Today we have the absolute pleasure to host a recent talk given by the great Paul E. Pepe, M.D., M.P.H.. This talk was recently given during his visit to the University of Maryland Emergency Medicine Department Grand Rounds. Dr. Pepe is: a Professor of Internal Medicine, Surgery, Pediatrics, Public Health, AND Emergency Medicine at UT Southwestern, the Dallas Director of Medical Emergency Services for Public Safety, Public Health, & Homeland Security, AND acts as the EMS/Public Safety Medical Director for Dallas County (phew…). Over his long career, Dr. Pepe has published over 400 per reviewed journals and is one of the world’s experts in resuscitative care. Today he gives just a small taste of his vast knowledge on the topic all while imparting some humor along that way!!
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Clinical Pearls
- Coronary perfusion pressure (CPP): the key factor in achieving ROSC!
- Rapidly lost with pauses in chest compressions
- Chest compression fraction determines survival (more time on compressions = more survival)
- Rapidly lost with pauses in chest compressions
- Is more compressions really better?
- using an impedance threshold device, the rate of 100-120 had the best outcome
- Allows time for filling and chest wall recoil
- using an impedance threshold device, the rate of 100-120 had the best outcome
- Impedance threshold device (ITD)
- Assists to pull blood into chest and push blood to the brain, but does it enhance flow?
- Simple device, attached to ETT, applies -12 cm H2O onto the airway
- A recent NEJM article showed no advantage in survival
- However, a recent Lancet article showed that an ITD coupled with the Active Compression Decompression (ACD) CPR Device DID show positive results (allows active compression + active decompression)
- Improved survival both at discharge and at one year post-discharge!
- However, a recent Lancet article showed that an ITD coupled with the Active Compression Decompression (ACD) CPR Device DID show positive results (allows active compression + active decompression)
- Is there a “sweet spot” to getting ROSC? Early data shows that perhaps ITD + compression rate 100-109 leads to improved survival with good neurological outcomes
- A recent article in Resuscitation shows that when you control for proper rate and depth with ITD there is an improved survival
- Assists to pull blood into chest and push blood to the brain, but does it enhance flow?
- Novel techniques:Â
- Vasodilators in cardiac arrest
- Nitroprusside for cardiac arrest? Decreases preload and afterload, BUT leads to a better coronary-cerebral flow!
- Animal lab: 15 mins, untreated VF, then treat with Nitroprusside and CPR
- Critical care medicine article showed improved neurological function after a DELAY to chest compressions (8-15 minutes)
- Proposed mechanisms:
- Nitric oxide donor
- Improves cardiac microcirculation
- Mitigate reperfusion injury to cardiac/neurological tissue
- Similar results when NTG was given in a cardiac arrest
- Animal lab: 15 mins, untreated VF, then treat with Nitroprusside and CPR
- Nitroprusside for cardiac arrest? Decreases preload and afterload, BUT leads to a better coronary-cerebral flow!
- Ischemic post-conditioningÂ
- “Trickle” blood flow back to hypoxic organs s/p arrest (similar to s/p organ transplant)
- Using controlled pauses: 20 seconds on and 20 seconds off + ACD-ITD + Non-traditional drugs (ex: Adenosine) for patients with prolonged downtime (~ 15 mins)
- Showed improved survival (animal models)!
- Possible target for patients s/p PROLONGED downtime
- Showed improved survival (animal models)!
- Using controlled pauses: 20 seconds on and 20 seconds off + ACD-ITD + Non-traditional drugs (ex: Adenosine) for patients with prolonged downtime (~ 15 mins)
- “Trickle” blood flow back to hypoxic organs s/p arrest (similar to s/p organ transplant)
- Vasodilators in cardiac arrest
Suggested Reading
- Yannopoulos D, Matsuura T, Schultz J, Rudser K, Halperin HR, Lurie KG. Sodium nitroprusside enhanced cardiopulmonary resuscitation improves survival with good neurological function in a porcine model of prolonged cardiac arrest. Crit Care Med. 2011 Jun;39(6):1269-74. [Pubmed Link]
- Yannopoulos D, Aufderheide TP, Abella BS, Duval S, Frascone RJ, Goodloe JM, Mahoney BD, Nadkarni VM, Halperin HR, O’Connor R, Idris AH, Becker LB, Pepe PE. Quality of CPR: An important effect modifier in cardiac arrest clinical outcomes and intervention effectiveness trials. Resuscitation. 2015 Sep;94:106-13. [Pubmed Link]
- YAufderheide TP, Frascone RJ, Wayne MA, Mahoney BD, Swor RA, Domeier RM, Olinger ML, Holcomb RG, Tupper DE, Yannopoulos D, Lurie KG. Standard cardiopulmonary resuscitation versus active compression-decompression cardiopulmonary resuscitation with augmentation of negative intrathoracic pressure for out-of-hospital cardiac arrest: a randomised trial. Lancet. 2011 Jan 22;377(9762):301-11. [Pubmed Link]
- Aufderheide TP, Nichol G, Rea TD, Brown SP, Leroux BG, Pepe PE, Kudenchuk PJ, Christenson J, Daya MR, Dorian P, Callaway CW, Idris AH, Andrusiek D, Stephens SW, Hostler D, Davis DP, Dunford JV, Pirrallo RG, Stiell IG, Clement CM, Craig A, Van Ottingham L, Schmidt TA, Wang HE, Weisfeldt ML, Ornato JP, Sopko G; Resuscitation Outcomes Consortium (ROC) Investigators. A trial of an impedance threshold device in out-of-hospital cardiac arrest. N Engl J Med. 2011 Sep 1;365(9):798-806. [Pubmed Link]
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