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JAMA 2002,Weisfeldt & BeckerResuscitation After Cardiac Arrest
A 3-Phase Time-Sensitive Model
Electrical Phase of VF
Defibrillation
Circulatory Phase
Compression
Defibrillation
Metabolic Phase
Hypothermia
Other Therapies
ECPB
0
20
40
60
80
100
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
Is the best treatment for VF herethe same as here?
0-4 min 4-10 min > 10 min
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Electrical Phase
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3 Phases of Cardiac Arrest
Electrical Phase of VF
Defibrillation
Circulatory Phase
Compression
Defibrillation
Metabolic Phase
New therapy
AEDs
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Casino Study: Survival--Time is of
the Essence
Trained Security Officers in AEDs
105 patients, VF arrest
92 witnessed arrests Average time, collapse to shock: 4.4 minutes
Valenzuela et al. NEJM, 2000
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Casino Study: Results
74%
49%
0%
10%
20%
30%
40%50%
60%
70%
80%
Survival to Hospital Discharge
< 3 min
>3 min
All survivors neurologically intact
Valenzuela et al. NEJM, 2000
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Circulatory Phase
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CPR Prior to Defibrillation
Shock patients as soon as recognized
Efficacy decreases with each passing minute
Study of immediate shock vs. 3 minutes of
chest compressions prior to shock 200 out-of-hospital cardiac arrest patients
3 minutes of chest compressions offered no
advantage in outcomes for population as awhole
But
Wik et al. JAMA, 2003
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Wik > 5 min ambulance
response
89% of survivors good neurologic outcome
Wik et al. JAMA, 2003
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Metabolic Phase
ATP Depletion
Calcium Influx
Free Radical
Production
Endothelial
Dysfunction
MitochondrialDysfunction
Ion PumpDysfunction
MetabolicAcidosis
Apoptosis
Inflammation
Permeability ofthe Blood
Brain Barrier
Pro-
coagulation
Early Injury Late Injury
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Time
%S
urviving
SHOCK < 3 min: 74%
CPR
ROSC
Hospital
d/c, 10%
To summarize: 3 phases of arrest
Arrest!
Valenzuela et al. NEJM, 2000
Penn Pre-TH
OHCA Data
34%
E C M
> 5 min, CPR 1st
: 22%
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Time
%S
urvivin
gWhat is happening?
Cellular level injuryEndothelial damage
Mitochondrial dysfunction
Hypothermia
Damage observed after restoration
of blood flow to ischemic tissues
To summarize: reperfusion injury
Vanden Hoek et al AJP 1996
10%
19%
34%