This document discusses ways to improve resuscitation outcomes beyond standard ALS/APLS/ATLS guidelines. It emphasizes the importance of high-quality chest compressions, early defibrillation, and aggressive post-ROSC care. New techniques discussed include impedance threshold devices, hypoventilation, intra-arrest ultrasound, various drug regimens, early PCI for cardiac arrests, and extracorporeal CPR. The document also covers post-cardiac arrest care including targeted temperature management, prognostication, and traumatic cardiac arrests. The overall message is that resuscitation outcomes can be improved through attention to many small details and being willing to think beyond standard algorithms.
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Resuscitation, ALS/APLS/ATLS are just the beginning....
1. RESUSCITATION:
ALS/APLS/ATLS are just the
beginning….
Peter Sherren
ST7 Anaesthesia and Intensive Care
petersherren@gmail.com
@pbsherren
2. Introduction
• ALS/APLS/ATLS essential to progression in
training and when applying for jobs
• Common language and a great starting
point
• Competence should be viewed as your
starting point, and not your destination
3. Why bother?
What should we be doing now and what
could we be doing in the future?
6. RESUSCITATION: WHAT MAKES THE
DIFFERENCE?
• Good leadership
• Uninterrupted chest compressions
• Early defibrillation
• Aggressive post ROSC care
• Knowing when to think beyond
standard algorithms
7. Airway
• Conflicting evidence for ETT/LMA/BVM
• Very rare airway should take priority
over chest compressions
• ETCO2 for ALL airways in cardiac arrest
Correct position/chest compression effectiveness/ROSC/prognostication
8. Ventilation
• Apnoeic vs Passive vs Active oxygenation
• Hyperventilation is endemic in resuscitation
• PPV and PEEP impairs venous
return and effectiveness of chest
compressions
• PPV worsens outcome in VF/VT OOHCA. 1000pt RCT, 25.8%
vs 38% survival to discharge. Bobrow et al Ann Emerg Med 2009
• Definite role for hypoventilation/zPEEP in haemorrhagic
shock and primary cardiac arrest
9. Impedance threshold device
• ITD augments –ve
intrathoracic pressure
• Improves cardiac and
cerebral perfusion
• Improved survival when
combined with ACD CPR. RCT
2470 pts. Aufderheide TP et al, Lancet
2011
10. Chest compressions
• CARDIOCEREBRAL resuscitation
• Uninterrupted chest compressions are
key (100-120, 1/3 AP, CCF >80%)
• Manual vs ACD vs Mechanical
• Manual vs mechanical. LINC trial, 2589 pts
RCT, JAMA 2014
• Use ETCO2 to monitor compression effectiveness
(>2.7kPa), and consider arterial line (CPP >20, DBP
>25mmHg)
• Role for internal cardiac compressions?
11. Defibrillation
• Good chest compressions before hand
• Pre/post shock pause minimised
• Biphasic 200J+
• 2x defibs in refractory VF?
• Hands on defibrillation?
13. Intra-arrest ultrasound
• Not good enough to say
PTx/tamponade/PE unlikely
• Abbreviated Ultrasound
should be a standard of care
• Tamponade
• PE
• Cardiac standstill
• PTx/hydrothorax
• AAA/haemoperitoneum
15. Primary PCI/Heart attack centres
• Heart attack centres. Sunde et al, Resuscitation 2007
• Sensitivity of post arrest ECG? Normal PPCI rules
are not sensitive enough
• PPCI for all VF/VT or suspected cardiac event?
• PPCI while undergoing mechanical chest
compressions. Sunde et al, Crit care med 2008
• Package of care
20. E-CPR/ECLS
• Save-J. 3 yrs 260 vs 240 pts, 12.4% vs 3.1%
survival with CPC 1&2. Sakamoto T et al, Resuscitation 2014
• 80 pts with propensity matched controls. Shin TG et
al, Crit care med 2011
• Prospective propensity matched trial. 59 vs 113
pts. 32.6 vs 17.4% survival to discharge. Chen YS et al,
Lancet 2008
• CHEER trial Victoria
• UK perspective
24. When should we stop?
• It’s complicated… don’t overly rely on ‘Down time’
• Prolonged resuscitation may be appropriate if
VF/VT/cardiac cause to arrest
• Use of ECG, ultrasound and ETCO2 can help
• One off pH/lactate/K+ in isolation are poor
discriminators of survival
• Deep hypothermic vs hypoxic/hypothermic arrests
26. Post cardiac arrest syndrome
management
• Treat underlying pathology and PPCI for all
VF/VT?
• Early ETT and controlled ventilation
• PaO2 >10 and SpO2 94-98%
• PaCO2 4.5-5
• MAP >70-80 Hope KJ et al, Crit care med 2014
• Glycaemic control
• Appropriate sedation/analgesia/seizure
control
• Aggressive targeted temperature
management
27. Targeted temperature management
• 36 vs 32-34̊C?
• Original HACA, NEJM 2002 vs Nielsen et
al, NEJM 2013
• Avoidance of hyperpyrexia is key
• TTM still essential, the target has just
changed
28. Prehospital/Intra-arrest cooling?
• No high grade evidence for prehospital
cooling Bernard et al, JAMA 2013
• Intra-arrest cooling – equipoise for future
trials
30. Traumatic cardiac arrest
• Resuscitation isn't futile
• Shouldn’t be treated like
a medical cardiac arrest
• C-ABC and aggressive
exclusion of pathology
• Blunt vs penetrating
• Role for external chest
compressions?
• Resuscitative thoracotomy
• SOP/Algorithm
34. Summary
• Resuscitation isn't as futile as people would
have you believe
• Aim for the best possible quality of care,
not standard care
• Cumulative effect of marginal benefits
• Know when to go beyond standard
resuscitation algorithms
