Cardiac Arrest January 217 Corey M. Slovis, M.D. Vanderbilt University Medical Center Metro Nashville Fire Department Nashville International Airport Nashville, TN CPR 217 Used data based on protocol that BLS was dispatched if ALS not available JAMA 215;175:196-24 Is ALS significantly better than BLS for out of hospital cardiac arrest? 31,292 ALS vs 1,643 BLS cases Medicare billing data records (2% of total) Harvard study 29 211, no rural services 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 3 Day to Survival Propensity Matched JAMA 215;175:1422-3 JAMA 215;175:1422-3 Evaluated survival to discharge 3 day survival 9 day survival CPC function outcomes 1 2 year survival 9 8 7 6 5 4 3 2 1 9.6% BLS 6.2% ALS RR 1.5 95% CI = (1.2 1.7) 1
Poor Neurologic Outcome Discharged Pts Propensity Matched JAMA 215;175:1422-3 BLS vs ALS 5 44.8% AEDs and O 2 by BVM are key 4 3 21.8% (95% CI = 18.6 27.4) How important is ALS? 2 Not a randomized study Many potential confounders BLS ALS Collapse to defibrillation Median Time NEJM 215; 372: 237-15 NEJM 215; 372: 237-15 How important is CPR pre EMS arrival 3,381 witnessed Swedish cardiac arrests CPR vs no CPR pre EMS Evaluated 3 day survival Multiple other variables evaluated 15 14 13 12 11 9 8 7 6 5 4 3 2 1 11 Min No CPR 13 Min CPR pre EMS P <.1 3 Day Survival NEJM 215; 372: 237-15 CPR start time and 3 day survival VF/VT NEJM 215; 372: 237-15 Hundreds 12% 11% % 9% 8% 7% 6% 5% 4% 3% 2% 1% % No CPR 4.%.5% CPR pre EMS P <.1 Hundreds 3% 25% 2% 15% % 5% % 26.4% P <.1 15.6% 7.9% 2.7% -3 4-8 9-14 > 14 Start Time (Min) 2
JAMA 215;314:247-54 Bystander CPR & AED use resulted in a 4.7% survival rate JAMA 215;314:255-64 Does a statewide CPR education and AED first responder program make a difference? North Carolina CARES registry 2-213 4,961 patients Increased AED use by police, rescue squads, etc. Urban, suburban, rural Hundreds 25% 2% 15% Bystander CPR & First Responder AED Use 14.1% 23.1% JAMA 215;314:255-64 P =.2 NEJM 215; 372: 2316-25 Does a phone alert to those close to a cardiac arrest improve bystander CPR % 5% % 2 213 5,989 volunteers CPR trained Used phones with GPS 667 cardiac arrests 911 system sends mobile alerts Bystander CPR NEJM 215; 372: 2316-25 This was a blinded study where phone activation to those within.3 miles (5 meters) was turned on or off in 1:1 randomized manner Hundreds 7% 6% 5% 4% 3% 62% 48% P <.1 2% % % GPS Sent No GPS 3
CPR 215-216 Bystander CPR can double survival More than 8% of 3-day survivors will be neurologically intact 911 center cell phone activation of CPR providers increases the likelihood of bystander CPR pre EMS arrival Importance of BCLS The more bystander CPR the better Can double survival rate Low cost, high yield AEDs in public locations < $1, Less A and more B in CLS Expert BCLS -12 compressions/minute Depress to 2 inches Allow full recoil Don t hyperventilate: 8- times/minute Minimize interruptions / pre shock pauses ACLS 217 The AHA 216 Guidelines for ACLS 147 references 15 writing groups All based on 215 ILCOR topics Oxygen Use Use % O 2 during CPR But not after ROSC 93-95% if well performed 89-92% if COPD 4
