UPDATE ON EMERGENCY CARDIAC CARE GUIDELINES

Mark L. Greenberg, MD Associate Professor of Medicine Director, Clinical Electrophysiology and Pacing

BLS and ACLS-Historical Perspective

1956: External defibrillation (Zoll) 1958: Mouth-to-mouth ventilation (Safar, Elam) 1960: Chest compressions (Kouwenhoven) 1979: Automatic External Defibrillator (AED) (Diack) 1996: Biphasic waveform approved for AED use in USA 2000: First international evidence-based resuscitation guidelines

The Chain of Survival of Cardiopulmonary Resuscitation

Interdependence of Early CPR and Early Defibrillation

Valenzuela, et al. Circulation. 1997;96:330813.

The physiologic mechanism of chest compressions: cardiac pump (A) or thoracic pump (B)?

Whats New in BLS

New

Chest Compression Rate and CompressionVentilation Ratio for Adults Interposed Abdominal Compression CPR (IACCPR)

INTERRUPTIONS IN CHEST COMPRESSIONS ARE DETRIMENTAL

Lay rescuers: 16 seconds to administer 2 breaths (cf 3-4 sec. for professionals). Compression: ventilation ratio of 5:1 yields higher PaO2 but lower oxygen delivery than 15:2 (64 compressions, 8 ventilations per minute).

New Chest Compression Rate and Compression-Ventilation Ratio for Adults Compression rate approx. 100/min for adults and children over age one Compression-ventilation ratio 15:2 for both one and two-rescuer CPR (5:1 after trachea intubated)

Interposed Abdominal Compression CPR (IACCPR)

An alternative for in-hospital resuscitation Abdomen compressed between xiphoid and umbilicus during relaxation phase of chest compression Increases forward blood flow during CPR and appears to improve survival

IAC-CPR

Seesaw-like Function of the Lifestick

ResQPump
Metronome
Force Gauge

Suction Cup Handle

Inspiratory Impedance Threshold Valve (ITV)

Concept: Lower intrathoracic pressure in the chest during the decompression phase of CPR enhances venous return to the thorax. Design: Each time the chest wall recoils following a compression, the ITV transiently blocks air/oxygen from entering the lungs, creating a small vacuum in the chest.

ResQValve (CPRx)
Disposable, oneway valve that fits into the respiratory circuit and impedes inspiratory gas exchange during decompression

Placement

ResQValve

Blood Flow During CPR (Porcine VF Model)

1.0

Blood Flow (ml/min/gm)

STD CPR 0.8 0.6 STD CPR + ITV ACD CPR ACD CPR + ITV

0.4 0.2 0.0

Left Ventricle

Lurie et al. Improving ACD CPR with an inspiratory impedance valve. Circulation 1995;91:1629-32.

Brain

Blood Pressure During CPR in Humans

120

100

mmHg

80 60 40 20 0 Systolic Diastolic

STD CPR ACD + ITV

Baseline (Normal)
Cohen et al, JAMA 1992 and Plaisance et al, Circulation 2000

RCT of ACD/ITV CPR vs. STANDARD CPR

220 patients, 157 with witnessed events (Mainz, Germany) 24 hr. survival 37% with ACD/ITV CPR vs. 22% with standard CPR (p=0.03)
Wolcke et. al. Circulation.2002;106:II-538.

Whats New in External Defibrillation

More emphasis on early defibrillation Automatic External Defibrillation (AED) and Public Access Defibrillation (PAD) Defibrillation with a biphasic waveform

The Time Factor*

Survival rates after VF cardiac arrest decrease approximately 7% to 10% with every minute that defibrillation is delayed.
* Non-linear
Guidelines 2000 for Cardiovascular Resuscitation and Emergency Cardiovascular Care.Circulation. 2000;102(suppl I)8. August 22,2000
100 90

Defibrillation

80

70

Percent of Survival

60 50 40 30 20

10

10

Time (min)

13 year old boy struck by a pitch

Commotio Cordis

Goals For Early Defibrillation

In

hospital: defibrillation within 3 minutes Out of hospital: defibrillation within 5 minutes of activation of the EMS (value of AED and PAD)

Unconscious patient, no pulse

Shock advised

Unconscious patient, no pulse

No shock advised?

It is time for the national government to help bring AEDs to public places all over America. . . I am working with Congress to complete a vital piece of legislation that would not only encourage the installation of AEDs in federal buildings, but also grant legal immunity to good Samaritans who use them. .. It is now our responsibility to bring this technology , this modern miracle, to every community in America.
President Bill Clinton, 5/20/00 radio address.

Prevalence of AEDs
National

Registry of CPR Hospitals: 31% VA Hospitals: 14% Commerical Airliners: 100%

OHare International Airport: 60-90 Second Walk To An AED

Caffrey et. al. N Engl J Med 2002;347:1242-7.

CHICAGO AIRPORT AED STUDY

Three airports, serving >100 million passengers/yr. 21 cardiac arrests over 2 yrs; 18 had VF, 11 of whom were resuscitated (10 alive & well one yr. later)

Caffrey et. al. N Engl J Med 2002;347:1242-7.

