Treatment of Cardiac Arrest January 28, 2016 Keith Lurie MD - - PowerPoint PPT Presentation

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Treatment of Cardiac Arrest January 28, 2016 Keith Lurie MD - - PowerPoint PPT Presentation

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Treatment of Cardiac Arrest January 28, 2016 Keith Lurie MD Professor of Emergency Medicine and Internal Medicine University of Minnesota Cardiac Electrophysiologist, St. Cloud hospital Disclosure Dr. Lurie is co-inventor of the impedance

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Keith Lurie MD Professor of Emergency Medicine and Internal Medicine University of Minnesota Cardiac Electrophysiologist, St. Cloud hospital

Treatment of Cardiac Arrest

January 28, 2016

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SLIDE 2

Disclosure

  • Dr. Lurie is co-inventor of the impedance threshold device (ITD)(ResQPOD) and

active compression decompression (ACD) CPR (CardioPump)

  • Dr. Lurie is a consultant for Zoll Medical Corporation.
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SLIDE 3

<7% Survival with Good Brain Function

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SLIDE 4

>30% Survival with Good Brain Function

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SLIDE 5

5

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SLIDE 6

Transformative Technologies

Bystander CPR Education ITD Therapeutic Hypothermia AED IO Meds ICD Angiography Automated CPR Lay Public Hospital EMS First Responder Survival

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SLIDE 7

Minnesota Resuscitation Consortium and the CARES Database

The MN Resuscitation Consortium connects bystander, prehospital and hospital initiatives to improve survival from sudden cardiac arrest (SCA).

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SLIDE 8

2013 Cardiac Arrest Registry to Enhance Survival Data

Minnesota has the highest survival rates with good brain function

8

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Continuous Quality Improvement Leads to Excellent Outcomes

  • 1. Better Perfusion
  • 2. Reperfusion Injury Protection
  • 3. Bundle of Care

9

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SLIDE 10
  • Conventional is the cornerstone of

resuscitation care; usually first

  • ption
  • Conventional CPR provides 15-30%

normal blood flow to the heart and brain

  • Inadequate cardiac and cerebral

perfusion contributes to the high mortality rates

10

Perfusion Today Depends on Conventional CPR

Conventional CPR remains the cornerstone of resuscitation care

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SLIDE 11

Ways to Improve Perfusion

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Index Case 1987 Saved by a Household Plunger San Francisco General Hospital

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ACD CPR Device Components

13

Metronome Force Gauge Suction Cup Handle

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STD (n = 377) ACD (n = 373)

Percent

Plaisance P et al. A comparison of standard CPR and ACD resuscitation for out-of-hospital cardiac arrest. N Engl J Med. 1999;341:569-75.

5 10 15 20 25 30 35 40 ROSC 1 Hr ICU

Admit

24 Hr Hosp Disch 1 Yr

*

*Statistically significant

Randomized Clinical Trial (Paris, France)

Survival After Cardiac Arrest

*

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SLIDE 15

Chest Compressions

  • Increase in intrathoracic

pressure

  • Cause forward blood flow
  • Force respiratory gases

from lungs

  • Minimal expiratory

resistance from ResQPOD

S- CPR ACD+ITD

15

Compression Phase

Standard CPR (S-CPR) vs. ACD+ITD

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SLIDE 16

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Decompression Phase

S-CPR vs. ACD+ITD

S- CPR – Passive Recoil

  • Minimal change in

intrathoracic pressure

  • Small circulation

Ventilation Chest Compressions Passive Chest Wall Recoil

16

  •   intrathoracic

pressure

  • Preload increased 

 cardiac output

  • ICP lowered 

 cerebral perfusion

ACD+ITD – Active Recoil

Active Chest Wall Recoil

Airway (Intrathoracic) Pressure

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Better Perfusion ACD + ITD

17

+

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Blood Flow to Heart and Brain

Porcine V-Fib Model

S-CPR S-CPR + ITD ACD-CPR ACD-CPR + ITD 0.2 0.4 0.6 0.8 1.0 normal normal

Brain Left Ventricle

Blood Flow (ml/min/gm)

Lurie et al. Circulation 1995;91:1629-32 (ACD +/- ITD) and Lurie et al. J Cardio Electrophysiology 1997;8(5):584-600

18

ACD+ITD work synergistically to achieve desired effect

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SLIDE 19

ACD+ITD CPR Mechanisms of Action

 Lowers intrathoracic pressure  Limits inflow of air to lungs between

positive pressure breaths

 Enhances venous return to right heart  Lowers ICP  Increases cerebral and coronary

perfusion and circulation

 Reduces pulmonary vascular resistance?