BVM vs SGA vs ETT No high quality evidence to favor any ETI may decrease compression fraction For healthcare providers trained in their use either an SGA or ETT may be used as the initial airway during CPR Assessment of ETT Placement Continuous waveform capnography is recommended for placement and monitoring If not available then colorimetric, EDD or ultrasound may be used Ventilation Rate breaths per minute (Q 6 seconds) after advanced airway in place Antiarrhythmic for VF/pVT Amiodarone may be considered Lidocaine may be considered as alternative Magnesium not recommended No antiarrhythmic as yet been shown to increase survival or neurologic outcome after cardiac arrest due to VF/pVT New Engl J Med 216; 374:1711-22 New Engl J Med 216; 374:1711-22 What is the best antiarrhythmic for shock resistant VF/pVT: Amiodarone vs Lidocaine vs Placebo? 3,26 pts., ROC sites Randomized, double blind, placebo controlled VF/pVT, s/p 1 or more shocks, s/p epi Only adult medical VF/pVT OOH Average age 63 ± 14 y; 8% M 6% had bystander CPR BLS in 5.8 min ALS in 8 min EMS call to drug: 19 min (prior trials 21-25 min) 5
Survival to Discharge Neurologic Outcome New Engl J Med 216; 374:1711-22 % 3 24.4 23.7 21 25 18.8 17.5 16.6 2 15 5 A L P A L P Survival Mod Rankin 3 Percentage Differences Amiodarone vs Placebo Amiodarone vs Lidocaine Lidocaine vs Placebo Amiodarone vs Placebo Modified Rankin 3 Amiodarone vs Lidocaine Modified Rankin 3 New Engl J Med 216; 374:1711-22 3.2% (p=.8).7% (p=.7) 2.6% (p=.16) 2.2% (p=.19) 1.3% (p=.44) NEJM 216:375;81-3 Authors Note in Letter to Editor 5% absolute improvement of Amiodarone over placebo (p.4) if arrest witnessed (1934 pts) 21.9% absolute increase Amiodarone vs placebo if EMS witnessed and gave drugs near immediately (p <.1 for 154 pts) Resuscitation 216;7:31-7 What do all studies combined tell us about Amiodarone vs Lidocaine in VF/pVT? 7 studies: 3 RCTs, 4 non-rcts 3,877 pts in RCTs and 7 in non-rcts Includes 216 NEJM trial Admission and Discharged Alive evaluated Results Resuscitation 216;7:31-7 Amiodarone vs Placebo: - trend for hospital discharge with Amio (p=.8) - No difference in favorable neuro outcomes Lidocaine vs Placebo: - No significant difference at discharge Amiodarone vs Lidocaine: - No difference in hospital discharge (p=.81) Amiodarone vs Lidocaine vs Placebo There is no strong evidence on antiarrhythmic efficacy in VF/pVT If 3% superiority of Amiodarone over placebo was true difference (requires larger study) then 1,8 lives would be saved in North America yearly The data is not conclusive The drugs are given -2+ minutes into arrest 6
At the present time, there is no clear benefit of Amiodarone vs Lidocaine Late in VF it s not clear either drug is beneficial Eur Heart J 216; June 28 Epub ahead of print Is amiodarone really the best antiarrhythmic for VTach / Wide complex QRS tachycardias? Randomized European trial of 62 patients mg/kg of procainamide over 2 minutes (33 pts.) 5 mg/kg of amiodarone over 2 minutes (29 pts.) All had BP > 9 mm Hg and no SOB Evaluated both efficacy and major adverse events 6% Hundreds7% 5% 4% 3% 2% % % Wide QRS Tachycardia Termination vs Side Effects 67% 38% Eur Heart J 216; June 28 Epub ahead of print P=.26 9% 41% Pro Amio Pro Amio Termination Major Adverse Effects P=.6 Hypotension Eur Heart J 216; June 28 Epub ahead of print Hypotension common with both drugs 41% of amiodarone required immediate cardioversion Less than 1/ (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 3 mg which is double the 15 mg/ 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 Stable Wide Complex Tachycardia 5 Steps Be sure it is regular Modified Vagal Maneuver Adenosine: 12 mg IVP Procainamide: mg/min x 2 then 5 mg/min x 5 Shock 7
