Take Home Pearls from 2017 UM EM Cardiac Arrest Symposium

Below is a review of the key points of each lecture from the 2017 University of Maryland Emergency Cardiology Symposium which was hosted by Amal Mattu, MD in Baltimore, MD. This year’s topic was Cardiac Arrest.

To view video and presentations of all of the lectures, visit: www.livestream.com/UMEmergencyMed.

How Far We’ve Come!

John M. Field, MD; Penn State University

  • JAMA 2016: trial showed LOWER likelihood of survival to discharge and worse neurological outcome for patients with in-hospital cardiac arrest treated with therapeutic hypothermia.
  • JAMA 2017: no mortality benefit for tracheal intubation during cardiac arrest – consider using LMA (quick placement and less compression interruption).

Running the Perfect Code

Michael Winters, MD; University of Maryland

  • Team leadership is key! (Take charge of your resuscitation. Assign roles prior to patient arrival.)
  • Early defibrillation
  • High-Quality CPR:
    • Highest rate of survival at 121-140 compressions/min.
      • Journal of Resuscitation: 120-140 compressions per minute (compared to ACLS taught 100-120) showed improved ROSC at this rate in the year 2017. Single center. Roughly 200 something patients.
    • 5-6 cm depth of compressions with appropriate recoil of chest wall.
    • Avoid leaning on the chest.
    • Chest compression fraction (percentage of time in which chest compressions are done by rescuers during cardiac arrest) should be greater than 60%; goal of 80%.
  • Hemodynamic-Directed CPR
    • Using femoral arterial line, aim for DBP >25-35 mmHg. This is also helpful for determining PEA vs pseudo-PEA.
    • Using end tidal CO2, aim for >20 mmHg.
    • Hold epinephrine if these parameters are met.
    • Aim for a coronary perfusion pressure (CPP = aortic diastolic pressure minus the left ventricular end-diastolic pressure) of >20 mmHg to attain ROSC. Need arterial and central line to obtain the CPP which may be difficult during a resuscitation. Instead, we can guide our resuscitations with the use of early arterial line placement and/or end tidal CO2.
  • Consider video laryngoscopy as first attempt in CPR because DL increases “no flow” time seen bc of holding compressions to optimize view.  Success rate is similar.
  • Code Medications: Epinephrine: ? evidence of efficacy.  There exists no definitive evidence of epi’s benefit to long term survival to date.
  • NEJM 2016:  Amiodarone vs Lidocaine vs Placebo in out of hospital cardiac arrest shockable rhythms:  NO DIFFERENCE.  However, there was a non-statistically significant trend towards benefit to hospital discharge in those getting amio or lido vs placebo.

ECHO Evaluation in Cardiac Arrest

Sarah A. Stahmer, MD; UNC

  • US can interrupt cardiac compressions. Need to use a focused approach to limit delay during CPR
  • Use ultrasound to evaluate pump, tank, pipes during the resuscitation
  • SHoC Study 
    • Look for the Four F’s:  Fluid (pericardial), Form (RV dilatation), Function (wall movement), Filling (IVC diameter
    • RUSH Exam – Rapid Ultrasound for Shock and Hypotension
    • FEEL Study
    • Asystole or PEA with any degree of wall movement had higher rate of survival
    • Use cardiac ultrasound to determine appropriate pacemaker capture; appropriate myocardial squeeze with capture.
    • A twitch in the heart muscle is not cardiac stand still.  Must be no cardiac muscle movement for standstill. However, valvular motion with cardiac stand still is considered cardiac death.
    • Sonographic asystole has a poor prognosis, but not no prognosis.  Small chance of survival exists.  If patient young, continue resuscitative efforts.  Older/Nursing home patients it may be reasonable to call the code.
    • Must consider all patient variables with continuation of resuscitative efforts.

A Rational Approach to PEA 

Laszio Littmann, MD; UNC

  • Almost impossible to remember all H’s and T’s during a code
  • New algorithm for PEA: Based on whether the QRS is Narrow or Wide
    • QRS Narrow:
      • Mechanical (RV) problem (tamponade, tension PTX, PE, mechanical hyperinflation) (US: hyperdynamic LV—PSEUDO PEA).  These patients may benefit from an intervention – fluids/phenylephrine/needle decompression etc. and not CPR.
    • QRS Wide:
      • Metabolic (LV) problem (HyperK, Na channel blocker tox) (US: Hypokinetic—TRUE PEA). These patients likely will benefit from CPR
      • Consider Phenylephrine (NOT Epinephrine) in pseudo-PEA (narrow QRS): 2-10 mcg/kg bolus. 200-500 mcg IVP over 10-30 seconds. May repeat in 10-15 minutes. Approximately 20-minute half-life. No scientific evidence behind using phenylephrine; Littmann’s personal experience.

Optimizing Post-Arrest Care

Joshua C. Reynolds, MD, MSU

  • Hard to share pearls considering detail of lecture
  • Best take home from this lecture is not to settle after initial resuscitation. Must consider domains of injury and phenotypes of injury. Direct care down to the cellular level.

Making ECMO a Reality in the ED

Zack Shinar, MD; San Diego

  • 8% survival to hospital discharge in cardiac arrests – number hasn’t moved in many years
  • JAHA 2016: 50% survival achieved by one hospital in Minnesota with wide use of ECMO
  • Arterial line for all cardiac arrest patients to monitor response
  • Getting ECMO in your ED: 1. Assess your capabilities; 2. Develop relationships (CT surg, Cardio, Intensive care); 3. Become a “professional proceduralist”

Where are we going?

Robert O’Connor, MD, MPH; University of Virginia

  • AHA 2012:  Dispatch pre-arrival instructions (on how to perform CPR until EMS arrives) improve survival in out of hospital cardiac arrest
  • Japan has a cardiac arrest registry. USA does not. Why??
  • Arterial line in codes – helpful in distinguishing PEA from pseudo-PEA.  Compressions may be harmful in the latter
  • What is a pulse?  Finger is not very accurate
  • Chain of Survival is key to appropriate care of out-of-hospital cardiac arrests
  • PulsePoint App for phone: allows those trained in BLS to know when they are close to an active cardiac arrest.
  • EMS Dispatcher guided CPR for bystanders
  • Prolonged prehospital care has increased patient mortality
  • Appropriate Cath lab activation for ROSC patients: refer to Mattu’s ECG weekly lecture.

Panel Discussion: 

  • Cool to 36 if mild sx moving around etc. Cool to 33 if in deep coma /sicker subset (Personal preference)
  • ECMO is reimbursed very well as long as your pt is insured
  • Fingers to palpate a pulse are not very good.  Ultrasound, arterial line, and end tidal may be better resources. One study done in prehospital setting with ultrasound in the field shows those with no pulse but ultrasound showing cardiac motion did better with Meds (pressors) verses starting compressions. These patients have “pseudo pea” bc they actually have a pulse you just can’t feel it.