63 YO M FOUND COLLAPSED IN COOLER AT CONVENIENCE STORE

EMS FOUND IN VFREFRACTORY TO SHOCKS ETC.

MECHANICAL CPR (LUCAS)PT HAS EXCELLENT ETCO2 AND SATDIRECT TRANSPORT TO CATH LAB

CATH LAB HIGH LAD OCCLUSION – UNSTABLE

PLACED ON ECMO IN CATH LABCOMPLETED PCI

COOLED TO 33C X 24OFF ECMO DAY 5 HOME DAY 11

MANAGING REFRACTORY VT/VFFROM FIELD TO RECOVERY –

AND THE BEYOND

Marvin Wayne, MD, FACEP, FAAEM, FAHA

Associate Clinical Prof. Univ. of Washington

EMS Medical Director Whatcom County

Emergency Dept. PeaceHealth St. Joseph Med Ctr

Bellingham, WA

REFRACTORY VF (RVF)

New focus on saving the “un-savable”

High risk, high reward?

DEFINITIONS

• Refractory VF/pVT is a rhythm never converting with

defibrillation (i.e. VF => VF => VF => VF)

• Recurrent VF/pVT is a conversion with defibrillation but

deteriorating back to VF/pVT (i.e. VF => PEA => VF => Asystole

=> VF)

• DSD is only utilized for Refractory VF/pVT

RVF: UNDERLYING CAUSE

• RVF

• Cardiac arrest patients stuck in VF after ACLS care and

3,4 or 5 failed shocks

• Small, but not insignificant % of cardiac arrest patients

• Majority of OHCA caused by a cardiac issue

• Majority of cardiac issues caused by acute

coronary occlusion (blockage)

• Likely cause of RVF is occluded main coronary

artery (proximal LAD or high Left Main)

• Feeds the main heart pump- the left ventricle

Open the artery quickly! Fix the problem. Ideally….

RVF: THE TOOLS

Double sequential

defibrillation (DSD)

Extracorporeal membrane oxygenation

(ECMO)

Cath lab for PCI (open the artery)

Targeted temperature management

(TTM)

Mechanical chest

compression

Early EMS transport

Intra-arrest to the cath lab

Alternate pad placement

defibrillation

DSD FOR RVF

How and why is DSD being used?

Into the unknown…

DEFINITION

•Double Sequential Defibrillation (DSD)

• Is not synchronous defibrillation

• Two separate shocks delivered as closely as

possible, with "separate pad placement"

• Believed different vectors provided by two

sets of pads provide the benefit

RATIONALE

• Theory current HPCPR / ACLS practices

producing more patients in REFRACTORY VF

• Theory DSD may reduce the VF threshold

• Theory DSD may reduce transthoracic

impedance

DEBATE/DISSENT

• Concern few VF patients are truly “refractory” to

therapy

• Concern Monitor/Defibrillator damage may

occur

• Concern DSD may interfere with HPCPR, a proven

therapy

DSD • What is it?

• Using two defibrillators and two sets of pads

• Two “myocardial sandwiches” instead of one

• Who might get DSD? • Used historically for in-hospital difficult AF and VF cases

• Now gaining momentum for OHCA stuck in RVF

• Initiated after 3-5 failed max energy shocks

• One mechanistic hypothesis • Likely not “doubling” energy (i.e. 360J x 2 = 720J)

• Nearly impossible to hit shock buttons simultaneously

• Likely delivering two max energy shocks, closely together, to cover more heart

DSD • What are the risks?

• Not FDA approved & is Off-Label use of ALL external

defibrillators

• Timing of shocks could actually LOWER shock success

• Timing of shocks could also damage the defibrillator

• Always perform manual diagnostic check after DSD

• Ongoing Research?

• Research teams are reviewing data from a few EMS

systems

• Research teams also will be doing an animal study on

DSD

DSD

• What are the unknowns?

• Does DSD work? No clinical trials, only case studies and

retrospective analyses.

• Optimal pad configurations?

• Optimal timing of the two shocks?

• DSD may benefit some patients, but are there

other options that could benefit RVF pts more?

• Take RVF patients directly to cath with mechanical CPR

or ECMO?

anterior-lateral configuration

examples

anterior-lateral + anterior-

posterior configuration examples

QUICK-COMBO

QUICK-COMBO

ECMO, LUCAS, TTM FOR RVF

How do we get RVF patients to the cath lab, WITH a viable heart and brain?

WHAT IS ECMO (ECPR)?

