Short and Long Term Hemodynamic Outcomes

From Cardiac Arrest

Peter J. Kudenchuk, MD, FACP, FACC, FAHA, FHRS Professor of Medicine, University of Washington Associate Medical Director, King County EMS

Access CPR Defibrillation ACLS Post Arrest Care

Disparity in Survival Outcomes

0

10

20

30

40

50

60

70

Sur

viva

l to

Hos

pita

l Dis

char

ge –

VF

(%)

Published Reports of Cardiac Arrest VF Survival 1990-2013

Nichol G et al. JAMA 2008;300:1423-31; Personal communication Eisenberg M.

Disparity in Research Support

Ornato J. Circulation 2010;122:1876-9

0100020003000400050006000700080009000

10000

MI Stroke HF Cardiac Arrest

NIH Funded Studies (1985-2009) Published RCTs

Deaths/yr 157,000 150,000 284,000 310,000 n/10000†/yr 439 490 294 243 349 145 8 6

7691

3639 4108

177

6886

4403

9919

257

n

Cardiovascular Research Publications and Expenditures

Disparity in Approach to Treatment

Protocol vs Parameter-Driven Resuscitation

n= 24 instrumented swine Unsupported VF x 7 min

n = 8 • Protocol-driven • Std AHA CPR - CC depth 51 mm • Q 4’ epi (0.02 mg/kg)

n = 8 • Hemodynamic-directed • Titrate depth + vasopressor to:

SBP ~100; CPP >20 mm Hg • PRN epi (0.02 mg/kg) → vasopressin

200 J Continued assigned Tx until ROSC or x 10 min

1° Endpoint = ROSC x 45 min Friess SH. Crit Care Med 2013;41:2698-2704

Manual standard AHA CPR x 10 min CPR feedback for rate, depth, recoil, vent

Hemodynamically-Directed vs Protocol-Directed CPR

Friess SH. Crit Care Med 2013;41:2698-2704

0

20

40

60

80

100

Any ROSC 45 min ICUsurvival

AHA CPR Depth 51 mm (n=8)

CPP >20 (n=8)

% P

atie

nts

38% 38%

100% 100%

Hemodynamically-Directed vs Protocol-Directed CPR

0 8 9 10 11 12 13 14 15 16 17

50 40 30 20 10

Time (minutes)

Mea

n Co

rona

ry P

erfu

sion

Pres

sure

(mm

Hg)

Survived

Died p<0.01

Friess SH. Crit Care Med 2013;41:2698-2704

Depth Shocks Rx Epi Rx any vaso- mm # # pressor #

44±0.8 1 (1-2) 2 (2-5) 3 (2-6)

47±0.5 3 (1-2) 5 (2-5) 5 (2-5)

NSD*

*Also NSD in CC rate (100±0.1/min), no flow % (3 ± 0.2%), 0 lean (>2.5 kg)

Treatment

Hemodynamically-Directed vs Protocol-Directed CPR

0 8 9 10 11 12 13 14 15 16 17

50 40 30 20 10

Time (minutes)

Mea

n Co

rona

ry P

erfu

sion

Pres

sure

(mm

Hg)

CPP-20

Protocol p<0.01

Near-infrared Spectroscopy

End tidal CO2

Schoene P. Heart Rhythm 2014;11:230-6

Predictive Value of AMSA Before 1st Shock on Outcome

0102030405060708090

OrganizedRhythm

ROSC (end) AdmissionAlive

DischargeAlive

CPC 1-2

Lowest AMSA <9.43 (n=130) Mid AMSA 9.43-9.91 (n=130) High AMSA >9.91 (n=130)… prior to shock #1

(post 1st shock)

%Pa

tient

s

28%

69%

80%

49%

72%

88%

45%

72%

89%

22%

51%

74%

16%

46%

71%

Test for trend across tertiles p<0.001 for each outcome

Course of Quantitative VF Waveform Measure and Cardiac Arrest Outcome

Schoene P. Heart Rhythm 2014;11:230-6

0102030405060708090

OrganizedRhythm

ROSC (end) AdmissionAlive

DischargeAlive

CPC 1-2

Deteriorated AMSA (n=38) Unchanged AMSA (n=199) Improved AMSA (n=360)… between shock 1-2

%Pa

tient

s 55% 49%

61% 53%

64%

78%

53%

63%

81%

45% 40%

61%

37% 36%

47%

p=0.03* p=0.01* p=0.17*

*Test for trend (post 2nd shock)

Predictive Value of Change in AMSA on Outcome

Course of Quantitative VF Waveform Measure and Cardiac Arrest Outcome

Immediate Steps That Can Improve Cardiac Arrest

Outcome

High Performance CPR • 30:2 • Attention to detail:

- Rate, depth, recoil - Controlled ventilation

• Minimize pauses • 2 min CPR between interventions

2005 2006 2007 2008 2009 2004 2003 2002 2001 2000

50

40

30

20

10

% Survival to hospital discharge - Witnessed VF Arrest

King County, WA

High Performance CPR • 30:2 • Attention to rate, depth, recoil, vent • Minimize pauses • 2 min CPR between interventions

Rea TD. Circulation 2006;114:2760-5

2005 2006 2007 2008 2009 2004 2003 2002 2001 2000

50

40

30

20

10

% Survival to hospital discharge - Witnessed VF Arrest

King County, WA

~33%

Rea TD. Circulation 2006;114:2760-5

~46% (p=0.008)

2005 2006 2007 2008 2009 2004 2003 2002 2001 2000

35

10

7.5

5

2.5

%ROSC

30 25

40

% Survival to Hospital Discharge % 1-Yr Survival

n=1774

Kudenchuk PJ. Circulation 2012;125:1787-94

Cardiac Arrest Due to Asystole/PEA

34% p<0.001

7% p=0.004

5% p=0.001

High Performance CPR • 30:2 • Attention to rate, depth, recoil, vent • Minimize pauses • 2 min CPR between interventions

2005 2006 2007 2008 2009 2004 2003 2002 2001 2000

35

10

7.5

5

2.5

%ROSC

30 25

40

% Survival to Hospital Discharge % 1-Yr Survival

n=1774 n=2186

Kudenchuk PJ. Circulation 2012;125:1787-94

Cardiac Arrest Due to Asystole/PEA

27%

34% p<0.001

4.6%

7% p=0.004

2.7%

5% p=0.001

Improving Hemodynamic Outcomes in

Cardiac Arrest: Next Steps

• Designate cardiac arrest as reportable event

• Encourage/support research in: − (Bio)parameter-directed resuscitation − . . .

• Promote/disseminate high performance CPR