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Short and Long Term Hemodynamic Outcomes
From Cardiac Arrest
Peter J. Kudenchuk, MD, FACP, FACC, FAHA, FHRS Professor of Medicine, University of Washington Associate Medical Director, King County EMS
Access CPR Defibrillation ACLS Post Arrest Care
Disparity in Survival Outcomes
0
10
20
30
40
50
60
70
Sur
viva
l to
Hos
pita
l Dis
char
ge –
VF
(%)
Published Reports of Cardiac Arrest VF Survival 1990-2013
Nichol G et al. JAMA 2008;300:1423-31; Personal communication Eisenberg M.
Disparity in Research Support
Ornato J. Circulation 2010;122:1876-9
0100020003000400050006000700080009000
10000
MI Stroke HF Cardiac Arrest
NIH Funded Studies (1985-2009) Published RCTs
Deaths/yr 157,000 150,000 284,000 310,000 n/10000†/yr 439 490 294 243 349 145 8 6
7691
3639 4108
177
6886
4403
9919
257
n
Cardiovascular Research Publications and Expenditures
Disparity in Approach to Treatment
Protocol vs Parameter-Driven Resuscitation
n= 24 instrumented swine Unsupported VF x 7 min
n = 8 • Protocol-driven • Std AHA CPR - CC depth 51 mm • Q 4’ epi (0.02 mg/kg)
n = 8 • Hemodynamic-directed • Titrate depth + vasopressor to:
SBP ~100; CPP >20 mm Hg • PRN epi (0.02 mg/kg) → vasopressin
200 J Continued assigned Tx until ROSC or x 10 min
1° Endpoint = ROSC x 45 min Friess SH. Crit Care Med 2013;41:2698-2704
Manual standard AHA CPR x 10 min CPR feedback for rate, depth, recoil, vent
Hemodynamically-Directed vs Protocol-Directed CPR
Friess SH. Crit Care Med 2013;41:2698-2704
0
20
40
60
80
100
Any ROSC 45 min ICUsurvival
AHA CPR Depth 51 mm (n=8)
CPP >20 (n=8)
% P
atie
nts
38% 38%
100% 100%
Hemodynamically-Directed vs Protocol-Directed CPR
0 8 9 10 11 12 13 14 15 16 17
50 40 30 20 10
Time (minutes)
Mea
n Co
rona
ry P
erfu
sion
Pres
sure
(mm
Hg)
Survived
Died p<0.01
Friess SH. Crit Care Med 2013;41:2698-2704
Depth Shocks Rx Epi Rx any vaso- mm # # pressor #
44±0.8 1 (1-2) 2 (2-5) 3 (2-6)
47±0.5 3 (1-2) 5 (2-5) 5 (2-5)
NSD*
*Also NSD in CC rate (100±0.1/min), no flow % (3 ± 0.2%), 0 lean (>2.5 kg)
Treatment
Hemodynamically-Directed vs Protocol-Directed CPR
0 8 9 10 11 12 13 14 15 16 17
50 40 30 20 10
Time (minutes)
Mea
n Co
rona
ry P
erfu
sion
Pres
sure
(mm
Hg)
CPP-20
Protocol p<0.01
Near-infrared Spectroscopy
End tidal CO2
Schoene P. Heart Rhythm 2014;11:230-6
Predictive Value of AMSA Before 1st Shock on Outcome
0102030405060708090
OrganizedRhythm
ROSC (end) AdmissionAlive
DischargeAlive
CPC 1-2
Lowest AMSA <9.43 (n=130) Mid AMSA 9.43-9.91 (n=130) High AMSA >9.91 (n=130)… prior to shock #1
(post 1st shock)
%Pa
tient
s
28%
69%
80%
49%
72%
88%
45%
72%
89%
22%
51%
74%
16%
46%
71%
Test for trend across tertiles p<0.001 for each outcome
Course of Quantitative VF Waveform Measure and Cardiac Arrest Outcome
Schoene P. Heart Rhythm 2014;11:230-6
0102030405060708090
OrganizedRhythm
ROSC (end) AdmissionAlive
DischargeAlive
CPC 1-2
Deteriorated AMSA (n=38) Unchanged AMSA (n=199) Improved AMSA (n=360)… between shock 1-2
%Pa
tient
s 55% 49%
61% 53%
64%
78%
53%
63%
81%
45% 40%
61%
37% 36%
47%
p=0.03* p=0.01* p=0.17*
*Test for trend (post 2nd shock)
Predictive Value of Change in AMSA on Outcome
Course of Quantitative VF Waveform Measure and Cardiac Arrest Outcome
Immediate Steps That Can Improve Cardiac Arrest
Outcome
High Performance CPR • 30:2 • Attention to detail:
- Rate, depth, recoil - Controlled ventilation
• Minimize pauses • 2 min CPR between interventions
2005 2006 2007 2008 2009 2004 2003 2002 2001 2000
50
40
30
20
10
% Survival to hospital discharge - Witnessed VF Arrest
King County, WA
High Performance CPR • 30:2 • Attention to rate, depth, recoil, vent • Minimize pauses • 2 min CPR between interventions
Rea TD. Circulation 2006;114:2760-5
2005 2006 2007 2008 2009 2004 2003 2002 2001 2000
50
40
30
20
10
% Survival to hospital discharge - Witnessed VF Arrest
King County, WA
~33%
Rea TD. Circulation 2006;114:2760-5
~46% (p=0.008)
2005 2006 2007 2008 2009 2004 2003 2002 2001 2000
35
10
7.5
5
2.5
%ROSC
30 25
40
% Survival to Hospital Discharge % 1-Yr Survival
n=1774
Kudenchuk PJ. Circulation 2012;125:1787-94
Cardiac Arrest Due to Asystole/PEA
34% p<0.001
7% p=0.004
5% p=0.001
High Performance CPR • 30:2 • Attention to rate, depth, recoil, vent • Minimize pauses • 2 min CPR between interventions
2005 2006 2007 2008 2009 2004 2003 2002 2001 2000
35
10
7.5
5
2.5
%ROSC
30 25
40
% Survival to Hospital Discharge % 1-Yr Survival
n=1774 n=2186
Kudenchuk PJ. Circulation 2012;125:1787-94
Cardiac Arrest Due to Asystole/PEA
27%
34% p<0.001
4.6%
7% p=0.004
2.7%
5% p=0.001
Improving Hemodynamic Outcomes in
Cardiac Arrest: Next Steps
• Designate cardiac arrest as reportable event
• Encourage/support research in: − (Bio)parameter-directed resuscitation − . . .
• Promote/disseminate high performance CPR
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