Cardiac Arrest 2017 - Vanderbilt Emergency Medicine€¦ · 1/3/2017 1 Cardiac Arrest January 2017 Corey M. Slovis, M.D. Vanderbilt University Medical Center Metro Nashville Fire

1/3/2017

1

Cardiac ArrestJanuary 2017

Corey M. Slovis, M.D.Vanderbilt University Medical Center

Metro Nashville Fire DepartmentNashville International Airport

Nashville, TN

CPR2017

• 31,292 ALS vs 1,643 BLS cases

• Medicare billing data records (20% of total)

• Harvard study 2009 – 2011, no rural services

• Propensity matching utilized

JAMA 2015;175:196-204

Is ALS significantly better than BLS for out of hospital cardiac arrest?

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

Used data based on protocol that BLS was dispatched if ALS not available

• Evaluated survival to discharge

• 30 day survival

• 90 day survival

• CPC function outcomes

• 1 – 2 year survival

JAMA 2015;175:1422-3

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9.6%

6.2%

30 Day to SurvivalPropensity Matched

BLS ALS

RR – 1.595% CI = (1.2 – 1.7)

JAMA 2015;175:1422-3

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21.8%

44.8%

Poor Neurologic Outcome – Discharged PtsPropensity Matched

BLS ALS

(95% CI = 18.6 – 27.4)

JAMA 2015;175:1422-3

BLS vs ALS Take Homes

• AEDs and O2 by BVM are key

• How important is ALS?

• Not a randomized study

• Many potential confounders

• 30,381 witnessed Swedish cardiac arrests• CPR vs no CPR pre EMS• Evaluated 30 day survival• Multiple other variables evaluated

How important is CPR pre EMS arrivalNEJM 2015; 372: 2307-15

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101112131415

No CPR CPR pre EMS

11 Min

13 Min

Collapse to defibrillation Median Time

NEJM 2015; 372: 2307-15

P < 0.001

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1%

2%

3%

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5%

6%

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8%

9%

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11%

12%

No CPR CPR pre EMS

4.0%

10.5%

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30 Day Survival NEJM 2015; 372: 2307-15

P < 0.001

0%

5%

10%

15%

20%

25%

30%

0-3 4-8 9-14 > 14

26.4%

15.6%

7.9%

2.7%

Hu

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Start Time (Min)

P < 0.001

CPR start time and 30 day survivalVF/VT

NEJM 2015; 372: 2307-15

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Bystander CPR & AED use resulted in a 40.7% survival rate

JAMA 2015;314:247-54

• North Carolina CARES registry 2010-2013

• 4,961 patients

• Increased AED use by police, rescue squads, etc.

• Urban, suburban, rural

Does a statewide CPR education and AED first responder program make a difference?

JAMA 2015;314:255-64

0%

5%

10%

15%

20%

25%

2010 2013

14.1%

23.1%

Hu

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Bystander CPR & First Responder AED Use

JAMA 2015;314:255-64

P = 0.02

• 5,989 volunteers CPR trained• Used phones with GPS• 667 cardiac arrests• 911 system sends mobile alerts

Does a phone alert to those close to a cardiac arrest improve bystander CPR

NEJM 2015; 372: 2316-25

This was a blinded study where phone activation to those within 0.3 miles (500 meters) was turned on or off in

1:1 randomized manner

0%

10%

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30%

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GPS Sent No GPS

62%

48%

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Bystander CPR NEJM 2015; 372: 2316-25

P < 0.001

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CPR 2015-2016Take Homes

• Bystander CPR can double survival

• More than 80% of 30-day survivors will be neurologically intact

• 911 center cell phone activation of CPR providers increases the likelihood of bystander CPR pre EMS arrival

• The more bystander CPR the better

• Can double survival rate

• Low cost, high yield

• AEDs in public locations < $1,000

• Less A and more B in CLS

Importance of BCLSTake Homes

• 100-120 compressions/minute

• Depress to 2 inches

• Allow full recoil

• Don’t hyperventilate: 8-10 times/minute

• Minimize interruptions / pre shock pauses

Expert BCLS

ACLS2017

• 147 references

• 15 writing groups

• All based on 2015 ILCOR topics

Circulation 2015:132 (suppl 2);5444-64

The AHA 2016 Guidelines for ACLS

But not after ROSC93-95% if well performed

89-92% if COPD


Use 100% O2 during CPR

Oxygen Use

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• No high quality evidence to favor any

• ETI may decrease compression fraction


BVM vs SGA vs ETT

“For healthcare providers trained in their use either an SGA or ETT may be used as the

initial airway during CPR”


Continuous waveform capnography is recommended for placement and monitoring

If not available then colorimetric, EDD or ultrasound may be used

Assessment of ETT Placement


10 breaths per minute (Q 6 seconds)after advanced airway in place

Ventilation Rate• 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”

Antiarrhythmic for VF/pVT

• 3,026 pts., 10 ROC sites

• Randomized, double blind, placebo controlled

• VF/pVT, s/p 1 or more shocks, s/p epi

• Only adult medical VF/pVT OOH

New Engl J Med 2016; 374:1711-22

What is the best antiarrhythmic for shock resistant VF/pVT:

Amiodarone vs Lidocaine vs Placebo?