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Saving the Brain During CPR and After ROSC

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ResQTrial: 2 CPR Methods

Conventional CPR ACD CPR + ITD (ResQCPR)

21

versus

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Conventional CPR ACD+ITD Relative Increase

Cardiac Etiology

(n=1655)

6.0%

(48/794)

9.0%

(74/822)

49%

All Patients

(n=2470)

5.8%

(68/1171)

7.8%

(96/1233)

34%

One Year Survival

First Medical Device Approved by FDA to Increase Survival after Cardiac Arrest

Aufderheide et al, Lancet 2011 Frascone et al, Resuscitation 2013

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Ways to Further Improve Perfusion

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Head Flat, Up or Down?

In cardiac arrest, elevation of the head with CPR technologies that enhance circulation compared with S-CPR reduce cerebral venous pressure, lower ICP, and improve outcomes.

24

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0° Supine 30° Head up 30° Head down A Different Angle?

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Supine 0° CPR 30° Head down CPR Change of position (CPR rate 100/min) Ao ICP CerPP

26

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Supine 0° CPR 30° Head up CPR Change of position (CPR rate 100/min) Ao ICP CerPP

27

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0° supine 30° Head up

  • 30° Head down

Ao RA ICP CerPP

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New Observation re: Head Flat CPR

Inherent Limitation Chest compressions increase arterial and venous pressures simultaneously, delivering a bidirectional high pressure compression wave to the brain with every compression

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Head-Up CPR: Effect of Angle on Mean Aortic and Intracranial Pressure

Debaty et al. Resuscitation, 2015

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Head-Up CPR: Is the ITD Needed?

The ITD is needed to optimize Head up CPR

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Brain Blood Flow Depends on Head Position

Brain blood flow is highest with elevation of the head

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VS

A Simple Change in Position

ACD+ITD and Conventional CPR

Untreated VF 8 minutes Conventional CPR flat - 2 minutes Randomize between CPR flat vs head and shoulders up for 20 minutes

30o

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Cerebral Pressure Pressures

34

  • 10

10 20 30 40 50 60 70 Pre-VF 5 10 15 20

mmHg Time (Minutes) ACD+ITD Head Up (n=8)

ACD+ITD Head Up (n=8) ACD+ITD Flat (n=8) S-CPR Head Up (n=7) S-CPR Flat (n=7) 8 min VF

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Conclusions re: Head Up CPR

  • 1. A potential breakthrough in understanding

how to save the brain during CPR.

  • 2. Head up CPR with the ITD enhances cerebral

circulation by increasing blood flow to the brain and lowering resistance to blood flow within the brain.

  • 3. Further research is needed.
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Better Perfusion to and in the Cath Lab and Beyond

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Current and Future Ways to Improve Brain Flow

  • 1. ACD+ITD (ResQCPR)
  • 2. Head up CPR
  • 3. Ongoing automated CPR
  • 4. ECMO as a bridge
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Advances in Defibrillation and PEA

  • 1. Shock with ongoing CPR
  • 2. VF characterization (AMSA) to

determine when to defibrillate

  • 3. Compressions timed with an ECG

signal

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Reperfusion Injury Protection

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40

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41

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Plugging the Holes with P-188

Synthetic surfactants such as poloxamer P188 has been shown in other ischemic models to reduce reperfusion injury

42

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Reperfusion Injury Protection Strategies

  • 3 intentional 20 pauses at the start of

ACD+ITD CPR – A Better BLS? Stay with 30:2?

  • Sodium Nitroprusside + ACD+ITD CPR
  • P-188 in combination with #1 and #2
  • Cyclosporin A
  • Anesthetics including sevoflurane
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ResQCPR, ‘Intentional Stutter’, Sevoflurane, P188, Defibrillation & Post-ROSC Hypothermia for 4 hours

44 Aortic Pressure P188 60 sec

100% ROSC with >50% normal neurological function after 48 hours

Bartos et al, 2015 Resuscitation 25 50 75 100 mmHg Stutter & Sevoflurane Shock

17 min V-Fib

Start CPR

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A Better Bundle of Care

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Starts with High Quality CPR…

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What is High Quality CPR?

