Resuscitation, ALS/APLS/ATLS are just the beginning

RESUSCITATION:

ALS/APLS/ATLS are just the beginning….

Peter SherrenST7 Anaesthesia and Intensive Care

petersherren@gmail.com

@pbsherren

Introduction

• ALS/APLS/ATLS essential to progression in training and when applying for jobs

• Common language and a great starting point

• Competence should be viewed as your starting point, and not your destination

Why bother?

What should we be doing now and what could we be doing in the future?

What's not going to be in this talk

What's not going to be in this talk

RESUSCITATION: WHAT MAKES THE DIFFERENCE?

• Good leadership

• Uninterrupted chest compressions

• Early defibrillation

• Aggressive post ROSC care

• Knowing when to think beyond standard algorithms

Airway

• Conflicting evidence for ETT/LMA/BVM

• Very rare airway should take priority over chest compressions

• ETCO2 for ALL airways in cardiac arrest Correct position/chest compression effectiveness/ROSC/prognostication

Ventilation• Apnoeic vs Passive vs Active oxygenation

• Hyperventilation is endemic in resuscitation

• PPV and PEEP impairs venous return and effectiveness of chest compressions

• PPV worsens outcome in VF/VT OOHCA. 1000pt RCT, 25.8% vs 38% survival to discharge. Bobrow et al Ann Emerg Med 2009

• Definite role for hypoventilation/zPEEP in haemorrhagic shock and primary cardiac arrest

Impedance threshold device

• ITD augments –ve intrathoracic pressure

• Improves cardiac and cerebral perfusion

• Improved survival when combined with ACD CPR. RCT 2470 pts. Aufderheide TP et al, Lancet 2011

Chest compressions• CARDIOCEREBRAL resuscitation

• Uninterrupted chest compressions are key (100-120, 1/3 AP, CCF >80%)

• Manual vs ACD vs Mechanical

• Manual vs mechanical. LINC trial, 2589 pts RCT, JAMA 2014

• Use ETCO2 to monitor compression effectiveness (>2.7kPa), and consider arterial line (CPP >20, DBP >25mmHg)

• Role for internal cardiac compressions?

Defibrillation• Good chest compressions before

hand

• Pre/post shock pause minimised

• Biphasic 200J+

• 2x defibs in refractory VF?

• Hands on defibrillation?

Leadership/CRM

Topcat2, Clarke S et al, Emerg Med J 2014

Intra-arrest ultrasound

• Not good enough to say PTx/tamponade/PE unlikely

• Abbreviated Ultrasound should be a standard of care

• Tamponade• PE• Cardiac standstill• PTx/hydrothorax• AAA/haemoperitoneum

Drugs• Adrenaline - Jacobs et al, Resuscitation 2010.

PARAMEDIC2 Perkins in Warwick, ongoing 8000pt RCT

• Amiodarone/Lignocaine

• Calcium Chloride/NaHCO3

• Thrombolysis

• Vasopressin/Sterioids/adrenaline - 230 pt RCT, Mentzelopoulos et al, JAMA 2013

Primary PCI/Heart attack centres

• Heart attack centres. Sunde et al, Resuscitation 2007

• Sensitivity of post arrest ECG? Normal PPCI rules are not sensitive enough

• PPCI for all VF/VT or suspected cardiac event?

• PPCI while undergoing mechanical chest compressions. Sunde et al, Crit care med 2008

• Package of care

E-CPR/ECLS

E-CPR/ECLS

E-CPR/ECLS

E-CPR/ECLS

E-CPR/ECLS

• Save-J. 3 yrs 260 vs 240 pts, 12.4% vs 3.1% survival with CPC 1&2. Sakamoto T et al, Resuscitation 2014

• 80 pts with propensity matched controls. Shin TG et al, Crit care med 2011

• Prospective propensity matched trial. 59 vs 113 pts. 32.6 vs 17.4% survival to discharge. Chen YS et al, Lancet 2008

• CHEER trial Victoria

• UK perspective

Selective aortic arch perfusion (SAAP)

Cardiac arrest post cardiac surgery

Toxic cardiac arrest• Specific considerations/antidotes

• Lipid rescue • High dose NaHCO3 & hyperventilation

• Calcium• HIET • Sugammadex • Others - Atropine/methylene blue/Pyridoxine

/Digibind/Hydroxycobalamin

• Prolonged resuscitation!!!

• E-CPR/ECLS or CPB

When should we stop?• It’s complicated… don’t overly rely on ‘Down

time’

• Prolonged resuscitation may be appropriate if VF/VT/cardiac cause to arrest

• Use of ECG, ultrasound and ETCO2 can help

• One off pH/lactate/K+ in isolation are poor discriminators of survival

• Deep hypothermic vs hypoxic/hypothermic arrests

Post cardiac arrest syndrome

• Ongoing pathology

• Myocardial stunning

• Inflammatory/reperfusion injury MODS

• Neurological insult – Anoxic/reperfusion/autoregulation

Post cardiac arrest syndrome management

• Treat underlying pathology and PPCI for all VF/VT?

• Early ETT and controlled ventilation• PaO2 >10 and SpO2 94-98%• PaCO2 4.5-5• MAP >70-80 Hope KJ et al, Crit care med 2014

• Glycaemic control• Appropriate sedation/analgesia/seizure

control• Aggressive targeted temperature

management

Targeted temperature management

• 36 vs 32-34 ̊C?

• Original HACA, NEJM 2002 vs Nielsen et al, NEJM 2013

• Avoidance of hyperpyrexia is key

• TTM still essential, the target has just changed

Prehospital/Intra-arrest cooling?

• No high grade evidence for prehospital cooling Bernard et al, JAMA 2013

• Intra-arrest cooling – equipoise for future trials

Prognostication

• Clinical examination

• Radiology

• Electrophysiology

• Biomarkers

Traumatic cardiac arrest• Resuscitation isn't futile

• Shouldn’t be treated like a medical cardiac arrest

• C-ABC and aggressive exclusion of pathology

• Blunt vs penetrating

• Role for external chest compressions?

• Resuscitative thoracotomy

• SOP/Algorithm

Lockey DJ et al. Resuscitation 2013

Sherren PB et al. Crit Care 2013

Suspended Animation/EPR

Summary

• Resuscitation isn't as futile as people would have you believe

• Aim for the best possible quality of care, not standard care

• Cumulative effect of marginal benefits

• Know when to go beyond standard resuscitation algorithms

Questions?