The Resuscitator sessions.
Back in February I attended ‘The Big Sick’ conference in Zermatt. I’ve been several times and talked about it a lot here and on the podcast. It was once again an incredible meeting with some great conversations about many different aspects of resuscitation. If you don’t already know the content is aimed at the management of most seriously ill and injured patients in the first few hours after content with health care teams. There is a lot of clinical content, lots of human factors content, and a lot of discussion between people at the top of their game (and/or who aspire to be there). We also discuss emerging technologies, especially those that look great on paper, but are perhaps not ready for prime time as yet.
One area where there a great disparity in opportunity is ECPR. There is no doubt that there are papers out there that show the feasibility and potential for ECPR, but is far from definitively proven, and it’s not available to the vast majority of the world. That feels somewhat iniquitous, because it is, and it can sometimes seem that ECPR is not really relevant to the rest of us. As I’ve said before in Virchester we don’t have ECMO, and if we ask we get EC-NO as an answer.
However, there was a very strong message across the conference that was encapsulated by our good friend Prof. Sheldon Cheskes, and it’s this…..
The message here is that there really is no point in setting up an ECPR program unless you have already optimised all the things that you can do to avoid needing to put the patient on ECPR in the first place. Some of these are simple, some a little more complex and some controversial, but all should be considered. One of the things that Anders at TBS has promoted over recent years, and especailly this year is to have a blend of formal lectures (really good lectures), but also to involve the expert audience and speakers in the same learning space. So there was time for questions, but also lots of workshops, fireside discussion sessions, and in conjunction with the ATACC group, walk and teach sessions around the town with expert, intimate and deep dive sessions with experts in their field. It’s quite a different proposition to most conferences and really effective.
The highlight for me was the ATACC fireside ‘Resuscitator’ session where we explored the evidence, lack of evidence and opportunities for improvement in shockable rhythmns. I had not taken notes at the time as I was doing live evidence searching as we went through but here are some of the main points we discussed. On the night we talked through so much and agreed strength of evidence for each of these elements (and more). A lot of this is not yet in the ILCOR guidelines, or national guidelines, and yes it’s controversial……, that’s kind of the point of the session. We had amazing experts in the room debating current, future, possible practice to see where cardiac arrest management may develop over the next few years. This was not an ALS course!!
This is my recollection of what we talked about. It is just my recollection, and
Whilst our expert panel wants you to think about all these things, don’t get sacked by going against your organisational policies! Do what you need to do tomorrow and next week, follow your guidelines and teaching, but always keep asking questions.
1. Two minute cycles: The two minute cycle approach in cardiac arrest are for convenience rather than rigorously scientifically evaluated in humans. It was designed for convenience. Think about that and how many times we see a patient remaining in VF/VT and yet wait 2 mins to do a next round of shocks. Does that make sense in an era where we have defibrillators that can ‘see through’ compressions? Could we shock more frequently? Perhaps we should.
2. See through defibs: Many defibs allow you to see through compressions to know what the underlying rhythmn is. If you have one of these why are you stopping to do pulse checks and rhythmn checks for up to 10 seconds. It no longer makes sense to do this. You can prepare to act on what you see, not on the basis of your watch.
3. Pre-charge your defib: We still see people stopping twice to shock patients. Once to stop, check the rhythmn, do a pulse check, then back on the chest whilst the charge the defib. This makes no sense. Pre-charge the defib and then if you have to stop, then you can very rapidly confirm the rhythmn and shock straight away.
4. Time off the chest counts: Every time you stop compressions you risk losing coronary perfusion pressure. A higher CPP is associated with more ROSC (as a result of more effective defibirillation) so minimise the time off the chest. Some papers suggest you lose 20mmHg of DBP in 10 seconds and that could be clinically important for the reasons given above.
5. Antero-lateral pad position really matters: This is highlighted in the recent ILCOR updates where there is mention of the need to palce the lateral pad right up in the armpit and LATERAL. So many time we see that pad forward of the anterior axillary line and below the costal margin. As Sheldon Cheskes of DSED fame said – ‘We’re not trying to defibrillate the spleen (or stomach or breast).”
6. Antero-Posterior pad position may be better: We know that impedence is an issue in defibrillation. There is data that suggests that the AP pad position has less impedance and should work better, but we use the AL position. Why? Probably because it’s more pragmatic in practice, and I get that if you are single rescuer with an AED, but for the team approach with a decent defib it’s not so much of a hassle, and it’s a staging strategy for what might come later (DSED). In Canada there are some services that have gone for an AP first approach and this has led to increases in ROSC rates. It’s observational data, and I would love to see a proper trial on this, but it kind of makes sense electrically and from limited studies.
