Resuscitation of Cardiac Arrest Are You Prepared?

Resuscitation of Cardiac Arrest Are You Prepared? S. Jill Ley RN, MS, CNS, FAAN Cardiac Surgery CNS, California Pacific Med Center Clinical Professor, Dept of Physiological Nursing University of California, San Francisco

Learning Outcomes Identify early indicators signaling deterioration prior to cardiac arrest. Discuss timing of interventions that impact survival during cardiac arrest. Review key recommendations for cardiac arrest in special circumstances.

What do we know about cardiac arrest? 300,000 out of hospital arrests occur in US annually, with survival to discharge at 7.9% 370,000-750,000 in hospital arrests with 29% survival to discharge Best survival in those with shockable rhythms VT/VF versus PEA or asystole Chan PS, et al. N Engl J Med 2008;358(1):9-17. Morrison LJ, et al. Circulation 2013;127(14):1538-1563.

Failure to Rescue Over 188,000 deaths from FTR in 2004-2006 High performing centers have same number of events but lower mortality They respond to emergencies differently www.qualityindicators.ahrq.gov

Factors Influencing Arrest Survival Early recognition - use of RRT to prevent arrest The only two factors proven to increase survival after arrest: Effective compressions Rapid defibrillation

Question #1 The MEWS Score is an assessment tool for: 1. Determining level of conscious 2. Predicting patient deterioration 3. Determining adequate CPR performance 4. Measuring seizure activity in cats

Early Recognition: Modified Early Warning Score (MEWS) MEWS Action Subbe CP, et al. QJM 2001;94:521-526. 0-2 Routine monitoring 3 VS frequency 4 Notify charge RN & MD 5 Call RRT >6 Call RRT & MD STAT Jonsson T, et al. Nursing in Critical Care, 2011.Vol 16 (4):164-69

Early Recognition: Rapid Response or Code Blue? Pulseless, apneic, unresponsive Something isn t right RRT call is... an unconditional request for urgent medical assistance.

Early Recognition: Critical Care If all tracings are flat, this is not a faulty line. DON T check for a pulse call for HELP. Commence resuscitation immediately! www.csu-als.com

Responding to Cardiac Arrest CPR can double or triple survival rates. Effects of CPR include: VF window for successful defibrillation Promotes small amount of blood flow, influenced heavily by technique Delayed onset of asystole Basic CPR alone, however, is unlikely to eliminate VF and restore a perfusing rhythm. International Liaison Committee on Resuscitation. Circulation 2005; 112:IV-35.

Electrical Therapy for VF Early defibrillation is critical to survival. Guidelines recommend defibrillation within 2 minutes.

How Well Are We Doing? Review of 6789 inpatient arrests 369 U.S. hospitals Only arrests for VF or VT included Median time to defibrillation = one minute Delay (> 2 minutes) in 30.1%

Time to Defibrillate vs. Survival

Neurological Outcomes

HOW CAN WE IMPROVE SURVIVAL OUTCOMES? The Basics: Good CPR and Prompt Defibrillation

Question #2 Which of the following interventions have been shown to improve survival? 1. Increasing depth of compressions by 5 mm 2. Reducing pauses in defibrillation by 5 seconds 3. Both 4. Neither

CPR Technique Counts! Successful resuscitation is associated with: Shorter, fewer delays in defibrillation Improved survival (OR 1.86) for every 5-sec in delay Call for help while initiating CPR Don t move patient unless required for safety Avoid pauses during CPR (charging, rhythm check, etc.) Greater compression depth Improved survival (OR 1.99) with only 5-mm greater compression depth Compress 100 times/minute to Stayin Alive Steen AP, Kramer-Johansen J. Curr Opinion Crit Care 2008; 14:299-304.

Manual Defibrillation vs AED Extremely accurate in rhythm interpretation Delays of up to 37 seconds may occur due to algorithms May be considered in hospital setting to facilitate early defibrillation in areas where staff have no rhythm recognition skills or defibrillators are used infrequently (Class IIb, LOE C) Link MS, et al. Part 6: Electrical therapies. Circulation 2010;122:S706-S719.

