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Don’t ForgetA & B!
Michael Winters, MD FACEP FAAEMAssociate Professor of Emergency Medicine and Medicine
Co-Director, Combined EM/IM/Critical Care ProgramUniversity of Maryland School of Medicine
Twitter: @critcareguys
June 25, 1987
> 500,000
< 15%
A B C
A BC
C RC
✓ High-Quality CPR
✓ Early Defibrillation
Resuscitation
✓ High-Quality CPR
✓ Early Defibrillation
✓ Ventilation
✓ Post-Arrest Care
Resuscitation
Don’t ForgetA & B!
Michael Winters, MD FACEP FAAEMAssociate Professor of Emergency Medicine and Medicine
Co-Director, Combined EM/IM/Critical Care ProgramUniversity of Maryland School of Medicine
Twitter: @critcareguys
Resuscitation Pearls
• Intra-Arrest
- “Death by hyperventilation”
• Post-Arrest
- Target normocapnia
- Target normoxia
June 25, 1987
June 25, 2015
CCR
• Primary cardiac arrest
CCR
• Primary cardiac arrest
- Most common cause of OHCA
- Most often due to ventricular arrhythmias
- Breathing normal / near normal
- Arterial oxygen saturation is near normal
CCR
• Primary cardiac arrest
- Most common cause of OHCA
- Most often due to ventricular arrhythmias
- Breathing normal / near normal
- Arterial oxygen saturation is near normal
• 30,381 patients in Sweden
• 30-day survival
✓ CPR: 10.5%
✓ No CPR: 4%
Hasselqvist-Ax I, et al. NEJM 2015
• 520 patients
• Survival to DC
✓ Compression only: 14.6%
✓ Standard CPR: 10.4%
Hallstrom A, et al. NEJM 2000
• 4068 patients
• Favorable neurologic outcome at 30 days
✓ Compression only: 6.2%
✓ Standard CPR: 3.1%
SOS-KANTO Study Group. Lancet 2007
Bystanders…
✓ Compressions only
✓ No ventilation
EMS…
• Oxygenation
• Advanced Airway
• Ventilation
Oxygenation
• Current convention is to oxygenate at 100%
• Animal studies demonstrate worse outcome
• No human studies have compared 100% with titrated levels during CPR
Passive Oxygenation
• Retrospective analysis of adult OHCA
• 1019 patients
• Passive oxygenation compared with BVM
Bobrow BJ, et al. Ann Emerg Med 2009
• Neurologically intact survival to hospital DC
- Passive oxygenation: 39%
- BVM: 25.8%
- Only in witnessed v.fib / v.tach arrests
Bobrow BJ, et al. Ann Emerg Med 2009
• Neurologically intact survival to hospital DC
- Passive oxygenation: 39%
- BVM: 25.8%
- Only in witnessed v.fib / v.tach arrests
Bobrow BJ, et al. Ann Emerg Med 2009
Passive Oxygenation
• Allows constant delivery of compressions during early phases of arrest
Passive Oxygenation
• Allows constant delivery of compressions during early phases of arrest
• Not sufficient in advanced stages of arrest
- Chest resistance higher
- Lung compliance significantly decreased
Lower Success Rates
109 seconds!
> 30%
Interrupted Compressions
Advanced Airway
VS
Advanced Airway
VS
Advanced Airway
• SGA - Limitations
✓ Laryngospasm present in early stages of arrest
✓ High peak pressures needed to overcome spasm
✓ May exceed maximal seal pressure of SGA
✓ May cause significant leak (> 20%)
Advanced Airway
• SGA - Limitations
✓ Ineffective in providing ventilation in patients with low lung compliance, high rigidity
✓ Carotid artery compression?
Advanced Airway
• ETI vs. SGA
- Wang, et al. Resuscitation 2012
- Tanabe, et al. J Emerg Med 2013
- McMullan, et al. Resuscitation 2014
- Benoit, et al. Resuscitation 2015
Confounding by Indication
Death by Hyperventilation!
Ventilation
• Low survival for OHCA may be result of uncontrolled ventilation
Ventilation
• Hyperventilation
✓ Increases intrathoracic pressure
✓ Decreases venous return
✓ Decreases cardiac output
✓ Decrease CPP
✓ Increased ICP
Intra-Arrest A & B✓ Passive oxygenation in early phases
✓ One size does NOT fit all
✓ Best airway / technique
- Patient factors
- Time-point during resuscitation
- Skill of rescuer
Intra-Arrest A & B
• Control ventilations!
