I mpact of Pre-hospital and Emergency Care on Cardiac Arrest Outcomes Pioneer in Pediatric Research Vinay Nadkarni MD, MS, FCCM, FAAP, FAHA Co-Chairman, International Liaison Committee on Resuscitation 2007-2010 Department of Anesthesia and Critical Care Medicine The Children s Hospital of Philadelphia, Philadelphia PA, USA
Potential Conflicts of I nterest Employment: University of Pennsylvania Research Grants: NI H/ NI CHD (Cardiac Arrest, Glucose Control) AHRQ ( Simulation Education) Laerdal Foundation ( Simulation and Resuscitation) Medical Education Technology, I nc ( Simulation) Science Advisory Board ( Volunteer) AHA National Registry of CPR Pediatric ALI and Sepsis I nvestigators World Federation of Pediatric and I CU Societies
PRESEN T PREHOSPI TAL Cardiac arrest outcom es 25% Die In Hospital 50% No Restoration of Spontaneous Circulation 25% Leave Hospital 15% Good Outcome 10% Brain Damage
Clinical Trials Registries and CQI Single Center Selected Specific Patient outcome Patient outcome 100% x 80% x 50% x 50% = 20% Multicenter Trial Efficacy Multi-center Application General Practice Effectiveness Efficiency
Pediatric Cardiac Arrest Process and Outcomes Patient I nterventions Outcomes Technique Drugs Devices Quality of Life Patient Factors Event Factors System Factors Education System/ Quality ROSC Short term Survival Discharge Survival Favorable Neurologic Survival
Three Phases of Adult VF Cardiac Arrest Electrical Phase (Early Defibrillation Critical) Hemodynamic Phase (Perfusion Critical) Metabolic Phase (Newer Modalities Needed) Becker et al. JAMA 2002;288:303
No CPR Delayed defibrillation Defibrillation 0-2% Survival Early CPR Delayed defibrillation CPR Defibrillation 2-8% Survival Early CPR Early defibrillation CPR Defibrillation 20% Survival Early CPR Very early defibrillation CPR Defibrillation ACLS 30% Survival minutes 2 4 6 8 10
Quality CPR Improves Short Term Survival Chest compression depth during out-ofhospital arrest associated with survival to hospital admission and discharge. Kramer-Johansen et. al., Resuscitation 2006
Shorter pre-shock pause and improved compression depth associated with defibrillation success. Edelson et. al., Resuscitation 2006
vs Adult Respiratory Insufficiency Shock MI Diabetes Renal Failure CHI LD 58% * 36% * 2% 1% 12% ADULT 40% 27% 35% * 28% * 31% * Nadkarni et al. JAMA 2006
Location in I CU Witnessed or monitored Witnessed & monitored Mechanical Ventilation Vasopressors Arterial Catheter Duration of CPR CHI LD 65% * 95% * 83% * 57% * 38% * 29% * 25 [12,45]* ADULT 45% 88% 66% 26% 27% 8% 18 [10,29] Nadkarni et al. JAMA 2006
ROSC (> 20 min) Survival to Hospital Discharge Survival with Favorable Neurologic Outcome I nitial VF/ VT vs Sub VF/ VT 70% vs. 35% OR 2.8 (1.5-5.4) 35% vs. 11% OR 2.9 (1.2-5.8) 33% vs. 8% OR 2.6 (1.2-5.8) Samson et al. NEJM 2006
Subsequent VF/ VT rhythm is bad ROSC (> 20 min) No VF/ VT vs Sub VF/ VT 51% vs 35% OR 2.1 (1.3-3.4) Survival to Hospital Discharge Survival with Favorable Neurologic Outcome 27% vs 11% OR 3.8 (1.8-7.6) 24% vs 8% OR 3.8 (1.9-7.7) Samson et al. NEJM 2006
Pediatric Cardiac Arrest: Facts Out-of of-hospital Pediatric Cardiac Arrest: Respiratory Etiology Rarely witnessed, monitored or shockable initial rhythms Donoghue et al. AEM 2005 In-Hospital Pediatric Cardiac Arrest Combined Respiratory/Cardiac Etiology Complex, critically ill patients Commonly witnessed, monitored and common shockable rhythms (14-27%) Nadkarni et al. JAMA 2006
Single Shock Epinephrine Single Shock Anti-arrhythmic? CPR Push Hard Push Fast Minimize Interruptions Complete Release Breathe Slow Seek reversible causes* Epinephrine CPR
Pre-Arrest Post-Arrest stabilization Cardiac Arrest CPR No Flow Low Flow Low, Normal or High Flow PROTECTION PRESERVATION RESUSCITATION RESUSCITATION / REGENERATION Rapid Recognition Call 9-1-1 Rapid Response Team Prompt CPR; Defibrillate if VF Waveform? Dose? 1 vs 3? Push hard, Push Fast Minimize interruption Full chest recoil Assist ventilation? Vasopressors? Cooling? Temperature control Blood pressure Glucose Ventilation (CO2) Goal Directed Care
ACLS Pre-Arrest Recognition and Intervention Neonatal Resuscitation Program Cardiac Arrest PALS Post Resuscitation Outcomes
What is Fact vs what is Fiction?..