• Provides out-of-body cardiac and respiratory support

• Replaces the need for CPR – mini heart lung machine

• Removes blood from the body, removes the CO2, oxygenates

blood, then returns it

• ECMO is used for longer-term support than CPB used

during open heart surgery, ranging from 3-10 days

WHAT IS ECMO (ECPR)?

• Traditionally used in infants with breathing or heart problems

• ECMO is now being used:

• For recovery from heart failure, lung failure or heart surgery.

• As a bridge to an left ventricular assist device (LVAD) or

coronary angiography/PCI.

• For support during high-risk coronary angiography/PCI.

WHAT IS ECMO (ECPR)?

ECMO starts with simultaneous CPR and cannulation via the

femoral artery and vein. CPR is stopped when ECMO is completely

initiated.

WHAT IS ECMO (ECPR)?

2015 AHA

Guidelines

2015 ERC Guidelines

MECHANICAL CHEST COMPRESSION

• LUCAS used as a bridge to ECMO

• LUCAS used as a bridge to cath lab (without ECMO)• New AHA research:

• PCI De Lucas: A Prehospital Pathway Direct to the Cath Lab for Patients Suffering From

Out-of Hospital Cardiac Arrest. (2016. AHA. Axelsson et al)

• 12% survival among pts transported with ongoing LUCAS compressions

• New FDA Indication:

• External cardiac compressor devices are used as an adjunct to manual cardiopulmonary

resuscitation (CPR) when effective manual CPR is not possible (e.g., during patient

transport or extended CPR when fatigue may prohibit the delivery of effective/consistent

compressions to the victim, or when insufficient EMS personnel are available to provide

effective CPR).

• Adding PCI which FDA does not mention but AHA supports. This is largely in line with our

current messages- we recommend manual CPR and defib before LUCAS, then, if indicated,

apply LUCAS

TTM

• Temp range is still unknow

• 32-36 (We are using 32-34)

• 36 hard to hold

• <32 too cold

• New data shows better outcome with 32-34

• Prevent hyperthermia and stabilize cerebral membrane and

cardiac membrane

RVF PROTOCOLS

Minneapolis, MN (Minnesota Resuscitation Consortium) Lincoln, NE Bellingham, WA

RVF PROTOCOLS

• Inclusion criteria • OHCA w/ presumed cardiac etiology

• First presenting rhythm shockable

• Age 18-75 years

• Received at least 3 shocks w/o sustained ROSC

• Amiodarone 300 mg given

• LUCAS w/ ITD

• Positive signs of life (ETCO2, movement, spontaneous

respiration etc.)

• Transfer time from scene to CCL ≤ 30 min (greater in select

cases)

• Exclusion criteria

• OHCA not of presumed cardiac etiology

• DNR, significant co-morbidities

• First presenting rhythm non-shockable or without

positive signs of life

• Prolonged transport time

RVF PROTOCOLS

• 18 pts transported to ED with LUCAS + ITD

• 15 pts received ECMO upon arrival to the hospital

• 3 pts had PCI w/ ongoing LUCAS + ITD

• 10 pts survived to hospital discharge (55%)

• 9 pts had CPC scores of 1-2 (50%)

• The protocol was feasible and led to a high functionally

favorable survival rate with few complications

• CPC of 1 = 3 pts

RVF PROTOCOLS

• Historical controls with same criteria at 8.2% survival vs. 50%

in MRC data – results encouraging but more research needed

• Survival more favorable with:

• Shorter time from 911 call to cath lab

• Bystander CPR given

• Evidence of reversible CAD

• Lower lactic acid levels on initial blood gas in cath lab

SOMETIME IN THE FUTURE…OR

MAYBE EVEN THE PRESENT

THE SCIENCE OF HEAD UP CPR

Can we improve neurologic

outcome from cardiac arrest?

29

BACKGROUND“ELEVATION OF THE HEAD FOR TBI”

• Lowers ICP

• Increases venous drainage from the brain

• Is only effective if the MAP is normal (low MAP,

bad outcome)

• Remains controversial

• Are the lessons from TBI useful in the

treatment of cardiac arrest?

BACKGROUND“SITTING FOR CHF”

• Pts with CHF and orthopnea often sit up and

feel better

• Cardiopulmonary circulation is improved with

elevation of the thorax

• Lessons from CHF may be useful cardiac

arrest

POTENTIAL FOR A “BRAIN CONCUSSION” WITH EVERY COMPRESSION (CPR)

• Chest compressions increase arterial and

venous pressures simultaneously

• Delivering a bidirectional high pressure

wave to the brain with every compression

WHAT IS THE OPTIMAL HEAD/HEART POSITION?

