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Highlights from the
2015 Guidelines update
Benjamin S. Abella, MD, MPhil
Clinical Research Director
Center for Resuscitation Science
Department of Emergency Medicine
University of Pennsylvania
HART program, October 2015
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Speaker disclosures
Research Funding: NIH – NHLBI
PCORI
AHA
Medtronic
Honoraria/consulting: CR Bard
Stryker Medical Corp
Medical Advisory Board: CardioReady
Equity: Resuscor LLC
Speaker disclosures
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Cardiac arrest: introduction The AHA guidelines: an overview
Resuscitation guidelines are updated every 5 years
Collaboration of physicians, nurses and EMTs
Science recommendations from ILCOR
US guidelines (AHA) based on ILCOR science recs
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Cardiac arrest: introduction Chest compression rate
New upper limit to
chest compression rate
Based on large OHCA studies
showing worse outcomes
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Cardiac arrest: introduction Chest compression depth
New upper limit to
chest compression depth
Upper limit based on weak
evidence; may be more academic than real-world
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Cardiac arrest: introduction Mechanical CPR devices
Mechanical CPR and manual CPR are equivalent – no advantage to mechanical CPR
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Cardiac arrest: introduction End-tidal carbon dioxide (ET-CO2)
A role for end-tidal CO2 in prognostication – less clear of a role to assess CPR effectiveness
expiration inspiration
ET-CO2
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Cardiac arrest: introduction TTM: target temperature
Acceptable range of TTM target temp now expanded: 32oC-36oC
Goal should be specific within this
range – selection tailored to patient
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Cardiac arrest: introduction Newer trials evaluating TTM target
2013
2015
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Cardiac arrest: introduction Survival in the Nielsen et al trial
No difference in outcomes at either 33oC or 36oC
No differences in adverse effects between groups
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Cardiac arrest: introduction Pre-hospital TTM via cold fluids
Cold fluids in the pre-hospital setting are not recommended – no RCT has shown benefit
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Cardiac arrest: introduction Hope for prehospital TTM?
Newer technologies may change perspective
Intra-arrest TTM as a possible approach?
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Cardiac arrest: introduction TTM: post-rewarming management
Fever after rewarming may require aggressive prevention to minimize neurologic injuries
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Temperature dynamics of TTM
Post-TTM normothermia: the science
2013
2013
Both studies: fever may
contribute to poor outcomes
Temperature (oC)
Pa
tie
nts
, n
Pyrexia (>38oC)
41% with post-TTM pyrexia
Median temp 38.7oC
Above median: worse outcomes
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Temperature dynamics of TTM
Biology of prolonged temp control
Ongoing injury up to 72 hours
supported by laboratory and
clinical studies
Neumar, 2008
Our TTM protocol specifies
24 hour period of “controlled
normothermia” post-rewarming
Longer period of TTM?
Longer period of post-TTM
normothermia?
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Cardiac arrest: introduction Post-arrest hemodynamic goals
Avoiding hypotension during post-arrest critical care is important
Analogous to CVA hemodynamics
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Cardiac arrest: introduction Post-arrest brain swelling
Elevated ICP in days following
Resuscitation from arrest
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Temperature dynamics of TTM
Hemodynamic management
2013
Higher mean arterial pressure
associated with improved outcome
Goal MAP unclear
>65 mm Hg per AHA guidelines
but this study suggests >80 mm Hg
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Temperature dynamics of TTM
Problem with MAP target post-arrest
We don’t measure ICP routinely following resuscitation from arrest
Hard to titrate blood pressure to ICP if the ICP isn’t measured
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Cardiac arrest: introduction Post-arrest neuroprognostication
Clinical exam is unreliable for at least 72 hours following resuscitation
Cannot withdraw based on bedside exam
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Prognostication is a challenge Timing of prognostication
Reinforces notion that withdrawal decisions should be delayed
>72 h post-rewarming; clinical neuro exam poorly predictive
2013
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Tools to assist neuroprognostication
EEG
neuroimaging Somatosensory
evoked potential
(SSEP)
Bispectral index (BIS)
Varying strength of data for each
modality; no one approach
sufficient for prognostication
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SSEP is an underutilized modality
Somatosensory
evoked potential
(SSEP)
N20 response at 72 hours –
Relatively strong predictor of
outcome
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BIS index as post-arrest monitor
BIS measurement is most
reliable neuroprognosticator
At 24 hours post-arrest
Still relatively poor predictor:
24 hr BIS cutoff of 45 to predict
good outcome: sensitivity of 63%,
specificity of 86% (positive likelihood ratio of 4.7)
BIS = 0 strongly predicted poor outcome
2010
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Cardiac arrest: introduction Options for neurologic assessment
AHA offers “menu” of options to help assess neurologic outcomes
Note the fine print: sedatives, paralytics, shock and other conditions can confound findings
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Cardiac arrest: introduction Post-arrest cardiac catheterization
Cardiac catheterization should be considered after resuscitation and performed for select patients
PCI required for STEMI post-arrest
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Difficult to predict coronary disease
Only prior coronary history and initial rhythm were associated with
significant coronary lesions on post-arrest catheterization
Age, troponin, ECG findings were NOT associated with coronary dz
2012
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Temperature dynamics of TTM
Benefit of prompt post-arrest PCI
2014
Post-arrest catheterization associated with improved
outcomes – effect size greater than for TTM
Important secondary result:
survival is greater if post-arrest
volume is larger
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Temperature dynamics of TTM
Benefit of prompt post-arrest PCI
2014
Angiography associated with improved survival
Similar results for both survival and good neurologic outcome
Most studies from 2010 onward (post-arrest TTM era)
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Acknowledgements
Center for Resuscitation Science
Lance Becker
Marion Leary
Audrey Blewer
Dave Gaieski
Barry Fuchs
Dan Kolansky
Vinay Nadkarni Raina Merchant
Robert Berg
Gail Delfin
Marisa Cinousis Kelsey Sheak
David Buckler
West Philadelphia – Penn campus
Acknowledgements