Ornato - Science driving the future of resuscitation · Science Driving the Future of...

Science Driving the Future of Resuscitation: ACLS

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Joseph P. Ornato, MD, FACP, FACC, FACEP

Professor & Chairman, Dept. of Emergency MedicineProfessor, Internal Medicine (Cardiology)

Virginia Commonwealth University Health System

Operational Medical DirectorRichmond Ambulance Authority

Richmond Fire & EMSHenrico County Division of Fire

Richmond, VA

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Joseph P. Ornato, MD, FACP, FACC, FACEPScience Driving the Future of Resuscitation: ACLS

FINANCIAL DISCLOSURE: Cardiac Co-Chair & Consultant: NIH Resuscitation

Outcomes Consortium (ROC) American Editor, Resuscitation Advisory Board, Key Technologies, Inc.

(Transnasal Cooling Device)

UNLABELED/UNAPPROVED USES DISCLOSURE: Transnasal cooling devices



Intra-arrest hot topics

Airway managementRole of ACLS drugs Extracorporeal Membrane

Oxygenation CPR (eCPR) Intra-arrest therapeutic hypothermia



AHA Guidelines Grading



Airway Management During CPR performed by providers trained in its use, the supraglottic

airway is a reasonable alternative to bag-mask ventilation (Class IIa, LOE B) and endotracheal intubation (Class IIa, LOE A).

For healthcare professionals trained in its use, the esophagealtracheal tube is an acceptable alternative to both bag-mask ventilation (Class IIa, LOE C) or endotracheal intubation (Class IIa, LOE A) for airway management in cardiac arrest.

For healthcare professionals trained in its use, the laryngeal tube may be considered as an alternative to bag-mask ventilation (Class IIb, LOE C) or endotracheal intubation for airway management in cardiac arrest (Class IIb, LOE C).

For healthcare professionals trained in its use, the laryngeal mask airway is an acceptable alternative to bagmask ventilation (Class IIa, LOE B) or endotracheal intubation (Class IIa, LOE C) for airway management in cardiac arrest.



Prehospital airway management in cardiac arrest - CARESMcMullan J et al. Resuscitation 2014; 85:617-22

10,691 out-of-hospital cardiac arrests in the CARES registry

Frequency of use ET= 5,591 (52%) SGA= 3,110 (30%) BVM= 1,929 (18%)

Survival to DC intact ET= 5.4% SGA= 6.7% BVM= 18.6%

BVM pts more likely to be: VF or VT initially EMS witnessed Bystander AED

Propensity matched, adjusted for confounders

-1 0 1 2 3 4 5 6

Survival by Airway Management Strategy

Favors SGA or ET Favors BVM

Odds Ratio [95% CI]

Sustained ROSC

Survival to admission

Survival to discharge

Survival to discharge intact

4.19

3.53

1.45

1.01



Prehospital airway management in cardiac arrest - CARESMcMullan J et al. Resuscitation 2014; 85:617-22

10,691 out-of-hospital cardiac arrests in the CARES registry

Frequency of use ET= 5,591 (52%) SGA= 3,110 (30%) BVM= 1,929 (18%)

Survival to DC intact ET= 5.4% SGA= 6.7%

Propensity matched, adjusted for confounders -1 -0.5 0 0.5 1 1.5 2 2.5 3

Survival by Advanced Airway Type

Favors SGA Favors ET

Odds Ratio [95% CI]

Sustained ROSC

Survival to admission

Survival to discharge

Survival to discharge neurologically intact

1.38

1.72

1.66

1.43



ET intubation vs. supraglottic airway in cardiac arrest - ROCWang HE et al. Resuscitation 2012; 83:1061-6

10,455 adult out-of-hospital cardiac arrest in Resuscitation Outcomes Consortium (ROC) registry

Not a randomized trial Frequency of use ET= 8,487 (81%) SGA= 1,968 (19%)

Survival to DC intact ET= 4.7% SGA= 3.9% -1 -0.5 0 0.5 1 1.5 2 2.5 3

Survival by Advanced Airway Type

Favors SGA Favors ET

Odds Ratio [95% CI]

Survival to DC neurologically intact

Survival to 24 hrs

ROSC

Airway or respiratory complications

1.40

1.78

0.84

1.74



ACLS Drugs

It is reasonable to consider administering a 1 mg dose of IV/IO epinephrine every 3 to 5 minutes during adult cardiac arrest (Class IIb, LOE A).

