UA-SHC Resus Research Group

27 Epinephrine OHCA Epinephrine OHCA Ewy, G.A. et al (UA-SHC Resus Research Group 105 Ewy, G.A. et al (UA-SHC Resus Research Group 106 Survival to Hospital Discharge < 9 min 9-13 min Ewy, G.A. et al (UA-SHC Resus Research Group > 13 min 107 Cardiocerebral Resuscitation Recognition 911 COCPR AED Initiating Resuscitation Revised ACLS Protocol Definitive Resuscitation The New CPR for Primary Cardiac Arrest Cardiac Receiving Centers Post-Resuscitation Care

28 Cardiac Receiving Centers Cardiac Receiving Center Includes 109 Spaite, Bobrow et al (Ewy senior author) Ann Emergency Med 2014:64: A boy from Kansas

29 113 Greg Thomas, M.D Prescott AZ. 114 Results Are Even Better than Seattle WA McPherson Kansas James Prescott, M.D. Greg Thomas, M.D

30 University of Arizona Sarver Heart Center CPR Research Group Sanders Ewy Berg Hilwig Kern THE UNIVERSITY OF ARIZONA Sarver Heart Center 117 Not shown Charles Otto, MD (anesthesia), Mathias Zuercher, MD (anesthesia) Mark Berg, MD (Peds) Ben Bobrow, MD and Lani Clark 118 Questions?