RESUSCITATION

- Advances in out of hospital resuscitation -

BY NIALL MAGEE 05/15 BSC HONS PARAMEDIC SCIENCE, UoG -AVERY HILL/ LONDON

Adrenaline - Epinephrine

“The PARAMEDIC2 trial is looking at whether adrenaline is helpful or harmful in the treatment of a cardiac arrest that occurs outside a hospital. Answering this question will help to improve the treatment of people who have a cardiac arrest.”

http://www2.warwick.ac.uk/fac/med/research/hscience/ctu/trials/critical/paramedic2

BY NIALL MAGEE 05/15 BSC HONS PARAMEDIC SCIENCE, UoG-AVERY HILL/ LONDON

Evidence on adrenaline

Adrenaline made no difference to survivalJacobs et al, 2011

Adrenaline was associated with a worse survival rateDumas et al, 2014

Adrenaline was associated with a better survival rate in a subgroup with a non-shockable heart rhythmNakahara et al, 2013

Adrenaline made no difference to survival or to the risk of severe brain damageMachida et al, 2012

Adrenaline was associated with a worse survival rate and increased risk of severe brain damageHagihara et al, 2012

Adrenaline made no difference to survival, but increased the risk of severe brain damageHayashi et al, 2012

Adrenaline made no difference to survivalWoodhouse et al, 1995

Adrenaline made no difference to survivalOng et al, 2007

Adrenaline made no difference to survival, but increased the risk of severe brain damageHayashi et al, 2012

Adrenaline was associated with a worse survival rate and increased risk of severe brain damageOlasveengen et al, 2012

Adrenaline was associated with a worse survival rateHerlitz et al, 1995

BY NIALL MAGEE 05/15 BSC HONS PARAMEDIC SCIENCE, UoG-AVERY HILL/ LONDON

BY NIALL MAGEE 05/15 BSC HONS PARAMEDIC SCIENCE, UoG-AVERY HILL/ LONDON

MORE EVIDENCE ON ADRENALINE

http://www.wjem.org/upload/admin/201306/ab7a33c595368dd07cad9f1990902fd5.pdf

http://www2.warwick.ac.uk/fac/med/research/hscience/ctu/trials/critical/paramedic2/evidence/dumas_et_al_2014.pdf

http://www.ncbi.nlm.nih.gov/pubmed/24642404

http://www.bmj.com/content/347/bmj.f7268

http://www.bmj.com/content/348/bmj.g2435

BY NIALL MAGEE 05/15 BSC HONS PARAMEDIC SCIENCE, UoG-AVERY HILL/ LONDON

Underlying Medical Conditions – Causes of cardiac arrest

Coronary artery disease. Your arteries become clogged with cholesterol and other deposits, reducing blood flow to your heart. This can make it harder for your heart to conduct electrical impulses smoothly.Heart attack. can trigger ventricular fibrillation and sudden cardiac arrest. In addition, a heart attack can leave behind areas of scar tissue. Electrical short circuits around the scar tissue can lead to abnormalities in your heart rhythm.Enlarged heart (cardiomyopathy). This occurs primarily when your heart's muscular walls stretch and enlarge or thicken. In both cases, your heart's muscle is abnormal, a condition that often leads to heart tissue damage and potential arrhythmias.Valvular heart disease. Leaking or narrowing of your heart valves can lead to stretching or thickening of your heart muscle or both. When the chambers become enlarged or weakened because of stress caused by a tight or leaking valve, there's an increased risk of developing arrhythmia.Congenital heart disease. When sudden cardiac arrest occurs in children or adolescents, it may be due to a heart condition that was present at birth (congenital heart disease). Even adults who've had corrective surgery for a congenital heart defect still have a higher risk of sudden cardiac arrest.Electrical problems in the heart. In some people, the problem is in the heart's electrical system itself instead of a problem with the heart muscle or valves. These are called primary heart rhythm abnormalities and include conditions such as Brugada's syndrome and long QT syndrome.

http://www.mayoclinic.org/diseases-conditions/sudden-cardiac-arrest/basics/causes/con-20042982

