12/22/2017 Beyond the guidelines: an approach to cardiac arrest in the Emergency Department - EMOttawa

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BEYOND THE GUIDELINES: AN APPROACH TO CARDIAC ARREST IN THE

EMERGENCY DEPARTMENT

MISSION STATEMENT

World-Class Emergency
Medicine: To provide
outstanding compassionate
emergency care through
practice-changing research
and innovative medical
education. For more about
According to the AHA guidelines, in 2016 the annual our department, visit us at

incidence of out-of-hospital cardiac arrest (OHCA) in EMOttawa.

the US was roughly 360,000 and was 209,000 for in-
hospital cardiac arrest. In Canada, we see 40,000 OHCA
per year (Moza arian 2016). 

Type Search Term …

Data from the ROC Epistry con rms survival to
hospital discharge in 2014 after non-traumatic EMS-
treated cardiac arrest with any rst recorded rhythm
was 12% for patients of any age. FOLLOW EMOTTAWA

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12/22/2017 Beyond the guidelines: an approach to cardiac arrest in the Emergency Department - EMOttawa

This number may not seem great, but survival was

10.4% in 2010 and 8.2% in 2006.
Survival increases to 38.6% in bystander-
witnessed ventricular brillation (VF) arrest. CATEGORIES

We are obviously doing something right, with extensive Select Category

cardiac arrest research and re nements to the

guidelines playing a major role.
ARCHIVES
Despite these encouraging numbers, many emergency
providers are still faced with a signi cant sense of Select Month

futility when it comes to the management of cardiac

arrest. At times, we nd ourselves simply going
through the motions when managing these patients, RECENT POSTS

when we should be leaders in the eld of resuscitation Beyond the guidelines: an

medicine. approach to cardiac
arrest in the Emergency
My objectives for this post are to provide evidence for
Department
controversial and cutting-edge topics, and ways in
Angiotensin II for the
which we can improve the care of cardiac arrest
Treatment of Vasodilatory
patients in the ED, beyond what is outlined in the
Shock
guidelines.
Resuscitation of the
Bariatric Trauma Patient
Minimizing interruptions in chest Focus on POCUS:
compressions Heartbreaker. Cardiac
Echo in the ED.
Risk of Intracranial
Hemorrhage in Ground-
level Fall With Antiplatelet
or Anticoagulant Agents

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12/22/2017 Beyond the guidelines: an approach to cardiac arrest in the Emergency Department - EMOttawa

The best evidence we have for interventions that

improve outcomes in cardiac arrest surround high-
quality CPR:

Chest compressions at a rate of 100-120/min with a

depth of 5-6 cm and maximum chest recoil (Link
2015)
The updated guidelines emphasize maximizing
compression time, with improved rates of ROSC and
survival to hospital discharge with chest
compression fractions of at least 60% (Vaillancourt
2011).

In order to minimize interruptions in chest

compressions:

Use quantitative end-tidal capnography:

ETCO2 correlates with measured cardiac output

during resuscitation, and can be used both to
judge the e ectiveness of resuscitative attempts
and as a marker of ROSC.
A rapid rise in ETCO2 may be a better marker for
ROSC than the pulse check, and does not require
interruption in compressions.

Anticipatory charging of the de brillator:

To maximize e ciency, ask the record-keeper to

announce when there are 30 seconds to the next
rhythm check.
The de brillator can be charged to 200J and ready

to deliver a shock as soon as VF/VT is identi ed.

If the rhythm is not shockable, the charge can

be dumped.

Patients with shorter pre- and peri-shock

pauses have higher odds of survival (Cheskes
2014).

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12/22/2017 Beyond the guidelines: an approach to cardiac arrest in the Emergency Department - EMOttawa

An alternative to this is the use of “see-through

CPR” machines, able to lter out compression
artefact.

Careful use of the advanced airway:

There is some emerging evidence that airway

management in the rst 15 minutes of cardiac
arrest may be associated with a decrease in rates
of survival to discharge (Andersen 2017).
This signal was ampli ed in patients who had an
initial shockable rhythm, leading to the hypothesis
that it is due to a delay in de brillation.
In primary cardiac arrest, consider avoiding early
intubation if a patient can be ventilated
adequately with a bag-valve mask.

