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Science Driving the Future of Resuscitation: ACLS
Paris Hotel and Casino Las Vegas, Nevada
Joseph P. Ornato, MD, FACP, FACC, FACEP
Professor & Chairman, Dept. of Emergency MedicineProfessor, Internal Medicine (Cardiology)
Virginia Commonwealth University Health System
Operational Medical DirectorRichmond Ambulance Authority
Richmond Fire & EMSHenrico County Division of Fire
Richmond, VA
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Disclosure Information
Joseph P. Ornato, MD, FACP, FACC, FACEPScience Driving the Future of Resuscitation: ACLS
FINANCIAL DISCLOSURE: Cardiac Co-Chair & Consultant: NIH Resuscitation
Outcomes Consortium (ROC) American Editor, Resuscitation Advisory Board, Key Technologies, Inc.
(Transnasal Cooling Device)
UNLABELED/UNAPPROVED USES DISCLOSURE: Transnasal cooling devices
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Intra-arrest hot topics
Airway managementRole of ACLS drugs Extracorporeal Membrane
Oxygenation CPR (eCPR) Intra-arrest therapeutic hypothermia
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AHA Guidelines Grading
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Airway Management During CPR performed by providers trained in its use, the supraglottic
airway is a reasonable alternative to bag-mask ventilation (Class IIa, LOE B) and endotracheal intubation (Class IIa, LOE A).
For healthcare professionals trained in its use, the esophagealtracheal tube is an acceptable alternative to both bag-mask ventilation (Class IIa, LOE C) or endotracheal intubation (Class IIa, LOE A) for airway management in cardiac arrest.
For healthcare professionals trained in its use, the laryngeal tube may be considered as an alternative to bag-mask ventilation (Class IIb, LOE C) or endotracheal intubation for airway management in cardiac arrest (Class IIb, LOE C).
For healthcare professionals trained in its use, the laryngeal mask airway is an acceptable alternative to bagmask ventilation (Class IIa, LOE B) or endotracheal intubation (Class IIa, LOE C) for airway management in cardiac arrest.
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Prehospital airway management in cardiac arrest - CARESMcMullan J et al. Resuscitation 2014; 85:617-22
10,691 out-of-hospital cardiac arrests in the CARES registry
Frequency of use ET= 5,591 (52%) SGA= 3,110 (30%) BVM= 1,929 (18%)
Survival to DC intact ET= 5.4% SGA= 6.7% BVM= 18.6%
BVM pts more likely to be: VF or VT initially EMS witnessed Bystander AED
Propensity matched, adjusted for confounders
-1 0 1 2 3 4 5 6
Survival by Airway Management Strategy
Favors SGA or ET Favors BVM
Odds Ratio [95% CI]
Sustained ROSC
Survival to admission
Survival to discharge
Survival to discharge intact
4.19
3.53
1.45
1.01
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Prehospital airway management in cardiac arrest - CARESMcMullan J et al. Resuscitation 2014; 85:617-22
10,691 out-of-hospital cardiac arrests in the CARES registry
Frequency of use ET= 5,591 (52%) SGA= 3,110 (30%) BVM= 1,929 (18%)
Survival to DC intact ET= 5.4% SGA= 6.7%
Propensity matched, adjusted for confounders -1 -0.5 0 0.5 1 1.5 2 2.5 3
Survival by Advanced Airway Type
Favors SGA Favors ET
Odds Ratio [95% CI]
Sustained ROSC
Survival to admission
Survival to discharge
Survival to discharge neurologically intact
1.38
1.72
1.66
1.43
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ET intubation vs. supraglottic airway in cardiac arrest - ROCWang HE et al. Resuscitation 2012; 83:1061-6
10,455 adult out-of-hospital cardiac arrest in Resuscitation Outcomes Consortium (ROC) registry
Not a randomized trial Frequency of use ET= 8,487 (81%) SGA= 1,968 (19%)
Survival to DC intact ET= 4.7% SGA= 3.9% -1 -0.5 0 0.5 1 1.5 2 2.5 3
Survival by Advanced Airway Type
Favors SGA Favors ET
Odds Ratio [95% CI]
Survival to DC neurologically intact
Survival to 24 hrs
ROSC
Airway or respiratory complications
1.40
1.78
0.84
1.74
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ACLS Drugs
It is reasonable to consider administering a 1 mg dose of IV/IO epinephrine every 3 to 5 minutes during adult cardiac arrest (Class IIb, LOE A).
