Here's my first lecture from SMACCgold: The New Intra-Arrest. It generated a bit of controversy amongst my critical care friends, so we'll be discussing various parts in more detail in the coming weeks.
Best Article of Arrest Physiology
Physio of Cardiopulmonary Resuscitation (Anesth and Analg 2016;122(3):767)
Links and References
- See this EMCrit Podcast on Hemodynamic Dosing of EPI
- The Music to Code By Compilation
- Waveform ETCO2 is the only way to confirm tube placement during a code (Anaesthesia 2011;66:1183)
- Max Harry Weil’s Disease-a-Month on CPR
- Steve Smith has the references for PCI during arrest in this ECG Blog Post
- Vent Settings for Arrest: Volume AC, Vt 500, Peak Flow 30 lpm, RR 10, PEEP 0, FiO2 100%, Pressure limit 100 cm H20
- EDECMO.org
- Eliminate the Peri-Shock Pause–it is crucial (Resuscitation. 2014 Mar;85(3):336-42.)
- Precharging the Defib helps eliminate the pause (10.1016/j.resuscitation.2021.09.037)
- Pulse Checks are Stupid and Likely you are Feeling over a Vein1
- See the Slides Below for all the rest of the references
VSE Stuff
JAMA 2013;310(3):270
1 mg Epi and 20 IU Vasopressin Q3 minutes for 5 cycles, plus 40mg methylprednisolone for the 1st cycle. Hydrocortisone if in persistent shock
Journal Club Crit Care 2014;18:308
Why Epi and not Phenylephrine
From MH Weil's Article Above:
Adrenergic agents with predominant a2 effect have been shown to be more effective as vasoconstrictor drugs, presumably because extrajunctional a2-receptors are more accessible to circulating catecholamines than postjunctional a1-receptors. This may explain why adrenergic amines that have predominant a1 actions such as methoxamine (Vasoxyl) and phenylephrine (Neo-Synephrine) are less effective than epinephrine after prolonged cardiac arrest.
Note: To do hemodynamic dosing of vasopressors properly, it is imperative you read this post (choosing the correct DBP); you should also probably listen to that podcast.
Mechanical CPR
LUCAS seems equivalent to excellent manual compressions (from ResusMe)
Cardiac Arrest: To the cath lab with ongoing chest compressions?
Steve Smith has a great post on the topic with a ton of evidence
Consider Dual-Shock for Non-Converting VF/VT
Charles Bruen has a great post with the evidence
But it may fry your defib and you won't even know it2 so separate the pads and wait 1 second between pushing the buttons
Esmolol
Sodium Bicarbonate
except for HyperK arrest when it seems to have efficacy while Ca doesn't (on pigs) [10.1097/CCM.0000000000006089]
Update: Association between Intra-arrest venous gas and survival
Critical Care volume 21, Article number: 322 (2017)
The Slides
Additional New Information
More on EMCrit
EMCrit Podcast 31 – Intra-Arrest Management(Opens in a new browser tab)
Additional Resources
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Professor
Nassau University Medical Center
No conflicts of interest (coi).
- EMCrit 383 – The Ultrasound Hierarchy of Needs in Cardiac Arrest with Mike Prats - September 6, 2024
- EMCrit RACC Lit Review – September 2024 - September 3, 2024
- EMCrit 382 – A Deep Dive on Vasopressin: Timing, Push Dose Vaso and the Vasopressin Load Test - August 23, 2024
Curious as to how are you able to get the other staff (nursing, respiratory, er tech etc.) not only understand “Truly Advanced Cardiac Life Support for Resuscitationist” but be on board after years of AHA “cook book” courses?
Everyone knows how to set up (all the equipment) Lucus device and all respiratory is on board to use the ventilator during arrest etc?
If you are not there to supervise is it still performed to your standards?
We have a great podcast on this at edecmo.org. Joe and Zack discuss how they work the logistics and got folks on board.
There is a “cancer” that can infiltrate your staff, especially after a few failed resusc attempts. You must fight that! Its trickle-down. Your attitude will set the tone for the entire code. Be the optimist and push hard for your patient. Scott’s reference: http://edecmo.org/tactical-approach-cardiac-arrest/
here, here Joe!
