QI/KT: Cardiac Arrest

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Welcome to a new kind of podcast and post from TamingtheSRU. This week kicks off a highlight of our residency program, which is a deep dive into the literature of a topic of clinical care in our ED. 

This month we have Dr. Shaun Harty and Dr. Joshua Gauger, current third-year residents at UC who did their project on cardiac arrest and the data behind the resuscitative measure we use every day as well as some that are more on the edge than ACLS. We will discuss the use of medications as well as prehospital ultrasound. If you are interested in our take on code airway management please see this post.

The basics

summary: Early defibrillation and good CPR are the keys to resuscitation

Electrical Phase

  • Defibrillation is key as the heart is not yet ischemic and is amenable to defibrillation
  • Defibrillation ~95% successful for shockable rhythm, as per data derived from EP-based studies

Circulatory Phase (4-10 minutes)

  • Increasing diastolic pressures are key to maintain coronary perfusion (via CPR) to prevent prolonged stress and metabolic phase

Metabolic Phase (>10 minutes)

  • Global hypo-perfusion and acidosis prevail, less likely to result in ROSC

Use of Ultrasound

Indications

  • Diagnostics
    • Recommend 2 person team (if possible) to not minimize compression with during compression interpretation
    • Can diagnose pseduo-PSA (cardiac activity without pulse from massive PE, hypovolemia, etc)
    • Can find vfib that appears to be asystole electrically
    • Cardiac activity found early during arrest course correlative with ROSC
  • Prognostic (Termination)
    • Conflicting data to suggest initial lack of cardiac activity (atraumatic arrest) as prognostic to unachievable ROSC

Intra-arrest Arterial Lines

  • Recent data lacking, however physiologic maintenance of coronary perfusion pressure is effective at predicting ROSC
  • DBP >25 found to have increased neuro intact outcomes in infants <1y

E-CPR

  • In selected, otherwise healthy, V-fib patients, mechanical CPR appears beneficial in conjunction with early reperfusion

Epinephrine

  • AHA guidelines maintain epinephrine as standard of care. Recent data confirm that epi may increase chance of ROSC however does not increase chance of neuro-intact survival.

vasopressin

  • Similar to epinephrine in increase in ROSC without increased neuro intact outcome, given lack of superiority was recently taken out of AHA guidelines

Amiodarone

  • Still given despite lack of effective evidence, may increase hospital admission without other patient centered outcomes

Bicarbonate

  • Data does not show improvement, keep in mind there are likely certain indications (TCA overdose, DKA, etc) that may benefit if arrest etiology is known

Calcium

  • Does not improve outcomes in allcomers, however in specific populations (Hyperkalemia, etc) may be very helpful adjunct

Thrombolytics / tPA

  • Excellent prehospital trial showing no benefit in undifferentiated arrest
  • Improvement in known PE arrests

Summary

  • Treat the patient in front of you, ACLS is for dentists (we love you dentists), use ultrasound, past history and early labs to guide your therapies
  • Prioritize early defibrilliation, quality CPR especially early in the course of resuscitation
  • Early A-lines, E-CPR and ultrasound may be beneficial but pending more confirmatory data

Content and Podcast by Josh Gauger, MD and Shaun Harty, MD

Editing and Moderation by Ryan LaFollette, MD

References

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