Do chest compressions have a role in the early treatment of haemorrhage - induced traumatic cardiac arrest

Transcription

1 15 th National Resuscitation Congress 4 th April 2018 Do chest compressions have a role in the early treatment of haemorrhage - induced traumatic cardiac arrest Dr Sarah Watts 1, Surg Capt Jason Smith 2 & Dr Emrys Kirkman 1 1 CBR Division, Dstl, Porton Down, UK 2 RCDM, Birmingham, UK

2 Overview Introduction Background to TCA Outcomes Treatment Pre-clinical study Animal model of haemorrhage-induced TCA to assess the utility of chest compressions Summary and conclusions

3 Introduction What is Traumatic Cardiac Arrest (TCA)? Different to medical-ca Patient that has sustained trauma, agonal or absent respiration and absent central pulses Healthy heart with arrest due to haemorrhage, hypoxia or obstruction Outcomes traditionally thought to be poor Battistella E et al. 2.6% patient survived to discharge with almost 50% having severe neurological disability Shimazu S et al. 2.6% long-term survival (1.5% functional)

4 Introduction Author No of Patients Primary Outcome Lockley D et al 909 Survival to discharge Comments 7.5% survived. Tarmey N et al 52 Survival 8% good neurological outcome Leis C et al 167 ROSC & CNR ROSC = 49.1%; CNR=6.6%. Better outcome if young, early initiation of treatment or if VF/PEA versus asystole Chien C-Y et al 396 Survival to discharge Evans C et al 2300 Survival to discharge 2.3% survived. Study concluded that 15min resuscitation was not appropriate for TCA 6.3% survived. Barnard E et al day survival 7.5% survived (>60% had moderate disability or good outcome). Outcome best if TBI or haemorrhage in absence of other injury.

5 Treatment of CA Medical-CA Evidence suggests chest compression only resuscitation effective CPR (SOS-KANTO Group Lancet 2007) Most recent guidance treat reversible causes Hypoxia, Tamponade, Tension pneumothorax, Hypovolaemia (Chinn & Colella JEMS 2017; Sherren et al Crit Care 2013; European Resuscitation Council 2015) Evidence for CPR and/or Chest compressions for TCA 2 animal studies (Luna GK BJ et al. J Trauma 1989 and Jeffcoach DR et al. J Trauma Acute Care Surg 2016) Study compared CCC to OCCM no difference in outcome

6 Pre-clinical Study of Haemorrhage Induced Cardiac Arrest

7 Aims For a resource constrained environment A. Determine whether chest compressions affect: 1. The attainment and 2. The maintenance of ROSC (MAP 50mmHg) AND B. Determine whether attainment ROSC is influenced by the choice of initial resuscitation fluid

8 Study Protocol Study conducted under UK A(SP)A 1986 Terminally anaesthetised Large White pigs 35kg (29-40kg) Ventilated Instrumented Invasive cardiovascular monitoring Blood sampling End Resusc. Cycle 3 Injury Shock 60 min TCA 5 Groups Closed chest compressions (CCC) Whole blood ± CCC (WB, n=8; WB+CCC, n=8) Resuscitation 3 cycles Saline ± CCC (Sal, n=8; Sal+CCC, n=9)

9 Study Protocol End Resusc. Cycle 3 Study End (ROSC) Injury Shock 60 min TCA If MAP <20mmHg continue CCC (CCC Gps) Resuscitation Chest compressions delivered using LUCAS II Chest Compression System Fluid (10ml/kg) delivered i/v via Belmont Rapid Infuser FMS 2000 CaCl 2 administered i/v to maintain Ca 2+ >1mM 5 Groups Closed chest compressions (CCC) Whole blood ± CCC (WB, n=8; WB+CCC, n=8) Saline ± CCC (Sal, n=8; Sal+CCC, n=9) ROSC = MAP 50mmHg; Partial ROSC = MAP >20 but < 50mmHg; Dead = MAP < 10mmHg

10 Results: Baseline Data MAP No significant difference between the groups from baseline to Start Resuscitation P=0.696 Significant difference over time in all groups P< way ANOVA

11 Results: Primary Outcome ROSC Study End CCC worse than fluid, P< WB better than saline, P=

12 Results: Primary Outcome ROSC Study End CCC worsen outcome with saline resuscitation, P= but not with blood, P=0.4411

13 Results: CCC Adversely Effects Attainment of ROSC P=0.003 P= P=0.001 P=0.0023

14 Results: CV effects of CCC

15 Study limitations No active bleeding (controlled haemorrhage) Modelling where catastrophic haemorrhage controlled Non-recovery Long-term neurological outcome not known Animals ventilated throughout To eliminate hypoxia as an experimental confounder Autologous whole blood

16 Summary & Conclusions TCA occurs in a relatively small number of trauma cases Recent clinical studies show improved outcomes Likely due to early targeted treatment e.g. fluid resuscitation In an animal study CCC only resuscitation resulted in 100% mortality ROSC was only achieved in those administered whole blood The addition of CCC resulted in cardiac compromise compared to fluid alone When CCC ceased during post-resuscitation phase there was an improvement in CV variables and attainment of ROSC (WB treatment only) TCA different aetiology to medical cardiac arrest and treatment protocols should differentiate to 2 conditions Clinical and pre-clinical evidence supports rationale of early treatment reversible causes of TCA

17 Acknowledgements Crown copyright (2018), Dstl. This material is licensed under the terms of the Open Government Licence except where otherwise stated. To view this licence, visit or write to the Information Policy Team, The National Archives, Kew, London TW9 4DU, or

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