Post-Arrest Goals1. Optimize neurologic resuscitation
2. Prevent secondary injury
Post-Arrest Goals
• A comprehensive approach:
✓ Optimize oxygenation & ventilation
✓ Optimize hemodynamics
✓ Targeted temperature management
✓ Emergent PCI
Post-Arrest Goals
• A comprehensive approach:
✓ Optimize oxygenation & ventilation
✓ Optimize hemodynamics
✓ Targeted temperature management
✓ Emergent PCI
Mechanical Ventilation
• Pulmonary dysfunction common
- Trauma from CPR
- Hydrostatic pulmonary edema
- Non-cardiogenic edema
- Aspiration
• Patients have regional V/Q mismatch
• Post-ROSC VILI
✓ Greater cerebral hemodynamic instability
✓ Increased cerebral inflammation, oxidative stress
✓ Triggers hippocampal apoptosis
Mechanical Ventilation
Gonzalez-Lopez A, et al. Am J Respir Crit Care Med 2013Polglase GR, et al. PLoS One 2012
Mechanical Ventilation
• Tidal Volume
✓ Patients at high risk of ARDS
✓ Use lung protective strategy
✓ 6 - 8 ml/kg PBW
Peberdy MA, et al. Circulation 2010
• After ROSC
✓ Cerebral hyperperfusion (up to 30 min)
✓ Subsequent period of significantly reduced CBF
✓ Cerebral vascular responsiveness to CO2 intact
Mechanical Ventilation
• After ROSC
✓ Cerebral hyperperfusion (up to 30 min)
✓ Subsequent period of significantly reduced CBF
✓ Cerebral vascular responsiveness to CO2 intact
Mechanical Ventilation
• CO2
- Potent regulator of cerebrovascular tone
- Hypocapnia
✓ Vasoconstriction
✓ Decreases CBF
✓ Increases intrathoracic pressure
Mechanical Ventilation
• CO2
- Potent regulator of cerebrovascular tone
- Hypercapnia
✓ Vasodilation
✓ Elevates ICP
Mechanical Ventilation
✓ 69% experienced pathologic values for PaCO2 after OHCA
Roberts, et al. Circulation 2013
• Observational cohort from ANZICS-APD
• 16,542 patients
✓ Hypocapnia group had trend toward higher in-hospital mortality
Schneider AG, et al. Resuscitation 2013
• Respiratory Rate
✓ Target “normocapnia”
✓ PaCO2 40-45 mm Hg
✓ PetCO2 35-40 mm Hg
Mechanical Ventilation
• Oxygenation
- Optimal level remains unknown
- Common to place on 100% FiO2
- Hypoxemia has lethal effects
Mechanical Ventilation
• Hyperoxemia
- May also have significant negative effects
- A precursor for reactive oxygen species
- Metabolic dysfunction
- Neurologic degeneration
Mechanical Ventilation
• Meta-analysis of 14 observational trials
• 49,951 patients
• Examine effects of hyperoxia on outcomes of post-ROSC patients
Wang CH, et al. Resuscitation 2014
✓ Hyperoxia significantly associated with in-hospital mortality
Wang CH, et al. Resuscitation 2014
• Retrospective analysis of CA database
• 184 patients from University of Pittsburgh
• Association between PaO2 over first 24 hours after cardiac arrest
Elmer J, et al. Intensive Care Med 2015
• 36% exposed to severe hyperoxia
• For every hour of exposure to severe hyperoxia, survival to hospital DC decreased
Elmer J, et al. Intensive Care Med 2015
✓ Highest hyperoxemic values associated with treatment in prehospital phase and ED
Nelskyla, et al. Scand J Trauma Resusc Emerg Med 2013
• Oxygenation
✓ Avoid hypoxia and hyperoxia
✓ Adjust FiO2 to achieve SpO2 > 94%
✓ Maintain PaO2 ≈ 100 mm Hg
Mechanical Ventilation
Don’t ForgetA & B!
Michael Winters, MD FACEP FAAEMAssociate Professor of Emergency Medicine and Medicine
Co-Director, Combined EM/IM/Critical Care ProgramUniversity of Maryland School of Medicine
Twitter: @critcareguys
Intra-Arrest A & B✓ Passive oxygenation in early phases
✓ One size does NOT fit all
✓ Best airway / technique
- Patient factors
- Time-point during resuscitation
- Skill of rescuer
Intra-Arrest A & B
• Control ventilations!
