Evolving Trends in Cardiac Arrest - American Heart Associationwcm/@gra/documents/... · • Advanced airway ventilation rate ... • Vasopressors for resuscitation: vasopressin and

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Evolving Trends in Cardiac Arrest

Michael W. Donnino, MDEmergency Medicine and Critical Care

Director of the Center for Resuscitation ScienceBeth Israel Deaconess Medical Center

[email protected]

Disclosures

• Consultant: Paid Consultant for the AHA

• Research Grants: AHA, NIH, Kaneka, General Electric, Bristol-Myers Squibb

• American Heart Association (paid and volunteer)• 2015 ACLS guidelines editor (paid)• Member, Research Task Force and Clinical – GWTG• Member, ACLS task force for ILCOR

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The 2015 ACLS Guidelines

• Focused update

• ILCOR � GRADE � AHA writing groups

• The path forward � ongoing continuous update

• Assessment sequence

• Chest compression rate and depth

• Advanced airway ventilation rate

• Targeted temperature management

• Vasopressors for resuscitation: vasopressin and epi

• Consideration of ECPR (not routine but in certain settings)

• Consideration of ETCO2 as one element of determining when to stop resuscitative efforts

• Neuroprognstication at 72 hours post TTM

• Timing of C-section “modifier”

Changes to ACLS Guidelines

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Philosophy of Changes• Keep things simple � removal of vasopressin from

algorithms, change in respiratory rate to avoid a range

• Recognize differences between arrest scenarios:• IN-hospital and OUT-of-hospital arrest � some split

recommendations, change in chain of survival, assessment sequence flexibility

• Different management for shockable and non-shockable

• More formalized and critical evaluation of the studies with GRADE approach and push to “try” to take a stand one way or another though often difficult…

NEW AHA ADULT CHAINS OF SURVIVAL

IN-HOSPITAL(note new Surveillance and Prevention link)

OUT-OF-HOSPITAL,Including EMS

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Philosophy of Changes• Keep things simple � removal of vasopressin from

algorithms, change in respiratory rate to avoid a range

• Recognize differences between arrest scenarios:• IN-hospital and OUT-of-hospital arrest � some split

recommendations, change in chain of survival, assessment sequence flexibility

• Different management for shockable and non-shockable

• More formalized and critical evaluation of the studies with GRADE approach and push to “try” to take a stand one way or another though often difficult…

The Pyramid of Learning

No Clue

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No Clue

Know the “sound bite” or “rule”


No Clue


Know “the study”

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No Clue



Literature


No Clue



Literature

Clinical Practice

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Try Not to Live in the “Sound Bite” !!

No Clue



Literature

Clinical Practice

Perimortem Ceasarean Delivery (PMCD)

Sound Bite:

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Sound Bite: PMCD should be consideredat 4 minutes after onset of maternal cardiac arrest or resuscitative efforts (for the unwitnessed arrest) if there is no maternal ROSC


Sound Bite: PMCD should be consideredat 4 minutes after onset of maternal cardiac arrest or resuscitative efforts (for the unwitnessed arrest) if there is no maternal ROSC

Deeper Dive: The clinical decision to perform a PMCD—and its timing with respect to maternal cardiac arrest—is complex because of the variability in level of practitioner and team training, patient factors (e.g., etiology of arrest, gestational age of the fetus), and system resources.

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KEY AND UPDATED RECOMMENDATOINS:

BLS

ASSESSMENT SEQUENCE

• Check for responsiveness (tap and shout)

• Shout for nearby help upon finding a patient unresponsive/activate emergency response system/get AED

• Check breathing and pulse simultaneously

• Use defibrillator as soon as it is available

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CHEST COMPRESSION RATE: UPDATED

Recommendation: • Compression rate: 100-

120/minute(2010:at least 100/min)

Why? • Absolute number of

compressions delivered/minute linked with survival

• Actual compression rate often well below 100/minute

• Rates below 100/min or above 120/min adversely affect outcomes

MO2

ADULT CHEST COMPRESSION DEPTH: UPDATED

Recommendation: •Compress at least 2 inches (5cm) for average adult•Avoid excessive compression depth, i.e., greater than 2.4 inches (6cm)

