Maintaining Perfusion When the Ticker Flickers:

Innovations in ECPR

Nicole Kupchik, MN, RN, CCNS, CCRN-K, PCCN-CMC, CSC And

Mike McEvoy, PhD, RN, CCRN, NRP

EMS Efforts to Improve SCA Survival

• Sudden Cardiac Arrest was the impetus for EMS

• 350,000 OOH arrests/year • Until recently, CPR and ACLS

were EMS focused • Many innovations are first

trialed in the field

Dispatcher Assisted CPR

• Nearly ALL arrests result in a call to 911 • Telephone CPR (T-CPR) – compression only • Results in 2 – 3 times greater survival

Am Heart Assn: Guidelines 2015 CPR and ECC

Citizen Responder Apps

• Mobile phone apps to alert citizens when CPR is needed

• Citizen alerting increases survival 50-70%

• www.pulsepoint.org is often used in US Ringh M, Rosenqvist M, Hollenberg J, et al. Mobile-phone dispatch

of laypersons for CPR in out-of-hospital cardiac arrest. N Engl J Med. 2015;372(24):2316-2325.

http://www.pulsepoint.org/

Pit Crew CPR

• Follows auto racing pit crew approach

• Clearly assigned roles, well practiced, focused on specific objectives

• Studies show survival Hopkins CL, Burk C, Moser S, et al. Implementation of pit crew approach and cardiopulmonary resuscitation metrics for out-of-hospital cardiac arrest improves patient survival and neurological outcome. J Am Heart Assoc. 2016;5(1).

Continuous Compressions

• We know interruptions in chest compressions lead to poor outcomes (intubation, defibrillation, pulse checks, etc)

• Analysis comparing continuous CPR (no ventilation) to CPR with interruptions for breaths show:

• Higher survival for continuous civilian CPR • Slightly better survival with interrupted paramedic CPR but NO

difference in neurological outcomes

Message: delay intubation, don’t stop CPR, precharge your defibrillator before pulse checks…

Zhan L, Yang LJ, Huang Y, He Q, Liu GJ. Continuous chest compression versus interrupted chest compression for cardiopulmonary resuscitation of non-asphyxial out-of-hospital cardiac arrest. Cochrane Database of Systematic Reviews 2017, Issue 3. Art. No.: CD010134.

Automatic CPR Devices

• Multiple studies • Routine use of mechanical CPR devices

does not improve survival

Perkins, Gavin D et al. Mechanical versus manual chest compression for out-of-hospital cardiac arrest (PARAMEDIC): a pragmatic, cluster randomised controlled trial. The Lancet , 2014; 385: 947 – 955.

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www.heart.org/HEARTORG/General/Resuscitation-Quality-Improvement_UCM_459324_SubHomePage.jsp

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Heads Up CPR

• Elevation of head significantly improved cerebral perfusion pressures

• Better neuro outcomes Ryu HH, Moore JC, Yannopoulos D, Lick M, McKnite S, Shin SD, Kim TY, Metzger A, Rees J, Tsangaris A, Debaty G, Lurie KG. The Effect of Head Up Cardiopulmonary Resuscitation on Cerebral and Systemic Hemodynamics. Resuscitation. 2016; 102:29-34.

Delayed or No Endotracheal Intubation

• ETI often interrupts CPR, takes focus away from high quality compressions

• No evidence of benefit for either BVM or ETI

• Many EMS systems delay or do not intubate

Link MS, Berkow LC, Kudenchuk PJ, et al. Part 7: Adult Advanced Cardiovascular Life Support: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2015;132:S444-64.

End Tidal CO2 (Waveform Capnography)

• Initially used for airway placement • Now guides entire resuscitation:

• Continued monitoring of airway placement • Chest compression quality • Cardiac output and acid-base status • Futility

Paiva EF, Paxton JH, O'Neil BJ. The use of end-tidal carbon dioxide (ETCO2) measurement to guide management of cardiac arrest: A systematic review. Resuscitation. 2018;123:1-7.

