Cómo Morimos Bryan E. Bledsoe, DO, FACEP The George Washington University Medical Center Bryan E....

Cómo MorimosCómo Morimos

Bryan E. Bledsoe, DO, FACEP

The George Washington University Medical Center



How We DieHow We Die






Life is pleasant. Death is peaceful. It is the transition that is troublesome.

Isaac Asimov

Life is pleasant. Death is peaceful. It is the transition that is troublesome.

Isaac Asimov


Estimated 500,000 deaths each year attributable to cardiac arrest.

Estimated 500,000 deaths each year attributable to cardiac arrest.


Regardless, the resuscitation rate remains < 5% and has changed little in the last 40 years.

Regardless, the resuscitation rate remains < 5% and has changed little in the last 40 years.

History of ResuscitationHistory of Resuscitation

1740—The Paris Academy of Sciences officially recommended mouth-to-mouth resuscitation for drowning victims.

1767—The Society for the Recovery of Drowned Persons became the first organized effort to deal with sudden and unexpected death.

1740—The Paris Academy of Sciences officially recommended mouth-to-mouth resuscitation for drowning victims.

1767—The Society for the Recovery of Drowned Persons became the first organized effort to deal with sudden and unexpected death.


1891—Dr. Friedrich Maass performed the first equivocally documented chest compression in humans.

1891—Dr. Friedrich Maass performed the first equivocally documented chest compression in humans.

History of ResuscitationHistory of Resuscitation1903—Dr. George Crile reported the first successful use of external chest compressions in human resuscitation.1904—The first American case of closed-chest cardiac massage was performed by Dr. George Crile.

1903—Dr. George Crile reported the first successful use of external chest compressions in human resuscitation.1904—The first American case of closed-chest cardiac massage was performed by Dr. George Crile.


1947—Claude Beck developed first defibrillator and first human saved with defibrillation.

1947—Claude Beck developed first defibrillator and first human saved with defibrillation.


1954—James Elam was the first to prove that expired air was sufficient to maintain adequate oxygenation.

1954—James Elam was the first to prove that expired air was sufficient to maintain adequate oxygenation.


1956—Peter Safar and James Elam invented mouth-to-mouth resuscitation.

1956—Peter Safar and James Elam invented mouth-to-mouth resuscitation.


1957—The United States military adopted the mouth-to-mouth resuscitation method to revive unresponsive victims.

1957—The United States military adopted the mouth-to-mouth resuscitation method to revive unresponsive victims.

History of ResuscitationHistory of Resuscitation1960—CPR was developed. The American Heart Association started a program to acquaint physicians with closed-chest cardiac resuscitation and became the forerunner of CPR training for the general public.

1960—CPR was developed. The American Heart Association started a program to acquaint physicians with closed-chest cardiac resuscitation and became the forerunner of CPR training for the general public.


1963—Cardiologist Leonard Scherlis started the American Heart Association's CPR Committee, and the same year, the American Heart Association formally endorsed CPR.

1963—Cardiologist Leonard Scherlis started the American Heart Association's CPR Committee, and the same year, the American Heart Association formally endorsed CPR.

History of ResuscitationHistory of Resuscitation1965—J. Frank Pantridge converted an ambulance into a mobile coronary care unit with a portable defibrillator and recorded ten pre-hospital resuscitations.

50% long-term survival rate.

1965—J. Frank Pantridge converted an ambulance into a mobile coronary care unit with a portable defibrillator and recorded ten pre-hospital resuscitations.

50% long-term survival rate.


1966—The National Research Council of the National Academy of Sciences convened an ad hoc conference on cardiopulmonary resuscitation to establish standardized training and performance standards for CPR.

1966—The National Research Council of the National Academy of Sciences convened an ad hoc conference on cardiopulmonary resuscitation to establish standardized training and performance standards for CPR.


1972—Leonard Cobb held the world's first mass citizen training in CPR in Seattle, Washington called Medic 2. He helped train over 100,000 people the first two years of the programs.

1972—Leonard Cobb held the world's first mass citizen training in CPR in Seattle, Washington called Medic 2. He helped train over 100,000 people the first two years of the programs.


1979—The first automated external defibrillators (AEDs) became available, further extending the concept of pre-hospital care.

1979—The first automated external defibrillators (AEDs) became available, further extending the concept of pre-hospital care.


