Resuscitation in cardiac arrest the role of the HEMS physician

Transcription

1 Resuscitation in cardiac arrest the role of the HEMS physician Dr Anne Weaver Consultant in Emergency Medicine & Pre-hospital Care AIRMED World Congress Rome 2014

2 Aims Describe standard care for cardiac arrest victims in London Describe our cool car initiative Outline the key steps to deliver high quality care for cardiac arrest patients

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4 London HEMS Pan London service Operates as a charity Now known as London s Air Ambulance Mixed funding part state / part charity Charity funding - corporate / individuals / lottery

5 Role of London s Air Ambulance Dedicated to major trauma patients Primary phase of incident 7 missions per day 4 day 3 night 365 days per year

6 Current workload 24/7 service 2000 trauma missions per year > pts treated over 25 yrs RTC 50% 50% pedestrian Falls 20% Penetrating Injury 25% Misc 5%

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9 Our medical team Senior physician and paramedic Physicians international recruitment Focused on delivery of exceptional care Appreciative of literature and guidelines Standard Operating Procedures Bespoke care for each patient

10 Background 7.2 million deaths worldwide from CHD Estimated 60,000 OHCA in UK each year 1 Survival across the UK ranges from 2-12% attended by LAS in Resuscitation attempted for 43.6% (80.3% presumed to be of cardiac cause) In London overall survival rate= 10.9% (cardiac cause)

11 London Ambulance Service

12 London Ambulance Service < 8 min response Bystander CPR / AED / BLS ALS - LMA / ETT, manual CPR, drugs ROLE recognition of life extinct Transfer ROSC to local hospital ED Transfer to Heart Attack Centre if: VF arrest & ROSC Diagnostic ECG post ROSC - STEMI / LBBB

13 Cardiac arrest evolution in the LAS Consultant Paramedic Mark Whitbread Network of Heart Attack Centres AED program Advanced Paramedic scheme But. patient must have a diagnostic ECG

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16 Would a man outside the stadium have received the same care?

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18 The Cool Car

19 The cardiac arrest car Strategy to deliver early high quality CPR in East London and the City Gold standard ALS Consistent, uninterrupted CPR Inspiratory impedance threshold device - ResQpod Therapeutic hypothermia Emergency anaesthesia Consideration of thrombolysis Medical leadership and clinical judgement Triage to PCI

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21 What would make a difference? Small team Training Physician delivered care Diagnostic approach Key performance indicators CPR adjuncts Evidence based care As if it were our families

22 The past? Stay and play Secure airway Follow full algorithm Quality compressions Reversible causes Scoop & run None of the above achieved safely Arrive in ED with v poor outlook

23 Key Performance Indicators During cardiac arrest: qetco 2 monitored and recorded qairway managed with SGD or ETT qoxygenation optimised throughout qchest compressions with ACD / Autopulse qthrombolysis considered qimpedance Threshold Device applied (ResQPOD) qintravenous or Intra-osseous access obtained qdefibrillation and drug therapy according to ERC guidelines 2010 qminimise hands-off time q30mls/kg cold fluid started during arrest qworking diagnosis described in patient record After Return of Spontaneous Circulation: qecg obtained and interpreted qcore temperature recorded qdefinitive airway secured qlong acting neuromuscular blockade initiated qno signs of anaesthetic awareness qbm measured and noted qoxygen sats maintained at 94-98% qdecision to transfer to PCI documented

24 Problems encountered with manual CPR Variation in performance of compressions Depth, rate, release Fatigue / distraction human factors Limited number of team members Confined spaces Transfer of patient in ambulance poor CPR

25 Mechanical CPR Limited team members Deployed < 25seconds Uninterrupted consistent compressions Useful in confined spaces Safer during transport air worthiness certificate Frees up bandwidth Time to think Make a diagnosis

26 Initiation of therapeutic hypothermia Cooling started during the arrest All rhythms Cold 0.9% 4 O C Oesophageal temp probe continuous Trial of Rhinochill intra-nasal evaporative cooling device. Good but expensive.

