why emergency physicians don’t care about cardiac arrest and should. robert swor, do professor,...
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Why Emergency Physicians Don’t Care about Cardiac Arrest and Should.
Robert Swor, DOProfessor, Emergency MedicineOakland University William BeaumontSchool of Medicine
Epidemiology of Cardiac Arrest SurvivalRelative impact of interventionsRelative impact of Phases of CareWhere do Emergency Physicians Make a
Difference
Objectives
Emergency Physician Perspectives of Cardiac Arrest ResuscitationIt’s FutileWe just bring back patients to a
vegetative stateThe Only people that arrest are
Gomers at the end of LifeThis One’s comatose-He’s ToastIt’s a poor use of Health Care Dollars
My QuestionAre physician attitudes a self
fulfilling prophecy?i.e Do post arrest patients do poorly
because we’re not aggressive with them in ED and hospital?
Emergency Department Patient ScenariosField Cardiac ArrestPost-Arrest- CPR in ProgressPost Arrest-DefibrillatedChest burns, alertPost arrest-ResuscitatedSTEMIPost Arrest- ComatosePre-Arrest-Crumps in the ED
Cardiac Arrest Outcomes
Out of Hospital Cardiac Arrest
225,000/yr
20-25% survival To Admission
(40-45% of Admitted Survive to Discharge)
Overall 5-10%Survival
In Hospital Cardiac Arrest
75,000/yr
ROSC 44%
17% Survive to Discharge
(38.6% of ROSC Survive to Discharge)
Neurologic Outcome Out of Hospital Arrest
Neurologic Death 25-30%If survive to discharge
Excellent QOL if Early Defib5 Year survival Similar to age and health matched controls
OPALS-Good quality of life for survivors at 1 year*
Bunch TJ, NEJM 2003:348:2626-2633 Steill, Circ 2003:108:1939
What Happens to Field Cardiac Arrest
CARES Registry27,675 OHCA events18,541 (67.0%) with no field ROSC.
12095 (65.2%) were pronounced in the field 5618 (30.3%) had resuscitation terminated in
the ED
828 (4.5%) survived to admission
Variation in Field Pronouncement after Failed Resuscitation-CARES
0
10
20
30
40
50
60
70
80
% F
ield
Pro
noun
cem
ent
3 12 17 19 27 30 34 36 40 55 58 Median
EMS Agency
Field Termination without ROSC-ROC Consortium
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Alab Iowa Ottawa Pitt Port Seattle Toronto Vanc Mean
Site
% T
erm
ina
tio
n
Survivors To Admission828 (14.7% of transported) Survive
to Admission128 survived to discharge (15.4%)81 (9.8%) survived with good cerebral performance.
Termination of Resuscitation in Field-Decision RulesALS
No ROSC No Bystander CPR Not witnessed arrest No shock Delivered
BLS No ROSC No witnessed No AED shock
Clinical Decision Rules for TOR-Evidence Based Review – Sherbino J. Em Med 2009:10:1016
Literature Review4 Decision Rules
3 BLS: 1 ALS6 Validation Studies
BLS Rule –PPV 99.5% (98.9%,99.8%) Decreases transport 62.6%
ALS rule-no good quality validation study
Cardiac Arrest Patients are All Gomers at the End of Life?Need better work on who shouldn’t get CPR
Decreased Survival with AgeEnd of Life Planning and Care
Unwanted or Not Indicated ResuscitationKing County 1994 (Dull)
7% had undocumented DNR25% Severe Chronic Disease
Possible Predictors of Outcomes After Cardiac ArrestClinical presentation
Arrest factorsAgeDiapersNeuro exam
HCTEEGN-100 Enolase
Impact of Therapeutic HypothermiaNielson Acta Anaes Scan 2009; 53:926-934
Scandinavian Registry238 pts with Hypothermia - 7 Countries
Good Neurological Outcome 22% Non VF 56% VF
Neurologic OutcomeOut of Hospital Arrest
Neurologic Death 25-30% If survive to discharge
Excellent QOL if Early Defib 5 Year survival Similar to age and health matched controls
OPALS-Good quality of life for survivors at 1 year*
Bunch TJ, NEJM 2003:348:2626-2633 Steill, Circ 2003:108:1939
Inability to Predict OutcomesObstacle to initiating
Aggressive CareNo reliable data on
predictors of outcome in first 3 days
Consistent with AHA 2010 Guidelines
ECMO To Support CPR in Adults1992-2007ELSO DatabaseAdults>18 yearsMean Age 52Survival in 27%Brain Death in 29%
Ann Thoracic Surg 2009:87:778-785
Case StudyRefractory Cardiac Arrest53 y/o male, severe 3 vessel dsPost op CABG-refractory VF post op day 465 minutes CPR during attempted
resuscitation-cannulationECMO for 4 daysNeuro intact, ICD placed, waiting for
transplant
Cost Effectiveness of Out of Hospital Cardiac Arrest Care
Cost Effective Public Access Defibrillation
Nichol-$56,000 (IQR $44,000,$77,000) Walker-$68,000 (Scotland)
Police AED $2,000-$15,000/year of life saved
Advanced Life Support Valenzuela-$8,800/year of Life saved (1990)
Money Mechanics of L1CAC Survival
Average Revenue
Per Patient
Direct Cost Per
Patient
Direct Margin
Per Patient
Discharged Alive
$57,783 $37,099 $20,684
Died in Hospital
$12,014 $8,686 $3,329
26Lick et al. Crit Care Med 2011;39(1):26-33.
ConclusionCPR in progress Ominous prognosisResuscitated arrest
VF-Good outcomeNon-VF- Uncertain
Prognostication-Fool’s gameTime’s they’re a changin’
HypothermiaAggressive therapy