BY NIALL MAGEE 05/15 BSC HONS PARAMEDIC SCIENCE, UoG-AVERY HILL/ LONDON

• Family history of coronary artery disease• Smoking• High blood pressure• High blood cholesterol• Obesity• Diabetes• A sedentary lifestyle• Drinking too much alcohol (more than one to two drinks a day)

Sudden Cardiac Arrest

• A previous episode of cardiac arrest or a family history of cardiac arrest• A previous heart attack• A personal or family history of other forms of heart disease, such as heart rhythm disorders, congenital heart defects, heart failure and cardiomyopathy• Age — the incidence of sudden cardiac arrest increases with age, especially after age 45 for men and age 55 for women• Being male — men are two to three times more likely to experience sudden cardiac arrest• Using illegal drugs, such as cocaine or amphetamines• Nutritional imbalance, such as low potassium or magnesium levels

http://www.mayoclinic.org/diseases-conditions/sudden-cardiac-arrest/basics/risk-factors/con-20042982

RISKS

BY NIALL MAGEE 05/15 BSC HONS PARAMEDIC SCIENCE, UoG-AVERY HILL/ LONDON

An implantable cardioverter-defibrillator (ICD) or automated implantable cardioverter defibrillator (AICD)

https://www.bhf.org.uk/heart-health/treatments/implantable-cardioverter-defibrillator

ICD is inserted just under your collar bone. It looks similar to a pacemaker and is a little bigger than a matchbox. It is made up of:• A pulse generator - a battery powered electronic circuit• one or more electrode leads which are placed into your heart through a vein

• Pacing - a series of low-voltage electrical impulses (paced beats) at a fast rate to try and correct the heart rhythm• Cardioversion - one or more small electric shocks to try and restore the heart to a normal rhythm• Defibrillation - one or more larger electric shocks to try and restore the heart to a normal rhythm

 Cardiomyopathy, Long QT syndrome or Brugada Syndrome

POST ROSC THERAPEUTIC HYPOTHERMIA

INDICATIONS: “Medical Cardiac arrest - asystole, pulseless electrical activity (PEA), ventricular fibrillation (VF) and pulseless ventricular tachycardia (VT).”

“Brain injury following cardiac arrest may be prevented by early cardiopulmonary resuscitation, including defibrillation to treat VF and pulseless VT rhythms. Drugs such as adrenaline are also commonly required.”

NICE interventional procedure guidance [IPG386] Published date: March 2011

BY NIALL MAGEE 05/15 BSC HONS PARAMEDIC SCIENCE, UoG-AVERY HILL/ LONDON

“After cardiac arrest, comatose patients who have a return of spontaneous circulation (ROSC) can be cooled to a core temperature of 32–34°C with the aim of reducing brain injury and improving neurological outcome. The exact mechanism by which cooling confers cerebral protection is unknown.”

NICE interventional procedure guidance [IPG386] Published date: March 2011

BY NIALL MAGEE 05/15 BSC HONS PARAMEDIC SCIENCE, UoG-AVERY HILL/ LONDON

The optimum temperature

BENEFITS:“Improves oxygen supply to ischemic areas and increases blood flow by decreasing vasoconstriction, as well as oxygen consumption, glucose utilization, lactate concentration, intracranial pressure, heart rate, cardiac output, and plasma insulin levels. TH has been shown to improve neurologic outcome in acute cerebrovascular accidents”

Ref: http://www.ncbi.nlm.nih.gov/pubmed/21464638

BY NIALL MAGEE 05/15 BSC HONS PARAMEDIC SCIENCE, UoG-AVERY HILL/ LONDON

ADVANCED TRAUMA TEAM - HEMS

BY NIALL MAGEE 05/15 BSC HONS PARAMEDIC SCIENCE, UoG-AVERY HILL/ LONDON

Damage Control Resuscitation

1. Permissive Hypotension

2. Haemostatic Resuscitation

3. Damage Control Surgery

“The concept of damage control resuscitation (DCR) was proposed in the mid 2000s as an alternative resuscitation approach to haemorrhagic shock.”