1981—A program to provide telephone instructions in CPR began in King County, Washington. Dispatcher-assisted CPR is now standard care for dispatcher centers throughout the United States.

1981—A program to provide telephone instructions in CPR began in King County, Washington. Dispatcher-assisted CPR is now standard care for dispatcher centers throughout the United States.


We now know a great deal more about the pathophysiology of sudden death—especially ventricular fibrillation.

We now know a great deal more about the pathophysiology of sudden death—especially ventricular fibrillation.


Three Phase Model:Electrical Phase

Circulatory Phase

Metabolic Phase

Three Phase Model:Electrical Phase

Circulatory Phase

Metabolic Phase

Phases of Cardiac ArrestPhases of Cardiac Arrest

Electrical Phase 0 - 4 minutes

Circulatory Phase 4 - 10 minutes

Metabolic Phase > 10 minutes

Electrical Phase 0 - 4 minutes

Circulatory Phase 4 - 10 minutes

Metabolic Phase > 10 minutes

Electrical PhaseElectrical Phase

Adequate oxygen content in myocardium.

Adequate energy substrates (ATP).

Near-normal pH.

No myocardial ischemia.

No myocardial infarction.

Adequate oxygen content in myocardium.

Adequate energy substrates (ATP).

Near-normal pH.

No myocardial ischemia.



Early defibrillation a Class I recommendation.

Survival rates approach 50%.

Early defibrillation a Class I recommendation.

Survival rates approach 50%.


Most effective treatment during electrical phase is rapid defibrillation.

Most effective treatment during electrical phase is rapid defibrillation.

Circulatory PhaseCirculatory Phase

Inadequate oxygen content in myocardium.

Inadequate energy substrates (ATP).

Acidosis.

Possible myocardial ischemia.


Inadequate oxygen content in myocardium.

Inadequate energy substrates (ATP).

Acidosis.

Possible myocardial ischemia.



DEFIBRILLATION IN THE GLOBALLY ISCHEMIC HEART MAY BE DETRIMENTAL!

DEFIBRILLATION IN THE GLOBALLY ISCHEMIC HEART MAY BE DETRIMENTAL!


Chest compressions and tissue oxygen delivery take precedence over defibrillation.

Initial therapy should be chest compressions and ventilations followed by defibrillation.

Defibrillation usually delayed by 1-3 minutes.

Chest compressions and tissue oxygen delivery take precedence over defibrillation.

Initial therapy should be chest compressions and ventilations followed by defibrillation.

Defibrillation usually delayed by 1-3 minutes.


Animals allowed to fibrillate for 1,3,5, or 9 minutes prior to defibrillation.

Immediate defibrillation optimal when performed in 3 minutes or less.

Animals allowed to fibrillate for 1,3,5, or 9 minutes prior to defibrillation.

Immediate defibrillation optimal when performed in 3 minutes or less.


CPR + epinephrine resulted in better survival when performed after 5-9 minutes.

> 5 minutes of cardiac arrest, immediate defibrillation resulted in 30% successful defibrillation and 0% ROSC.

1 minute of CPR + epinephrine before defibrillation resulted in 70% conversion rate and 40% ROSC.

Yakaitis et al. Crit Care Med. 1980;8:157-163

CPR + epinephrine resulted in better survival when performed after 5-9 minutes.

> 5 minutes of cardiac arrest, immediate defibrillation resulted in 30% successful defibrillation and 0% ROSC.

1 minute of CPR + epinephrine before defibrillation resulted in 70% conversion rate and 40% ROSC.

Yakaitis et al. Crit Care Med. 1980;8:157-163


In animals with 7.5 minutes of untreated v-fib, 5 minutes of CPR + epinephrine was compared to immediate defibrillation.

Significant improvement (64% vs. 21% survival) when compared to immediate defibrillation.

Niemann et al. Resusc. 1992;85:281-287

In animals with 7.5 minutes of untreated v-fib, 5 minutes of CPR + epinephrine was compared to immediate defibrillation.

Significant improvement (64% vs. 21% survival) when compared to immediate defibrillation.

Niemann et al. Resusc. 1992;85:281-287


In animals, 8 minutes of untreated v-fib treated with immediate defibrillation or CPR + drug cocktail (epinephrine, lidocaine, bretylium, propranolol) then defibrillation.