Fact: Interventions that seem to work in animals do NOT always translate to improved clinical outcomes
What is the relevant endpoint for resuscitation outcome?
How do we change? Basis for Decision Measure Device Unit of measure EVI DENCE Eloquence Randomized Controlled Trial Smoothness of Tongue Metaanalysis Keynote speech Odds Ratio Kissoon unit Vehemence Loudness of voice Audiometer Decibels Confidence Bravado Sweat test No sweat
Challenges: Etiology based approach Trauma Overdose Submersion Airway Obstruction Newly born Sudden VF Prolonged VF Acute Coronary Syndromes
Pediatric First Documented Cardiac Arrest Rhythm 80 70 60 50 40 30 20 10 0 Prehospital In-hospital Nadkarni et al. JAMA 2006 and Young et al. Pediatrics 2004
AHA National Registry of CPR: Shockable Rhythms in Hospitalized Children < 18 years 25% 25% 20% 15% 15% 10% 5% 7% Pediatric 0% All Events with CC Pulseless CA Events Anytime during event Samson et al NEJM 2006 Nadkarni et al JAMA 2006
I n-hospital: CPR was inconsistent and often did not meet published guideline recommendations Too few compressions, too many ventilations, too many pauses.
71% 19% 42% 58%
Lay Rescuer Babbs, Kern 2002
Mathematical Modeling Compression : Ventilation Ratios Children Optimal CPR (best systemic oxygen delivery) Optimal C-V ratio for: lay rescuers professional 10 kg ~ 12:2 ~ 12:2 20 kg ~ 24:2 ~ 15:2 40 kg ~ 30:2 ~ 20:2 Babbs C, Nadkarni V Resuscitation 2004
Vasopressors Adrenergic Adrenaline Methoxamine Phenylephrine Norepinephrine Dopamine Isoproterenol Orciprenaline Dobutamine Non-Adrenergic Angiotensin II Endothelin-1 Vasopressin Antiarrhythmics Others Theophylline Atropine Lidocaine Amiodarone Buffer NaHCO 3 TRIS Na 2 CO 3 Carbicarb Tribonate Thrombolysis? B-Blockers? Short-acting vasoconstrictors? Chemical defibrillation? Chemical Hibernation?
10 Most Frequently Administered Medications from the CHOP pediatric code cart 0 20 40 60 80 100 120 140 160 180 200 Epinephrine Sodium Bicarbonate Sodium Bicarbonate #2 127 184 Calcium Gluconate Calcium Gluconate #3 121 Atropine 99 0.9% NaCl 87 Tromethamine 61 Vecuronium 47 Pancuronium 41 Fentanyl 39 Midazolam 37 Roberts KR et al. Crit Care Med 2005: A
Improving the post cardiac arrest link in the chain of survival
Infant undergoing Selective Hypothermia with a cooling cap Courtesy: Dr. David Durand, Children s Hospital Oakland
Infant undergoing Total Body Cooling with a Cooling Blanket
Mechanical Support during or After CPR Morris M, Wernovsky G et al. CCM 2004, Morris M, Nadkarni V et al, PCCM 2004, demos et al CCM 2006
Pre-Load Contractility Afterload Heart rate and rhythm Check the plumbing Physiology? Fluid bolus? Diuretics? Check the function Contraction? Relaxation? R/o tamponade? Check the circuits Systemic? Pulmonary? Shunt fxn? Pressors? Dilators? Check the rate and rhythm Too fast? Too slow? Atrial kick? Pacer fxn?
