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Out-of-hospital Cardiac Arrest Contemporary Issues Kwan S Lee MD FSCAI FACC Associate Professor of Medicine Sarver Heart Center University of Arizona Relevant Disclosures None Improving Bystander Chest Compression CPR An Alternative Form of CPR: CardioCerebral Resuscitation Three Pillars Chest Compression-Only BLS for witnessed unexpected collapse in adults New Cardiocerebral Resuscitation ACLS algorithm for dispatchers and EMS personnel Post Resuscitation Care to include the use of mild hypothermia and aggressive reperfusion Thank You Thank You “OK, Doc…but what are you going to differently when we bring more post cardiac arrest patients to the hospital with a pulse and BP?” Current Outcomes From OOH CA Number of Patients 100 100 pts 80 Δ= 60% 60 40 40 pts 20 Largest drop off occurs In hospital, where 75% Of those initially resuscitated die Δ=75% Δ= 50% 10 pts pts Pre-arrest ROSC Hosp DC Surv at yr 15 (26%) Resuscitation 2007;73:29-39 What Makes the Difference?  Aggressive Post Resuscitation Care Two major factors: • Mild Therapeutic Hypothermia • Early Coronary Angiography & PCI Passage of Time  10 of conventional Rx (Saio et al)1  10-15 (Reynolds et al )2  5-10 (Belohlavek et al)3 Resuscitation 2015;92:70-76 2494 Circulation 2013;128:2488- Completion of Certain Therapies? Defibrillation attempts: 3 shocks (Saio)1 3 shocks and IV/IO Amio (Yannopoulos)4 Resuscitation 2015;92:70-76 Personal communication A Major ACLS Paradigm Shift? Currently: Stay and Play Approach Future?: Load and Go Approach PCI for Refractory VFCA How? Protocol to identify optimal candidates Utility of Mechanical CPR for such cases • Transporting to PCI facility with ongoing CPR – Mechanical CPR Devices Use during Transport » Class 2A recommendation (2010) » Choices: LUCAS™ AutoPulse™ Systemic Circulatory Support • ECMO; PCPB, Impella PCI for Refractory VFCA Who and When? Best for patients with shorter arrest • Fear is always long-term neurological function • Shorter times best » Short “downtime” » Short CPR time » Short time to Cath Lab What’s the use if we save the heart and lose the brain! PCI for Refractory VFCA Who and When? How to we guarantee “shorter times”? Arrest must be: • Witnessed • Bystander CPR • Early EMS arrival and quality CPR provided • Decision for PCI during CPR made “early”, not after “all else tried and failed” PCI for Refractory VFCA How? Protocol to identify optimal candidates Utility of Mechanical CPR for such cases • Transporting to PCI facility with ongoing CPR – Mechanical CPR Devices Use during Transport » Class 2b recommendation (2015) » Choices: LUCAS™ AutoPulse™ Systemic Circulatory Support • ECMO; PCPB, Impella CPR in Ambulance: Manual vs Mechanical Quality Manual: • < 50% CPR fraction • too swallow 70% of time Mechanical • Rate improved • CPR fraction improved • Proper depth improved CPR in Ambulance: Manual vs Mechanical Safety CHEER Trial-S Bernard    Phase trial (NCT01186614) Clinical Trial n=26 patients Unsuccessful Resuscitation        Age 18-65 Cardiac etiology of CA Chest compressions begun w/i 10 of collapse Mechanical CPR available Intervention: Mech (AP) CPR & TH in field, ECMO in ED then PCI before ICU Primary endpt: Survival to DC with CPC or Secondary endpt: ROSC, weaning ECMO, and LOS Stub et al Resuscitation 2015;86:88-94 Stub et al Resuscitation 2015;86:88-94 Outcomes  ROSC 25/26 (96%)  Surv to DC 14/26 (54%) OOHCA Inpt CA  CPC or 5/11 9/15 14/26 (45%) (60%) (54%) Stub et al Resuscitation 2015;86:88-94 Refractory OOH VFCA Studies N CHEERS 11 MRC’s 18 Sum 29 24 Hr Surv 5/11 (45%) 10/18 (53%) 15/29 (52%) Favorable Neuro among Survivors 5/5 (100%) 9/10 (90%) 14/15 (93%) Refractory OOH VFCA Studies N CHEERS 11 *MRC’s 34 Sum 45 24 Hr Surv 5/11 (45%) 18/34 (53%) 23/45 (51%) Favorable Neuro among Survivors 5/5 (100%) 16/18 (89%) 21/23 (91%) * Update via personal communication 7/1/16 ... arms are active Rx ! TTM 80% VF/VT How can this be? CAD and OOH Cardiac Arrest   70% of Adult victims of OOH CA have CAD Culprit Vessel Concept The worst presentation of ACS is not STEMI … but