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)

December 14, 2020

Background: In the US out-of-hospital cardiac arrest (OHCA) has an estimated survival rate of <10% overall, but slightly better survival rates with shockable rhythms of approximately 30% [2]. A small proportion of these patients will have refractory VF/VT OHCA not treatable by standard ACLS guidelines.  One possible modality for these patients is extracorporeal membrane oxygenation (ECMO, followed by immediate coronary angiography and percutaneous coronary intervention (PCI).  How would this ECMO-facilitated resuscitation strategy fair when applied in a US metropolitan community?

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.

March 16, 2020

Traditionally, endotracheal intubation has been the gold standard for airway management in cardiac arrest. However, more recent data suggests that maybe less is more (i.e. supraglottic airways and/or bag valve mask ventilation).  The AHA guidelines have also de-emphasized airway management as the old acronym of ABC's has now been changed to CAB's.  In this talk from Rebellion in EM 2019, Dr. Chris Hicks, MD discusses the optimal airway management in OHCA.
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