Amiodarone may be considered for VF or pulseless VT unresponsive to CPR, defibrillation, and a vasopressor therapy (Class IIb, LOE B).

Lidocaine may be considered if amiodarone is not available (Class IIb, LOE B).



Benefit of each link in the chain of survivalStiell I et al. N Engl J Med 2004;351:647-56

1.6 [1.2, 2.3]

4.4 [3.1, 6.4]

3.7 [2.5, 5.4]

3.4 [1.4, 8.4]

1.1 [0.8, 1.5]

ccv

Variable

Age <75 yr

Early Access

Early CPR

Early DF

Early ACLS

Adjusted Odds Ratio [95% CI]

ccv0.1 1.0 10.0

Adjusted Odds Ratio [95% CI]

Survival worse Survival better

5,638 OOH-CA patients17 cities in Ontario, CASequential addition of each link in

the chain of survivalOutcome= survival to hospital

discharge



ACLS meds vs. no ACLS drugs in OsloOlasveengen TM et al. JAMA 2009; 301:2222-9

851 OOH-CA cases Randomized to

ACLS with vs. without drugs

EMS response time interval= 10 min

Initial VF= 33% Byst witn= 65% Byst CPR= 63% MD on unit= 37% 8%9%

20%21%25%

10%11%

30%32%

40%

0%

10%

20%

30%

40%

50%

ROSC Admitted tohospital

Admitted toICU

Discharged Alive at 1 year

No drugs

Drugsp> .001 p> .001 p> .002 p> .61 p> .53



Prehospital randomized trial of no epinephrine vs. epinephrineJacobs I et al. Resuscitation 2011;82(9):1138-43

8%13%

2%

24%25%

4%

0%

5%

10%

15%

20%

25%

30%

ROSC Admitted Discharged

No epinephrine Epinephrine

p <0.001

p <0.001

p =.15

534 out-of-hospital cardiac arrest patients Randomized to receive no epinephrine vs. epinephrine during resuscitation Perth, Australia



Model

ROSCUnadjustedAdjusted for propensityAdjusted for propensity and selected variablesAdjusted for all covariates

1 month survivalUnadjustedAdjusted for propensityAdjusted for propensity and selected variablesAdjusted for all covariates

CPC 1 or 2UnadjustedAdjusted for propensityAdjusted for propensity and selected variablesAdjusted for all covariates

OPC 1 or 2UnadjustedAdjusted for propensityAdjusted for propensity and selected variablesAdjusted for all covariates

Odds Ratio [95% CI]

Favors NoPrehospital Epinephrine

FavorsPrehospital Epinephrine

Favors NoPrehospital Epinephrine

FavorsPrehospital Epinephrine

Prehospital epinephrine use & survival in JapanHagihara A et al. JAMA 2012; 307:1161-8

417,188 OOH-CA cases EMS skills: CPR AED IV Give epi 1 mg q4min x 3 Epinephrine vs. no

epinephrine by EMS 3.7% of patients received

epinephrine



Antiarrhythmic drugs for VF/pVT

American Heart Association 2010 ACLS Guidelines Amiodarone or lidocaine (each is a class Iib “may be considered”

recommendation for shock-refractory VF/VT)

Amiodarone and lidocaine may have other adverse effects

Neither drug has been proven (or tested adequately) to improve survival to discharge

Unproven therapies may be . . . Beneficial Inconsequential (make no difference) Harmful

The only way to know if lidocaine or amiodarone “work” is to compare either against placebo



Persistent or recurrent VF/VT

• IIb medications• Lidocaine• Bretylium• Mg sulfate• Procainamide• (Na bicarb)

• Continue CPR• Intubate at once• Obtain IV access

• Epi 1 mg IV q 3-5 min

• DF 360 J within 30-60 sec

• DF 360 J 30-60 sec after med dose• Pattern “drug-shock”, “drug-shock”