Amiodarone may be considered for VF or pulseless VT unresponsive to CPR, defibrillation, and a vasopressor therapy (Class IIb, LOE B).
Lidocaine may be considered if amiodarone is not available (Class IIb, LOE B).
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Benefit of each link in the chain of survivalStiell I et al. N Engl J Med 2004;351:647-56
1.6 [1.2, 2.3]
4.4 [3.1, 6.4]
3.7 [2.5, 5.4]
3.4 [1.4, 8.4]
1.1 [0.8, 1.5]
ccv
Variable
Age <75 yr
Early Access
Early CPR
Early DF
Early ACLS
Adjusted Odds Ratio [95% CI]
ccv0.1 1.0 10.0
Adjusted Odds Ratio [95% CI]
Survival worse Survival better
5,638 OOH-CA patients17 cities in Ontario, CASequential addition of each link in
the chain of survivalOutcome= survival to hospital
discharge
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ACLS meds vs. no ACLS drugs in OsloOlasveengen TM et al. JAMA 2009; 301:2222-9
851 OOH-CA cases Randomized to
ACLS with vs. without drugs
EMS response time interval= 10 min
Initial VF= 33% Byst witn= 65% Byst CPR= 63% MD on unit= 37% 8%9%
20%21%25%
10%11%
30%32%
40%
0%
10%
20%
30%
40%
50%
ROSC Admitted tohospital
Admitted toICU
Discharged Alive at 1 year
No drugs
Drugsp> .001 p> .001 p> .002 p> .61 p> .53
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Prehospital randomized trial of no epinephrine vs. epinephrineJacobs I et al. Resuscitation 2011;82(9):1138-43
8%13%
2%
24%25%
4%
0%
5%
10%
15%
20%
25%
30%
ROSC Admitted Discharged
No epinephrine Epinephrine
p <0.001
p <0.001
p =.15
534 out-of-hospital cardiac arrest patients Randomized to receive no epinephrine vs. epinephrine during resuscitation Perth, Australia
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Model
ROSCUnadjustedAdjusted for propensityAdjusted for propensity and selected variablesAdjusted for all covariates
1 month survivalUnadjustedAdjusted for propensityAdjusted for propensity and selected variablesAdjusted for all covariates
CPC 1 or 2UnadjustedAdjusted for propensityAdjusted for propensity and selected variablesAdjusted for all covariates
OPC 1 or 2UnadjustedAdjusted for propensityAdjusted for propensity and selected variablesAdjusted for all covariates
Odds Ratio [95% CI]
Favors NoPrehospital Epinephrine
FavorsPrehospital Epinephrine
Favors NoPrehospital Epinephrine
FavorsPrehospital Epinephrine
Prehospital epinephrine use & survival in JapanHagihara A et al. JAMA 2012; 307:1161-8
417,188 OOH-CA cases EMS skills: CPR AED IV Give epi 1 mg q4min x 3 Epinephrine vs. no
epinephrine by EMS 3.7% of patients received
epinephrine
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Antiarrhythmic drugs for VF/pVT
American Heart Association 2010 ACLS Guidelines Amiodarone or lidocaine (each is a class Iib “may be considered”
recommendation for shock-refractory VF/VT)
Amiodarone and lidocaine may have other adverse effects
Neither drug has been proven (or tested adequately) to improve survival to discharge
Unproven therapies may be . . . Beneficial Inconsequential (make no difference) Harmful
The only way to know if lidocaine or amiodarone “work” is to compare either against placebo
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Persistent or recurrent VF/VT
• IIb medications• Lidocaine• Bretylium• Mg sulfate• Procainamide• (Na bicarb)
• Continue CPR• Intubate at once• Obtain IV access
• Epi 1 mg IV q 3-5 min
• DF 360 J within 30-60 sec
• DF 360 J 30-60 sec after med dose• Pattern “drug-shock”, “drug-shock”
PlaceboAmio 300 mg
Amiodarone vs. lidocaine OOH-CA
38%
64%
17%
49%44%
33%
41%
12%
39%34%
0%
10%
20%
30%
40%
50%
60%
70%
All patients VF Asys or PEA ROSC No ROSC
