Today, I get to speak with my buddy Zack Shinar about soem cardiac arrest science.
Questions Discussed
- Is there a no-flow time past which there is no hope for survival?
- If there is, how do we know the pt was actually fully no-flow–are we are conflating no-cpr for no flow?
- What is the survival limit on low flow time?
- VF survival is not linear across time. What happens to that number if you strip out all the 1-2 shock v-fib (real comparator for ecmo right?
- Who are the few (5%) of non-ecpr patients who survive after 30 minutes of CC?
- Effect of Transient ROSC on outcome data
Current Cardiac Arrest Assumptions – mantras needs changing
- Cardiac arrest rhythms have overlap but are very different disease
- Termination of Resuscitation (TOR) is outdated
- Pre-hospital prognostication needs an increase in sophistication
Some Literature on the Stuff Spoken About
- Asystole in patients with wearable ICDs are much better than historical1
- Shockable rhythm patients can have neurologically intact survival with CPR out to 47 minutes (mRS 0-3)2
- When Should EMS Transfer-Transport for ECPR should be considered between 8 to 24 minutes of professional on-scene resuscitation, with 16 minutes balancing the risks and benefits of early and later transport. Earlier transport within this window may be preferred if high quality CPR can be maintained during transport and for those with initial non-shockable rhythms.3 50%of ROSC would be captured at 8 minutes and 90% by 16 minutes.
- Reynolds et al. found similar data with 21 minutes being the 90% capture mark.4
- PEA should prob. not be an exclusion for ECMO, they can have a 23% neuro intact survival in this paper.5
- Wake County Data Packet
- Rate of Brain Death and organ donation, possibly another reason field termination in the field is a bad strategy in viable cohorts
- Adnet et al. on No-Flow and Low-Flow Durations
Other EMCrit Links of Interest
References
1.
Liang J, Bianco N, Muser D, Enriquez A, Santangeli P, D’Souza B. Outcomes after asystole events occurring during wearable defibrillator-cardioverter use. World J Cardiol. 2018;10(4):21-25. [PubMed]
2.
Reynolds J, Grunau B, Rittenberger J, Sawyer K, Kurz M, Callaway C. Association Between Duration of Resuscitation and Favorable Outcome After Out-of-Hospital Cardiac Arrest: Implications for Prolonging or Terminating Resuscitation. Circulation. 2016;134(25):2084-2094. [PubMed]
3.
Grunau B, Reynolds J, Scheuermeyer F, et al. Relationship between Time-to-ROSC and Survival in Out-of-hospital Cardiac Arrest ECPR Candidates: When is the Best Time to Consider Transport to Hospital? Prehosp Emerg Care. 2016;20(5):615-622. [PubMed]
4.
Reynolds J, Grunau B, Elmer J, et al. Prevalence, natural history, and time-dependent outcomes of a multi-center North American cohort of out-of-hospital cardiac arrest extracorporeal CPR candidates. Resuscitation. 2017;117:24-31. [PubMed]
5.
Pabst D, Brehm C. Is pulseless electrical activity a reason to refuse cardiopulmonary resuscitation with ECMO support? Am J Emerg Med. 2018;36(4):637-640. [PubMed]
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Editor-in-Chief, at EMCrit.org
An ED Intensivist from NY.
Professor
Nassau University Medical Center
No conflicts of interest (coi).
Professor
Nassau University Medical Center
No conflicts of interest (coi).
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I am the one that was saved by ecmo in des moines Iowa. Crash episode iowa with Dr Terry on edecmo. In the podcast you talk about the patient family meeting all the staff.. I agree it is very important for the family and staff. On the one year anniversary of my heart attack/cardiac arrest Aug 9 2018. Mercy Hospital arranged a celebration for me. Cake and had a photographer. They notified all the staff that was on my case..I was finally able to meet the cath lab staff that put me on Ecmo.. It was terrific for them as… Read more »
Great podcast, I was especially interested in the brief conversation at the end about the cost per QALY. You speak about the comparison of a drug for Fabry’s disease that costs $250,000 annually and ECPR, which is possibly less costly per QALY. Does that take into account effectiveness? For example, if the Fabry’s treatment is 50% effective (admittedly, I have no idea), then the expected cost per QALY is $500k. If ECPR only costs, say, $100k (an arbitrary guess, but seems low to me) with a 1-5% effectiveness rate, as you cite, then the expected cost per QALY is $2-$10… Read more »