Preparation for Defibrillation Standardize crash carts throughout hospital/facility Maintain connections Defib to cable Cable to pads All staff check cart Regular drills

Placement of Defibrillator Pads Manual Defibrillation Pads superior to paddles for safety 4 pad placements equally effective Anterio-lateral, anterior-posterior, anterior-left infrascapular, anterior-right infrascapular For ease of placement and education, anterolateral is a reasonable default. Link MS, et al. Part 6: Electrical therapies. Circulation 2010;122:S706-S719.

Reducing Time to Defibrillation: ICU and Step Down Defibrillator at bedside for 24 hours after cardiac surgery Device kept plugged in with cable for multi-function pads Pads on patient from OR Orders to implement defibrillation protocol

How Do You Manage THIS?

Emergency Transcutaneous Pacing Apply multifunction pads in standard position Place additional ECG leads from defib for sensing Turn pacer functions ON Set RATE (ppm) Set OUTPUT (ma) Set MODE (Demand vs Fixed Rate/Asynch) Start! Defib

Question #3 When given during a cardiac arrest, epinephrine results in: 1. Decreased 30-day mortality 2. Increased survival to discharge 3. Decreased survival to discharge 4. No impact on survival

What Doesn t Impact Survival? Epinephrine ACLS Used for both arrhythmia arms Dosage 1 mg IV Repeat every 3-5 minutes

Epinephrine

ARREST IN SPECIAL CIRCUMSTANCES Cardiac Surgery or Pregnancy

Key Differences After CV Surgery CVS patient highly monitored & intubated Arrest is identified immediately Skilled staff members readily available Wider range of possible therapies Chest re-opening is part of standardized protocol Chest compression may cause trouble

Cardiac Surgical Arrest Guideline 2009 Guideline first published 2010 Guideline adopted by European Resuscitation Council

CSU-ALS vs ACLS CSU-ALS For VF/VT Defibrillation takes priority; may defer massage for up to 1 minute ACLS External massage should be performed on all patients 3 successive shocks before CPR CPR 1 shock CPR For Asystole DDD pacing at maximal output For VF/VT, Asystole, Pulseless Electrical Activity No vasopressor unless senior MD Pre-arrest: Epi dose < 100 mcg Utilize 6 key roles during arrest Additional 2 people gown & glove Rapid resternotomy (<5 min) if no response to defib/pacing External massage & vasopressor Epinephrine 1000 mcg every 3-5 minutes +/- vasopressin 40u x 1 Similar roles w/emphasis on team leader N/A

Protocol for Resuscitation After Cardiac Surgery

What is this rhythm and what should you do? DEFIBRILLATE!

Cardiac Arrest in Pregnancy Occurs in 1:20,000 pregnancies Incidence on the rise Management of two potential patients Survival 37% vs. non-pregnant females (26%)* Most common causes Embolic, pre-eclampsia, ectopic pregnancy, sudden collapse Sinz E, et al. Cardiac arrest in special situations: 2010 American Heart Association. Circulation 2010; 122:S829-S861 * Cardiopulmonary resuscitation of pregnant women in the emergency department. http://dx.doi.org/10.1016/j.resuscitation.2015.01.017

Why is this happening? Older moms 14% now > age 35 More co-morbidities Congenital heart disease survival 85% of children born with CHD now live to be adults

Question #4 Optimal hemodynamics in pregnancy can be achieved by positioning the patient in: 1. Left lateral side-lying position 2. Reverse trendelenburg position 3. Flat position without elevating head of bed 4. Head of bed elevation of 90 degrees

Aortocaval Compression Weight of gravid uterus compresses great vessels when supine; venous return Important when > 20 weeks gestation When fundus is above umbilicus When hemodynamically compromised

Lipman S, et al. Anesth Analg 2014;118:1003-16

Summary Cardiac arrest can be prevented by use of scoring systems that trigger appropriate interventions (e.g., RRT). Cardiac arrest outcomes are optimized by rapid recognition, effective CPR, and timely defibrillation. Specialized populations may require a modification to standard resuscitation strategies.