Surv
ival
to A
dmis
sion
Amiodarone 300 mg PlaceboN= 504
Kudenchuk P et al. N Engl J Med 1999; 341:871-8
11%
23%
0%
5%
10%
15%
20%
25%
Amio Lido
Ad
mis
sio
n
p< .004
N= 348
Amio vs. Lido
Toronto EMS
911-1st DF = 12±7 min
911-drug = 25±8 min
Dorian P et al. N Engl J Med. 2002 Mar 21;346(12):884-90
ARREST Trial ALIVE Trial
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NIH Resuscitation Outcomes Consortium (ROC)Amiodarone vs. Lidocaine vs. Placebo Study (ALPS)
• N=
SYRINGE # AMIODARONE KIT LIDOCAINE KIT PLACEBO KIT
1Amiodarone
150 mg (3 cc)
Lidocaine 60 mg (3 cc)
Placebo (3 cc)
2Amiodarone
150 mg (3 cc)
Lidocaine 60 mg (3 cc)
Placebo (3 cc)
3Amiodarone
150 mg (3 cc)
Lidocaine 60 mg (3 cc)
Placebo (3 cc)
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Extra Corporeal Membrane Oxygenation (ECMO) CPR (eCPR)
In settings where eCPR is readily available, it may be considered when the time without blood flow is brief and the condition leading to the cardiac arrest is reversible (e.g., accidental hypothermia drug intoxication) or amenable to heart transplantation (eg, myocarditis) or revascularization (e.g., acute myocardial infarction) (Class IIb, LOE C).
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Extra Corporeal Membrane Oxygenation (ECMO) CPR (eCPR)
Lack of randomized trials Available data is from small case series
and observational reports Most are retrospective
Age 18-83 (median= 56) years Duration of CPR 20-90+ minutes Initial rhythm Typical exclusion criteria IHCA vs. OHCA Survival 20-33%
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ECPR associated with hypothermia and normoxiain refractory cardiac arrestFagnoul D et al. Resuscitation 2013;84:1519-24
Collapse to ECPR 58 min [45-70] Survivors 41 min [39-58] Non-survivors 60 min [55-77]
p=0.059 ALL had mechanical chest compression ALL had intra arrest hypothermia Tight PaO2 & PaCO2 management PCI on ECMO for suspected ischemia
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eCPR for patients with OHCA of cardiac origin: A propensity matched studyMaekawa K et al. Crit Care Med 2013;41:1186-1196
Hazard Ratio [95% CI] Adjusted Hazard Ratio [95% CI] p
Pre-existing arrhythmia 0.33 [0.10-1.06] 0.59 [0.15-2.13] 0.42
Atropine administration (+1 mg) 1.55 [1.16-2.07] 1.28 [0.92-1.77] 0.14
Duration of CPR (+10 min) 1.18 [0.98-1.42] 1.08 [0.85-1.34] 0.52
Pupil diameter on hospital arrival (+1 mm) 1.56 [1.26-1.93] 1.39 [1.09-1.78] 0.007
Breathing spontaneously on hospital arrival 0.28 [0.11-0.71] 0.42 [0.14-1.28] 0.13
Shockable rhythm on hospital arrival 0.39 [0.20-0.77] 0.84 [0.36-1.99] 0.69
Initial lactate level (+1 mmol/L) 1.05 [0.99-1.12] 1.03 [0.96-1.10] 0.40
Sopporo, Japan Witnessed OHCA of cardiac origin Failed CPR >20 min
eCPR (n= 48, PCI 40%)
Manual CPR (n= 48, PCI 5%)
Log-rank p= 0.018
Primary Endpoint: Neuro IntactSurvival 3-months post-arrest
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Two year survival and neurological outcome of IHCA patients rescued by eCPRShin TG, et al. International Journal Cardiol 2013;168:3434-3430
eCPR increased 2-year survival2.4 fold compared to CCPR
NNT: 7 patients over 2 years Best candidates: < 65 years CPR duration < 35 min Potentially reversible causes
eCPR
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Intra-Arrest Hypothermia
In summary, we recommend that comatose (ie, lack of meaningful response to verbal commands) adult patients with ROSC after out-of-hospital VF cardiac arrest should be cooled to 32°C to 34°C (89.6°F to 93.2°F) for 12 to 24 hours (Class I, LOE B).
