Resuscitation Articles 2017 Corey M. Slovis, M.D. Vanderbilt University Medical Center Metro Nashville Fire Department Nashville International Airport Nashville, TN Annal Emerg Med 2017;Epub ahead of print BMJ 2016;353:1577-87 Does giving epinephrine before 2 nd shock help or hinder resuscitation? 2,974 VF/pVT arrests, 1,510 with epi < 2 min Inpatient data from 300 GWTG-R hospitals Propensity matched cardiac arrest pts Compared epi before vs after 2 nd shock Epi Before vs After 2 nd Shock BMJ 2016;353:1577-87 51% of patients received epi before 2 nd shock 87% of both groups received 2 nd defib Groups equal for total defibrillations (3) Early epi group received 3 mgs or epi on average vs 1 mg in later dosing Similar TOR times (22 vs 21 mins) % 80 70 60 50 40 30 20 10 0 67% ROSC 79% 31% 48% < 2 > 2 min < 2 > 2 min Survival BMJ 2016;353:1577-87 All p < 0.001 41% 25% < 2 > 2 min Good Neuro 1
Early Epinephrine Administration Wait for second shock before administering epinephrine The role of epi is still not clearly defined but wait to administer it Epinephrine is the most potent cardiac stimulant wait to give it during VF Tachycardia Termination vs Side Effects 67% Eur Heart J 2016; June 28 Epub ahead of print Eur Heart J 2016; June 28 Epub ahead of print Is amiodarone really the best antiarrhythmic for VTach / Wide complex QRS tachycardias? Randomized European trial of 62 patients 10 mg/kg of procainamide over 20 minutes (33 pts.) 5 mg/kg of amiodarone over 20 minutes (29 pts.) All had BP > 90 mm Hg and no SOB Evaluated both efficacy and major adverse events 60% Hundreds70% 50% 40% 30% 20% 10% 0% 41% 38% P=0.026 9% Pro Amio Pro Amio Termination Major Adverse Effects P=0.006 Amiodarone vs Procainamide Hypotension Eur Heart J 2016; June 28 Epub ahead of print Hypotension common with both drugs 41% of amiodarone required immediate cardioversion Less than 1/10 (9%) in procainamide group required emergency cardioversion Total adverse events double with amiodarone (48% vs 24%) Amiodarone vs Procainamide for VTach Procainamide clearly superior in this study and much less toxic Amiodarone dose of 5 mg/kg is about 300 mg which is double the 150 mg/10 minutes But even with high dose amiodarone, procainamide much more efficacious My bias is to not use amio in stable wide complex patients and I use procainamide as my antiarrhythmic of choice 2
Stable Wide Complex Tachycardia 5 Steps Be sure it is regular Modified Vagal Maneuver Adenosine: 12 mg IVP Amiodarone: Procainamide: 150 100 mg/10 mg/min min x 2 then 50 mg/min x 5 Shock Prehosp Emerg Care 2015;20:220-5 Are we missing opportunities to administer naloxone during cardiac arrests? 127 opioid proven cardiac arrest deaths State of Rhode Island database 2012-2014 Evaluated how often naloxone given during CPR Analyzed age, sex and signs of drug abuse Drug Overdose Resuscitation Prehosp Emerg Care 2015;20:220-5 140 124 130 120 110 100 90 80 70 60 50 40 30 20 10 0 Narcotics OD Deaths 33.4% 42 No Narcan Older patients, females and NO visible drugs, needles or track marks make Naloxone use less likely Narcan and CPR All respiratory arrests and PEA arrests should have Narcan considered Critical Care 2015;19:160 Is glucose helpful or dangerous in cardiac arrest? 100,029 CPR patients, 349 GWTG hospitals 4,173 (4%) got D50W Compared D50 to no D50 Looked at ROSC, discharge, neuro outcome 3