PlaceboAmio 300 mg

Amiodarone vs. lidocaine OOH-CA

38%

64%

17%

49%44%

33%

41%

12%

39%34%

0%

10%

20%

30%

40%

50%

60%

70%

All patients VF Asys or PEA ROSC No ROSC

Surv

ival

to A

dmis

sion

Amiodarone 300 mg PlaceboN= 504

Kudenchuk P et al. N Engl J Med 1999; 341:871-8

11%

23%

0%

5%

10%

15%

20%

25%

Amio Lido

Ad

mis

sio

n

p< .004

N= 348

Amio vs. Lido

Toronto EMS

911-1st DF = 12±7 min

911-drug = 25±8 min

Dorian P et al. N Engl J Med. 2002 Mar 21;346(12):884-90

ARREST Trial ALIVE Trial



NIH Resuscitation Outcomes Consortium (ROC)Amiodarone vs. Lidocaine vs. Placebo Study (ALPS)

• N=

SYRINGE # AMIODARONE KIT LIDOCAINE KIT PLACEBO KIT

1Amiodarone

150 mg (3 cc)

Lidocaine 60 mg (3 cc)

Placebo (3 cc)

2Amiodarone

150 mg (3 cc)


Placebo (3 cc)

3Amiodarone

150 mg (3 cc)


Placebo (3 cc)



Extra Corporeal Membrane Oxygenation (ECMO) CPR (eCPR)

In settings where eCPR is readily available, it may be considered when the time without blood flow is brief and the condition leading to the cardiac arrest is reversible (e.g., accidental hypothermia drug intoxication) or amenable to heart transplantation (eg, myocarditis) or revascularization (e.g., acute myocardial infarction) (Class IIb, LOE C).



Extra Corporeal Membrane Oxygenation (ECMO) CPR (eCPR)

Lack of randomized trials Available data is from small case series

and observational reports Most are retrospective

Age 18-83 (median= 56) years Duration of CPR 20-90+ minutes Initial rhythm Typical exclusion criteria IHCA vs. OHCA Survival 20-33%



ECPR associated with hypothermia and normoxiain refractory cardiac arrestFagnoul D et al. Resuscitation 2013;84:1519-24

Collapse to ECPR 58 min [45-70] Survivors 41 min [39-58] Non-survivors 60 min [55-77]

p=0.059 ALL had mechanical chest compression ALL had intra arrest hypothermia Tight PaO2 & PaCO2 management PCI on ECMO for suspected ischemia



eCPR for patients with OHCA of cardiac origin: A propensity matched studyMaekawa K et al. Crit Care Med 2013;41:1186-1196

Hazard Ratio [95% CI] Adjusted Hazard Ratio [95% CI] p

Pre-existing arrhythmia 0.33 [0.10-1.06] 0.59 [0.15-2.13] 0.42

Atropine administration (+1 mg) 1.55 [1.16-2.07] 1.28 [0.92-1.77] 0.14

Duration of CPR (+10 min) 1.18 [0.98-1.42] 1.08 [0.85-1.34] 0.52

Pupil diameter on hospital arrival (+1 mm) 1.56 [1.26-1.93] 1.39 [1.09-1.78] 0.007

Breathing spontaneously on hospital arrival 0.28 [0.11-0.71] 0.42 [0.14-1.28] 0.13

Shockable rhythm on hospital arrival 0.39 [0.20-0.77] 0.84 [0.36-1.99] 0.69

Initial lactate level (+1 mmol/L) 1.05 [0.99-1.12] 1.03 [0.96-1.10] 0.40

Sopporo, Japan Witnessed OHCA of cardiac origin Failed CPR >20 min

eCPR (n= 48, PCI 40%)

Manual CPR (n= 48, PCI 5%)

Log-rank p= 0.018

Primary Endpoint: Neuro IntactSurvival 3-months post-arrest



Two year survival and neurological outcome of IHCA patients rescued by eCPRShin TG, et al. International Journal Cardiol 2013;168:3434-3430

eCPR increased 2-year survival2.4 fold compared to CCPR

NNT: 7 patients over 2 years Best candidates: < 65 years CPR duration < 35 min Potentially reversible causes

eCPR



Intra-Arrest Hypothermia

In summary, we recommend that comatose (ie, lack of meaningful response to verbal commands) adult patients with ROSC after out-of-hospital VF cardiac arrest should be cooled to 32°C to 34°C (89.6°F to 93.2°F) for 12 to 24 hours (Class I, LOE B).