Incidence of Unexpected Cardiac Arrest

AEDs: UNANSWERED QUESTIONS

Does

formal training improve performance? How are they best deployed? Are they cost effective?

DEFIBRILLATOR WAVEFORMS

Current Flow

Defibrillation

Biphasic defibrillationcurrent flows in two phases, first in one direction from one electrode, and then current flows the other way from the other electrode

Biphasic Defibrillation

Risk of Damage
Monophasic Peak Current 40% Difference Biphasic Peak Current

40

30

Current (amps)

20

10

-10

-20 0 5 10 15 20

Time (msec)

Much less peak current and better efficacy than monophasic Source: SL Higgins, Prehospital
Emergency Care 2000; 4:305-313

Transthoracic Impedance

Measured by the defibrillator Higher impedance

Skin surfaceespecially dry Hair Fat Bone Air in chest

Impedance
60 50

Current variance due to impedance, energy held constant

Peak Current (amps)

40

30

20

10

25

50

75

100

125

150

Patient Impedance (ohms)

The current a heart receives from a 200J shock depends on the patients impedance

Impedance Distribution
Histogram of patient impedances
16

Percentage of Patients

14 12 10 8 6 4 2 0 30 40 50 60 70 80 90 100 110 120 130 140 150 More

Impedance (ohms)
Medtronic Physio-Control: Impedance data on 723 SCA patients.

Biphasic Defibrillators Are NOT All the Same

Waveforms vary (with regard to voltage or pulse duration) in their response to transthoracic impedance measurements. Energy settings may be fixed, lowdose escalating, or standard dose escalating. No clear superiority among manufacturers.

IMPEDANCE ADJUSTMENT WITH PHILIPS FR2

50 40 30

50, 150 J 75, 150 J 125, 150 J

SMART Biphasic

Current (A) 20
10 0 -10 -20 0 5 10

150-150-150 J Current adjusted for impedance Customized waveform shape for each patient and each shock

15

20

25

30

35

40

Time (msec)

Why Will Biphasic Defibrillators Replace Standard Monophasic Models?

Impedance compensating, lower shock strength biphasic waveforms have less potential to damage cells. Biphasic waveforms have superior efficacy for treating atrial fibrillation and ventricular fibrillation.

Randomized, controlled trial of 150 J biphasic shocks with 200-360 J monophasic shocks in 115 patients with out-of-hospital VF; time to first shock 8.9+/-3.0 min.
98% (53/54)
p < 0.0001

96% (52/54)

p <0.0001

69% (42/61) 59%(36/61)B

Biphasic

Monophasic

Biphasic

Monophasic

1st shock

3 shocks
Schneider T, et al, Circulation 2000;102:1780-1787.

Whats New in ACLS?

Airway

Management Vasopressin IV amiodarone as a first-line drug

Whats New in Airway Management

Emphasis on skilled bag-mask ventilation with continuous cricoid pressure Validation of airway adjuncts like the laryngeal mask and Combitube Recommendation for secondary confirmation techniques to verify ETT placement (e.g.end-tidal CO2)

Cricoid Pressure Can Minimize Gastric Inflation

Advanced Airway Devices

Esophagealtracheal combitube

Advanced Airway Devices

Laryngeal mask airway (LMA) Superior to ETT for BLS-level personnel Equal to ETT for ACLS-level personnel

Laryngeal Mask

Confirming Tracheal Tube Placement

Esophageal detector devices

Vasopressin 40 U IV Before Epinephrine 1 mg IV?

Vasopressin appears at least as effective as epinephrine (large RCT underway in Europe). Vasopressin is non-beta-adrenergic and does not increase myocardial 02 consumption. Longer half-life (10-20 min. vs. 3-5 min.) simplifies administration.

Amiodarone 300 mg IV Should Be Given Before Lidocaine

Advantage lidocaine: rapid onset of action, no hypotension Game, set, and match amiodarone: minimal proarrhythmia, much stronger evidence for efficacy

Amiodarone vs. Placebo in 504 Pts. with Shock Refractory Outof-Hospital VT/VF

Kudenchuk et. al. NEJM 1999;341:871-8.

Amiodarone vs. Lidocaine for Shock-Resistant VF

Dorian et al. N Engl J Med 2002;346:884-90.

Stable Ventricular Tachycardia

Monomorphic VT
Is cardiac function impaired?

Reasonable LV function

Poor LV function

Medications:
* Procainamide

Amiodarone
* 150 mg IV over 10 minutes or

Others acceptable
* Amiodarone * Lidocaine

Lidocaine
* 0.5 to 0.75 mg/kg IV push Then use

Synchronized cardioversion

Polymorphic Ventricular Tachycardia

Polymorphic VT
* Is QT baseline interval prolonged?

Normal baseline QT Interval

Prolonged baseline QT Interval (suggests Torsades) Long baseline QT Interval

* Correct abnormal electrolytes Interventions: * Magnesium * Overdrive pacing * Isoproterenol * Lidocaine

Normal baseline QT Interval

* Treat ischemia * Correct electrolytes Medications: * Beta Blockers or * Lidocaine or * Amiodarone or * Procainamide or * Sotalol