• Average age 63 ± 14 y; 80% M

• 60% had bystander CPR

• BLS in 5.8 min

• ALS in 8 min

• EMS call to drug: 19 min(prior trials 21-25 min)

New Engl J Med 2016; 374:1711-22

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30 24.4 23.7

Survival to DischargeNeurologic Outcome

Survival

2118.8

New Engl J Med 2016; 374:1711-22

%

A PL A

17.516.6

Mod Rankin ≤ 3

L P

Percentage Differences• Amiodarone vs Placebo

• Amiodarone vs Lidocaine

• Lidocaine vs Placebo

• Amiodarone vs Placebo

Modified Rankin ≤ 3

• Amiodarone vs Lidocaine

Modified Rankin ≤ 3

3.2% (p=0.08)

0.7% (p=0.70)

2.6% (p=0.16)

2.2% (p=0.19)

1.3% (p=0.44)

New Engl J Med 2016; 374:1711-22

• 5% absolute improvement of Amiodarone over placebo (p ≤ 0.04) if arrest witnessed (1934 pts)

• 21.9% absolute increase Amiodarone vs placebo if EMS witnessed and gave drugs near immediately (p < 0.01 for 154 pts)

NEJM 2016:375;801-3

Authors Note in Letter to Editor

• 7 studies: 3 RCTs, 4 non-RCTs

• 3,877 pts in RCTs and 700 in non-RCTs

• Includes 2016 NEJM trial

• Admission and Discharged Alive evaluated

Resuscitation 2016;107:31-7

What do all studies combined tell us about Amiodarone vs Lidocaine in VF/pVT?

ResultsAmiodarone vs Placebo:

- trend for hospital discharge with Amio(p=0.08)

- No difference in favorable neuro outcomes

Lidocaine vs Placebo:- No significant difference at discharge

Amiodarone vs Lidocaine:- No difference in hospital discharge (p=0.81)


Amiodarone vs Lidocaine vs PlaceboTake Homes

• 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 1,800 lives would be saved in North America yearly

• The data is not conclusive

• The drugs are given 10-20+ minutes into arrest

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At the present time, there is no clear benefit of Amiodarone vs Lidocaine

Late in VF it’s not clear either drug is beneficial

• 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

Eur Heart J 2016; June 28 Epub ahead of print

Is amiodarone really the best antiarrhythmic for VTach / Wide complex QRS tachycardias?

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Wide QRS Tachycardia Termination vs Side Effects


Termination Major Adverse Effects

67%

Pro Amio Pro Amio

P=0.026 P=0.006

9%

41%38%

Hypotension

• 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 VTachTake Homes

• 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

Stable Wide Complex Tachycardia5 Steps

• Be sure it is regular

• Modified Vagal Maneuver

• Adenosine: 12 mg IVP

• Procainamide: 100 mg/min x 2 then 50 mg/min x 5

• Shock

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• Use not addressed during VF/pVT

• “Inadequate evidence” to support post CPR use

• May be considered

• Not enough evidence to be for or against lidocaine or beta blockers s/p VF/pVT


Beta Blockers

• Retrospective ED study

• All EMS to ED arrivals

• All s/p 3 shocks, 3 doses Epi, 300mg Amio

• Compares Esmolol vs no Esmolol


Is Esmolol effective in refractory VF/VT?

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33%

66%

Esmolol for Refractory VF/VTSustained ROSC and Good Neuro D/C

Sustained ROSC Good Neuro D/C

10.5%

50%

No NoEsmolol Esmolol


• Very small study

• But impressive results

• Certainly not harmful

• Has been suggested for 50 years

• I think worth a try

BB For Refractory VF/VT

• Vasopressin + Epi no longer recommended

• Vasopressin no longer recommended


Vasopressin has been removed from ACLS algorithm

VasopressinCirculation 2015:132 (suppl 2);5444-64

Standard dose epinephrine (1 mg Q 3-5 minutes) may be reasonable for patients

with cardiac arrest (class 11b)

Epinephrine Use

• Early administration may improve ROSC and neurologic outcomes – later administration may decrease both

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• 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 2nd shock

BMJ 2016;353:1577-87

Does giving epinephrine before 2nd shock help or hinder resuscitation?

• 51% of patients received epi before 2nd shock

• 87% of both groups received 2nd 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)

BMJ 2016;353:1577-87

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8067%

79%

Epi Before vs After 2nd Shock

ROSC

31%

48%

BMJ 2016;353:1577-87

%

< 2 < 2> 2 min > 2 min

25%

41%

Good Neuro

< 2 > 2 min

Survival

All p < 0.001

Early Epinephrine AdministrationTake Homes

• 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

JAMA 2015;314:802-10

• 1,558 pediatric patients

• Average age = 9 mos

• 31.3% overall survival rate

• 17.1% favorable neurologic status

• Matched rhythm and numerous variables

Does time to epinephrine affect outcomes innon-VF-VT pediatric arrests?