Check out these links for more information on chest

compressions during cardiac arrest:

Mechanical vs manual chest compressions for OHCA

What is optimal chest compression depth during
OHCA resuscitation of adult patients
Mechanical chest compressions and simultaneous
de brillation vs conventional CPR in OHCA
Trial of continuous vs. interrupted compressions
during CPR

E ective use of PoCUS in cardiac

arrest
In the updated guidelines, the use of point-of-care
ultrasound has been recommended as a highly
sensitive and speci c tool for real-time con rmation of
endotracheal tube placement. PoCUS is also being
used to guide chest compressions real-time, and in lieu
of pulse checks in some centres, given the reportedly

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dismal accuracy of 78% (Tibballs 2009). However,

transthoracic ultrasound can be challenging in cardiac
arrest given subcutaneous air from chest compression
trauma and the patient’s body habitus – image
acquisition may not always fall within the guideline-
recommended 10 second maximum for interruption of
compressions.

A recent study examines the potential harms of PoCUS

in cardiac arrest (Huis in’t Veld 2017):

The authors found that the use of ultrasound nearly

doubled the duration of pulse checks in cardiac
arrest, with a mean time of 21 seconds.
This study reinforces that PoCUS is not a harmless
tool; in order to use it e ciently, there should be a
focused clinical question and deliberate practice.
Ultrasound in cardiac arrest should be used to
identify reversible etiologies and considered in
prognostication.

Prognostication
The absence of spontaneous cardiac activity on
ultrasound is strongly associated with poor outcomes,
with a negative likelihood ratio of 0.06 for survival
(Tsou 2017). This information can then be integrated
with other variables in the clinical picture for decision-
making surrounding termination of resuscitation.

See also this 2012 paper by Blyth et al.

Reversible causes
PoCUS should be used methodically in cardiac arrest,
seeking to identify classic “ultrasound signatures” of
potentially reversible etiologies, such as cardiac

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tamponade, pneumothorax, pulmonary embolism, and

hypovolemia (Tsou 2017). In the REASON trial (Gaspari
2016), patients found to have pericardial e usion or
signs of pulmonary embolism on PoCUS had
signi cantly higher rates of survival to hospital
discharge.

Several ultrasound algorithms have been described (ie

RUSH, EGLS); none have been shown to outrank the
others, but all underscore the importance of a
structured approach for e cient use of resuscitative
ultrasound in cardiac arrest to answer a focused
question. Simulation can be useful to practice tting
image generation into the resuscitation (Olszynski
2016). The sonographer should be set up in the
subcostal position prior to pause for rhythm analysis,
loop record videos, and analyze while someone else
resumes compressions. Another alternative that
doesn’t require holding compressions is the use of
transesophageal echocardiography, a tool gaining

traction in the ED.

High quality chest compressions with minimal

interruptions is the rst priority in cardiac arrest
management. Resuscitative ultrasound has the
potential for harm when used incorrectly, but is a
useful tool when applied e ectively, with the purpose
of answering a focused clinical question.

See this post by Dr. Rajiv Thavanathan for further

information on PoCUS (speci cally ECHO) in cardiac
arrest.

A novel approach to PEA management

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12/22/2017 Beyond the guidelines: an approach to cardiac arrest in the Emergency Department - EMOttawa

Traditionally, the management of pulseless electrical

activity arrest revolves around high-quality CPR and
identi cation of reversible causes.
The “H’s & T’s” are still taught and memorized by
ACLS providers, but can be di cult to remember in
the heat of the moment.

http://adelaideemergencyphysicians.com/2014/08/a-new-pea-
diagnostic-algorithm-ecg-and-ultrasound/

A simpli ed approach published in 2014 (Littman)

helps to re ne the DDx based on width of the QRS.