Maybe there is also space for further improvements when using TEE.
“One fits all” might be also not the answer when it comes to mechanical CPR…
http://doi.org/cbx6w6
that is v. interesting
Would like to know more on using a custom bent Levitan/Shikani/Bonfils optical stylet down a LMA. Is it easier than a bronchscope/flexible scope down a LMA? Which LMA? Do you use it outside of CPR? Wee?
it is already up on the site. search for bonfils
Long time listner. This podcast really blew my mind. It made me rethink my whole approach to running a code and what is really possible. The dosing of epi along with the femoral aline is a great idea.
thanks my friend!
Credit to you Scott. You are a pioneer blazing pathways in the most admirable fashion possible. Your talk on the New Intra-Arrest was totally “inspirational”. Keep up the GREAT work!
thanks so much, Ken!
What is your dose of steroids and vasopressin? How many times do you give each? Do you give the 300mg dose of hydrocortisone after ROSC?
straight-up study dosing. I defer the hydrocortisone decision to my ICU colleagues, though I think it is prob. a good idea.
ECPR patients? Solumedrol 40mg x1 with first or second epi then stress dose hydrocortisone 300mg x 7 day taper. That’s what I do.
Great talk. I really like the idea of adrenaline titrated to diastolic BP, makes alot of sense. Just curious if you’re thinking about using long a-lines to get into the aortic arch as suggested in the SAAP podcast? Or do you think actually at the moment it’s best to bypass that and go straight to ECMO? While in med school not very long ago i heard a talk from Prof. Douglas Chamberlain for was one of the guys who really pushed forward ALS in europe. He wasn’t a fan of adrenaline any more but he also passionate that we as… Read more »
SAAP is not ready for clinical use yet. I think someone will do a series on REBOA for medical arrest and I bet it works well.Until then, normal fem aline is what I use
…and the A-line can be up-graded to the arterial ECMO cannula if ROSC not achieved and your patient is not palliative!
hells yeah!
I agree with the other listeners that this truly is a cutting edge approach to resuscitation. However, I think it seems to be best suited for an ED resus room or perhaps even ICU / OR. Have you published or plan on publishing data that show improved neurologically intact survival when you use this bundle? How would you modify your approach to be cutting edge intra-arrest care for the “floor code” inpatient where we don’t have quantitative ETCO2, Mechanical Ventilators, A-Line Transducers/Monitors, LUCAS devices, ECMO cannula etc. readily available?
Do you have a resus officer that comes along to arrests? One of the hospitals i worked in had one who’d bring a monitor that had etc02. If the patient was an ITU canditate the tech would bring up an oxylog too. Hospital i’m at now has a pocket etc02 monitor for the gasman (or woman) who’s on the crash team that day. LUCAS comes in a bag too so you could potentially bring that to every arrest if there was the motivation.
Reference for steroids? As usual great talk that will improve the care i deliver! I love emcrit.
Just search for VSE JAMA or its in the slides
Terrific talk as usual. I think your citation above for etCO2 during arrest is slightly off, it looks like you meant Anaesthesia 2011;66:1183.
http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2044.2011.06964.x/abstract
Jordan Schooler
EM PGY-3
Carilion Clinic
thanks brother!
