*Stayin Alive:Optimizing Outcomes for Victims of In-Hospital Cardiac Arrest

Julianna Jung, MD, FACEPDepartment of Emergency Medicine

ObjectivesDiscuss recent evidence regarding:Cardiopulmonary resuscitation Advanced cardiac life supportPost-resuscitation hypothermiaPost-resuscitation coronary interventionsProvider education**

Cardiac Arrest in Brazil~200,000 cases/yearHalf in hospital, half out of hospitalLimited data availableEpidemiology may differ from US/Europe**Gonzalez et al, Arq Bras Cardiol, 2013

In-Hospital Cardiac Arrest (IHCA)Average survival ~20% in USOne Brazilian study with 32% survivalVariation between and within hospitals Suggests hospital resuscitation processes are not optimized

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Median OR of survival = 1.4242% greater likelihood of identical patient surviving at one hospital vs. another

**Variation Between Hospitals in Survival Rates for ICHAMerchant RM et al, J Am Heart Assoc, 2014

Variation Within Hospitals in Survival Rates for ICHASignificantly lower survival during nights and weekendsSurvival varies by location :9% unmonitored38% OR/PACU**Perberdy et al, JAMA, 2008

**We Can Do Better!!!

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Cardiopulmonary ResuscitationSingle most important intervention Key determinant of:Return of spontaneous circulation (ROSC)Short and long term survivalNeurologic outcome**

Components of High-Quality CPRMinimize interruptionsCompress at adequate rateCompress to adequate depthAllow full recoilAvoid hyperventilation

**Meaney et al, Circulation, 2013

Breaking it Down**

Minimizing InterruptionsGoal: CCF > 80%CCF = chest compression fraction% time during which CPR is performedHigher CCF linked to increased survival**

CCF > 80%: Human Studies**Christenson et al, Circulation, 2009

**CCF > 80%: Human StudiesVaillancourt et al, Resuscitation, 2011

Adequate RateGoal: Rate = 100-120 bpmLower rates reduce cardiac outputHigher rates reduce coronary perfusionInappropriate rates associated with decreased survival**

Rate 100-120: Human Studies**Idris et al, Circulation, 2012

Adequate DepthGoal: Depth >50mm (adult)Suboptimal depth is commonDepth is variable over timeInadequate depth associated with reduced survival rates

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Depth >50mm: Human Studies**Compression depth >38mm: OR 1.91 of survival to DCStiell et al, Crit Care Med, 2012

Allow Full RecoilGoal: No residual leaningDecreases cardiac filling and outputDecreases coronary and cerebral perfusion pressuresLeaning is common no human studies**Meaney et al, Circulation, 2013

Avoid HyperventilationGoal:

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ACLS Does it Matter?Advanced life support includesAdvanced airway placementVascular accessParenteral medicationsDe-emphasized in 2010 guidelinesNo drug improves long-term survival**

Arrest Drugs Human Studies**Olasveengen et al, JAMA, 2009

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Post-Resuscitation HypothermiaUnadjusted OR for good outcome from hypothermia= 2.65Adjusted OR = 5.25 **Bernard et al, N Engl J Med, 2002

Hypothermia: 2010 GuidelinesCool to 32-34C for 12-24hr after ROSCComatose patients onlyOut-of-hospital VF Class IOther arrests Class IIbWidespread adoption

**Peberdy et al, Circulation, 2010

Hypothermia: CriticismNo control for hyperthermiaFailure to reach target temperature in 30-50% of cases confounds analysisUse of discharge destination as outcomeConflicts of interest for investigators

**Little & Feldman, JAMA Neurol, 2014

Hypothermia: New DataBlindedRandomized arrest victims to 33 or 36CTight temperature regulationNo difference in survival or neurologic outcome

**Nielsen et al, N Engl J Med, 2013

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Coronary Syndromes: AHA Guidelines12-lead ECG after ROSC (Level I)Perform percutaneous coronary intervention (PCI) for STEMI Coma or hypothermia not contraindicationsConsider PCI regardless of STEMI

**Peberdy et al, Circulation, 2010

PCI: Human StudiesNO randomized trialsCrude positive association between PCI and survival**Larsen & Ravkilde, Resuscitation, 2012

PCI: Human StudiesPCI associated with better survival ratesPCI group had more favorable factorsAdjusted for this using logistic regression survival still higher**Dumas et al, J Am Coll Cardiol, 2012

PCI: Who Should Get It?ST-elevations on EKG:85% PPV and 67% NPV1/3 with ACS had NO ST-elevation!ST-elevations are NOT adequate predictor of need for PCI**Zanuttini et al, Resuscitation, 2013

PCI: Who Should Get It?Alternate EKG criteria:ST-elevation, ST-depression, wide QRS48% PPV and 100% NPVAvoids needless interventionsBroader EKG abnormalities may considered in decision regarding PCI

**Sideris et al, Resuscitation, 2011

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Training MattersBrazilian studyACLS provider associated with greater ROSC numbersOR = 2.06**

