b-card symposium

Cardiac Arrest in the Field TodayU A Goes Beyond ACLS

TuesdayMarch 7th

2017

Nicolas PESCHANSKI, MD, PhD

Acknowledgments

Salim R. Rezaie, MD@srrezaie

Tom R. Bouthillet, EMT@tbouthillet

Cardiac Arrest in the Field

USA

2016

STATE

of

the

UNION

Principles for EMS in the Field

Immediate Recognition & EMS Activation (911)

Early CPR w/ Emphasis on Chest Compressions

Rapid Defib’

Effective ACLS

Integrated Post-Resus Care

Cardiac Arrest Process of Care

Call Processing

Collapse(Time Zero)

ReactionTime

Pit Crew / High Performance CPR

Public Access Defibrillation(Social Media Citizen Responders)

9-1-1Call

Dispatch

En Route(Wheels-Up)

At Patient(CPR)

First Shock

ArrivalCurbside

(Wheels Down)

Second Shock

Third Shock

Fourth Shock

Sweet Spot

Telephone CPR (T-CPR)Dispatcher Instructions

ROSC

“It isn’t complicated

but it’s not easy.”

Multidisciplinary

Approach

Is the patient conscious? Is the patient breathing normally?Begin CPR instructions!

No!

No!

9-1-1DISPATCH

ONSCENEBLS

3% to 78%

Al-Khatib SM et al. Circulation CVQO 2016

ONSCENEBLS+

T-CPR & More

Good SamApps

ONSCENEBLS+

EMSTeamsACLS

Fire Dept Stations

CPREpiPulse

EMSFOCUS

CPR

EMSACLS

2015 AHA CPR

RATE100 – 120/min

DEPTH:2in - 2.4in

RECOILAllow Full Recoil

INTERRUPTIONSMinimize Pauses

RULES

Guideline Update

CPR: Man or Machine?

vs

EMSACLS+

Gates S et al. Resuscitation 2015

Cunningham LM et al. AJEM 2012

PAUSE = Decreased Perfusion

PERFUSION

PRESSURE

TIME

No Pause… Should Be Your Cause!

EMSACLS*

0%

10%

20%

30%

40%

50%

60%

Survival to Discharge

HQ-CPR

Davis DP et al. Resuscitation 2015

RhythmEMSACLS

vs

Shockable Non-Shockable

Early DefibrillationEMSACLS

PulseChecks

EMSACLS

>5sec 43%

>10sec 4%

Ochoa FJ et al. Resuscitation 1998

Pulse Check

EMSACLS Problem with Manual

Is the Pulse Check Dead?EMSACLS

Trans Thoracic Echo

No Cardiac Activity on

TTE

ROSC = 2.4%

Cardiac Activity on

TTE

ROSC = 51.6%

Blyth L et al. Acad Emerg Med 2012

EMSACLS+

Pseudo-PEA vs PEAEMSACLS+

EMSACLS

IV Epinephrine

1mg q3 – 5min

MAYBEReasonable

Class I (Strong)Benefit>>>Risk

Class IIa (Moderate)Benefit>>Risk

Class IIb (Weak)Benefit≥Risk

Class III (No Benefit)Benefit=Risk

Class III (Harm)Risk>Benefit

1mg q3 – 5min

MAYBEReasonable

EMSACLS

Evidence for Epi

OHCA

EMSACLS+

ROSC ≠ Neuro

Intact Survival

↑ ROSCNo ↑ Survival↑ Mortality

IV Access in the Field

EMSACLS

IO vs PIV

Higher Success Rate

Faster Access Achieved

EMSACLS+

Cardiac Arrest Ventilation

Fouche PF et al. Prehosp Emerg Care 2014

> >

BVM Vent is Difficult!

EMSACLS

Guyette FX et al. Prehosp Emerg Care 2007

EMSACLS+

Is There Still Room for ETI?

Sunde GA et al. Scan J Trauma Resus Emerg Med 2015

EMSACLS+

Maybe… YES

Benoit JL et al. Resuscitation 2015

b-card

ACLS & Beyond…?ACLS2020

b-card symposium

Thank You for Your AttentionQ & A

TuesdayMarch 7th

2017

Nicolas PESCHANSKI, MD, PhD