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The Inspiration

Blood Pressure during Conventional CPR +/- ITD

43 85 30 40 50 60 70 80 90

MMHG

Systolic BP Sham ITD Active ITD

*p<0.05

n = 22 *

A Clinical Study in Milwaukee, WI

BP after 14 Minutes of ITD Use

Pirrallo et al. Resuscitation 2005;66:13-20.

15 20 12 14 16 18 20

MMHG

Diastolic BP Sham ITD Active ITD

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No Silver Bullet for Sudden Cardiac Arrest

Improved circulation is not enough Quality of CPR is Essential A Systems-based approach is key

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CPR Quality Affects Outcomes

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Ventilation Strategies

Excessive Ventilation can be DEADLY

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  • Compression:Ventilation

Ratio = 2:1

  • Ventilation rate = 47

breaths / minute

Ventilation rate: 47/min

Death by Hyperventilation

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Baseline CPR

5 10 15 20

Brain O2 Tension (mmHg)

p<0.03

2 vs 10: Effect on Brain Oxygen Tension

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Resp Rate 2/min Resp Rate 10/min

Lurie et al - Resp Care 2008

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BLS Compression:Ventilation

Options: 1) continuous chest compressions with no ventilation 2) continuous chest compression with 1 breath/10 compressions 3) 30:2

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Effect of No Ventilation

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Normal Ventilation (Inflated Lungs) No Ventilation (Deflated lungs)

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Aufderheide et al Resuscitation 2005

Chest Compression & Release

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Translational Research – from animals to humans Treatment of Out-of- Hospital Cardiac Arrest with High Quality CPR and the ITD

Aufderheide et al Crit Care Med 2008

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Outcome Results from Improved BLS and ALS, including ITD Use

Control Intervention P-value Odds Ratio (95% CI) ROSC 30.4% (535/1757) 34.1% (586/1719) 0.022 1.18 (1.022, 1.366) Hospital Discharge 9.7% (170/1757) 12.6% (216/1719) 0.007 1.34 (1.078, 1.671) HD (VF) 19.0% (85/447) 31.1% (128/412) <0.001 1.91 (1.384, 2.667) CPC 1 or 2 31.4% (11/35) 55.2% (32/58) 0.033 2.68 (1.027, 7.213)

Aufderheide et al. Heart Rhythm 2010

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Survival with good brain function significantly improved with high quality CPR and use of ITD

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Implementing the 2005 AHA Guidelines and Use of the ITD Improves Hospital Discharge Rates after In-Hospital Cardiac Arrest

Hospital Discharge Control Intervention P-value Odds Ratio (95% CI) V-Fib 31.6% (18/57) 43.8% (21/48) 0.0228 1.68 (0.70, 4.04) PEA 14.4% (14/97) 29.7% (27/91) 0.014 2.50 (1.15, 5.58) Asystole 11.5% (10/87) 20.9% (23/110) 0.087 2.04 (0.86, 5.09) Overall 17.4% (42/241) 35.3% (71/249) <0.001 2.59 (1.63, 4.13)

Thigpen et al – J Resp Care 2010 59

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SLIDE 60

N Engl J Med 2011;365:798-806.

Results: Of 8718 patients included in the analysis, 4345 were randomly assigned to treatment with a sham ITD and 4373 to treatment with an active device. A total of 260 patients (6.0%) in the sham-ITD group and 254 patients (5.8%) in the active-ITD group met the primary outcome (P=0.71). Conclusions: Use of the ITD did not significantly improve survival with satisfactory function among patients with

  • ut-of-hospital cardiac arrest receiving standard CPR.

Resuscitation Outcomes Consortium (ROC) PRIMED

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CPR Quality - Device Interactions

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Compression Depth Compression Rate

Probability of Survival to Hospital Discharge

Variations in CPR quality strongly linked to outcomes

Depth (mm) Average Rate Per Minute

Wide variations in practice even in some of the best EMS systems (data from NIH- funded Resuscitation Outcomes Consortium - ROC) Variable compression depth and rate limit blood flow and worsens outcomes

Probability of Survival to Hospital Discharge

Stiell 2012 Idris 2012

Variable Quality of Conventional CPR

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SLIDE 63

19/341 34/606 47/812 39/618 25/397 24/347 17/310 32/561 74/833 32/691 16/376 19/306

1 2 3 4 5 6 7 8 9 10 <90 90-99 100-109 110-119 120-129 >129 Sham ITD Active ITD

Survival to Discharge with MRS≤3 (%) Chest Compression Rate (CC/min) N = 6198

Survival to Hospital Discharge with good neurologic function by Compression Rate (all rhythms)