Training MattersACLS provider associated with greater short and long-term survival**

Teaching ResuscitationCertification course competenceSimulation training enhancesPerformance in the simulation labPerformance in the clinical areaPatient outcomes**Deiorio et al, Acad Emerg Med, 2012

Teaching Resuscitation**2011 < 1 min: 58%2012 < 1 min: 75%p < 0.00012013 < 1 min: 98%Scordino et al, CORDEM, 2014

Teaching Resuscitation**2011 < 3 min: 47%2012 < 3 min: 40%p < 0.00012013 < 3 min: 83%Scordino et al, CORDEM, 2014

Teaching ResuscitationPerfect practice makes perfect!Well-defined goalRepetitive practiceConstructive feedbackIncorporate into future practicePerfection!**

ReferencesGonzalez MM, Timerman S, de Oliveira RG, Polastri TF, Dallan LA, Araujo S, Lage SG, Schmidt A, de Bernoche CS, Canesin MF, Mancuso FJ, Favarato MH. Guideline for cardiopulmonary resuscitation and emergency cardiovascular care -- Brazilian Society of Cardiology: executive summary. Arq Bras Cardiol. 2013 Feb;100(2):105-13.Merchant RM, Berg RA, Yang L, Becker LB, Groeneveld PW, Chan PS. Hospital variation in survival after in-hospital cardiac arrest. J Am Heart Assoc. 2014 Jan 31;3(1).Peabody MA, Ornato JP, Larking GL, Braithwaite RS, Kashner TM, Carey SM, Meaney PA, Cen L, Nadkami VM, Praestgaard AH, Berg RA. Survival from in-hospital cardiac arrest during nights and weekends. JAMA. 2008 Feb 20;299(7):785-92. Meaney PA, Bobrow BJ, Mancini ME, Christenson J, de Caen AR, Bhanji F, Abella BS, Kleinman ME, Edelson DP, Berg RA, Aufderheide TP, Menon V, Leary M. Cardiopulmonary resuscitation quality: improving cardiac resuscitation outcomes both inside and outside the hospital: a consensus statement from the American Heart Association. Circulation. 2013 Jul 23;128(4):417-35. **

ReferencesChristenson J, Andrusiek D, Everson-Stewart S, Kudenchuk P, Hostler D, Powell J, Callaway CW, Bishop D, Vaillancourt C, Davis D, Aufderheide TP, Idris A, Stouffer JA, Stiell I, Berg R. Chest compression fraction determines survival in patients with out-of-hospital ventricular fibrillation. Circulation. 2009 Sep 29;120(13):1241-7. Vaillancourt C, Everson-Stewart S, Christenson J, Andrusiek D, Powell J, Nichol G, Cheskes S, Aufderheide TP, Berg R, Stiell IG. The impact of increased chest compression fraction on return of spontaneous circulation for out-of-hospital cardiac arrest patients not in ventricular fibrillation. Resuscitation. 2011 Dec;82(12):1501-7.Idris AH, Guffey D, Aufderheide TP, Brown S, Morrison LJ, Nichols P, Powell J, Daya M, Bigham BL, Atkins DL, Berg R, Davis D, Stiell I, Sopko G, Nichol G. Relationship between chest compression rates and outcomes from cardiac arrest. Circulation. 2012 Jun 19;125(24):3004-12. Stiell IG, Brown SP, Christenson J, Cheskes S, Nichol G, Powell J, Bigham B, Morrison LJ, Larsen J, Hess E, Vaillancourt C, Davis DP, Callaway CW. What is the role of chest compression depth during out-of-hospital cardiac arrest resuscitation? Crit Care Med. 2012 Apr;40(4).**

ReferencesAufderheide TP, Sigurdsson G, Pirrallo RG, Yannopoulos D, McKnife S, von Briesen C, Sparks CW, Conrad CJ, Provo TA, Lurie KG. Hyperventilation-induced hypotension during cardiopulmonary resuscitation. Circulation. 2004 Apr 27;109(16):1960-5. Olasveengen TM, Sunde K, Brunborg C, Thowsen J, Steen PA, Wik L. Intravenous drug administration during out-of-hospital cardiac arrest: a randomized trial. JAMA. 2009 Nov 25;302(20):2222-9. Bernard SA, Gray TW, Buist MD, Jones BM, Silvester W, Gutteridge G, Smith K. Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia. N Engl J Med. 2002 Feb 21;346(8):557-63.Little NE, Feldman EL. Therapeutic Hypothermia After Cardiac Arrest Without Return of Consciousness: Skating on Thin Ice. JAMA Neurol. 2014 May 5.