7. After three shocks and you only have one defib: At this point if you were using AL pads, you should put a new set of pads on in the AP position (Vector change defibrillation) and use that. DOSE-VF showed increased rates of ROSC if you do this (but not a statistical increase in neuro intact survivors).
8. After three shocks and you have more than one defib: it’s time for DSED. Although the evidence is not perfect, there. isa strong pathophysiological/electrical/patient outcome data argument that this works, so go for it. Initial concerns about exploding defibs is waning with more manufacturers accepting that this won’t damage the machines.
9. We don’t understand why ERC recommends vector change but not DSED. DSED is accepted in the ILCOR guidelines as an option, but not in the ERC ones. This doesn’t really make sense for two reasons. The best evidence for VC is the DOSE-VF trial, which also tested DSED. In that trial only DSED improved neuro intact patient survival. So why would you opt for one and not the other? Maybe there is a sound scientific argument for this, but we can’t see it.
10. Physiological resus makes sense. What we mean by this is that we should be trying to achieve the physiological circumstances that will allow ROSC to be achieved and sustained. The literature suggests that this requires a decent coronary perfusion pressure. Now, that’s pretty tricky to measure as it’s the difference between diastolic BP and coronary sinus BP, and so we have to approximate that using the diastolic blood pressure intra-arrest. In order to do that you really need an arterial line. This may seem tricky to place intra-arrest, but with a bit of practice it’s possible, and it’s my standard practice in workable arrests. Once placed you need to try and get the DBP above 35mmHg
11. Once you have a DBP, the question is then how to improve it. We have found that the quickest and most effective way to do this is to move the point of CPR around on the chest. We typically use the LUCAS device which does not really allow for much flexibility, and so removing it and going back to manual CPR is an option. You can then move the point of CPR around the chest until you get the best pressure possible. Typically this is more lateral (left) than the LUCAS device sits. Newer devices such as the Corpuls mechanical CPR device allow you to do this by moving the arm around the chest and this ,may well be the way forward, but we would love to see some more evidence on this to prove what seems to make a lot of sense. That said, our BASICS scheme in the NW was convinced enough to purchase one and we will be deploying it at cardiac arrests in preference to other devices going forward.
12. Everything I’ve just said is open to debate, and I hope, new evidence to come that might strengthen or weaken the opinions, and that’s great, because that’s science.
I’m going to stop there, as I can’t reproduce everything that was said, and I don’t want to take away from the fact that you really had to be there in the room taking part in the discussions to get the most out of it. You can see from the graphical summary of the event that we only covered a small part of cardiac resuscitation despite the session lasting an hour, there really is a lot to talk about even within the first few minutes of the resuscitation journey.
The ATACC group is taking all of this forward in developing new courses to support truly advanced cardiac resuscitation. You can find more about them here and on the graphic below. These are courses aimed at those who want to do more than just follow an algorithm, but who want to truly understand cardiac arrest physiology, and to explore how we can optimise it to get more ROSC and more neurologically intact survivors.
vb
Simon and Mark Forrest summarised the session
Expert panel members, representing themselves and not their organisations
- Alice Hutin
- Marcus Rudolph
- Toby Edmunds
- Sheldon Cheskes
- Mike Abernethy
- SImon Carley
- Mark Forrest
- Leilani Doyle
- Par Forsman
- Darren Braude
- Plus all those who joined in the chat from the course on the night.
vb
S
Further reading
- Resuscitator series with ATACC: https://www.ataccgroup.com/resuscitator-series/
- Vortex series with ATACC: https://www.ataccgroup.com/vortex/
- SPEAR course with ATACC: https://www.ataccgroup.com/spear/
Also: if you think I spent the week skiing then you’d be wrong. Whilst there were breaks in the program to allow this (midday) but then with sessions extending into the evening, on occasion past 10pm for those who like that sort of thing, my skiing days ended in Italy many years ago. My last memories of skiing are of being stretched off a mountain but the ski patrol, collapsing in a hotel, surgery to knee and pelvis, and three months non-weight bearing! However, if you do ski this conference is even more incredible as there is time to do it amongst the mountains and glaciers of one of the most wonderful places on the planet.