Induced hypothermia also may be considered for comatose adult patients with ROSC after in-hospital cardiac arrest of any initial rhythm or after out-of-hospital cardiac arrest with an initial rhythm of pulseless electric activity or asystole (Class IIb, LOE B).



Randomized Trial of Prehospital Induction of Hypothermia in OOH-CA with Rapid Infusion of 4ºC SalineKim et. al. JAMA 2014; 311:45-52

Mean temp change NS vs controlVF= -1.1 ºCNon-VF= -1.2 ºC

62%

18%

64%

16%

0%

10%

20%

30%

40%

50%

60%

70%

80%

VF Not VF

Surv

ival t

o Di

scha

rge

Cooled Not Cooled

p= .69

p= .30

26%

41%

21%

30%

0%

10%

20%

30%

40%

50%

Rearrest Pulm Edema on CXR

Surv

ival

to D

ischa

rge

Cooled Not Cooled

p= .008

p= .0001

N= 1,359 Median times from 911 call

to ROSC = 25-30 min



Intra-arrest hypothermiaNozari et al. Circulation, 2006; 113: 2690-96

10 min 20 min

17 dogs VF cardiac arrest No flow 3 min, 7 min BLS before ALS Randomized to early vs. delayed intra-arrest

hypothermia to 34 ºC



Intra-arrest hypothermiaNozari et al. Circulation, 2006; 113: 2690-96

Early Hypothermia Delayed Hypothermia

OPC-1 (normal) OOOO O

OPC-2 (mildly impaired) O

OPC-3 (moderately impaired O

OPC-4 (severely impaired) O

OPC-5 (death) O OOOOOOOO

17 dogsVF cardiac arrestNo flow 3 min, 7 min BLS before ALSRandomized to early vs. delayed intra-arrest

hypothermia to 34 ºC



Design of the Rapid Infusion of cold Normal SalinE by paramedics during CPR (RINSE trial) Deasy C et al. BMC Emergency Medicine. 2011;11:17

Australian pre-hospital randomized clinical trialDuring CPR, infuse up to 2L of 4°C saline

rapidly IVPrimary outcome: survival to d/cSecondary outcomes: ROSC, survival to

admission, temp on ED arrival, 12 month quality of life in survivors



External Head/Neck CoolingCallaway C et al. Resuscitation 2002;52:159-65

27 OOH-CA pts randomized to usual care vs. ice bags on head & neck during resuscitation

Monitored nasopharyngeal & esophageal temp



Comparison between transnasal head cooling begun during CPR and surface cooling after resuscitation in a pig model of cardiac arrestGuan J, Barbut D, Wang H, et al. Critical Care Medicine.2008:36(11) Suppl:S428-S433



Selective Brain Cooling (“Rhinochill”)

Non-invasive Intranasal PFC spray delivered

through nasal prongsCan be initiated early Ambulance or EDVery rapid cooling Upper airways designed for heat

exchange “Preferential” brain coolingBrain-core gradient



Intra-arrest transnasal coolingCastren et al. Circulation 2010;122(7):729-36

194 out-of-hospital cardiac arrest patients

15 sites, 5 European countries Pts randomized to prehospital

nasal cooling or no prehospitalnasal cooling

Standard therapeutic hypothermia used after hospital arrival



Transnasal cooling with dehumidified high flow airHarikrishna Tandri H, Zviman M, Srinivas MR, et al. Circulation 2012; 126:A1

18 adult pigs Intubated, mechanically ventilated Core body temp in R atrium Brain temp of frontal, parietal, occipital

lobes using thermocouples Rate of temp cooling measured at

80L/min transnasal dehumidified air flowMR thermography showed uniform

global brain cooling



Intra-arrest hot topics summary

Airway managementRole of ACLS drugs Extracorporeal Membrane

Oxygenation CPR (eCPR) Intra-arrest therapeutic hypothermia



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