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ReferencesNielsen N, Wetterslev J, Cronberg T, Erlinge D, Gasche Y, Hassager C, Horn J, Hovdenes J, Kjaergaard J, Kulper M, Pellis T, Stammet P, Wanscher M, Wise MP, Aneman A, Al-Subaie N, Boesgaard S, Bro-Jeppesen J, Brunetti I, Bugge JF, Hingston CD, Juffermans NP, Koopmans M, Kaber L, Langergen J, Lilja G, Moller JE, Rundgren M, Rylander C, Smid O, Werer C, Winkel P, Friberg H. Targeted temperature management at 33C versus 36C after cardiac arrest. N Engl J Med. 2013 Dec 5;369(23):2197-206. Peberdy MA, Callaway CW, Neumar RW, Geocadin RG, Zimmerman JL, Donning M, Gabrielli A, Silvers SM, Zaritsky AL, Merchant R, Vanden Hoek TL, Kronick SL. Part 9: post-cardiac arrest care: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010 Nov 2;122(18 Suppl 3):S768-86. Dumas F, White L, Stubbs BA, Cariou A, Rea TD. Long-term prognosis following resuscitation from out of hospital cardiac arrest: role of percutaneous coronary intervention and therapeutic hypothermia. J Am Coll Cardiol. 2012 Jul 3;60(1):21-7.

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ReferencesLarsen JM, Ravkilde J. Acute coronary angiography in patients resuscitated from out-of-hospital cardiac arrest--a systematic review and meta-analysis. Resuscitation. 2012 Dec;83(12):1427-33. Zanuttini D, Armellini I, Nucifora G, Grillo MT, Morocutti G, Carchietti E, Trillo G, Spedicato L, Bernardi G, Proclemer A. Predictive value of electrocardiogram in diagnosing acute coronary artery lesions among patients with out-of-hospital-cardiac-arrest. Resuscitation. 2013 Sep;84(9):1250-4. Sideris G, Voicu S, Dillinger JG, Stratiev V, Logeart D, Broche C, Viven B, Brun PY, Deye N, Capan D, Aout M, Megarbane B, Baud FJ, Henry P. Value of post-resuscitation electrocardiogram in the diagnosis of acute myocardial infarction in out-of-hospital cardiac arrest patients. Resuscitation. 2011 Sep;82(9):1148-53.

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ReferencesMoretti MA, Cesar LA, Nusbacher A, Kern KB, Timerman S, Ramires JA. Advanced cardiac life support training improves long-term survival from in-hospital cardiac arrest. Resuscitation. 2007 Mar;72(3):458-65.Deiorio NM, Fitch MT, Jung J, Promes SB, Thibodeau LG, Woolley WL, Gisondi MA, Gruppen LD. Evaluating educational interventions in emergency medicine. Acad Emerg Med. 2012 Dec;19(12):1442-53. Scordino D, Crichlow A, Rice J, Jung J. Assessment Drives Teaching: An iterative evidence-based approach to curriculum development yields superior educational outcomes. Presented at Council of Residency Directors in Emergency Medicine, New Orleans 2014.**

*Variation persists despite adjustment for case mix and hospital characteristics*Variation persists despite adjustment for case mix and hospital characteristics*135000 arrests at 468 hospitalsAdjusted for demographics and other variables to generate risk-adjusted survival ratesStratified into deciles survival ranged from 8 to 31% before adjustment, 12% to 22% after (light/dark bars)*Failure to monitor resuscitation quality Unacceptable disparities in outcomesOpportunities to save more lives*N~`500, out of hospital arrest victim, VF/VT onlyIncreased likelihood of survival to discharge as CCF increases up to 80% Highest survival in 61-80% group*N ~2100, out-of-hospital arrest victims, NOT VF/VTIncreasing rates of ROSC as CCF increasesCould not use survival as endpoint due to prohibitively large sample size required survival is rare in out of hospital non-VF/VT

*Probability of ROSC and survival to DC are optimized between 100-120 compressions/minuteSurvival drops off at higher/lower numbersChange is most pronounced at higher numbers calls into question the recommendation for >100*2 inches!*Association between probability of ROSC/survival and compression depthDifferences are more pronounced for survival to dischargeDepth >38 may be adequate, though other studies suggest higher depths are needed safer to aim high*High tidal volumes further impair cerebral and cardiac blood flow and should be avoidedGoal is just visible chest rise at appropriate rate*N ~900, randomized controlled trial in Oslo, NorwayHigher ROSC in IV drug groupNo difference in long-term outcome*N = 77Comatose after out-of-hosp VF arrestRandomized to hypothermia vs no hypothermia*I = should doIia = likely reasonableIib = may be considered*NEJM 2013N ~950Randomized to 33 vs 36 degrees*Meta analysis *US/France study with ~5000 out of hospital arrests and ~1000 survivors to DCObservational all participants got standard careSurvivor to DC group compared with respect to whether PCI performedPCI associated with better survival but also with other factors predicting survival (young age, witnessed arrest, bystander CPR, shockable rhythm) logistic regression model addressed this*University of Sao Paolo study~150 in-hospital arrestsEndpoints ROSC and short/long term survival with/without ACLS provider present*Only half of trained learners initiated timely CPRWith curricular modification focused on deliberate practice in sim lab, and *