ECMO for Refractory Cardiac Arrest In-Hosp Cardiac Arrest CPR + ALS x 10 minutes CPR + ALS Anti- Coagulate???Cold Perfusate Endpoint? ECMO team notified ECMO circuit clear prime Cannulate Neck V-A ECMO: Induced Hypothermia Controlled blood flow titrated to SvO2 Standard Sedation/Monitoring Normalize glucose, Blood Pressure, pco2 Follow markers of Organ injury/function
Cerebral perfusion Sedation Control of seizures Temperature control Glucose control
CHALLENGES NOTED DURI NG SI MULATI ONS Child Weight Estimates I O preparation I V Fluid Bolus Order Glucose bolus % of Centers 34% 69% 89% 97% Difficulty with 25/ 44 (57% ) C-Spine Stabilization Tasks Simulation of C-Spine Stabilization in 35 North Carolina Emergency Departments Hunt E et al. Pediatrics 2006
Team Training building competence to Patient Minutes Safety to Mannequin Education, Active the early Learning! days Task training to competence! Excellence! Just-in-time.Just-in-place
Mechanisms to evaluate and see-through artifacts to allow near continuous chest compressions
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Defibrillator Pads (mv) Ventilations and Feedback Chest Compression Depth (mm) Still Going Time: 25:00 Acceleration (G) Impedance (Ohm) What happened here? Force (grams)
Chest Compression (CC) Quantitative Data: n=10 Total Time Total CC Delivered Chest Compression Rate Chest Compression Count No Flow Time No Flow Fraction Percent Incomplete Release Percent Adequate Depth 134.32 min 13,136 113 ± 13.4 CC/min 98 ± 7.1 CC/min 10.33 ± 0.9 min 7.7 ± 5.4 % 13.6 ± 9.5 % 86.8 ± 16.1 %
Chest Compression (CC) Quantitative Data: n=10 Total Time PEDI ATRI C Total CC Delivered Chest No Compression Flow FractionRate Chest Percent Compression Adequate Depth Count No Flow Fraction Percent Adequate Depth 134.32 min 13,136 1137.7 CC/min % 9886.8 CC/min % 7.7 % 86.8 % Out-of-Hospital I 134.32 n-hospital min Adult* 13,136 12124 CC/min % 64 62 CC/min % 48 % 38 % * NO FEEDBACK UTI LI ZED I N ADULT STUDI ES *Abella, * Wik, JAMA JAMA 2005 2005
For Out of Hospital Cardiac Arrest: Push hard, push fast, complete release, Minimize interruptions, Do NOT over-ventilate For In-Hospital Cardiac Arrest: Etiology specific response will improve outcome Respond before arrest (Rapid Response) Emphasize Quality of CPR Use adjuncts and monitor effects/feedback Advanced techniques have merit but are not proven
ISCHEMIA Cardiac Arrest And Resuscitation Oxidative Stress with Free Radical Production And Endothelial Damage AXONAL & DENDRITIC INJURY K + EAA NO Ca ++ - O 2 AA Mitochondrial Failure NEURO- TOXICITY BBB VASOGENIC EDEMA ASTROCYTE SWELLING Thrombosis TISSUE OSMOLAR LOAD Free Radicals VASCULAR DYSREGULATION CBV NECROSIS APOPTOSIS Brain Injury INFLAMMATION & REGENERATION
Early Detection and Intervention Universal monitoring METS Automated Directive Feedback (Prompts) Improved Circulation Less interruption (C:V ratio, Fewer shocks) Less Ventilation (titrated to blood flow and microcirculation) Adjuncts (circumferential, thoracic pump) Real-time Corrective feedback based upon the patient s metabolic status
Metabolic therapies Therapeutic hypothermia Chemical hibernation Post-resuscitative care Blood Pressure, Temperature, Glucose, Ventilation, Thrombolysis, myocardial support, rapid mechanical support Better Predictors Imaging, Neurophysiology and biomarkers Genomics and proteomics Hibernation / Regeneration / Transplantation
Home therapies Smart AEDs in the home, video links, smoke alarm and fire extinguisher mentality Short and simple training School, Work, Driver s License Just-in time support and training 111, flashes, physiologic feedback, incorporation into everyday life (ATM, stadium, groceries)
Pre-Arrest Post-Arrest stabilization Cardiac Arrest CPR No Flow Low Flow Low, Normal or High Flow PROTECTION PRESERVATION RESUSCITATION RESUSCITATION /REGENERATION Rapid Recognition Call 9-1-1 METs Prompt CPR; Defibrillate if VF Waveform? Dose? 1 vs 3? Push hard, Push Fast Minimize interruption Full recoil Assist ventilation? Vasopressors? Cooling? Temperature control Blood pressure Glucose Ventilation (CO2) Goal Directed Care
Next planned revision of AHA Guidelines: 2010
Pre-Arrest Post-Arrest stabilization Cardiac Arrest CPR No Flow Low Flow Low, Normal or High Flow PROTECTION PRESERVATION RESUSCITATION RESUSCITATION /REGENERATION Rapid Recognition Call 9-1-1 METs Prompt CPR; Defibrillate if VF Waveform? Dose? 1 vs 3? Push hard, Push Fast Minimize interruption Full recoil Assist ventilation? Vasopressors? Cooling? Temperature control Blood pressure Glucose Ventilation (CO2) Goal Directed Care
Quality of CPR CPR Push Hard Push Fast Allow full chest recoil Minimize Interruptions Don t Overventilate
Local Databases International Databases Europe Australia New Zealand USA Latin America Asia Canada HYPCAP ( Hutchison) NRCPR pheart (Berg/ Nadkarni) PECARN (Moler) NICHD PCCRN Network (Dean/ Willson) Virtual- PICU/ PALISI (Zaritsky)
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