77% versus 22% ROSC for the drug cocktail group.

Menegazzi et al. Ann Emerg Med 1993;22:235-239

In animals, 8 minutes of untreated v-fib treated with immediate defibrillation or CPR + drug cocktail (epinephrine, lidocaine, bretylium, propranolol) then defibrillation.

77% versus 22% ROSC for the drug cocktail group.

Menegazzi et al. Ann Emerg Med 1993;22:235-239


Seattle:Standard immediate defibrillation: 24% survival

90 seconds CPR then defibrillation: 30% survival

Subgroup analysis:Immediate defibrillation superior to 90 seconds CPR for first 3 minutes only.

Cobb et al. JAMA 1999;281:1182-1188

Seattle:Standard immediate defibrillation: 24% survival

90 seconds CPR then defibrillation: 30% survival

Subgroup analysis:Immediate defibrillation superior to 90 seconds CPR for first 3 minutes only.

Cobb et al. JAMA 1999;281:1182-1188


Oslo:> 5 minutes after collapse, if CPR performed for 3 minutes prior to defibrillation.

Survival to hospital discharge 22% vs. 4%

1 year survival 20% vs. 4%Wik et al. Circ. 2002;106 (Suppl 2):A1823

Oslo:> 5 minutes after collapse, if CPR performed for 3 minutes prior to defibrillation.

Survival to hospital discharge 22% vs. 4%

1 year survival 20% vs. 4%Wik et al. Circ. 2002;106 (Suppl 2):A1823

The Metabolic PhaseThe Metabolic Phase

Effectiveness of both immediate defibrillation and CPR + defibrillation decrease rapidly.

Survival rates poor.

Effectiveness of both immediate defibrillation and CPR + defibrillation decrease rapidly.

Survival rates poor.


Tissue injury from global ischemic events and reperfusion cause circulating metabolic factors that cause injury in excess of local ischemia.

Tissue injury from global ischemic events and reperfusion cause circulating metabolic factors that cause injury in excess of local ischemia.


Gut mucosa begins to malfunction secondary to ischemia.

Translocation of gram-negative bacteria cause endotoxin and cytokine release.

Both suppress myocardial function after defibrillation.

Gut mucosa begins to malfunction secondary to ischemia.

Translocation of gram-negative bacteria cause endotoxin and cytokine release.

Both suppress myocardial function after defibrillation.


Reperfusion in this phase can contribute to cell death and diminished organ function independent of the adverse effects of ischemia.

Key to survival during this phase appears to be control of injurious factors during reperfusion.

Reperfusion in this phase can contribute to cell death and diminished organ function independent of the adverse effects of ischemia.

Key to survival during this phase appears to be control of injurious factors during reperfusion.


Induced-hypothermia may be the answer for patients in the metabolic phase.

Induced-hypothermia may be the answer for patients in the metabolic phase.


Induced-hypothermia (34-32˚ C) have shown an improvement in neurologically-intact survival after out-of-hospital cardiac arrest.

Patients cooled late in cardiac arrest:49% survival compared with 26%

55% good neurological outcomeHypothermia Study Group NEJM 2002;346:549-556

Induced-hypothermia (34-32˚ C) have shown an improvement in neurologically-intact survival after out-of-hospital cardiac arrest.

Patients cooled late in cardiac arrest:49% survival compared with 26%

55% good neurological outcomeHypothermia Study Group NEJM 2002;346:549-556


Possible beneficial technologies:Correcting calcium-entry

Correcting sodium alterations

Preventing inflammation

Possible beneficial technologies:Correcting calcium-entry

Correcting sodium alterations

Preventing inflammation



Metabolic-focused treatmentCardiopulmonary bypass

Administration of metabolic therapies (similar to what is used in cardiac bypass procedures):

Amino acid-enriched solution with:Buffer

Low calcium

Increased potassium

High-dextrose

Metabolic-focused treatmentCardiopulmonary bypass

Administration of metabolic therapies (similar to what is used in cardiac bypass procedures):

Amino acid-enriched solution with:Buffer

Low calcium

Increased potassium

High-dextrose


Whereas epinephrine may be beneficial during the circulatory phase, it may be detrimental during the metabolic phase.