JAMA 2015;314:802-10

• Longer time to epi = worse survival

• Longer time to epi = ROSC

• time to epi = neurologic outcomes

Results

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• 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

Epinephrine in CPRTake Homes


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”

TherapeuticHypothermia

ACC/AHA GuidelinesPCI and 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)

• What temperature for Therapeutic Hypothermia?

• 939 patients in randomized trial

• 36 ICUs in Europe and Australia

• Evaluated: mortality & neuro outcome at 180d

• 80% VF/VT; 20% AS and PEA (12%/7%)

New Engl J Med 2013, 369:2197-2206

• Compares 32 -33 to 35 -36 TH

• No unwitnessed Asystole patients

• 24% intravascular; 76% surface cooled

• 28 hours of cooling

• Rewarmed at 0.5 /hour

New Engl J Med 2013, 369:2197-2206

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• Groups the same for:

‾ First measured temps (35.2 – 35.3)

‾ Serum pH (7.2)

‾ Serum lactate (6.7)

‾ Circulatory shock (70% vs 67%)

‾ ST segment (40% vs 42%)

New Engl J Med 2013, 369:2197-2206

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%52

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Hypothermia vs Normal TempSurvival and Neuro Outcomes

Survival Poor Neuro

36Survival Poor Neuro

33

53 52

P = NS

New Engl J Med 2013, 369:2197-2206

• 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

Therapeutic HypothermiaTake Homes

• 35 – 36 looks like the new 32 – 34

• 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

JAMA 2014;311:45-52

• EMS cooling: up to 2L of 4 C LR

• Mean core temp by 1.20 C to ED

• EMS patients took 1 hr less to get to 34

• Study evaluated mortality and neuro status

• EMS pts: 7-10mg pavulon + 1-2mg valium

JAMA 2014;311:45-52

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64.3%

16.3%

Survival to Discharge

VF Non-VF

No EMS THVF

EMS TH

62.7%

19.2%

Non-VF

P = NS

JAMA 2014;311:45-52

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• No improvement in neuro status in any group

• EMS TH group had more re-arrests

• EMS TH group had more pulmonary edema

• No difference in pressor use (9%)

Additional Results

(26% vs 21%; p = 0.008)

(41% vs 30%; p < 0.001)

JAMA 2014;311:45-52

• TH by EMS offers no benefits

• Lots of EMS training, resources and expense,

• In my opinion: this is a large and definitive

Prehospital TH InductionTake Homes

yet no benefits shown

study

Does ECMO have a role in CPR?


• Refractory VF x 30 minutes

• No known underlying severe disease

• CPR within 10 minutes of arrest

• Mechanical CPR available

• ECMO Team with 2 MDs present

Does ECMO improve post-arrest resuscitation outcomes – The CHEER trial


• ECMO

• Mechanical CPR

• Therapeutic Hypothermia

• Immediate post ECMO PCI

• 24 hours of TH

“E-CPR”• 26 patients (11 OHCA, 15 IHCA)

• ECMO within 56 minutes; 2 days on

• 96% ROSC

E-CPR Results

54% (14/26) survived to discharge with CPC score of 1 – full neurologic recovery


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• Requires large team and planning

• Careful patient selection

• 76% complication rate

• May require transfer to OR

• Things continue to get more complex

ECMO CPRTake Homes

Lancet 2015;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

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Arrest and 3 Months Survival

LUCAS CONTROL

EventLUCAS CONTROL

4 Months

6% 6%

Lancet 2015;385:947-55

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.

• No proven benefit yet

• Excellent for stairs or long transports

• Essential for Cath Lab

• Expensive

Mechanical CPRTake Homes

Can we have a TOR criteria that gives us 100% specificity and a PPV of 100% 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

Annals Int Med 2016;165:770-8

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• Not witnessed by FF/EMS First Responders

• Non-shockable rhythm

• No ROSC after 2 doses of epinephrine

Paris TOR Criteria 2,799 Patients Meeting All 3 CriteriaNot witnessed, no shock, 2 doses epi

Study

Paris 1 year cohort

Paris validation cohort

PRESENCE Trial

King County, USA

N Survived

772 0

1569 1*

285 0

173 0

*Persistent vegetative state

Take Homes• Use 3 criteria for TOR

- Non-shockable, not witnessed by first responders

- Non-responsive to two doses epi

• Terminating sooner can decrease transport with 100% reliability

• Has potential to increase organ donations

• 30 minutes on scene for non-shockable rhythm is not needed

BCLS 2016Take Homes

• Bystander CPR can double survival

• More than 80% of 30-day survivors will be neurologically intact

• 911 center cell phone activation of CPR providers increases the likelihood of bystander CPR pre EMS arrival

• 30:2 may be superior to continuous

• 100-120 compressions/minute

• Depress to 2 inches

• Allow full recoil

• Don’t hyperventilate: 8-10 times/minute

• Minimize interruptions / pre-shock pauses

Expert BCLS

Documents

Cardiac Arrest 2017 - Vanderbilt Emergency Medicine€¦ · 1/3/2017 1 Cardiac Arrest January 2017 Corey M. Slovis, M.D. Vanderbilt University Medical Center Metro Nashville Fire