2

Stayin Alive:
Optimizing Outcomes for Victims
of In-Hospital Cardiac Arrest

Julianna Jung, MD, FACEP
Department of Emergency Medicine
Objectives
Discuss recent evidence regarding:
Cardiopulmonary resuscitation
Advanced cardiac life support
Post-resuscitation hypothermia
Post-resuscitation coronary interventions
Provider education
August 20, 2014 3
Cardiac Arrest in Brazil
~200,000 cases/year
Half in hospital, half out of hospital
Limited data available
Epidemiology may differ from US/Europe
August 20, 2014 4 Gonzalez et al, Arq Bras Cardiol, 2013
In-Hospital Cardiac Arrest (IHCA)
Average survival ~20% in US
One Brazilian study with 32% survival
Variation between and within hospitals
Suggests hospital resuscitation
processes are not optimized

August 20, 2014 5
Median OR of
survival = 1.42
42% greater
likelihood of
identical patient
surviving at one
hospital vs.
another

August 20, 2014 6
Variation Between Hospitals in
Survival Rates for ICHA
Merchant RM et al, J Am Heart Assoc, 2014
Variation Within Hospitals in
Survival Rates for ICHA
Significantly
lower survival
during nights and
weekends
Survival varies
by location :
9% unmonitored
38% OR/PACU
August 20, 2014 7 Perberdy et al, JAMA, 2008
August 20, 2014 8
We Can Do Better!!!
August 20, 2014 9
Cardiopulmonary Resuscitation
Single most important intervention
Key determinant of:
Return of spontaneous circulation (ROSC)
Short and long term survival
Neurologic outcome
August 20, 2014 10
Components of High-Quality CPR
Minimize interruptions
Compress at adequate rate
Compress to adequate depth
Allow full recoil
Avoid hyperventilation

August 20, 2014 11 Meaney et al, Circulation, 2013

Breaking it Down
August 20, 2014 12
Minimizing Interruptions
Goal: CCF > 80%
CCF = chest compression fraction
% time during which CPR is performed
Higher CCF linked to increased survival
August 20, 2014 13
CCF > 80%: Human Studies
August 20, 2014 14 Christenson et al, Circulation, 2009

August 20, 2014 15
CCF > 80%: Human Studies
Vaillancourt et al, Resuscitation, 2011

Adequate Rate
Goal: Rate = 100-120 bpm
Lower rates reduce cardiac output
Higher rates reduce coronary perfusion
Inappropriate rates associated with
decreased survival
August 20, 2014 16
Rate 100-120: Human Studies
August 20, 2014 17 Idris et al, Circulation, 2012

Adequate Depth
Goal: Depth >50mm (adult)
Suboptimal depth is common
Depth is variable over time
Inadequate depth associated with
reduced survival rates

August 20, 2014 18
Depth >50mm: Human Studies
August 20, 2014 19
Compression depth >38mm: OR 1.91 of survival to DC
Stiell et al, Crit Care Med, 2012

Allow Full Recoil
Goal: No residual leaning
Decreases cardiac filling and output
Decreases coronary and cerebral
perfusion pressures
Leaning is common no human studies
August 20, 2014 20 Meaney et al, Circulation, 2013

Avoid Hyperventilation
Goal: <12 breaths/min, minimal
chest rise
Hands only is OK for arrhythmia, but
ventilation is needed for asphyxia
Positive-pressure ventilation reduces
coronary and cerebral perfusion
Hyperventilation is common
August 20, 2014 21
<12 Breaths/Min: Animal Studies
August 20, 2014 22
Aufderheide et al, Circulation, 2004

August 20, 2014 23
ACLS Does it Matter?
Advanced life support includes
Advanced airway placement
Vascular access
Parenteral medications
De-emphasized in 2010 guidelines
No drug improves long-term survival
August 20, 2014 24
Arrest Drugs Human Studies
August 20, 2014 25
Olasveengen et al, JAMA, 2009

August 20, 2014 26
Post-Resuscitation Hypothermia
Unadjusted OR
for good
outcome from
hypothermia=
2.65
Adjusted OR =
5.25
August 20, 2014 27 Bernard et al, N Engl J Med, 2002

Hypothermia: 2010 Guidelines
Cool to 32-34C for 12-24hr after
ROSC
Comatose patients only
Out-of-hospital VF Class I
Other arrests Class IIb
Widespread adoption


August 20, 2014 28 Peberdy et al, Circulation, 2010

Hypothermia: Criticism
No control for hyperthermia
Failure to reach target temperature in 30-
50% of cases confounds analysis
Use of discharge destination as outcome
Conflicts of interest for investigators

August 20, 2014 29 Little & Feldman, JAMA Neurol, 2014

Hypothermia: New Data
Blinded
Randomized arrest
victims to 33 or 36C
Tight temperature
regulation
No difference in
survival or
neurologic outcome



