May 1, 2021

Background: Head up (HUP) CPR is an emerging concept.  The theory behind HUP is it allows for venous blood to drain from the brain to the heart thereby decreasing intracranial pressure and lowering the arterial/venous pressure waves which concuss the brain with each compression.  Additionally, conventional CPR increases vascular pressure in both the venous and arterial sides of the heart simultaneously which in turn increases intrathoracic and intracranial pressure which can impede cerebral blood flow and compromise coronary circulation.  All of these theories were evaluated and confirmed in animal models with very limited human trials. In order for HUP to work however, we have to be able to effectively pump blood up to the brain which is not typically achieved with conventional CPR (C-CPR). Active Compression Decompression with Impedance Threshold Devices (ACD-ITD) are one way to improve C-CPR.  They can theoretically help by reducing intracranial pressure (ICP), reduce the potential for concussion with every compression, increase cerebral perfusion pressure (CerPP) and coronary perfusion pressure (CorPP). However, with any new approach, we should always temper enthusiasm, as the realities of implementing them may actually not be helpful, and maybe even harmful.

January 14, 2021

Background Information: Out-of-hospital cardiac arrest (OHCA) remains a diagnostic challenge to providers and a significant burden on healthcare systems globally. Despite the advancement of invasive medical therapies such as percutaneous coronary intervention (PCI) and extracorporeal membranous oxygenation (ECMO) at designated cardiac catherization centers, the majority of these patients sustain poor outcomes due to hypoxic brain injury. Clinical features of neurologic injury are typically delayed until 72 hours after admission. As a result, many neuro-prognostication tools have been developed to assist with clinical decision making as well as reduce expensive futile interventions.1 Some of these neuroprognostication tools include the Cardiac Arrest Hospital Prognosis (CAHP), OHCA and Targeted Temperature Management (TTM) risk tools. Unfortunately, these are complex and time consuming, thus limiting their use in the emergency department (ED). The authors of the following study sought out to develop and validate a point-based risk score to support clinical decision making and predict neurologic outcomes using the cerebral performance category (CPC) scale (Figure 1)

November 9, 2020

Background/Introduction: The use of Sodium Bicarbonate (SB) in cardiac arrest has had a complicated history with strong and varied opinions on its effectiveness. SB was recommended in earlier ACLS guidelines, mostly stemming from the notion that severe metabolic acidosis due to hypoxia and hypoperfusion during cardiac arrest led to impaired myocardial contractility, decreased effectiveness of vasopressors, and increased risk of dysrhythmias. Subsequent data called into question the benefits of SB in cardiac arrest and highlighted potential harms such as hypernatremia, hyperosmolarity, metabolic alkalosis, as well as reduction in ionized calcium, vascular resistance, and extracellular fluid volume expansion. This led to the 2010 ACLS guidelines stating that routine use of SB is not recommended (Class IIIB) and that it may be considered in special circumstances (preexisting metabolic acidosis, Hyperkalemia, or TCA overdose). Despite this, the use of SB during cardiac arrest is still common in emergency departments with varying opinions on its effectiveness. In fact, recently published data from the National Emergency Medicine Services Information System (NEMSIS) noted that besides epinephrine and normal saline, sodium bicarbonate was the third most commonly used medication in out of hospital cardiac arrest (Chan 2020). This study aimed to consolidate the state of evidence behind the use of SB in cardiac arrest.

April 6, 2020

Background: Epinephrine remains a staple in cardiopulmonary resuscitation (CPR) in out-of-hospital cardiac arrest (OHCA).  However, the optimal dose, timing, and route of administration are still unknown.  Standard dosing of epinephrine is 1mg every 3 to 5 minutes via the intravenous (IV) or intraosseous (IO) route. IO lines are quicker to establish and have a higher first-attempt success rate compared to IV access. Rapid placement and ease of use minimizes delays for critical patients requiring quick access. The literature, although methodologically limited, is mixed about the use of IV vs IO access for epinephrine in OHCA.

February 27, 2020

A 57-year-old man is watching his son’s baseball game when he suddenly collapses. Witnesses did not appreciate a pulse, so they started CPR. Unfortunately, an AED was not available. EMS was called and when they arrived within minutes the patient was found to be in vfib arrest and was defibrillated. When the patient arrived to the hospital, he was in PEA arrest. Ultrasound of the patient’s heart showed some coordinated cardiac activity. ACLS doesn’t really tell us how to proceed with cardiac activity but not enough to generate a pulse on the monitor.
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