Glucose is Bad in CPR Unless Patient Hypoglycemic Decreases survival to discharge ( 51%) Decreases neurological outcomes ( 67%) Has no benefits and is dangerous How valuable is early intubation in cardiac arrest? Do not use! ETI vs No ETI ROSC and Survival 59.3% 57.3% JAMA 2017;317:494-506 JAMA 2017;317:494-506 Matched intubated vs non-intubated pts min by min 108,079 pts from 668 GWTH hospitals 60% 50% 40% 30% RR 0.97 19.4% 16.3% RR 0.84 Used 43,314 ETI vs no-eti matched pts over 15 min 20% 10% Evaluated ROSC, survival and good neuro outcomes 0% No ETI ROSC ETI No ETI ETI Survival ETI vs No ETI Good Neuro JAMA 2017;317:494-506 16% 14% 12% 13.6% 10.6% 10% 8% RR 0.78 6% 4% 2% 0% No ETI ETI Good Neuro 4
ETI in Adult Cardiac Arrest Intubation decreased absolute survival and good neuro outcome by 3% This is a 22% relative reduction in good neuro outcomes at discharge Biggest difference was in shockable rhythm 32% relative decrease in good neuro Focus on timely defibrillation and high quality CPR! JAMA 2016;316:1786-97 Should we be intubating children in cardiac arrest? Inpatient study, 2,294 pts, 1,555 intubated GWTG Registry Hospitals; 2/3 ED or ICU Median age: 7 months 75% were 21 days 4 years old; 90% witnessed Used matched non-eti controls % 45 40 35 30 25 20 15 10 5 0 36% ETI Survival To Intubate or Not No 41% 30% ETI 42% No Pulse Favorable Neuro DC JAMA 2016;316:1786-97 14% ETI 17% No No Pulse Favorable Neuro D/C Peds Intubation During Arrest Another bag more, intubate less No improved survival with ETI, maybe less Most children were witnessed arrests, in EDs & ICUs we in the field see already hypoxic patients who need oxygenation as the priority The less kids you routinely intubate, the less you should try A 38 yo woman being treated for a calf DVT presents SOB, tachypnic and with pleuritic CP. She arrests in PEA awaiting a CTA to R/O PE. Are lytics proven to be effective in cardiac arrests due to PE? Am J Emerg Med 2016;34:1963-7 Is TPA effective in PEA arrests due to a massive PE? The PEAPETT study 23 pts with confirmed massive PE and PEA 17 ED pts, 3 in Radiology, 2 ICU, 1 Floor 16/23 PE diagnosed before arrest All treated with 50 mg TPA over 1 minute Heparin then given: 2,000-5,000 bolus 5
Results Am J Emerg Med 2016;34:1963-7 CPR to lytic time was 6.5 min (± 2.1 min) 22/23 regained a pulse within 2-15 min No minor or major bleeding PA pressures dropped from 58 to 40 at 48 hrs 20/23 alive at 22 months Lytics for PEA and PE If PEA is due to, or believed due to, a PE use TPA during CPR 50 units over 1 minute Great results in this trial of proven PE No proven benefit for undifferentiated PEA PEA overall survival = 2-4% With lytics to 80-90% at 2 years!! Before we leave ACLS Two more things: - Hands on defibrillation - Optimal Valsalva Resuscitation 2016;103:37-40 Can we safely perform hands-on defibrillation? Blinded cadaver study 6 different techniques tried 360 joules used (only 30 for bare handed) Ten volunteers Hands on Defibrillation Another study shows it is possible All detected bare handed shock Resuscitation 2016;103:37-40 1% of all other shocks detected 0.2% shocks detected with single layer glove 0.6% with double layer gloves detected No shock detected with firefighter gloves 0.2 amps leaks a safe level Nitrile gloves block > 99% of shocks Not a safety study, no current leak measured Hands-on continues to look feasible 6
PSVT Management Stable Younger Older Valsalva Carotid massage Both Valsalva and Carotid Consider ice water Adenosine 12 mgs IVP Valsalva -- -- -- Adenosine 12 mgs IVP Can you really make the Valsalva a key therapy in PSVT? Lancet 2015;386:1747-53 Can lying the patient down and raising their legs 45 for 15 seconds immediately post Valsalva increase its effectiveness? 428 Patients with PSVT Randomized 1:1 for standard vs. modified Sitting vs sitting then lie back with legs raised Modified Valsalva 5 Steps Lying the patient back and raising their legs 45 maximizes venous return during the relaxation phase of the Valsalva Patient sitting on stretcher Valsalva for 15 seconds Immediately lie patient flat and lift Lift patient s legs 45 for 15 seconds Return to sitting position 7