August 20, 2014 30
Nielsen et al, N Engl J Med, 2013

August 20, 2014 31
Coronary Syndromes: AHA Guidelines
12-lead ECG after ROSC (Level I)
Perform percutaneous coronary
intervention (PCI) for STEMI
Coma or hypothermia not contraindications
Consider PCI regardless of STEMI

August 20, 2014 32 Peberdy et al, Circulation, 2010

PCI: Human Studies
NO
randomized
trials
Crude
positive
association
between PCI
and survival
August 20, 2014 33 Larsen & Ravkilde, Resuscitation, 2012

PCI: Human Studies
PCI associated with
better survival rates
PCI group had more
favorable factors
Adjusted for this using
logistic regression
survival still higher
August 20, 2014 34 Dumas et al, J Am Coll Cardiol, 2012

PCI: Who Should Get It?
ST-elevations on EKG:
85% PPV and 67% NPV
1/3 with ACS had NO ST-elevation!
ST-elevations are NOT adequate
predictor of need for PCI
August 20, 2014 35 Zanuttini et al, Resuscitation, 2013

PCI: Who Should Get It?
Alternate EKG criteria:
ST-elevation, ST-depression, wide QRS
48% PPV and 100% NPV
Avoids needless interventions
Broader EKG abnormalities may
considered in decision regarding PCI

August 20, 2014 36 Sideris et al, Resuscitation, 2011

August 20, 2014 37
Training Matters
Brazilian study
ACLS provider
associated with
greater ROSC
numbers
OR = 2.06
August 20, 2014 38
Training Matters
ACLS provider
associated with
greater short
and long-term
survival
August 20, 2014 39
Teaching Resuscitation
Certification course competence
Simulation training enhances
Performance in the simulation lab
Performance in the clinical area
Patient outcomes
August 20, 2014 40 Deiorio et al, Acad Emerg Med, 2012

Teaching Resuscitation
August 20, 2014 41
2011 < 1 min: 58%
2012 < 1 min: 75%
p < 0.0001
2013 < 1 min: 98%
Scordino et al, CORDEM, 2014

Teaching Resuscitation
August 20, 2014 42
2011 < 3 min: 47%
2012 < 3 min: 40%
p < 0.0001
2013 < 3 min: 83%
Scordino et al, CORDEM, 2014

Teaching Resuscitation
Perfect practice makes perfect!
Well-defined goal
Repetitive practice
Constructive feedback
Incorporate into future practice
Perfection!
August 20, 2014 43
References
Gonzalez MM, Timerman S, de Oliveira RG, Polastri TF, Dallan LA, Araujo S,
Lage SG, Schmidt A, de Bernoche CS, Canesin MF, Mancuso FJ, Favarato MH.
Guideline for cardiopulmonary resuscitation and emergency cardiovascular care
-- Brazilian Society of Cardiology: executive summary. Arq Bras Cardiol. 2013
Feb;100(2):105-13.
Merchant RM, Berg RA, Yang L, Becker LB, Groeneveld PW, Chan PS.
Hospital variation in survival after in-hospital cardiac arrest. J Am Heart Assoc.
2014 Jan 31;3(1).
Peabody MA, Ornato JP, Larking GL, Braithwaite RS, Kashner TM, Carey SM,
Meaney PA, Cen L, Nadkami VM, Praestgaard AH, Berg RA. Survival from in-
hospital cardiac arrest during nights and weekends. JAMA. 2008 Feb
20;299(7):785-92.
Meaney PA, Bobrow BJ, Mancini ME, Christenson J, de Caen AR, Bhanji F,
Abella BS, Kleinman ME, Edelson DP, Berg RA, Aufderheide TP, Menon V,
Leary M. Cardiopulmonary resuscitation quality: improving cardiac
resuscitation outcomes both inside and outside the hospital: a consensus
statement from the American Heart Association. Circulation. 2013 Jul
23;128(4):417-35.
August 20, 2014 44
References
Christenson J, Andrusiek D, Everson-Stewart S, Kudenchuk P, Hostler D,
Powell J, Callaway CW, Bishop D, Vaillancourt C, Davis D, Aufderheide TP, Idris
A, Stouffer JA, Stiell I, Berg R. Chest compression fraction determines survival
in patients with out-of-hospital ventricular fibrillation. Circulation. 2009 Sep
29;120(13):1241-7.
Vaillancourt C, Everson-Stewart S, Christenson J, Andrusiek D, Powell J, Nichol
G, Cheskes S, Aufderheide TP, Berg R, Stiell IG. The impact of increased chest
compression fraction on return of spontaneous circulation for out-of-hospital
cardiac arrest patients not in ventricular fibrillation. Resuscitation. 2011
Dec;82(12):1501-7.
Idris AH, Guffey D, Aufderheide TP, Brown S, Morrison LJ, Nichols P, Powell J,
Daya M, Bigham BL, Atkins DL, Berg R, Davis D, Stiell I, Sopko G, Nichol G.
Relationship between chest compression rates and outcomes from cardiac
arrest. Circulation. 2012 Jun 19;125(24):3004-12.
Stiell IG, Brown SP, Christenson J, Cheskes S, Nichol G, Powell J, Bigham B,
Morrison LJ, Larsen J, Hess E, Vaillancourt C, Davis DP, Callaway CW. What is
the role of chest compression depth during out-of-hospital cardiac arrest
resuscitation? Crit Care Med. 2012 Apr;40(4).
August 20, 2014 45
References
Aufderheide TP, Sigurdsson G, Pirrallo RG, Yannopoulos D, McKnife S, von
Briesen C, Sparks CW, Conrad CJ, Provo TA, Lurie KG. Hyperventilation-
induced hypotension during cardiopulmonary resuscitation. Circulation. 2004
Apr 27;109(16):1960-5.
Olasveengen TM, Sunde K, Brunborg C, Thowsen J, Steen PA, Wik L.
Intravenous drug administration during out-of-hospital cardiac arrest: a
randomized trial. JAMA. 2009 Nov 25;302(20):2222-9.
Bernard SA, Gray TW, Buist MD, Jones BM, Silvester W, Gutteridge G, Smith K.
Treatment of comatose survivors of out-of-hospital cardiac arrest with induced
hypothermia. N Engl J Med. 2002 Feb 21;346(8):557-63.
Little NE, Feldman EL. Therapeutic Hypothermia After Cardiac Arrest Without
Return of Consciousness: Skating on Thin Ice. JAMA Neurol. 2014 May 5.