Ultrasound

• Has diagnostic value when used appropriately • Controversial – interruptions/delays

Huis In 't Veld MA, Allison MG, Bostick DS, Fisher KR, Goloubeva OG, Witting MD, Winters ME. Ultrasound use during cardiopulmonary resuscitation is associated with delays in chest compressions. Resuscitation. 2017;119:95-98.

Amaya SC, Langsam A. Ultrasound detection of ventricular fibrillation disguised as asystole. Ann Emerg Med. 1999;33:344-6.

Hand Placement - CPR

• Studies suggest LV location varies

• Compressions over LV increase blood flow dramatically

Kyoung Chul Cha et al. Emerg Med J 2013;30:615-619

Patient Destination – ECPR/ECMO ?

• Is the patient a candidate for ECPR? • survival

Columbus, Ohio EMS Protocol

What is E-CPR?

Extracorporeal Cardiopulmonary Resuscitation: • Mechanical Chest Compression

device • PCI Percutaneous Coronary Intervention • ECMO Extracorporeal Membrane Oxygenation

Cardiac Catheterization Lab

Should the patient go to the cath lab?

• Get a 12 Lead ECG post arrest

• Class I, LOE B

• PCI should be performed emergently in OHCA with STEMI

• Class I, LOE B-NR

• Reasonable to perform PCI regardless of awake or comatose

• Class IIa, C-LD Dumas, F et al. Circ Cardiovasc Interv. 2017

• Case series: • PCI was needed in 95% of all

post arrest patients with STEMI • PCI was needed in 58% of

patients post arrest who didn’t have ST elevation!

56 year old with OHCA

• Transient ROSC • 4 mg of Epi, but

continues loss of pulse • Unclear if STEs on

ECG • What to do next?

Would anyone take this patient to the cath lab?

Mechanical Chest Compression Devices

Case continued…OHCA, RBBB

Re-arrest in the Cath

Lab

Stent placed to the LAD

ROSC post-stent placement

ECMO

ECMO - Extracorporeal Membrane Oxygenation

Minnesota experience with eCPR

Yannopoulos, D et al. J of Am Heart Assoc. 2016

Minnesota Experience with eCPR

Outcomes: • 53% survival! • Most had CPC 1

or 2!

Yannopoulos, D et al. J of Am Heart Assoc. 2016

Troponin Levels

Yannopoulos, D et al. J of Am Heart Assoc. 2016

Heart Function with Support

Yannopoulos, D et al. J of Am Heart Assoc. 2016

The Paris Experience

Pre-hospital E-CPR in the Louvre Museum, Paris

Mechanical CPR as a bridge? The “Art” of E-CPR!

ECMO comes to you?

E-CPR

Mechanical CPR + ECMO + PCI + Hypothermia

Stub, D et al. Resuscitation. 2015

CHEER Trial Outcomes

• ROSC 25/26 (96%) • Survival to DC 14/26 (54%)

• OHCA 5/11 (45%) • IHCA 9/15 (60%)

• Survival with favorable Neuro outcome 14/26 (54%)

Stub, D et al. Resuscitation. 2015

Resources

https://edecmo.org/

System of Care

Maintaining Perfusion �When the Ticker Flickers: �Innovations in ECPREMS Efforts to Improve SCA SurvivalDispatcher Assisted CPRCitizen Responder AppsPit Crew CPRContinuous CompressionsAutomatic CPR DevicesHeads Up CPRDelayed or No Endotracheal IntubationEnd Tidal CO2 (Waveform Capnography)UltrasoundHand Placement - CPRPatient Destination – ECPR/ECMO ?Columbus, Ohio EMS ProtocolWhat is E-CPR?Cardiac Catheterization LabShould the patient go to the cath lab?Slide Number 1856 year old with OHCAMechanical Chest Compression DevicesCase continued…OHCA, RBBBStent placed to the LADECMOECMO - Extracorporeal Membrane OxygenationMinnesota experience with eCPRMinnesota Experience with eCPRTroponin LevelsHeart Function with SupportThe Paris ExperienceMechanical CPR as a bridge?�The “Art” of E-CPR!ECMO comes to you?E-CPRCHEER Trial OutcomesResourcesSystem of Care