Daniel Davis, MD UCSD Center for Resuscitation Science
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Transcript of Daniel Davis, MD UCSD Center for Resuscitation Science
Daniel Davis, MD
UCSD Center for Resuscitation Science
New Frontiers inResuscitation
Science
Key Concepts
• Compressions
• Ventilations
• Pressors
• PetCO2
• Post-resuscitative care
1. Optimal Compressions
The Primary Directive
Chest compressions should be performed
from the moment of arrest until return of
spontaneous circulation is assured.
Kern (2002) Circulation
Prime the Pump!
Christenson (2009) Circulation
Stay on the chest!
* Adjusted for: age, gender, bystander CPR, public location, response time, compression rate
Compression Interruptions
• Initiating compressions
• Rhythm analysis
• Shock sequence
• Pulse check
• Intubation
• Vascular access
Bystander CPR
ECG Filtration
Return of Spontaneous Circulation
Electrical(HR)
Mechanical(PetCO2)
Stiell et al (2008) AHA Scientific Sessions
Deeper Compressions
Aufderheide (2005) Resuscitation
Good Recoil
Rate
0 to 80 81 to 120 121+ (N=65) (N=478) (N=122)
38 mm 49% 44% 69%
38-51 mm 28% 44% 30%
>51 mm 23% 12% 2%
Depth
Stiell et al (2008) AHA Scientific Sessions
Rate vs Depth
CPR Process
Code # 79265 (11/28/12) Code Leader: Brendan Daly, MD Recorded CPR time: 5 minutes Type of arrest: VF/VT Minute Chest Compression
Fraction (goal >90%)
Average Compression Rate (goal 100)
Average Compression
Depth (inches) (goal 2-4 inches)
1 100% 118 3.02 2 73% 107 2.98 3 82% 115 3.10 4 85% 121 2.85 5
Defibrillations: 1 Pre-shock pause (goal <3 seconds) 14 seconds Post-shock pause (goal < 6 seconds) 3 seconds Use of End Tidal Carbon Dioxide: Yes Other comments: Good compression rate and depth, great use of EtCO2. Summary: (selected strips below)
Defibrillation:
Results• Chest compression fraction 91%
• Compression rate 123/min
• Compression depth 2.6 inches
• Pre-shock pause 2.6 sec
• Post-shock pause 3.6 sec
• Perfusion check 4.3 sec
• Ventilation rate 9.7/min
• PetCO2 15.3 mmHg
What if we’re wrong?
2. Controlled ventilation
Kern (2002) Circulation
Prime the Pump!
Continuous Chest Compressions with Synchronous Ventilations (10:1)
3. Pressor Therapy
Pressors
Mader (2008) Resuscitation
Hagihara (2012) JAMA
*
*
*
Vasopressin?
Fluids?
4. PetCO2 in resuscitation
Lung Perfusion in ShockPaCO2
40 mmHgPaCO2
40 mmHg
PetCO237 mmHgPetCO2
37 mmHgPetCO2
29 mmHgPetCO2
29 mmHgPetCO2
21 mmHgPetCO2
21 mmHg
PetCO2 MonitoringPetCO2 Monitoring
PetCO2 Associations
• Initial PetCO2 α ROSC
• Pre-shock PetCO2 α ROSC for VF
• Rise in PetCO2 α ROSC
• Initial PetCO2 α arrest etiology
• Compression depth/patient wt α PetCO2
5. Post-resuscitation care
Hyperventilation: Three Flavors
Cerebral Perfusion During Shock
0
5
10
15
20
25
30
35
40
45
RR6 RR12 ETCO2
P = .004 v 12P = .004 v 12
mL/100 gm/min
Ventilation in Resuscitation
Rapid, Shallow Breaths?95% CI for the regression estimate
0 20 40 60 800
500
1000
1500
Est TV
VR
95% CI for the regression estimate
0 20 40 60 800
500
1000
1500
Est TV
VR
Intrathoracic Pressure
Evidence for Hypothermia?
Hypothermia After Cardiac Arrest Study Group (2002) NEJM
Hypothermia vs. Normothermia?
When should we cool?
no cooling
33oC
0 10 20 30 40 50 60 % survival
36%
53%
no cooling
33oC
26%
49%
36oC
33oC
52%
50%
Post-Arrest Hypothermia HACA
Bernard
TTM
How should we cool?
How should we cool?
Current U.S. Benchmark
Conclusions
• The opportunity is staggering
• Compressions
• Technology
• Post-resuscitative care