Epinephrine:Increases gut ischemia

May lead to sepsis

Whereas epinephrine may be beneficial during the circulatory phase, it may be detrimental during the metabolic phase.

Epinephrine:Increases gut ischemia

May lead to sepsis

So What Does This All Mean?So What Does This All Mean?

This concept based on ventricular fibrillation.

May be similar for trauma and hypoxia induced cardiac arrest.

This concept based on ventricular fibrillation.

May be similar for trauma and hypoxia induced cardiac arrest.




Vilke et al. The three-phase model of cardiac arrest as applied to ventricular fibrillation is a large, urban emergency medical services system. Resuscitation. 2005;84:341-346

Vilke et al. The three-phase model of cardiac arrest as applied to ventricular fibrillation is a large, urban emergency medical services system. Resuscitation. 2005;84:341-346

What Does This All Mean?What Does This All Mean?

EMS arrival < 4 minutes after collapse EMS arrival < 4 minutes after collapse

Immediate defibrillationImmediate defibrillationBystander CPR not as important during this phase.


EMS arrival less than >4 but <10 minutes after collapse EMS arrival less than >4 but <10 minutes after collapse

CPR + defibrillationCPR + defibrillationBystander CPR VERY important during this phase.


EMS arrival > 10 minutes after collapse EMS arrival > 10 minutes after collapse

??

> 10 Minute Down Time> 10 Minute Down Time

Induced-HypothermiaInduced-Hypothermia

Dandenong Hospital, Melbourne, VIC

30 mL/kg cold (4˚- 8˚ C) lactated Ringer’s administered in ED after out-of-hospital resuscitation by paramedics.

Dandenong Hospital, Melbourne, VIC

30 mL/kg cold (4˚- 8˚ C) lactated Ringer’s administered in ED after out-of-hospital resuscitation by paramedics.


Patients: n=22

Age: 70 (55-75)

Cause of Arrest:Cardiac=21

TCA OD=1

Rhythm:V-fib=14

Asystole=4

PEA=4

Patients: n=22

Age: 70 (55-75)

Cause of Arrest:Cardiac=21

TCA OD=1

Rhythm:V-fib=14

Asystole=4

PEA=4

EMS Call: 2 minutes

Response: 8 minutes

EMS arrival to ROSC: 16 minutes

Collapse to ROSC: 26 minutes

ROSC to infusion:73 minutes

EMS Call: 2 minutes

Response: 8 minutes

EMS arrival to ROSC: 16 minutes

Collapse to ROSC: 26 minutes

ROSC to infusion:73 minutes



Survival (initial rhythm):

V-fib: 8/14 (80%)

Not v-fib: 2/8 (25%)Bernard et al. Resusc. 2003;56:9-13

Survival (initial rhythm):

V-fib: 8/14 (80%)

Not v-fib: 2/8 (25%)Bernard et al. Resusc. 2003;56:9-13

What about ventilations?What about ventilations?

Lay public can not or will not do mouth-to-mouth in many cases.

Adequate oxygen stores initially.

Patient may gasp for a minute.

May take away from effective chest compressions.

Lay public can not or will not do mouth-to-mouth in many cases.

Adequate oxygen stores initially.

Patient may gasp for a minute.

May take away from effective chest compressions.

2005 AHA Recommendations2005 AHA Recommendations

Chain of SurvivalChain of Survival

SummarySummary

Try and know the phase your patient is in.

Most EMS responses will arrive in the circulatory phase and 1-3 minutes of chest compressions are essential.

Many new therapies coming down the line.

Try and know the phase your patient is in.

Most EMS responses will arrive in the circulatory phase and 1-3 minutes of chest compressions are essential.

Many new therapies coming down the line.

Major ReferenceMajor Reference

Weisfeldt ML and Becker LB. Resuscitation After Cardiac Arrest: A 3-Phase Time-Sensitive Model. Journal of the American Medical Association. 2002;288(23):3035-3038

Weisfeldt ML and Becker LB. Resuscitation After Cardiac Arrest: A 3-Phase Time-Sensitive Model. Journal of the American Medical Association. 2002;288(23):3035-3038

SummarySummary

Questions?

This presentation available at: http://www.bryanbledsoe.com

Questions?

This presentation available at: http://www.bryanbledsoe.com

http://www.bryanbledsoe.com/

http://www.bryanbledsoe.com/

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