Upload
others
View
1
Download
0
Embed Size (px)
Citation preview
Maintaining Perfusion When the Ticker Flickers:
Innovations in ECPR
Nicole Kupchik, MN, RN, CCNS, CCRN-K, PCCN-CMC, CSC And
Mike McEvoy, PhD, RN, CCRN, NRP
EMS Efforts to Improve SCA Survival
• Sudden Cardiac Arrest was the impetus for EMS
• 350,000 OOH arrests/year • Until recently, CPR and ACLS
were EMS focused • Many innovations are first
trialed in the field
Dispatcher Assisted CPR
• Nearly ALL arrests result in a call to 911 • Telephone CPR (T-CPR) – compression only • Results in 2 – 3 times greater survival
Am Heart Assn: Guidelines 2015 CPR and ECC
Citizen Responder Apps
• Mobile phone apps to alert citizens when CPR is needed
• Citizen alerting increases survival 50-70%
• www.pulsepoint.org is often used in US Ringh M, Rosenqvist M, Hollenberg J, et al. Mobile-phone dispatch
of laypersons for CPR in out-of-hospital cardiac arrest. N Engl J Med. 2015;372(24):2316-2325.
http://www.pulsepoint.org/
Pit Crew CPR
• Follows auto racing pit crew approach
• Clearly assigned roles, well practiced, focused on specific objectives
• Studies show survival Hopkins CL, Burk C, Moser S, et al. Implementation of pit crew approach and cardiopulmonary resuscitation metrics for out-of-hospital cardiac arrest improves patient survival and neurological outcome. J Am Heart Assoc. 2016;5(1).
Continuous Compressions
• We know interruptions in chest compressions lead to poor outcomes (intubation, defibrillation, pulse checks, etc)
• Analysis comparing continuous CPR (no ventilation) to CPR with interruptions for breaths show:
• Higher survival for continuous civilian CPR • Slightly better survival with interrupted paramedic CPR but NO
difference in neurological outcomes
Message: delay intubation, don’t stop CPR, precharge your defibrillator before pulse checks…
Zhan L, Yang LJ, Huang Y, He Q, Liu GJ. Continuous chest compression versus interrupted chest compression for cardiopulmonary resuscitation of non-asphyxial out-of-hospital cardiac arrest. Cochrane Database of Systematic Reviews 2017, Issue 3. Art. No.: CD010134.
Automatic CPR Devices
• Multiple studies • Routine use of mechanical CPR devices
does not improve survival
Perkins, Gavin D et al. Mechanical versus manual chest compression for out-of-hospital cardiac arrest (PARAMEDIC): a pragmatic, cluster randomised controlled trial. The Lancet , 2014; 385: 947 – 955.
34% 27%
10%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
3 months 6 months 12 months
Average Skill Loss
% P
assi
ng S
kills
Tes
t
www.heart.org/HEARTORG/General/Resuscitation-Quality-Improvement_UCM_459324_SubHomePage.jsp
http://www.heart.org/HEARTORG/General/Resuscitation-Quality-Improvement_UCM_459324_SubHomePage.jsphttp://www.heart.org/HEARTORG/General/Resuscitation-Quality-Improvement_UCM_459324_SubHomePage.jsp
Heads Up CPR
• Elevation of head significantly improved cerebral perfusion pressures
• Better neuro outcomes Ryu HH, Moore JC, Yannopoulos D, Lick M, McKnite S, Shin SD, Kim TY, Metzger A, Rees J, Tsangaris A, Debaty G, Lurie KG. The Effect of Head Up Cardiopulmonary Resuscitation on Cerebral and Systemic Hemodynamics. Resuscitation. 2016; 102:29-34.
Delayed or No Endotracheal Intubation
• ETI often interrupts CPR, takes focus away from high quality compressions
• No evidence of benefit for either BVM or ETI
• Many EMS systems delay or do not intubate
Link MS, Berkow LC, Kudenchuk PJ, et al. Part 7: Adult Advanced Cardiovascular Life Support: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2015;132:S444-64.
End Tidal CO2 (Waveform Capnography)
• Initially used for airway placement • Now guides entire resuscitation:
• Continued monitoring of airway placement • Chest compression quality • Cardiac output and acid-base status • Futility
Paiva EF, Paxton JH, O'Neil BJ. The use of end-tidal carbon dioxide (ETCO2) measurement to guide management of cardiac arrest: A systematic review. Resuscitation. 2018;123:1-7.