Nice talk. Common sense stuff. A couple of thoughts: – If you could really get ECMO down (and complication rates) eventually we could presumably do away with ventilators and chest compressions altogether. Even for routine OR cases or ICUs. That would be pretty cool. Right now the engineering issues (flow through a tube, RBC destruction, coagulation issues) haven’t been worked out, but never say never… – I like the Cook gas “AirQ” intubating LMA. Works well if you’re doing one of those tube-through-LMA deals – Machine CPR compression in theory is great; logistically my experience is that it’s a pain.… Read more »
….and you just sent me to the online databases. Again. (Which I don’t mind at all…). Great stuff! We gotta talk about the playlist, though….how did “Kickstart My Heart” not make the cut?? 🙂
list was crowd-sourced; guess there are no Crue fans
Scott, Awesome discussion! I’ve always wondered about ACLS and have had arguments with other peers that ACLS is just guidelines that cavemen could perform…A bad meal from the pages of cook-book medicine…. We should be doing more for these patients. Nice to hear the frustration being displayed on a national level.. I’m fortunate to work in a facility that has Lucas devices in place. Amazing results and echo how calm the room is without the long line waiting to jump on the “compression stool.” Some of our pre-hospsital provider agencies have the Lucas device in the ambulances. For the other… Read more »
v. nice, Kyle
Dr. Weingart, Excellent and thought provoking talk. A couple of questions based on what you said: – Isn’t there more evidence showing harm from mechanical CPR devices than benefit? – Is there any evidence to support advanced airways in the cardiac arrest patient? I understand that there is research showing harm with the use of “cuffed” supraglottic devices, but we use the I-gel, which I have not seen any evidence against; furthermore, it appears it would be more beneficial to utilize upstroke ventilation with or without a ET tube in place. – In regards to epinephrine, if it is the… Read more »
1. Nope-the real trials of current devices show no increased complications
2. You’d have to clarify what you mean that it appears more beneficial to utilize upstroke ventilation
3. I think levophed is a better choice than epi as well, but we have to either do a norepi vs. placebo or a norepi vs. placebo vs. epi. Do you have 6000 patients you can lend me
4. Bundle publications are fraught with problems, I’d rather see each component proven. People smarter than me are working on exactly that.
Thank you for your quick reply.
Does the current research recommend one particular mechanical compression device over the other (circumferential band vs. piston driven)?
In regards to the second question. You made mention to supraglottic devices and how we can not achieve the pressures necessary to ventilate the patient on the downstroke of chest compressions. I was just asking if ventilation on the upstroke is preferred.
I unfortunately do not have a 6000 patient study group to loan you, there are a ton of people in East Asia though. 😉
as I mentioned during the talk, ventilation on the downstroke of compressions is preferred
Scott, is there any literature specifically on the crappy sealing pressure during downstroke? I have been searching but couldn’t find anything except for the swine study demonstrating low carotid blood flow. Thanks!
Don’t believe your own dis-hype, it was a great lecture! Way to integrate all the cutting edge stuff, and not “just” one, and make people see, more importantly, the physiology of it, and the importance of tailoring to each patient. I’ve always said that people confuse the concept of guidelines with that of optimal care. Guidelines are just that, lines by which to guide you, not railroad tracks. They are needed to some degree, however, as there are some who do resuscitation but are not resuscitationists, if you catch my drift, and then those guidelines are better than what they… Read more »
thanks so much my friend. Can’t wait to see you at the Montreal Resus conference
As per my prior comment – this was a GREAT and truly inspirational talk by you Scott! My QUESTION to you is HOW (in what direction) you would want to see the AHA go the next time (2015?) that they update their ACLS Guidelines. I would imagine that they will again come out with a “basic cookbook” approach, since these are international standards written for providers of all capability levels working at all different types of institutions. Perhaps there should be a separate ACLS Manual for Resuscitationists that provides guidelines for optimal resuscitation? What does SCOTT think would be the… Read more »
Hi,
Question about the epi – do use still use IV push as required by DBP or do you use a continuous drip and adjust the dose?
Thanks,
Daniel
push. if you wanted to use a drip it would need to be at concetrations orders of magnitude higher than standard
Great talk which inspired me to read the JAMA VSE article.
The JAMA article refers to cardiac arrest in general. If you have a patient in PEA, give epinephrine and vasopressin, then go into VF, so you shock and give epi – are you still continuing the vasopressin during that second round of CPR?
Seems like this trial overall had good results. I wish it would be followed in more hospitals in order to hopefully better help our critically ill patients.
Thanks again!!
QUESTION: If a skilled EMS unit arrives at the scene of cardiac arrest – HOW LONG should they work in the field at trying to attain ROSC before initiating transport of the patient to the nearest ED facility? How much does the answer depend on: i) If there is a mechanical CPR device that can provide continuous high-quality CPR en route during a bumpy ambulance ride? and ii) Availability of an ED in close proximity capable of offering services not possible in the field (ie, bedside Echo; ECMO; cath and PCI)?
what beta blocker would you use for electrical storm if esmolol not easily available?