Published on March 7, 2014
Refractory Cardiac Arrest The CHEER Protocol Stephen Bernard MD FACEM FCICM FCCM
The Victorian setting • • • • 000 call system Computer aided dispatch Post dispatch instructions (ECM only) “3-tier” system – PAD/ Firefighters/ CERT – ALS paramedics – Intensive Care Paramedics • ACLS at scene • Transport to ED if ROSC
The Victorian setting • If no ROSC at ~30 minutes- declared deceased – All ACLS provided at scene – Asystole as final rhythm – No compelling other factors (hypothermia/ OD) • • • • EMS transport with effective CPR not practical Hazardous for EMS crew No new therapy in ED Considered futile
The Victorian setting • Data from Victorian Ambulance Cardiac Arrest Register for Melbourne – 12 month period (2012) – Age < 65 years – VF as initial cardiac rhythm • 222 patients • 149 ROSC (Survival of these = 55%) • 68 no ROSC • 5/68 transported with CPR (Autopulse) • 63 declared deceased at scene
The Victorian setting • Data from Victorian Ambulance Cardiac Arrest Register for Melbourne – 12 month period (2012) – Age < 65 years – VF as initial cardiac rhythm • 222 patients • 149 ROSC (Survival of these = 50%) • 68 no ROSC • 5/68 transported with CPR (Autopulse) • 63 declared deceased at scene
ECMO • 2008 Swine flu • Increasing experience in VV ECMO • Intensivists at Alfred undertake training program – 2 day program – Cannulation in dogs – Circuit management
E-CPR Reports from Japan in 2000-2012 J Am Coll Cardiol 2000; 36(3):776-83.
E-CPR • January 2004 and May 2011 • E-CPR in 86 patients with ACS • Median age 63 years/ 81% were male • Intra-arrest PCI was performed in 61 patients (71%). • ROSC 88% • 30-day survival 29% • Favorable neurological outcome 24% Kagawa E, et al. Should we emergently revascularize occluded coronaries for cardiac arrest?: Rapid-response extracorporeal membrane oxygenation and intra-arrest percutaneous coronary intervention. Circulation 2012 Sep 25;126(13):1605-13
The CHEER Trial – Pilot observational trial – Post-VF arrest – <70 years old – No ROSC at 30 minutes • • • • • CPR to ED with Autopulse Hypothermia ECMO Emergency Reperfusion
The CHEER Trial – Mechanical CPR to ED
The CHEER Trial Cannulae Cold fluid Autopulse Primed circuit – Notification by AV – Equipment immediately available in ICU – Brought to ED by ICU team Drapes etc
In the ED • Clearly defined roles to prevent chaos – – – – – – – – – ED Consultant manages airway/ventilator No shocks or cannulation during ECPR ED nurses (x 2) equipment and scribe ICU SR pumps ice cold saline x 3L ICU Consultants x 2 cannulate ICU/ED manage U/S upper abdo for wires ICU nurse manages Autopulse and ECMO circuit Cardiology review need for PCI All others stand back
In the ED – Percutaneous cannulation by Intensivists x 2 – 15F arterial/ 17F venous – Ultrasound of femoral vessels – Ultrasound of IVC – No defibs/ CVC during cannulation
VENO-ARTERIAL ECMO V-A ecmo for CPR Low flow configuration (3-4L/min) Oxygen vs Air?
The CHEER Trial – Cold IV saline – 3 L bolus IV – Cools rapidly Bernard SA, et al. Therapeutic hypothermia induced during cardiopulmonary resuscitation using large-volume, ice-cold intravenous fluid. Resuscitation 2008; 76:311-3
In the cath lab: •Coronary angiogram •Stent any blockages •Then the heart will start!
To the ICU: •Cooling for 24 hours •33°C •Slow rewarming over 12 hours @ 0.25°C/hr
In-hospital cardiac arrest – Refractory cardiac arrest following in-hospital arrest – No ROSC at 30 minutes – The “CHEER” approach – Reversible cause • • • • Age <70 ACS in ED Reperfusion arrest in Cath lab Pulmonary embolism
Experience to date Definitions for this presentation • OHCA- CPR into the ED and > 30 minutes • IHCA- CPR > 30 minutes • Excludes – VA-ECMO for shock with arrest < 30 minutes – IHT from other centre
Experience to date Site ECMO Survival OHCA 7/9 3/7 IHCA 13/13 8/13 E-CPR Good neurological outcome 11/20 (55%)
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What we are doing now… – Extra 10 Autopulses donated to AV by Zoll – Covers most of Melbourne – 24/7 ICU Consultant roster – Strategy to move patients within 20 minutes of arrest- ECMO < 60 minutes – Scenario training for the team
Summary – Every large city should have E-CPR available – Safe transfer to hospital with CPR now possible – Intensivist rapid percutaneous cannulation in ED feasible – Cooling during CPR is recommended (40mL/kg cold fluid bolus) – Normal neurological outcomes possible with up to 125 minutes of CPR – 55% good outcomes at The Alfred (11/20)
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