Yannopoulos et al, Circulation 2015

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* p = 0.02

*

Survival with Good Brain Function Improved by ITD and High Quality CPR

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0.02 0.04 0.06 0.08 0.1 0.12

1 2.5 4 5.5 7 Rate (comp/min)

Hospital discharge with MRS≤3

Depth (cm)

Survival with MRS≤3 at rate x depth/Survivors with MRS≤3 (Active)

0.02 0.04 0.06 0.08 0.1 0.12

1 2.5 4 5.5 7 Rate (comp/min)

Hospital discharge with MRS≤3

Depth (cm)

Survival with MRS≤3 at rate x depth/Survivors with MRS≤3 (Sham)

Importance of the Correct Rate and Depth for Improving Survival with Good Brain Function (ROC PRIMED)

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SLIDE 65

37/854 25/421 61/875 50/419

2 4 6 8 10 12 14 All patients Witnessed arrest Sham ITD Active ITD

Survival to hospital discharge with MRS≤3 (%) Outcomes from ROC PRIMED: Subjects who received Quality CPR (rate 80-120/minute; depth 4-6 cm; fraction ≥50%)

Yannopoulos et al Resuscitation 2015

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p=0.02 p<0.01

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High Quality CPR

 Essential for saving lives  To be performed well, rate and depth

monitoring and feedback are needed

 Devices such as the ITD need high

quality CPR to work

 Training and feedback to rescue

personnel is essential

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Pit Crew CPR

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Pit Crew Concept Pit Crew CPR

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PIT Crew CPR Cards

Use the card on every arrest!

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Importance of Following Protocol During Cardiac Arrest

Survival to Hospital Discharge (%)

6.7% 18.1% 2 4 6 8 10 12 14 16 18 20 Protocol Not Followed Protocol Followed

(n=419) (n=570)

OR (95% CI) 3.1 (2.02, 4.82) P<0.001

Lick et al, 2013

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How Long Should We Perform CPR?

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68 minutes with Automated CPR + ITD

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Automated CPR

Provides High Quality CPR

LUCAS Autopulse

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Automated CPR Devices

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Flying Blind

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Need

 Physiological monitor to guide CPR and

post-ROSC care

 Responsive to changes in

BP/circulation/brain activity

 Works despite potential for motion artifact

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Potential Non-Invasive Monitors

  • ETCO2
  • BP cuff
  • BIS
  • Cardiovascular Reserve Index
  • Somatic Evoked Response
  • NIRS/Reflectance
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Anesthesia & Analgesia 1959

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What about Prehospital Cooling?

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Who should we cool?

Everyone who is unconscious upon arrival to the ED after OHCA and or after in-hospital cardiac arrest

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When to pull the plug?

Redefining the limits of life…

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80

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Findings: 25% of all survivors are comatose 48 hours after rewarming but wake up eventually, some take as long as 2 weeks. Patients with VF, witnessed arrest, bystander CPR, and prolonged time from 911 to profession EMS have a good prognosis.

Awakening After Hypothermia and Rewarming

# of Patients Who Wake Up Time (Hours) to Awakening

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Compliance!

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Systems Approach to Cardiac Arrest in Alameda County, CA

2005 2006 2007 2008 2009 2010

ACLS Updates: (2005 AHA) Changes to Drug, Defibrillation and CPR. One MPDS Center AEDs required in health clubs. Changes to intubation procedures Intensive airway and enhanced CPR training by

  • Dr. Levitan.

CPR in the schools pilot project. Res-Q-Pod CPR device added. Re-emphasis on CPR technique. CPR7 program implemented. Two MPDS Centers Induced hypothermia. Introduction of cardiac arrest centers.

Ventricular Fibrillation / Pulseless Ventricular Tachycardia Enhancements for Prehospital Cardiac Arrest Resuscitation

Sporer, Jacobs, et al AHA Scientific Sessions 2015

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Compliance is a Challenge

Full Bundle

(ITD, automated CPR, and TH)

No Bundle

(No ITD, no automated CPR, no TH)

p-value Overall Survival to Hospital Discharge All rhythms

37.8% (34/90) 12.1% (132/1090)

<0.001 VF

62.5% (20/32) 29.1% (60/206)

<0.001 Non-VF

24.1% (14/58) 8.1% (72/884)

<0.001 Survival to Hospital Discharge with CPC≤2 All rhythms

25.3% (21/83) 6.9 % (72/1051)

<0.001 VF

51.7% (15/29) 23.4 % (46/197)

