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RESUSCITATION: 
ALS/APLS/ATLS are just the 
beginning…. 
Peter Sherren 
ST7 Anaesthesia and Intensive Care 
petersherren@gmail.com 
@pbsherren
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
Why bother? 
What should we be doing now and what 
could we be doing in the future?
What's not going to be in this talk
What's not going to be in this talk
RESUSCITATION: WHAT MAKES THE 
DIFFERENCE? 
• Good leadership 
• Uninterrupted chest compressions 
• Early defibrillation 
• Aggressive post ROSC care 
• Knowing when to think beyond 
standard algorithms
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
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
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
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?
Defibrillation 
• Good chest compressions before hand 
• Pre/post shock pause minimised 
• Biphasic 200J+ 
• 2x defibs in refractory VF? 
• Hands on defibrillation?
Leadership/CRM 
Topcat2, Clarke S et al, Emerg Med J 2014
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
Drugs 
• Adrenaline - Jacobs et al, Resuscitation 2010. PARAMEDIC2 
Perkins in Warwick, ongoing 8000pt RCT 
• Amiodarone/Lignocaine 
• Calcium Chloride/NaHCO3 
• Thrombolysis 
• Vasopressin/Sterioids/adrenaline - 230 pt 
RCT, Mentzelopoulos et al, JAMA 2013
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
E-CPR/ECLS
E-CPR/ECLS
E-CPR/ECLS
E-CPR/ECLS
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
Selective aortic arch perfusion 
(SAAP)
Cardiac arrest post cardiac surgery
Toxic cardiac arrest 
• Specific considerations/antidotes 
• Lipid rescue 
• High dose NaHCO3 & hyperventilation 
• Calcium 
• HIET 
• Sugammadex 
• Others - Atropine/methylene blue/Pyridoxine 
/Digibind/Hydroxycobalamin 
• Prolonged resuscitation!!! 
• E-CPR/ECLS or CPB
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
Post cardiac arrest syndrome 
• Ongoing pathology 
• Myocardial stunning 
• Inflammatory/reperfusion injury MODS 
• Neurological insult – Anoxic/reperfusion/autoregulation
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
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
Prehospital/Intra-arrest cooling? 
• No high grade evidence for prehospital 
cooling Bernard et al, JAMA 2013 
• Intra-arrest cooling – equipoise for future 
trials
Prognostication 
• Clinical examination 
• Radiology 
• Electrophysiology 
• Biomarkers
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
Lockey DJ et al. Resuscitation 2013
Sherren PB et al. Crit Care 2013
Suspended Animation/EPR
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
Questions?

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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?
  • 4. What's not going to be in this talk
  • 5. What's not going to be in this talk
  • 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?
  • 12. Leadership/CRM Topcat2, Clarke S et al, Emerg Med J 2014
  • 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
  • 14. Drugs • Adrenaline - Jacobs et al, Resuscitation 2010. PARAMEDIC2 Perkins in Warwick, ongoing 8000pt RCT • Amiodarone/Lignocaine • Calcium Chloride/NaHCO3 • Thrombolysis • Vasopressin/Sterioids/adrenaline - 230 pt RCT, Mentzelopoulos et al, JAMA 2013
  • 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
  • 21. Selective aortic arch perfusion (SAAP)
  • 22. Cardiac arrest post cardiac surgery
  • 23. Toxic cardiac arrest • Specific considerations/antidotes • Lipid rescue • High dose NaHCO3 & hyperventilation • Calcium • HIET • Sugammadex • Others - Atropine/methylene blue/Pyridoxine /Digibind/Hydroxycobalamin • Prolonged resuscitation!!! • E-CPR/ECLS or CPB
  • 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
  • 25. Post cardiac arrest syndrome • Ongoing pathology • Myocardial stunning • Inflammatory/reperfusion injury MODS • Neurological insult – Anoxic/reperfusion/autoregulation
  • 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
  • 29. Prognostication • Clinical examination • Radiology • Electrophysiology • Biomarkers
  • 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
  • 31. Lockey DJ et al. Resuscitation 2013
  • 32. Sherren PB et al. Crit Care 2013
  • 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