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Emergency Medicine

Prehospital Post Arrest CareAHA Strive to Revive 2017November 3, 2017

Jon Rittenberger, MD, MSDepartment of Emergency MedicineUniversity of Pittsburgh

Emergency Medicine

Disclosures - Rittenberger• Employers:

– University of Pittsburgh

– UPMC

• Grants:

– Mallincrodt, LLC (inhaled NO study)

– BrainCool, LLC (surface cooling device study)

– Laerdal Foundation (early EEG study)

– AHA Innovation Award (Rehabilitation after cardiac arrest)

– AHA Grant in Aid (Neurostimulants after cardiac arrest)

– NIH/NINDS (NETT and SIREN research consortia)

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Emergency Medicine

Outline

• Preventing the ”Crump”

• Treating the etiology

• Resuscitate the Brain

Emergency Medicine

• 64M arrests on treadmill at YMCA

• Bystander calls 911, applies AED with shock *1

• ALS arrives to find asystolic

• Receives 3mg IV epinephrine, shock *2 with

ROSC

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Emergency Medicine

Emergency Medicine

Why do patients die after CPR?

• Classify cause of

death in 223 charts

of non-survivors

– Deaths < 72 hours

were mostly (50%)

“unstable”

– Deaths > 72 hours

were mostly (63%)

“neurological”

0

10

20

30

40

50

60

70

Pe

rce

nt

of

Ca

ses

<72 hrs >72 hrs

University of Pittsburgh 2011

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Emergency Medicine

The Crump!

Emergency Medicine

Goals?

SBP>100mmHg

SpO

2>90

%

HR>0

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Emergency Medicine

Blood Pressure and Ventilation

MAP

CBF

pCO2

50 150 25 35 45 55

Auto-regulationImpaired / right-shifted

CO2-reactivityPreserved

Emergency Medicine

Blood Pressure and Ventilation

MAP

CBF

pCO2

50 150 25 35 45 55

Auto-regulationImpaired / right-shifted

CO2-reactivityPreserved

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Emergency Medicine

Infused norepinephrine to increase CBF

Emergency Medicine

Blood pressure goal?

• We aim for MAP >80 mmHg– Kilgannon, et al. Crit Care Med.

2014.Threshold: MAP >70

– Beylin, et al. Int Care Med. 2013. Higher is betterRegardless of pressor use

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Emergency Medicine

A bolt in the head…

Emergency Medicine

Individual physiology varies

Intact autoregulationTissue hypoxia

Pressure passiveHypoxia corrected

Autoregulation essentially intact throughoutNo tissue hypoxia at any MAP

109mmHg 75mmHg

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Emergency Medicine

Hyperoxia

• Drives oxidative injury, ROS generation, etc

• Hyperoxia is common despite guideline

recommendation SaO2 98-100%

• Some OBSERVATIONAL data associate

hyperoxia with worse outcomes

0 10 200

100

200

300

400

Hours after return of spontaneous circulation

PaO

2 (m

mH

g)

Severe hyperoxia

Moderate hyperoxia

Normoxia

Kilgannon, et al. JAMA . 2010.

Emergency Medicine

This effect varies across patients

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Emergency Medicine

Oxygenation goals

• In absence of monitoring, we aim for

normoxia to mild hyperoxia (PaO2 100-200)

• With monitoring,

PbtO2 >20 mmHg

Emergency Medicine

Carbon dioxide goals

• We aim for PaCO2 40mmHg (temp corrected)

• Observational data mixed

Roberts, et al. Circ. 2013

Schneider, et al. Resus. 2013

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Emergency Medicine

Blood Pressure and Ventilation

MAP

CBF

pCO2

50 150 25 35 45 55

This is scenario for first several hours after CPR

Emergency Medicine

WHY?

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Emergency Medicine

Brain: Catastrophic CNS Event

Heart: ACS-Primary Arrhythmia-Congenital/Structural Heart Disease-Secondary Arrhythmia (cardiomyopathy)-Cardiogenic Shock-Pulmonary Hypertension/RV Failure

Lung: Large airway obstruction-Pulmonary failure (COPD, Asthma, etc)

Blood: TraumaNon-traumatic exsanguination

Blockages: PE-Obstructive shock

Minerals: Metabolic derangements (hypokalemia, DKA, etc)

Bugs: Distributive Shock (sepsis)

Toxicological

Environment: Electrocution-Hypothermia

Emergency Medicine

Brain: Catastrophic CNS Event

Heart: ACS

Blood: TraumaNon-traumatic exsanguination

Minerals: Metabolic derangements (DKA) Toxicological

Environment: Electrocution-Hypothermia

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Emergency Medicine

Emergency Medicine

• Stenting or coronary bypass surgery (CABG) followed

CATH

– 34/42 (81%) STEMI

– 30/54 (55%) nonSTEMI cases.

• Intraaortic Balloon Pump (IABP) was used

– 16/42 (38%) STEMI

– 18/54 (33%) nonSTEMI cases.

• LV assist device (LVAD), or transplantation for

– 4/42 (9.5%) STEMI

– 10/54 (19%) nonSTEMI cases.

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Emergency Medicine

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Early

CATH

Delayed

+ No

CATH

Early

CATH

Delayed

+ No

CATH

Early

CATH

Delayed

+ No

CATH

Early

CATH

Delayed

+ No

CATH

Early

CATH

Delayed

+ No

CATH

All Type I Type II Type III Type IV

Mo

rta

lity

Hemodynamically unstable / intractable shock

Multi-system organ failure

CMO for non-neurologic prognosis

Brain death / CMO for neurologic prognosis

Reynolds. Resuscitaiton 2014;85:1232-9.

Emergency Medicine

Examination

• AV fistula: Hyperkalemia

• Needle in arm: Overdose?

• Tracheostomy with mucous plug: Obstruction?

• Found in snowbank: Hypothermia?

• Blood on floor: Bleeding?

• Low glucose: Hypoglycemia?

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Emergency Medicine

Emergency Medicine

“Primum Non Nocere”

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Emergency Medicine

TTM better than no TTM

TEMPERATURE?

Emergency Medicine

Prehospital Cooling

• Circulation 2010

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Emergency Medicine

Bernard 2010- Circulation

• Randomized 234 subjects to prehospital

cooling or not

• Median fluid administration: 1900mL

Emergency Medicine

Bernard 2010- Circulation

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Emergency Medicine

Bernard 2010- Circulation

Emergency Medicine

Bernard 2010- Circulation

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Emergency Medicine

Bernard 2010- Circulation

Emergency Medicine

• RCT of 1364 patients to prehospital TH or not

• VF survival 43% in TH and 50% in not

• Non VF survival 9% in TH and 9% in not

• More diuretics and CHF in TH group

• More re-arrest in TH group (early death not different)

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Emergency Medicine

Emergency Medicine

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Emergency Medicine

Emergency Medicine

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Emergency Medicine

What is our Cardiac Arrest Center?

• Comprehensive post

arrest care

– Early aggressive

resuscitation

– Temperature management

– Coronary revascularization

– Prognostication

– Secondary prevention

– Rehabilitation

– Teach CPR to survivors and

their families

• Feedback to providers

and referring physicians

• Referral to survivor

support groups

• Research infrastructure

to generate new

knowledge

• System-wide quality

control and

improvement

• Survivor celebrations

Emergency Medicine

Take Home

• First, prevent the re-arrest

– Optimize organ oxygenation/perfusion

• Start working on the etiology

– Fix what you can (i.e. bleeding, hypoglycemia,

popsickles)

• Make sure they go to the right place

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Emergency Medicine

Thanks for your time!