Induced hypothermia also may be considered for comatose adult patients with ROSC after in-hospital cardiac arrest of any initial rhythm or after out-of-hospital cardiac arrest with an initial rhythm of pulseless electric activity or asystole (Class IIb, LOE B).
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Randomized Trial of Prehospital Induction of Hypothermia in OOH-CA with Rapid Infusion of 4ºC SalineKim et. al. JAMA 2014; 311:45-52
Mean temp change NS vs controlVF= -1.1 ºCNon-VF= -1.2 ºC
62%
18%
64%
16%
0%
10%
20%
30%
40%
50%
60%
70%
80%
VF Not VF
Surv
ival t
o Di
scha
rge
Cooled Not Cooled
p= .69
p= .30
26%
41%
21%
30%
0%
10%
20%
30%
40%
50%
Rearrest Pulm Edema on CXR
Surv
ival
to D
ischa
rge
Cooled Not Cooled
p= .008
p= .0001
N= 1,359 Median times from 911 call
to ROSC = 25-30 min
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Intra-arrest hypothermiaNozari et al. Circulation, 2006; 113: 2690-96
10 min 20 min
17 dogs VF cardiac arrest No flow 3 min, 7 min BLS before ALS Randomized to early vs. delayed intra-arrest
hypothermia to 34 ºC
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Intra-arrest hypothermiaNozari et al. Circulation, 2006; 113: 2690-96
Early Hypothermia Delayed Hypothermia
OPC-1 (normal) OOOO O
OPC-2 (mildly impaired) O
OPC-3 (moderately impaired O
OPC-4 (severely impaired) O
OPC-5 (death) O OOOOOOOO
17 dogsVF cardiac arrestNo flow 3 min, 7 min BLS before ALSRandomized to early vs. delayed intra-arrest
hypothermia to 34 ºC
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Design of the Rapid Infusion of cold Normal SalinE by paramedics during CPR (RINSE trial) Deasy C et al. BMC Emergency Medicine. 2011;11:17
Australian pre-hospital randomized clinical trialDuring CPR, infuse up to 2L of 4°C saline
rapidly IVPrimary outcome: survival to d/cSecondary outcomes: ROSC, survival to
admission, temp on ED arrival, 12 month quality of life in survivors
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External Head/Neck CoolingCallaway C et al. Resuscitation 2002;52:159-65
27 OOH-CA pts randomized to usual care vs. ice bags on head & neck during resuscitation
Monitored nasopharyngeal & esophageal temp
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Comparison between transnasal head cooling begun during CPR and surface cooling after resuscitation in a pig model of cardiac arrestGuan J, Barbut D, Wang H, et al. Critical Care Medicine.2008:36(11) Suppl:S428-S433
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Selective Brain Cooling (“Rhinochill”)
Non-invasive Intranasal PFC spray delivered
through nasal prongsCan be initiated early Ambulance or EDVery rapid cooling Upper airways designed for heat
exchange “Preferential” brain coolingBrain-core gradient
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Intra-arrest transnasal coolingCastren et al. Circulation 2010;122(7):729-36
194 out-of-hospital cardiac arrest patients
15 sites, 5 European countries Pts randomized to prehospital
nasal cooling or no prehospitalnasal cooling
Standard therapeutic hypothermia used after hospital arrival
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Transnasal cooling with dehumidified high flow airHarikrishna Tandri H, Zviman M, Srinivas MR, et al. Circulation 2012; 126:A1
18 adult pigs Intubated, mechanically ventilated Core body temp in R atrium Brain temp of frontal, parietal, occipital
lobes using thermocouples Rate of temp cooling measured at
80L/min transnasal dehumidified air flowMR thermography showed uniform
global brain cooling
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Intra-arrest hot topics summary
Airway managementRole of ACLS drugs Extracorporeal Membrane
Oxygenation CPR (eCPR) Intra-arrest therapeutic hypothermia
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