Post-Arrest Breathing
• Tidal Volume
✓ Patients at high risk of ARDS
✓ Use lung protective strategy
✓ 6 - 8 ml/kg PBW
Peberdy MA, et al. Circulation 2010
• Respiratory Rate
✓ Target “normocapnia”
✓ PaCO2 40-45 mm Hg
✓ PetCO2 35-40 mm Hg
Post-Arrest Breathing
• Oxygenation
✓ Avoid hypoxia and hyperoxia
✓ Adjust FiO2 to achieve SpO2 > 94%
✓ Maintain PaO2 ≈ 100 mm Hg
Post-Arrest Breathing
Passive Oxygenation
• Chest compressions and recoil generates passive airflow while applying NRB mask
• Vt > dead space → air moves into lungs
• Vt < dead space → turbulent mixing of air can lead to molecular diffusion
• 95 patients
• Boussignac tube vs. intermittent PPV
• % of ROSC / survival to admission same
Saissy JM, et al. Anesthesiology 2000
• 1042 patients
• ETI + MV versus Boussignac tube
• No difference in outcome; less complications
Bertrand C, et al. Intensive Care Med 2006
• Secondary analysis of ROC PRIMED trial
• Non-traumatic OHCA receiving ETI or SGA
• Survival to hospital DC with satisfactory neurologic outcome
Wang HE, et al. Resuscitation 2012
• 10,455 patients
- ETI: 8,487
- SGA: 1,968
Wang HE, et al. Resuscitation 2012
• Nationwide, population-based study
• OHCA database in Japan
Tanabe S, et al. J Emerg Med 2013
• 318,141 patients
- ETI: 16,054
- LMA: 34,125
- Esophageal obturator: 88,069
Tanabe S, et al. J Emerg Med 2013
• Secondary analysis of CARES Registry
• Compared outcomes of OHCA patients with ETI, SGA, or no airway
McMullan J, et al. Resuscitation 2014
• 10,691 patients
- ETI: 5,591
- SGA: 3,110
- No airway: 1,929
McMullan J, et al. Resuscitation 2014
✓ Approximately 45% of patients experienced hypocapnia or hypercapnia
Falkenbach P, et al. Resuscitation 2009
• Prospective, nationwide, population-based
• OHCA database in Japan
Hasegawa, et al. JAMA 2013
• 649,654 patients
- 367,837 had BVM
- 281,522 had advanced airway
• 41,972 ETI
• 239,550 SGA
Hasegawa, et al. JAMA 2013
• Neurologically favorable survival
- Lower for ETI and SGA
Hasegawa, et al. JAMA 2013
Advanced Airway
• SGA vs. BVM
✓ Similar ABG values
✓ Less regurgitation (3.5% vs. 12%)
Advanced Airway
• SGA vs. ETI
✓ Greater insertion success rates
✓ Less time to insertion
✓ Ventilation parameters
• 10,455 patients
• Survival to hospital DC with satisfactory neurologic outcome
- ETI: 4.7%
- SGA: 3.9%
Wang HE, et al. Resuscitation 2012
• 318,141 patients
• Neurologically favorable 1-month survival
- ETI: 1.14%
- LMA: 0.98%
- Esophageal obturator: 1.04%
Tanabe S, et al. J Emerg Med 2013
• 10,691 patients
• Neurologically intact survival
- ETI: 5.4%
- SGA: 5.2%
- No airway: 18.6%
McMullan J, et al. Resuscitation 2014
• ETI vs. SGA
- ETI
✓ Higher sustained ROSC
✓ Higher survival to hospital DC
✓ Higher hospital DC with good neurologic outcome
McMullan J, et al. Resuscitation 2014
• 10 observational studies
- 34,533 patients with ETI
- 41,116 patients with SGA
Benoit JL, et al. Resuscitation 2015
• ETI patients
- Higher odds of ROSC (OR 1.28)
- Higher odds of survival to hospital admission
- Higher odds of neurologically intact survival
Benoit JL, et al. Resuscitation 2015
• 6,326 patients
✓ Higher in-hospital mortality in hyperoxemic group
Kilgannon JH, et al. JAMA 2010