27 To cool or not to cool? 33? 34? 36? When? NielsenNielsen N, et al. "Targeted temperature management at 33 C versus 36 C after cardiac arrest" N Engl J Med 2013; DOI: /NEJMoa ) No decreased mortality comparing cooling at 33 degrees to 36 degrees 50% vs 48% CI KimKim F, et al. "Effect of prehospital induction of mild hypothermia on survival and neurological status among adults with cardiac arrest: a randomized clinical trial" JAMA 2013; DOI: /jama ) Pre Hospital vs hospital cooling: survival to discharge does not increase Shockable: 62.7% vs 64.3% p=0.69 Non shockable: 19.2% vs 16.3 p=0.30

28 Thrombolysis? ESC guidelines support thrombolysis ONLY where delay to PPCI >2-3 hours Should only be a pre-hospital therapy, and then ONLY in remote settings Retains a role in stroke, massive and selected sub-massive PE Results of peri-arrest thrombolysis studies are disappointing Keeley et al, Lancet 2003

29 Transfer direct to PCI Consider for any arrest of cardiac origin or uncertain aetiology ie where there isn t an obvious non-cardiac cause eg drug OD, hanging Regardless of presenting rhythm or ECG

30 PROCAT registry - France Physician led team Routine invasive strategy, regardless of ECG 435 OOHCA ROSC - survivors 70% lesion on angiography STEMI 96% lesion Non-STEMI 58% Successful angioplasty independent predictor of survival Dumas et al. Immediate PCI is associated with better outcome after OOHCA. Circ Cardiovasc Interv. 2010;3:

31 National Infarct Angioplasty project October 2008

32 Advantages for direct to PCI at cardiac centres Allows us to better define the disease Damage control revascularisation Only fix the lesions which are causing problems Other advantages (even if PE) Intra-aortic balloon pump ECHO in cath lab Experienced ICU - better survival rates

33 Why PCI? Make or exclude a diagnosis >95% chance of opening artery Reduced stroke, re-infarction and angina rate Lasting reductions in mortality Early discharge (LOS 10.1 days pre-lab, now 2.1 days) Early senior cardiology review

34 Findings of PCI Immediate catheterisation will reveal CAD in 80% of OOHCA with ROSC Acute cath findings Normal 20% Obstructive CAD 71% Recent occlusion 67% LMCA ~1%

35 PCI in arrest - with ongoing CPR 34 patients identified in literature (71% in-lab arrest) Feasible using CPR-device / Autopulse (47%) Percutaneous support / ECMO (18%) Urgent PCI with ongoing CPR successful in 88% Survival to discharge 41% (inclusion bias) Even after a catastrophic cardiac event, full neurological recovery is possible Chain of survival even with maximal ALS, fix the problem or ROSC may never occur! Noc M; Radsel P, 2008

36 No ROSC? Don t stop! Should we go to the cath lab! Resistant VF / PEA / asystole History of events Clinical judgment A blocked coronary artery is a reversible cause Thrombolysis or PCI? Autopulse bridge quality CPR en route No clear patient subset what are the cut offs? Asystolic survivors

37 Physician Response Unit data HEMS CPR database Information from PRFs, CRS, Cath lab imaging at LCH. 149 patients 43 (29%) of these were taken direct to PCI 28 (19%) Patients taken to LCH (single centre) Full data with PCI results found available for 23 pts.

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39 Results LCH (23) Patients 26% (6) PLE before PCI 26% (6) PLE after Diagnostic Procedure 48% (11) survived to discharge 10 Therapeutic Hypothermia 8 Mechanical CPR 8 RSI 11 good neurological outcome 81 % stented vessel (all VF) Cardiomyopathy and unobstructed coronary arteries.

40 Cath results PLE - 6 patients (26%) Normal coronary arteries - 3 pts (13%) LAD - 6 pts (26%) LMS - 1 patient (4%) Multiple vessels - 5 pts (22%) Cardiomyopathy - 1 pt Cardiogenic shock - 1 pt

41 Successful? Survival to CICU 56% Survival to discharge 48% Survivors - 100% good neurological outcome

42 In practice today Aim to recognise reversible causes which we can t fix with ALS eg LAD stenosis causing resistant VF Consider thrombolysis for PE Train to minimise time on scene and deliver good care en route Cardiac arrest team ECHO Cardiologist Anaesthesia / ICU Options IABP / ECMO

43 Why does the cool car work? Small dedicated team allows bespoke care SOPs based on experience and literature Pathway for direct to PCI for a wider group Non-reliance on algorithms Active use of clinical judgment Encouraged to act as a patient advocate

44 The future Train more experts / enthusiasts Cardiac arrest champions - Advanced Paramedics Engage wider audience Improve data quality Monitors with capability to download CPR data Focused CPR review sessions Improve the standard UK pathway Integration of NSTEMI ROSC into PCI pathway Mechanical CPR as standard for the ambulance service Define the group for Autopulse bridge to PCI whilst in arrest Innovation - ECMO / EPR pre-hospital

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