Valsalva Effectiveness (n=214 each group) % 50 45 40 35 30 25 20 15 10 5 0 15% Standard Lancet 2015;386:1747-53 47% Lie back, Legs up p < 0.0001 or = 4.9 Modifying the Valsalva in PSVT Great maneuver, free and easy No disadvantages Highest reported conversion rate RSI and Airways Takes 15 seconds Legs up better than just supine Practice Changing Etomidate vs Ketamine Annal Emerg Med 2017;69:24-33 Is ketamine superior to etomidate for RSI? 968 trauma patients in retrospective analysis 2 yrs of etomidate vs 2 yrs of ketamine Evaluated mortality, ventilator-free days, pressors Etomidate 20 mg vs 100-150 mg ketamine usual Etomidate - historically used until recently - potential for adrenal suppression - inhibits 11-B hydroxylase Ketamine - previously just in pediatrics - may increase ICP and IOP - HR and direct myocardial depression 8
Single trauma center experience All adult patients (> 18 yo) All were ED airways Direct and multivariate analysis Annal Emerg Med 2017;69:24-33 Adrenal function not directly measured Annal Emerg Med 2017;69:24-33 Etomidate vs Ketamine Annal Emerg Med 2017;69:24-33 Neither drug statistically superior No differences in subgroup most severely injured Ketamine group had lower odds of developing sepsis Etomidate group had lower days on pressors We switched due to concerns from small study (and lots of noise ) about adrenal suppression caused by etomidate Appears to be no difference in a large group analysis Use drug of your choice Etomidate if concerns over tachycardia Ketamine if lower BP Annal Emerg Med 2017;69:7-9 Hypoxia is our enemy Use techniques to O 2 saturation High flow nasal decreases desaturation Annals of Emerg Med 2017;69:62-72 How deleterious is hypoxia and/or hypotension on patients with traumatic brain injury 13,151 EMS patients with TBI Arizona State Trauma Registry pts 4.6% had hypotension (< 90 mm SBP) 6.0% were hypoxic (<90 O 2 sat) 1.6% were both hypoxic and hypotensive 9
50% 40% 30% 20% Mortality in TBI Annals of Emerg Med 2017;69:62-72 43.9% 28.1% 20.7% RSI and Head Trauma We need to be expert at RSI Hypoxia and Hypotension are our enemies Oxygenate well by 2 different means 10% 5.6% Follow BP closely 0% WNL Hypotension Hypoxia Hypoxia & Hypotension Know your induction agents effects Anaphylaxis Is epinephrine safe in older patients with anaphylaxis? 2,995 allergy-related visits; 492 with anaphylaxis 24.8% (122 pts) were 50 yo 2 urban academic British Columbia teaching hospitals BC Ambulance service Looked at IV and IM epi use Resus 2017;Jan 6:Epub ahead of print Results Resus 2017;Jan 6:Epub ahead of print Equal # of older and younger pts BP < 90 mm Older pts more likely to get IV epi (5/122 vs 2/370) The number one cause of death is in anaphylaxis is the failure to give epi in a timely manner 5 pts had complications 4/5 patients were over age 50 10
World Allergy Org J 2015;8:32 Epi Use in Confirmed Anaphylaxis Older vs Younger 70% 60% 50% 60.8% Resus 2017;Jan 6:Epub ahead of print 36.1% OR=0.4 (0.2 0.6) 40% Less than ¼ of cardiac arrests due to anaphylaxis received epi before arrest 30% 20% 10% 0% Younger < 50 Older > 50 on Epi in the Elderly Very, very safe Don t use IV epi routinely in older pts! Don t use IV epi routinely in younger pts! IV epi is for profound shock only Resus 2017;Jan 6:Epub ahead of print And only diluted in 100-1000 cc ED Therapy of Anaphylaxis Epi Diphenhydramine H-2 Blocker In Conclusion Steroids Volume 11
Summary Points Consider procainamide in VT Wait for second shock to give epi TPA if PE possible cause of PEA Don t intubate arrests early Etomidate or Ketamine 12