http://www.perioperativemedicinejournal.com/content/2/1/13

BY NIALL MAGEE 05/15 BSC HONS PARAMEDIC SCIENCE, UoG-AVERY HILL/ LONDON

Damage Control Resuscitation

Battlefield Emergency Medicine Civilian Pre-Hospital Emergency Care

HYPOVOLEMIC SHOCK CARDIAC ARREST

EZ-IO, QUICKCLOT, C.A.T. Combat Application Tourniquet

“Only 10% of United States servicemen wounded in Iraq and Afghanistan between 2003 and 2009 died, compared with 24% in the first Gulf War (1990-1991) and Vietnam War (1961-1973).”

http://www.bmj.com/content/338/bmj.b1778

ABC TO CABC

BY NIALL MAGEE 05/15 BSC HONS PARAMEDIC SCIENCE, UoG-AVERY HILL/ LONDON

Blood products at the roadside

- Fresh Frozen Plasma- Red Blood Cells- Platelets Ratio 1:1:1

BY NIALL MAGEE 05/15 BSC HONS PARAMEDIC SCIENCE, UoG-AVERY HILL/ LONDON

Damage Control Resuscitation Medication  

 Tranexamic Acid .TXA 

“Tranexamic acid is an antifibrinolytic agent used to prevent, stop or reduce unwanted bleeding.” (NICE, 2012)

http://www.nice.org.uk/advice/esuom1/chapter/key-points-from-the-evidence

Contra-indications:

- Isolated head Injury

- Critical interventions required (if critical Interventions leave insufficient time for TXA administration

- Bleeding now stopped

(JRCALC, CLINICAL PRACTICE GUIDELINES 2013)

0.9 % Sodium Chloride

Adult Trauma Emergencies

- Blunt trauma, head trauma, penetrating limb trauma, penetrating torso trauma, burns, limb crush injury (JRCALC, CLINICAL PRACTICE GUIDELINES 2013)

BY NIALL MAGEE 05/15 BSC HONS PARAMEDIC SCIENCE, UoG-AVERY HILL/ LONDON

Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA)

CODE RED!

An Hour to Save a Life- London's Air Ambulance

MAJOR TRAUMA- MAJOR HAEMORRHAGE (PELVIS)

http://www.bbc.co.uk/programmes/p01tbbp5

BY NIALL MAGEE 05/15 BSC HONS PARAMEDIC SCIENCE, UoG-AVERY HILL/ LONDON

Pre-Hospital Resuscitative Thoracotomy

- Carried out by HEMS- BASICS Trauma Doctor- Paramedic & Doctor Team

Critical – Last resort procedure to restart the heart

PIT CREW CARDIAC ARREST TEAM APPROACH

BY NIALL MAGEE 05/15 BSC HONS PARAMEDIC SCIENCE, UoG-AVERY HILL/ LONDON

- Improves quality of CPR by minimising time off the chest & rotating persons doing compression

- Improves resus management i.e. one person on the chest, others doing iv/io access, attach pads, set up defib/monitor, medication & airway management

- Enables the lead clinician to stand back, manage the resus & think ahead for procedures and plan

DEVICES

- LUCAS Chest Compression System 

- AutoPulse Non-Invasive Cardiac Support PumpBENEFITS: - Frees up clinicians from CPR to continue care- Continuous CPR during transport - Does not get tired - Portable device

BY NIALL MAGEE 05/15 BSC HONS PARAMEDIC SCIENCE, UoG-AVERY HILL/ LONDON

BY NIALL MAGEE 05/15 BSC HONS PARAMEDIC SCIENCE, UoG-AVERY HILL/ LONDON

Basic & Advanced Airway Management

PRE-HOSPITAL ULTRASOUND

BY NIALL MAGEE 05/15 BSC HONS PARAMEDIC SCIENCE, UoG-AVERY HILL/ LONDON

- Device used by highly skilled Paramedics and Doctors.

- Mainly used by HEMS.

http://www.sonoguide.com/ems_pre-hospital.html

http://resus.me/prehospital-ultrasound/

Focused Assessment with Sonography for Trauma 

BY NIALL MAGEE 05/15 BSC HONS PARAMEDIC SCIENCE, UoG-AVERY HILL/ LONDON

THE ENDTHANKYOU FOR LISTENING

QUESTIONS?