0.004 Non-VF

11.1% (6/54) 3.0 % (26/854)

0.054

Only 10% of patients were treated with the full bundle

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Survival after Out-of-Hospital Cardiac Arrest (All Rhythms) Today and Tomorrow

Interventions Neurologically-Intact Survival 10% 20% 30% 40% 50% 0%

US Average: CARES 2012 ITD + High Quality CPR Improved Perfusion in Systems-Based Approach Automated Optimal Perfusion in Systems-Based Approach Automated CPR - Optimal Perfusion and Head up in Systems-Based Approach

Possible Within Next 5 Years Today

85 Automated CPR - Optimal Perfusion and Head up in Systems-Based Approach + Reperfusion Injury Protection

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Continuous Quality Improvement: A CPR Roadmap Where Should We Focus Next?

86

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Cardiac Arrest CQI Roadmap

Care Location Lay Rescuer First Responder ALS Post ROSC and No ROSC Transport In-Hospital Post Discharge

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Cardiac Arrest CQI Roadmap

Care Location Lay Rescuer First Responder ALS Post ROSC and No ROSC Transport In-Hospital Post Discharge Care Provided

  • Rural,

Suburban, Urban CPR

  • Defibrillate
  • High

Quality CPR

  • Defibrillate
  • High Quality

CPR

  • Airway
  • Defibrillation
  • Monitoring
  • Drugs (IV

access)

  • Process Data
  • ALS care
  • Safe for Pt

and EMS

  • Protect

against brain injury

  • TH
  • ICU
  • PCI
  • EP
  • Outcome

Data Data/ Outcomes, survivor support

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Cardiac Arrest CQI Roadmap

Care Location

Lay Rescuer First Responder ALS Post ROSC and No ROSC Transport In-Hospital Post Discharge

Care Provided

  • Rural, Suburban, Urban

CPR

  • Defibrillate
  • High Quality CPR
  • Defibrillate
  • High Quality CPR
  • Airway
  • Defibrillation
  • Monitoring
  • Drugs (IV access)
  • Process Data
  • ALS care
  • Safe for Pt and EMS
  • Protect against brain

injury

  • TH
  • ICU
  • PCI
  • EP
  • Outcome Data

Data/ Outcomes, survivor support

QI Needed

  • AHA CPR
  • Dispatcher

CPR

  • DNR status
  • AED

locations

  • SCA alert
  • Optimize

circulation

  • CPR

feedback

  • Optimize

shocks

  • Minimize

reperfusion injury

  • Medical

director feedback

  • Optimize

circulation

  • CPR feedback
  • Optimize

shocks

  • Minimize

reperfusion injury

  • Optimize drugs

and drug delivery

  • Monitor

circulation

  • Rhythm

management

  • Medical

director feedback

  • prepare for

rearrest more CPR

  • Transport

safe CPR

  • activate

cath lab

  • Start TH
  • Optimize

cerebral circulation

  • Optimize

hemodynamics

  • Minimize

brain injury

  • Rapid

assessment of coronary anatomy and revascularize

  • Optimize

rhythm management

  • Need

hospital

  • utcomes,
  • Establish

support groups

  • - Provide

EMS teams feedback

  • Celebrate

saves

  • Publicize

save rates

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SLIDE 90

Cardiac Arrest CQI Roadmap

Care Location

Lay Rescuer First Responder ALS Post ROSC and No ROSC Transport In-Hospital Post Discharge

Care Provided

  • Rural, Suburban,

Urban CPR

  • Defibrillate
  • High Quality CPR
  • Defibrillate
  • High Quality CPR
  • Airway
  • Defibrillation
  • Monitoring
  • Drugs (IV access)
  • Process Data
  • ALS care
  • Safe for Pt and EMS
  • Protect against brain

injury

  • TH
  • ICU
  • PCI
  • EP
  • Outcome Data

Data/ Outcomes, survivor support

QI Needed

  • AHA CPR
  • Dispatcher CPR
  • DNR status
  • AED locations
  • SCA alert
  • Optimize circulation
  • CPR feedback
  • Optimize shocks
  • Minimize reperfusion

injury

  • Medical director

feedback

  • Optimize circulation
  • CPR feedback
  • Optimize shocks
  • Minimize reperfusion injury
  • Optimize drugs and drug

delivery

  • Monitor circulation
  • Rhythm management
  • Medical director feedback
  • prepare for rearrest