Ultrasound
• Has diagnostic value when used appropriately • Controversial – interruptions/delays
Huis In 't Veld MA, Allison MG, Bostick DS, Fisher KR, Goloubeva OG, Witting MD, Winters ME. Ultrasound use during cardiopulmonary resuscitation is associated with delays in chest compressions. Resuscitation. 2017;119:95-98.
Amaya SC, Langsam A. Ultrasound detection of ventricular fibrillation disguised as asystole. Ann Emerg Med. 1999;33:344-6.
Hand Placement - CPR
• Studies suggest LV location varies
• Compressions over LV increase blood flow dramatically
Kyoung Chul Cha et al. Emerg Med J 2013;30:615-619
Patient Destination – ECPR/ECMO ?
• Is the patient a candidate for ECPR? • survival
Columbus, Ohio EMS Protocol
What is E-CPR?
Extracorporeal Cardiopulmonary Resuscitation: • Mechanical Chest Compression
device • PCI Percutaneous Coronary Intervention • ECMO Extracorporeal Membrane Oxygenation
Cardiac Catheterization Lab
Should the patient go to the cath lab?
• Get a 12 Lead ECG post arrest
• Class I, LOE B
• PCI should be performed emergently in OHCA with STEMI
• Class I, LOE B-NR
• Reasonable to perform PCI regardless of awake or comatose
• Class IIa, C-LD Dumas, F et al. Circ Cardiovasc Interv. 2017
• Case series: • PCI was needed in 95% of all
post arrest patients with STEMI • PCI was needed in 58% of
patients post arrest who didn’t have ST elevation!
56 year old with OHCA
• Transient ROSC • 4 mg of Epi, but
continues loss of pulse • Unclear if STEs on
ECG • What to do next?
Would anyone take this patient to the cath lab?
Mechanical Chest Compression Devices
Case continued…OHCA, RBBB
Re-arrest in the Cath
Lab
Stent placed to the LAD
ROSC post-stent placement
ECMO
ECMO - Extracorporeal Membrane Oxygenation
Minnesota experience with eCPR
Yannopoulos, D et al. J of Am Heart Assoc. 2016
Minnesota Experience with eCPR
Outcomes: • 53% survival! • Most had CPC 1
or 2!
Yannopoulos, D et al. J of Am Heart Assoc. 2016
Troponin Levels
Yannopoulos, D et al. J of Am Heart Assoc. 2016
Heart Function with Support
Yannopoulos, D et al. J of Am Heart Assoc. 2016
The Paris Experience
Pre-hospital E-CPR in the Louvre Museum, Paris
Mechanical CPR as a bridge? The “Art” of E-CPR!
ECMO comes to you?
E-CPR
Mechanical CPR + ECMO + PCI + Hypothermia
Stub, D et al. Resuscitation. 2015
CHEER Trial Outcomes
• ROSC 25/26 (96%) • Survival to DC 14/26 (54%)
• OHCA 5/11 (45%) • IHCA 9/15 (60%)
• Survival with favorable Neuro outcome 14/26 (54%)
Stub, D et al. Resuscitation. 2015
Resources
https://edecmo.org/
System of Care
Maintaining Perfusion �When the Ticker Flickers: �Innovations in ECPREMS Efforts to Improve SCA SurvivalDispatcher Assisted CPRCitizen Responder AppsPit Crew CPRContinuous CompressionsAutomatic CPR DevicesHeads Up CPRDelayed or No Endotracheal IntubationEnd Tidal CO2 (Waveform Capnography)UltrasoundHand Placement - CPRPatient Destination – ECPR/ECMO ?Columbus, Ohio EMS ProtocolWhat is E-CPR?Cardiac Catheterization LabShould the patient go to the cath lab?Slide Number 1856 year old with OHCAMechanical Chest Compression DevicesCase continued…OHCA, RBBBStent placed to the LADECMOECMO - Extracorporeal Membrane OxygenationMinnesota experience with eCPRMinnesota Experience with eCPRTroponin LevelsHeart Function with SupportThe Paris ExperienceMechanical CPR as a bridge?�The “Art” of E-CPR!ECMO comes to you?E-CPRCHEER Trial OutcomesResourcesSystem of Care