Why? •Small study: more injuries with compressions greater than 2.4 inches (6cm). (Hellevuo et al, Resuscitation, 2013)

Note:•Difficult to judge depth without devices•Rescuers typically don’t “push hard” enough

Slide 19

MO2 Gen session slideMaureen Ortega, 11/23/2015

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ADVANCED AIRWAY VENTILATION RATE

• Deliver 1 breath every 6 seconds (10 breaths per minute) while continuous chest compressions are being performed

• Single rate for adults should be easier to learn, remember, and perform

MECHANICAL CHEST COMPRESSION DEVICES

Recommendation:• Manual chest compressions remain standard of care

over mechanical chest compression devices.

• Mechanical piston/compression devices may be a reasonable alternative to conventional CPR in specific settings (eg, where the delivery of manual compressions may be

challenging or dangerous to the provider).

Why?• Three large randomized trials comparing mechanical

chest compression devices to conventional CPR demonstrated survival similar to that with conventional CPR. Such devices may enable continuation of high-quality chest compressions in a vehicle or during PCI, etc.

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KEY NEW AND UPDATED

RECOMMENDATIONS:

ACLS

VASOPRESSORS FOR RESUSCITATION: VASOPRESSIN

• Vasopressin in combination with epinephrine offers no advantage as a substitute for standard-dose epinephrine in cardiac arrest

• Efficacy of the two drugs is similar, and there is no demonstrable benefit from administering both epinephrine and vasopressin as compared with epinephrine alone

• For simplicity, vasopressin has been removed from the algorithm

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VASOPRESSORS FOR RESUSCITATION: EPINEPHRINE

• Administer epinephrine as soon as feasible after the onset of cardiac arrest due to an initial nonshockable rhythm

• Association between early administration of epinephrine and increased ROSC, survival to hospital discharge, and neurologically intact survival

Epinephrine Versus Placebo

Jacobs et al. Resuscitation 82 (2011) 1138-1143.

“Patients receiving adrenaline during cardiac arrest had no statistically significant

improvement in the primary outcome of survival to hospital discharge although there was a

significantly improved likelihood of ROSC.”

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Epinephrine Versus Placebo

• Pre-hospital ROSC: 8.4% (placebo) vs 23.5% (epinephrine)

• ED to hospital admission: 13% (placebo) vs 25.4% (epinephrine)

• Hospital discharge: 1.9% (placebo) vs 4% (epi) [NS] (50% relative reduction in mortality though not enough patients for statistical significance – thus, caution with interpretation of “negative” trial)


VF/VT versus PEA/asystole


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Time To Epinephrine – PEA/Asystole

(Donnino et al. British Medical Journal 2014 )



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Figure 3. Time to epinephrine and survival

(Andersen et al., JAMA, 2015)

Time To Epinephrine – PEA/Asystole in pediatrics

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Very Early Epinephrine in VF/VT

)Early administration of epinephrine in patients with cardiac arrest and initial shockable rhythm. Andersen LW, Kurth T, Chase M, Berg KM, Cocchi MN, Callaway C, Donnino MW; BMJ. 2016 6;353

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Epinephrine Conclusions• Controversy: Epinephrine “not proven” and may be

harmful or counterproductive

• Current Guidelines:

• PEA/asystole � early and every 3-5 min (Class IIb)

• VFIB/VT � after the second defibrillation

• MY opinion: Maybe it depends – timing, context, alternative options/etiology of arrest may all factor in…However, I don’t think anyone should die without epinephrine

Amiodarone Vs. Lidocaine

Survival to Hospital Discharge??