Use not addressed during VF/pVT Inadequate evidence to support post CPR use May be considered Beta Blockers Not enough evidence to be for or against lidocaine or beta blockers s/p VF/pVT Resuscitation 214;85:1337-1341 Is Esmolol effective in refractory VF/VT? Retrospective ED study All EMS to ED arrivals All s/p 3 shocks, 3 doses Epi, 3mg Amio Compares Esmolol vs no Esmolol Esmolol for Refractory VF/VT Sustained ROSC and Good Neuro D/C 8 7 6 5 4 3 2 33% 66% No Esmolol Sustained ROSC Resuscitation 214;85:1337-1341.5% 5% No Esmolol Good Neuro D/C BB For Refractory VF/VT Very small study But impressive results Certainly not harmful Has been suggested for 5 years I think worth a try Vasopressin Vasopressin + Epi no longer recommended Vasopressin no longer recommended Vasopressin has been removed from ACLS algorithm Epinephrine Use Standard dose epinephrine (1 mg Q 3-5 minutes) may be reasonable for patients with cardiac arrest (class 11b) Early administration may improve ROSC and neurologic outcomes later administration may decrease both 8
BMJ 216;353:1577-87 Does giving epinephrine before 2 nd shock help or hinder resuscitation? 2,974 VF/pVT arrests, 1,5 with epi < 2 min Inpatient data from 3 GWTG-R hospitals Propensity matched cardiac arrest pts Compared epi before vs after 2 nd shock BMJ 216;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) Epi Before vs After 2 nd Shock BMJ 216;353:1577-87 79% % 67% 8 All p <.1 7 48% 6 41% 5 31% 4 25% 3 Early Epinephrine Administration Wait for second shock before administering epinephrine The role of epi is still not clearly defined but wait to administer it 2 < 2 > 2 min < 2 > 2 min < 2 > 2 min Epinephrine is the most potent cardiac stimulant wait to give it during VF ROSC Survival Good Neuro JAMA 215;314:82- Does time to epinephrine affect outcomes in non-vf-vt pediatric arrests? 1,558 pediatric patients Average age = 9 mos 31.3% overall survival rate 17.1% favorable neurologic status Matched rhythm and numerous variables JAMA 215;314:82- Results Longer time to epi = worse survival Longer time to epi = ROSC time to epi = neurologic outcomes 9
Epinephrine in CPR The role of epinephrine remains unclear but this study shows earlier use improves survival Each minute delay decreases survival One of the few positive studies on the efficacy of epinephrine Not an epi vs no-epi study Steroids There is no recommendation for or against steroids for in-hospital cardiac arrest Use of steroids in out-of-hospital arrests are of uncertain benefit ACC/AHA Guidelines PCI and Hypothermia Therapeutic Hypothermia Therapeutic hypothermia should be started ASAP for all comatose STEMI patients and out of hospital arrests due to VF or VT (1B) Immediate PCI is indicated in all STEMI arrest patients including those who are receiving therapeutic hypothermia (1B) New Engl J Med 213, 369:2197-226 What temperature for Therapeutic Hypothermia? 939 patients in randomized trial 36 ICUs in Europe and Australia Evaluated: mortality & neuro outcome at 18d 8% VF/VT; 2% AS and PEA (12%/7%) New Engl J Med 213, 369:2197-226 Compares 32-33 to 35-36 TH No unwitnessed Asystole patients 24% intravascular; 76% surface cooled 28 hours of cooling Rewarmed at.5 /hour
Hypothermia vs Normal Temp Survival and Neuro Outcomes New Engl J Med 213, 369:2197-226 New Engl J Med 213, 369:2197-226 Groups the same for: First measured temps (35.2 35.3) % 6 5 4 52 54 53 52 P = NS Serum ph (7.2) 3 Serum lactate (6.7) Circulatory shock (7% vs 67%) ST segment (4% vs 42%) 2 Survival Poor Neuro 36 Survival Poor Neuro 33 Therapeutic Hypothermia The future of deep TH is unclear Preventing Hyperthermia appears crucial Future studies will determine optimal TH temp Well done study, but likely not the final study 35 36 looks like the new 32 34 JAMA 214;311:45-52 Does Prehospital TH have benefits? 1.359 patients; Randomized trial King County Washington Medic 1 583 with VF; 776 without VF Almost all patients cooled on hospital arrival Survival to Discharge JAMA 214;311:45-52 JAMA 214;311:45-52 EMS cooling: up to 2L of 4 C LR Mean core temp by 1.2 C to ED EMS patients took 1 hr less to get to 34 Study evaluated mortality and neuro status EMS pts: 7-mg pavulon + 1-2mg valium 7 6 5 4 3 2 64.3% 16.3% VF Non-VF No EMS TH 62.7% 19.2% VF Non-VF EMS TH P = NS 11