more CPR

  • Transport safe CPR
  • activate cath lab
  • Start TH
  • Optimize cerebral

circulation

  • Optimize hemodynamics
  • Minimize brain injury
  • Rapid assessment of

coronary anatomy and revascularize

  • Optimize rhythm

management

  • Need hospital
  • utcomes,
  • Establish support

groups

  • - Provide EMS

teams feedback

  • Celebrate saves
  • Publicize save rates

Ways to achieve QI

  • CPR

feedback tools,

  • Dispatch

instruction

  • AED locators
  • Real time

public notification

  • Know DNR

status

  • 30:2
  • Widespread

AEDs availability

  • ACD +ITD
  • CPR

feedback

  • Optimal

airway

  • CPR before

shock

  • Raise Head
  • ACD+ITD
  • Automated CPR
  • Optimal airway
  • IO drug
  • Optimal epi

/vasopressin

  • CPR feedback
  • Utilize ETCO2
  • Amiodarone
  • O2
  • Ventilate per

AHA

  • Raise Head
  • BIS
  • Automated

CPR available

  • Track VS and

ETCO2

  • Start TH
  • Raise Head
  • Titrate to

MAP

  • ECMO
  • Active IPR
  • Cath in <2 hr

for VF

  • Cath others

rapidly

  • Cool rapidly

to 33o C , rewarm slowly

  • ICU care
  • EP routinely
  • Allow time to

wake up

  • Ongoing CPR

to the cath lab

  • IABP
  • ECMO
  • Nitroprusside
  • CARES
  • Support

groups

  • PR
  • Share
  • utcomes
  • Celebrate

Saves

  • EMS

Feedback

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SLIDE 91

How Do We Get There?

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SLIDE 92

Cardiac Arrest CQI Roadmap

Care Location

Lay Rescuer First Responder ALS Post ROSC and No ROSC Transport In-Hospital Post Discharge

Care Provided

  • Rural, Suburban,

Urban CPR

  • Defibrillate
  • High Quality CPR
  • Defibrillate
  • High Quality CPR
  • Airway
  • Defibrillation
  • Monitoring
  • Drugs (IV access)
  • Process Data
  • ALS care
  • Safe for Pt and EMS
  • Protect against brain

injury

  • TH
  • ICU
  • PCI
  • EP
  • Outcome Data

Data/ Outcomes, survivor support

QI Needed

  • AHA CPR
  • Dispatcher CPR
  • DNR status
  • AED locations
  • SCA alert
  • Optimize circulation
  • CPR feedback
  • Optimize shocks
  • Minimize reperfusion

injury

  • Medical director

feedback

  • Optimize circulation
  • CPR feedback
  • Optimize shocks
  • Minimize reperfusion injury
  • Optimize drugs and drug

delivery

  • Monitor circulation
  • Rhythm management
  • Medical director feedback
  • prepare for rearrest

more CPR

  • Transport safe CPR
  • activate cath lab
  • Start TH
  • Optimize cerebral

circulation

  • Optimize hemodynamics
  • Minimize brain injury
  • Rapid assessment of

coronary anatomy and revascularize

  • Optimize rhythm

management

  • Need hospital
  • utcomes,
  • Establish support

groups

  • - Provide EMS

teams feedback

  • Celebrate saves
  • Publicize save rates

Ways to achieve QI

  • CPR

feedback tools,

  • Dispatch

instruction

  • AED locators
  • Real time

public notification

  • Know DNR

status

  • 30:2
  • Widespread

AEDs availability

  • ACD +ITD
  • CPR

feedback

  • Optimal

airway

  • CPR before

shock

  • Raise Head
  • ACD+ITD
  • Automated CPR
  • Optimal airway
  • IO drug
  • Optimal epi

/vasopressin

  • CPR feedback
  • Utilize ETCO2
  • Amiodarone
  • O2
  • Ventilate per

AHA

  • Raise Head
  • Automated

CPR available

  • Track VS and

ETCO2

  • Start TH
  • Raise Head
  • Titrate to

MAP

  • ECMO
  • Active IPR
  • Cath in <2 hr

for VF

  • Cath others

rapidly

  • Cool rapidly

to 33o C , rewarm slowly

  • ICU care
  • EP routinely
  • Allow time to

wake up

  • Ongoing CPR

to the cath lab

  • IABP
  • ECMO
  • Nitroprusside
  • CARES
  • Support

groups

  • PR
  • Share
  • utcomes
  • Celebrate

Saves

  • EMS

Feedback

slide-93
SLIDE 93

Thank you