No Difference but not powered for this

Amiodarone 5% vs. Lidocaine 3% (p = NS)

(Dorian et. al. NEJM)

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Amiodarone vs. Lidocaine• Bottom Line: Amiodarone currently has “the

nod” but the study was small and had some flaws including provision of lipoprotein with deleterious effects to lidocaine group. Thus, giving lidocaine is acceptable alternative

• Currently, being reproduced with very large trial




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Amiodarone vs. Lidocaine

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LOW ETCO2 FOR PREDICTING FAILED RESUSCITATION

Recommendation:• In intubated patients, failure to achieve an ETCO2

greater than 10 mm Hg by waveform capnography after 20 minutes of CPR may be considered one component of a multimodal approach to decide when to end resuscitative efforts, but it should not be used in isolation

Why?• Failure to achieve an ETCO2 greater than 10 mm

Hg after 20 minutes has been associated with poor outcome in case series

A patient is unresponsive and in ventricular fibrillation. A shock is delivered. The team leader orders the continuation of 2 minutes of compressions but before the "compressor” begins, another member of the team detects a carotid pulse. In this case, you should:

a) Cease CPRb) Provide an additional 2 minutes of chest compressions but do not deliver any medications during this periodc) Provide an additional 2 minutes of chest compressions and consider providing 1 mg or epinephrine or 40 Units of vasopressind) Provide an additional 2 minutes of chest compressions and consider providing 300 mg of amiodaronee) Both 3 and 4

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CPR in patients with ROSC??

(Giberson, Journal of Intensive Care Medicine, 2014)

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Well, not everyone was happy…

2010 AHA Recommendations

Treatment Recommendation 1: “We recommend that comatose (i.e., lack of meaningful response to verbal commands) adult patients with ROSC after out-of-hospital VF cardiac arrest should be cooled to 32oC to 34oC for 12 to 24 hours”

(Class I, LOE B)

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2010 AHA Recommendations

Treatment Recommendation 2: “Induced hypothermia also may be considered for comatose adult patients with ROSC after out-of-hospital cardiac arrest with an initial rhythm of pulseless electric activity or asystole”

(Class IIb, LOE B)

Targeted Temperature Management (TTM)1 - Should we perform TTM?

- Shockable versus non-shockable rhythms- Out-of-hospital versus in-hospital

2 - If so, what temperature should we choose?

3 - If so, when should we start? Prehospital?

4 - How long should we go?

5 – What do we do about fever after TTM is done?

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Mortality

Neurologic

Study Limitations

1 – Non-blinded assessors

2 – One “pseudo-randomized”

3 – Unclear attention to temp management in the control arm

4 – No report of longer term neuro outcomes or granular neurologic outcomes

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ILCOR Recommendation

We recommend TTM as opposed to no TTM for adults with OHCA and initial shockable rhythm who remain

unresponsive after return of spontaneous circulation.

(Strong recommendation, low quality evidence)


We suggest TTM as opposed to no TTM for adults with OHCA and initial non-shockable rhythm who remain unresponsive after return of spontaneous circulation.

(Weak recommendation, low quality evidence)

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We suggest TTM as opposed to no TTM for adults with IHCA and any initial rhythm who remain unresponsive after

return of spontaneous circulation.








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950 Enrolled

473 (33 degrees) 466 (36 degrees)

Mortality 235 (50%) Mortality 225 (48%) p = 0.51

33 degrees vs 36 degrees

950 Enrolled




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950 Enrolled




EQUALLY MATCHED GROUPS

950 Enrolled




EQUALLY MATCHED GROUPS

Median Time BLS: 1 min [0-2] 1 min [0-2]

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950 Enrolled




Nielsen et. al Targeted Temperature Management at 33 versus 36 degrees after cardiac arrest. New England Journal of Medicine (2013)

Other Differences• Hypotension criteria

• Rhythm inclusion differences

• Sedation/NMB strategies

• Targeted temperature control for 3 days (no fevers in all patients both groups in latest study)

• Follow-up protocol for neuro-prognostication

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Survival Curve Differences

Temperature Differences

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Temperature Differences






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We recommend selecting and maintaining a constant target temperature between 32-36o Celsius for those for whom

TTM is being used.

(Strong recommendation, moderate quality evidence)

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Theoretical Complications from TTM1 – Bleeding – no increase in the RCTs but…

2 – Infection (Pneumonia) – trend toward increase

3 – Bradycardia – occurs but is this harmful?

4 – Hypokalemia – yes, increased incidence







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Prehospital Hypothermia Trials

3551 Assessed

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Re-arrest post-ROSC (26% versus 21%) p = 0.008


Pulmonary Edema (41% versus 30%) p < 0.001

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We recommend against routine use of prehospital cooling with rapid infusion of large volumes of cold intravenous

fluid immediately after ROSC.