A narrow QRS is more likely to be due to a

mechanical problem

Most commonly: hypovolemia, cardiac

tamponade, tension pneumothorax, and
pulmonary embolism
These etiologies can be identi ed by PoCUS

A wide QRS is more likely to be due to a metabolic

cause

Focus on: hyperkalemia and sodium-channel

blocker toxicity
Management is medical, with calcium and
bicarbonate

New data is emerging that supports separating out a

di erent set of patients from PEA arrest, those with

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12/22/2017 Beyond the guidelines: an approach to cardiac arrest in the Emergency Department - EMOttawa

“pseudo-PEA” vs. true electromechanical dissociation.

“Pseudo-PEA”

Occurs in a severe shock state, with such profound

hypotension that peripheral pulses may not be
palpable
But, the basic physiology of the cardiac
contraction remains intact

Gaspari 2017

Secondary analysis of the REASON data

Found that patients in PEA arrest with cardiac
activity on PoCUS who received vasopressors were
8 times more likely to have ROSC
These patients were also much more likely to
survive to hospital discharge (Flato 2015)

We should therefore use the tools at our disposal

(PoCUS, invasive blood pressure monitoring with
arterial lines) to identify this subset of patients and
treat them accordingly with a norepinephrine infusion
while identifying reversible etiologies.

Refractory VF/VT

Cardiac arrest survival in individuals with a shockable

rhythm is approximately 30%, compared with 2-10%
for asystole and PEA. This number can increase to 60%
with high quality CPR in the setting of a strong
coordinated system of care. Refractory VF, or VF storm,

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is de ned as VF resistant to at least 3 de brillation

attempts, 3 mg of epinephrine, and 300 mg of
amiodarone. Electrical storm can be frustrating for
emergency providers to treat, given what we know
about the potential for good outcomes. Evidence for
the management of this condition is evolving, with
some innovative options presented here:

Dual-sequential de brillation (DSD):

The addition of a second set of pads and

de brillator ensures a second vector through the
heart.
Evidence for DSD is sparse and mostly
retrospective (Cortez 2016), but shows survival to
hospital discharge with good neurologic
outcomes.

Beta-blockers:

Refractory VF is exacerbated by high levels of

catecholamines, both endogenous and
exogenous.
Epinephrine administered during cardiac arrest
management may be harmful through activation
of beta-1 myocardial receptors, which increase
oxygen demand and lower the VF threshold.

The administration of selective beta-blockers,

such as esmolol, has been shown to increase
survival to hospital discharge with good
neurologic outcomes (Driver 2014, Lee 2016).
Esmolol is ideal given its beta-1 selectivity,
rapidity of onset, and short duration of action.

ECMO:

Evidence for survival bene t with good neurologic

outcomes comes out of Melbourne and Minnesota
(Stub 2015, Yannopoulos 2016), with a protocol for

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12/22/2017 Beyond the guidelines: an approach to cardiac arrest in the Emergency Department - EMOttawa

ECMO that involved pre-hospital services and ED

cannulation.
These protocols require buy-in from the hospital’s
intensivists, cardiac surgeons, and pre-hospital
systems with careful selection of appropriate
patients.

Conclusions
Cardiac arrest care is protocolized in ACLS for universal
access, simpli ed for those who rarely run codes. As
consultants specializing in Emergency Medicine, we
should be on the forefront of resuscitation
management, using cutting edge technologies and
research to advance the eld and save lives. That
includes minimizing interruptions in chest
compressions, using point-of-care ultrasound wisely
and e ectively; integrating interpretation of the QRS
and ultrasound into the management of pulseless
electrical activity; and the consideration of dual-
sequential de brillation, selective beta-blockers, and
ECMO for the treatment of refractory ventricular
brillation.

References

 Bio

Lauren Lacroix
Dr. Lauren Lacroix is an 5th year
Emergency Medicine resident at the
University of Ottawa, with a special
interest and fellowship expertise in
resuscitation management.

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12/22/2017 Beyond the guidelines: an approach to cardiac arrest in the Emergency Department - EMOttawa

 Bio  Twitter

Richard Hoang
Dr. Richard Hoang is an Emergency
Medicine Resident Physician at the
University of Ottawa with a variety of
academic interests including medical
education, FOAMed, social media,
simulation, and palliative care.

By: Lauren Lacroix On: December 21, 2017 In: cardiac

arrest, Featured, Grand Round Summaries

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