August 20, 2014 46
References
Nielsen N, Wetterslev J, Cronberg T, Erlinge D, Gasche Y, Hassager C, Horn J,
Hovdenes J, Kjaergaard J, Kulper M, Pellis T, Stammet P, Wanscher M, Wise
MP, Aneman A, Al-Subaie N, Boesgaard S, Bro-Jeppesen J, Brunetti I, Bugge
JF, Hingston CD, Juffermans NP, Koopmans M, Kaber L, Langergen J, Lilja G,
Moller JE, Rundgren M, Rylander C, Smid O, Werer C, Winkel P, Friberg H.
Targeted temperature management at 33C versus 36C after cardiac arrest.
N Engl J Med. 2013 Dec 5;369(23):2197-206.
Peberdy MA, Callaway CW, Neumar RW, Geocadin RG, Zimmerman JL,
Donning M, Gabrielli A, Silvers SM, Zaritsky AL, Merchant R, Vanden Hoek TL,
Kronick SL. Part 9: post-cardiac arrest care: 2010 American Heart Association
Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular
Care. Circulation. 2010 Nov 2;122(18 Suppl 3):S768-86.
Dumas F, White L, Stubbs BA, Cariou A, Rea TD. Long-term prognosis
following resuscitation from out of hospital cardiac arrest: role of percutaneous
coronary intervention and therapeutic hypothermia. J Am Coll Cardiol. 2012 Jul
3;60(1):21-7.

August 20, 2014 47
References
Larsen JM, Ravkilde J. Acute coronary angiography in patients resuscitated
from out-of-hospital cardiac arrest--a systematic review and meta-analysis.
Resuscitation. 2012 Dec;83(12):1427-33.
Zanuttini D, Armellini I, Nucifora G, Grillo MT, Morocutti G, Carchietti E, Trillo G,
Spedicato L, Bernardi G, Proclemer A. Predictive value of electrocardiogram in
diagnosing acute coronary artery lesions among patients with out-of-hospital-
cardiac-arrest. Resuscitation. 2013 Sep;84(9):1250-4.
Sideris G, Voicu S, Dillinger JG, Stratiev V, Logeart D, Broche C, Viven B, Brun
PY, Deye N, Capan D, Aout M, Megarbane B, Baud FJ, Henry P. Value of post-
resuscitation electrocardiogram in the diagnosis of acute myocardial infarction in
out-of-hospital cardiac arrest patients. Resuscitation. 2011 Sep;82(9):1148-53.

August 20, 2014 48
References
Moretti MA, Cesar LA, Nusbacher A, Kern KB, Timerman S, Ramires JA.
Advanced cardiac life support training improves long-term survival from in-
hospital cardiac arrest. Resuscitation. 2007 Mar;72(3):458-65.
Deiorio NM, Fitch MT, Jung J, Promes SB, Thibodeau LG, Woolley WL, Gisondi
MA, Gruppen LD. Evaluating educational interventions in emergency medicine.
Acad Emerg Med. 2012 Dec;19(12):1442-53.
Scordino D, Crichlow A, Rice J, Jung J. Assessment Drives Teaching: An
iterative evidence-based approach to curriculum development yields superior
educational outcomes. Presented at Council of Residency Directors in
Emergency Medicine, New Orleans 2014.
August 20, 2014 49