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We suggest that if TTM is used, duration should be at least 24 hours as done in the two largest previous RCTs.







5 – What about fever after TTM is done?

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We suggest prevention and treatment of fever in persistently comatose adults after completion of TTM between 32 and

36o Celsius.


Keeping the Doctors Away Might Be Among One of the Most Important

Post-Cardiac Arrest Interventions

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Keeping the Doctors Away Might Be Among One of the Most Important

Post-Cardiac Arrest Interventions

• Non-TTM: 72 hours post-ROSC

• TTM: It is reasonable to wait 72 hours post return of normothermia before undergoing neuroprognostication

Case 1

• 65 year old male history of recent CABG surgery is on the hospital floor on POD #4

• A nurse obtaining vital signs witnesses the patient become unresponsive and ashen and calls for help…

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Case 1

Case 2

• 60 year old male presents with respiratory distress secondary to pneumonia and is intubated without complication (ETT confirmed by auscultation, end-tidal, and CXR)

• Patient initially stable after intubation with fluids/antibiotics and on low dose of vasopressors

• However, 2 hours later, nurse calls for help and…

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Case 3

• 66 year old female who presents with hypotension, urosepsis, and acute renal failure

5.6

90

13

191

133 80

3.3

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Case 3

!

Case 3

• 78 year old female history of COPD is on the hospital ward recovering from pneumonia

• She is found by nursing staff to be unresponsive and breathing at a rate of less than 8 breaths per minute

• She is obtunded and hypoxic but has a good pulse; you are called to intubate the patient…

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Conclusions • ACLS guidelines have stepped into a new era of

continuous review and online fluidity

• Most of the guidelines are based on expert opinion of limited evidence

• Don’t live in the sound bite – dive deeper than the one sentence recommendation….

Conclusions

• END

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Well, how about some stuff we got wrong?

• The “Earth is Flat”…

• Important items we did not cover: IO versus intravenous access

• Elements that may be misinterpretated: Beta blockers and lidocaine post-arrest


Pulmonary Edema (41% versus 30%) p < 0.001

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Prehospital Hypothermia Trials

3551 Assessed


We recommend against routine use of prehospital cooling with rapid infusion of large volumes of cold intravenous

fluid immediately after ROSC.


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Donnino M, et al. Temperature Management after Cardiac Arrest: An Advisory Statement by the ACLS Task Force at ILCOR. Circulation 132 (25) 2448-56.2015

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What did we get right and do I know??

• “Known Knowns”

• Known Unknowns”

• “Unknown unknowns”

The Process

• ILCOR � evidence reviewing using GRADE and creation of the “Consensus on Science”

• AHA writing groups incorporate the findings from ILCOR into guidelines with levels of evidence to support…

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Could NMB be a confounder?

Salciccioli JD, Cocchi MN, Rittenberger JC, Ornato JP, Abella BJ, Callaway CW, Donnino MW. Continuous neuromuscular blockade is associated with decreased mortality in post-arrest patients. Resuscitation (2013) 84:1728-33

Amiodarone vs. Lidocaine

Survival to Hospital Discharge??

No Difference but not powered for this

Amiodarone 5% vs. Lidocaine 3% (p = NS)

(Dorian et. al. NEJM)

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ACLS Drugs - Summary� Epinephrine

� Vasopressin: removed from ACLS algorithms but is it magic when combined with steroids??

� Amiodarone versus Lidocaine versus placebo ???

� Sodium Bicarbonate: “Routine use” not recommended

� Calcium: “Routine use” not recommended

� Magnesium: “Routine use” not recommended

� Atropine: Remains out of pulseless ACLS algorithms –

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EXTRACORPOREAL CPR

• Extracorporeal CPR may be considered among select cardiac arrest patients who have not responded to initial conventional CPR, in settings where it can be rapidly implemented

Documents

Evolving Trends in Cardiac Arrest - American Heart Associationwcm/@gra/documents/... · • Advanced airway ventilation rate ... • Vasopressors for resuscitation: vasopressin and