Additional Results JAMA 214;311:45-52 No improvement in neuro status in any group EMS TH group had more re-arrests (26% vs 21%; p =.8) EMS TH group had more pulmonary edema (41% vs 3%; p <.1) No difference in pressor use (9%) Prehospital TH Induction TH by EMS offers no benefits Lots of EMS training, resources and expense, yet no benefits shown In my opinion: this is a large and definitive study Does ECMO have a role in CPR? Resuscitation 215;86:88-94 Does ECMO improve post-arrest resuscitation outcomes The CHEER trial Refractory VF x 3 minutes No known underlying severe disease CPR within minutes of arrest Mechanical CPR available ECMO Team with 2 MDs present E-CPR ECMO Mechanical CPR Therapeutic Hypothermia Immediate post ECMO PCI 24 hours of TH Resuscitation 215;86:88-94 26 patients (11 OHCA, 15 IHCA) ECMO within 56 minutes; 2 days on 96% ROSC E-CPR Results Resuscitation 215;86:88-94 54% (14/26) survived to discharge with CPC score of 1 full neurologic recovery 12
ECMO CPR Requires large team and planning Careful patient selection 76% complication rate May require transfer to OR Things continue to get more complex Lancet 215;385:947-55 Can mechanical CPR improve resuscitation outcomes PARAMEDIC trial 4471 patients randomized Used LUCAS-2 mechanical device 4 UK Ambulance Services 21% VF, 25% PEA, 49% AS Arrest and 3 Months Survival Lancet 215;385:947-55 3 23% 23% 25 2 15 6% 6% 5 PARAMEDIC trial found no evidence of any advantages with mechanical CPR: Both acute and long term survival, along with neurologic function were all similar manual vs mechanical. LUCAS CONTROL Event LUCAS CONTROL 4 Months Mechanical CPR No proven benefit yet Excellent for stairs or long transports Essential for Cath Lab Expensive Annals Int Med 216;165:77-8 Can we have a TOR criteria that gives us % specificity and a PPV of % for non-survival? Prospective French trial, the PRESENCE Study 1,771 pts from Paris Sudden Death Expertise Center Tested and applied 3 criteria Used prospective data from Paris & King County Prospectively tested in 5,192 patients 13
Paris TOR Criteria 2,799 Patients Meeting All 3 Criteria Not witnessed, no shock, 2 doses epi Study N Survived Not witnessed by FF/EMS First Responders Non-shockable rhythm No ROSC after 2 doses of epinephrine Paris 1 year cohort Paris validation cohort PRESENCE Trial King County, USA 772 1569 1* 285 173 *Persistent vegetative state Use 3 criteria for TOR - Non-shockable, not witnessed by first responders - Non-responsive to two doses epi Terminating sooner can decrease transport with % reliability Has potential to increase organ donations 3 minutes on scene for non-shockable rhythm is not needed BCLS 216 Bystander CPR can double survival More than 8% of 3-day survivors will be neurologically intact 911 center cell phone activation of CPR providers increases the likelihood of bystander CPR pre EMS arrival 3:2 may be superior to continuous Expert BCLS -12 compressions/minute Depress to 2 inches Allow full recoil Don t hyperventilate: 8- times/minute Minimize interruptions / pre-shock pauses 14