A

B

C

Supine 0° CPR 30° Head down CPR

Change of position

(CPR + ITD: rate 100/min)

Ao

ICP

CerPP

Debaty et al, Resuscitation, 2014

Change of Position: Head Down

Supine 0° CPR 30° Head up CPR

Change of position

(CPR + ITD: rate 100/min)

Ao

ICP

CerPP

Debaty et al, Resuscitation, 2014

Change of Position: Head Up

Head-Up CPR: Is the ITD Needed?

CPPCerP

P

CPR angle (˚)

Pre

ssu

re (

mm

Hg

)

4

0

3

0

2

0

1

0

0

0 +30 +30 0 +30 +30

*, ***, **

**

0 CPR + ITD

30 CPR + ITD

30 CPR Only

Debaty et al, Resuscitation, 2014

The ITD is needed to optimize Head up CPR

BRAIN BLOOD FLOW DEPENDS ON HEAD POSITION

During CPR brain blood flow is highest with head

elevation

EVOLUTION OF HEAD UP CPR

Unique Benefits of “D”

❑ Lower ICP

❑ Lower RA pressure

❑ Higher CerPP

❑ Higher CorPP

❑ Preserves central blood

volume

❑ Lower PVR

A

B

C

D

Brain Blood Flow after 5’ and 15’ of ACD CPR + ITD

(% of baseline blood flow with beating heart)

Brain flow doubled with HeadUP CPR vs flat after 15 min of CPR

SUP = supine or flat

HUP = Head up

* P<0.01

Moore et al, Resuscitation, 2017

ACD + ITD Flat

Intrathoracic

pressure

Intracranial

pressure

Cerebral perfusion

pressure

Effect of Head Up CPR in Human

Cadaver ACD + ITD + Head

Up

“CONCUSSION WITH EVERY COMPRESSION” MITIGATED WITH HEAD UP CPR

LIMITATIONS OF FLAT CPR

• Venous blood backs up in the brain raising ICP

• Potential for a “brain concussion” with every

compression

• Blood flow through the lungs is reduced due to

pulmonary congestions (think of lungs as a wet

boggy sponge)

These limitations are overcome with Head Up CPR

POTENTIAL HARMFUL MISTAKES

• Elevation of the head before starting CPR (need to prime

system)

• Elevation of the head too quickly

• Too much elevation of the head

• Elevation of the head with the feet down for prolonged

periods of time

• Elevation of the head during CPR without circulatory

enhancers (e.g. ITD)

Without an adequate MAP elevation of the head during CPR

can be harmful

THE TECHNOLOGY OF HEAD UP CPR

The Evolution

SIMPLE WEDGE

47

WEDGE AND TOWEL

48

ONE SIZE DOES NOT FIT ALL, HARD TO ADD AUTOMATED CPR

49

MECHANICAL LIFT

50

BODY AND LUCAS-SLIPS

SNIFFING POSITION LOST WITH HEAD UP AS BODY CURLS

52

CURRENT PROTOTYPE: WEIGHT WITHOUT LUCAS BACKPLATE: 15 LBS

Meets major design specifications

53

PROTOTYPE UNIT GOING DOWN IN 6 SECONDS

MRS 525 WITH LUCAS 3 IN HEAD UP POSITION

Heart elevated 5 cm, Head elevated 25 cm55

CONCLUSIONS• Head up CPR with conventional CPR+ITD or ACD+ITD

• lowers ICP

• improves blood flow to the brain in pigs (humans)

• Elevation of the head and shoulders during ACD+ITD

doubles brain flow after 15 min of CPR in pigs

• To be safe and effective, these tools need to be used in

systems that focus on CPR quality and a ’Bundle of Care’

including high quality BLS and post-resuscitation care

• Elevation of head has been tried in two different EMS

systems as part of a new bundle of care with a near

doubling of outcomes

FIRST INTERNATIONAL STATE OF THE FUTURE OF RESUSCITATION MEETING: SEPTEMBER 2018

Oakland CA Sept 28-29

Co-sponsors

Eagles, French Resuscitation Council, Dutch

Resuscitation Council, JEMS, Minnesota

Resuscitation Consortium, Take Heart America

Speakers: key thought leaders in resuscitation

Cadaver lab to observe latest science and technology

Go to www.takeheartamerica.org

57

Questions?

Thank you…..