slides rosc lecture 4 part 5
TRANSCRIPT
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Suspended Animation =
Emergency Preservation and
Recovery
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Hypovolemic Cardiac Arrest
Trauma hypovolemia cardiac arrest
1984: Safar and Bellamy:
Suspended animation: rapid preservationof viability of the organism in temporarily
unresuscitable cardiac arrest
Immediate deep to profound hypothermia
Pharmacology
Surgical repair
1988: Tisherman dog model of EPR
Safer Center for Resuscitation Research. http://www.safar.pitt.edu/content/programs/safar/
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CoolColdUltra Cold!
Normothermia: 37oC
Mild hypothermia: 34 36oC
Moderate hypothermia: 30
o
C
Profound hypothermia: 5 - 10oC
Ultraprofound hypothermia: < 5oC
Deep hypothermia: 20oC
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Safar: Suspended Animation
Design 14 dogs exsanguinate > 5min, cardiac arrest
Flush of saline at 2C into the femoral artery
at 2 min of cardiac arrest until animal is 10C Randomized
No trauma
Trauma- laparotomy, splenic injury prior to
exsanguination; after cardiac arrest, underwentthoracotomy and splenectomy
Resuscitated after cardiac arrest no-flow of60 minutes with CPB and defibrillation
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Results
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REGIONALIZATION
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Post-arrest care: problem #1
300,000 arrest patients each year in USA
50,000 arrests reach hospital with a pulse
5,000 hospitals in USA
10 arrests per year per hospital
SOME HOSPITALS LACK EXPERIENCE
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Post-arrest care: problem #2
No catheterization lab
No early hemodynamic management strategy
Cannot perform EEG/neurocritical care
Do not have 24/7 intensivist availability
SOME HOSPITALS dOnT PrOvIdE
ESSEnTIAL ASPEcTS Of bundLE Of cArE
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Post-arrest care: problem #3
Emergency Medical Services (EMS)designed to bring to nearest hospital
post-arrest care is complex,
? trauma bypass EMS model
EMS BRINGS to closest HOSPITALS
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Possible solution: Regionalization?
Concept is not new; specialization in:
Stroke Centers
Trauma Centers
Burn Centers
http://images.google.com/imgres?imgurl=http://img.medscape.com/fullsize/migrated/editorial/clinupdates/2001/713/fig9.jpg&imgrefurl=http://cme.medscape.com/viewarticle/416589_2&usg=__vRbSWDkPe9_lourGVTyskJZSmL4=&h=272&w=400&sz=37&hl=en&start=4&tbnid=MGHgyxbqMzP0cM:&tbnh=84&tbnw=124&prev=/images?q=burn+patient&hl=en&rlz=1T4SMSN_enUS323US324http://images.google.com/imgres?imgurl=http://teleburst.files.wordpress.com/2009/07/cliveowensplash_450x450.jpg&imgrefurl=http://teleburst.wordpress.com/2009/07/15/&usg=__r5r-btF2bT1xYUsfh1FXkHibxNE=&h=450&w=450&sz=46&hl=en&start=13&tbnid=UvHCQKemsgSEEM:&tbnh=127&tbnw=127&prev=/images?q=gunshot+victim&hl=en&rlz=1T4SMSN_enUS323US324http://images.google.com/imgres?imgurl=http://www.getthecholesterolfacts.com/images/how-a-stroke-happens.gif&imgrefurl=http://www.getthecholesterolfacts.com/heart-attack-and-stroke.jsp&usg=__egqq7MPNL3eFyeA5oXicLajBjyg=&h=291&w=374&sz=26&hl=en&start=5&tbnid=qOb-Gw6ph3reLM:&tbnh=95&tbnw=122&prev=/images?q=brain+with+stroke&hl=en&rlz=1T4SMSN_enUS323US324http://images.google.com/imgres?imgurl=http://www.laxcast.com/images/Penn%20Logo3.jpg&imgrefurl=http://www.laxcast.com/laxcasts.php&h=575&w=504&sz=86&hl=en&start=2&tbnid=FQB_-U94MtoUWM:&tbnh=134&tbnw=117&prev=/images?q=Penn+logo&svnum=10&hl=en&lr=&rls=DKUS,DKUS:2006-32,DKUS:en -
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Initial experiences in the USA
Initial attempts at regionalization:
ArizonaMinneapolis
New York City
Philadelphia
Some also attempting cooling in the field
http://images.google.com/imgres?imgurl=http://www.laxcast.com/images/Penn%20Logo3.jpg&imgrefurl=http://www.laxcast.com/laxcasts.php&h=575&w=504&sz=86&hl=en&start=2&tbnid=FQB_-U94MtoUWM:&tbnh=134&tbnw=117&prev=/images?q=Penn+logo&svnum=10&hl=en&lr=&rls=DKUS,DKUS:2006-32,DKUS:en -
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ArizonaBureau of EMS met 12/2007
Established Cardiac Arrest Centercriteria
Voluntary hospital participation/no cost All acute care hospitals meeting criteria were invited
to participate
EMS bypass guideline (approved 5/2008)
Arizona experience
http://images.google.com/imgres?imgurl=http://www.photoatlas.com/photo/usa_monument_valley_arizona.jpg&imgrefurl=http://www.photoatlas.com/pics02/pictures_of_usa_07.html&usg=__GI7lOE06BpMaOaqeoX36nKKqnBQ=&h=419&w=640&sz=60&hl=en&start=14&um=1&tbnid=_TM19zf7O4LFvM:&tbnh=90&tbnw=137&prev=/images?q=arizona&hl=en&rlz=1T4SMSN_enUS323US324&sa=N&um=1http://images.google.com/imgres?imgurl=http://www.destination360.com/north-america/us/arizona/images/s/arizona-scottsdale.jpg&imgrefurl=http://www.destination360.com/north-america/us/arizona/scottsdale-arizona&usg=__1VvHb8yXBLwhrsTk7HOnae5c5Xg=&h=332&w=415&sz=44&hl=en&start=20&um=1&tbnid=nLwtCzVKndwYIM:&tbnh=100&tbnw=125&prev=/images?q=arizona&hl=en&rlz=1T4SMSN_enUS323US324&sa=N&um=1 -
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0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
35.00%
40.00%
45.00%
All rhythms --Non-shockable --Witnessed VF
Initial EMS Rhythm
Survivalto
Disc
harge
Pre-
Post-
OR: 2.1 [1.3-3.4]
OR: 1.6 [0.5-4.8]
OR: 3.1 [1.3-7.6]
10.9%
20.5%
3.9% 6.0%
20.3%
39.5%
Arizona CACs save lives
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The Penn experience
6 helicopters
100 mile flight radius
Most hospitals have
helipads
http://images.google.com/imgres?imgurl=http://www.laxcast.com/images/Penn%20Logo3.jpg&imgrefurl=http://www.laxcast.com/laxcasts.php&h=575&w=504&sz=86&hl=en&start=2&tbnid=FQB_-U94MtoUWM:&tbnh=134&tbnw=117&prev=/images?q=Penn+logo&svnum=10&hl=en&lr=&rls=DKUS,DKUS:2006-32,DKUS:en -
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