Transcript Diapositive 1 - European Emergency Number 112

Dominique Biarent
Hôpital Universitaire des Enfants
Urgences et Soins Intensifs
http://www.c2005.org/presenter.jhtml?identifier=3022512
Your Guide to the 2005 International
CoSTR Conference
What is the purpose of the evidence evaluation
process?
The endpoint of this process is the preparation
of the International Consensus on CPR and ECC
Science with Treatment Recommendations.
Consensus on Sciences and
Treatment Recommendations
What is the purpose of the
International CoSTR Conference?
ILCOR is conducting systematic reviews and
updates of scientific evidence supporting ECC
treatment recommendations.
More than 300 CPR and ECC scientific
topics will undergo evidence-based
review
This process represents the most comprehensive,
systematic review of the resuscitation literature to
date
Who's in charge?
ILCOR - the International Liaison Committee on Resuscitation.
includes 7 international resuscitation organizations
American Heart Association (AHA),
European Resuscitation Council (ERC),
Heart and Stroke Foundation of Canada (HSFC),
Resuscitation Council of Southern Africa (RCSA),
Australia and New Zealand Council on
Resuscitation (ANZCOR),
InterAmerican Heart Foundation (IAHF).
Japan Resuscitation Council JRC : international observer to
ILCOR.
China (Ministry of Health) : international observer to the C2005
Conference.
C2005 Evidence Evaluation
Worksheets
« Vasopressine leads to better
outcome from pediatric cardiac
arrest than epinephrine »
Level of Evidence (LOE)
Rating
Direction
Search Strategy
• Vasopressin and cardiac arrest, children,
ventricular fibrillation , resuscitation, asystole
and children (MeSH term and textwords)
• Pubmed 244 hits (19 Aug 2004)
• Embase141 hits (19 Aug 2004)
• Cochrane Library 1 hit (15 Aug 2004)
• Update 24 Jan 2005 : 1 hit
• Wenzel V, Krismer AC, Arntz HR, Sitter H, Stadlbauer
KH, Lindner KH. A comparison of vasopressin and
epinephrine for out-of-hospital cardiopulmonary
resuscitation. N Engl J Med 2004;350(2):105-13.
• LOE1 excellent RCT (intention to treat)
• 1189 patients (no children)
• Similar rate of survival to hospital admission for VF
/PEA
• Better survival for asystolic patients treated with
vasopressin
• In absence of ROSC with study drug, additional
epinephrine improved survival in VP group not in EPI
group
Wenzel
2004
VF
H admission
H discharge
PEA
H admission
H discharge
ASYSTOLE
H admission
H discharge
H discharge
after epi
Additional
epinephrine
w/o ROSC
H discharge
Intact neurol
AVP
EPI
RR–CI
95%
46.2 %
17.8 %
33.7%
5.9 %
29%
4.7%
3.8%
6.2 %
10/40
43%
19.2%
30.5%
8.6 %
20.3%
1.5%
0
1.7 %
4/10
0.9 (0.6-1.3)
(p0.48)
1.1 (0.7-1.8) (p0.7)
0.8 (0.5-1.8)
(p0.65)
1.4 (0.5-4.7)
(p0.47)
0.6 (0.4-0.9)
(p0.02*)
0.3 (0.1-1.0)
(p0.04*)
(p0.008*)
0.3 (0.1-0.6)
(p0.002*)
(ns)
• Voelckel WG, Lurie KG, McKnite S, et al.
Comparison of epinephrine and vasopressin in a
pediatric porcine model of asphyxial cardiac arrest.
Crit Care Med 2000;28(12):3777-83.
•
•
•
•
•
Paediatric piglet model of asphyxial arrest
Epi or VP+Epi : higher myocardial BF
VP+Epi : higher cerebral BF
ROSC Epi 6/6* VP+Epi 5/6
VP 1/6
Limitation : use of high dose Epi (200 mcg/kg)
• Voelckel WG, Lurie KG, McKnite S, et al. Effects of
epinephrine and vasopressin in a piglet model of
prolonged ventricular fibrillation and cardiopulmonary
resuscitation. Crit Care Med 2002;30(5):957-62.
• Paediatric piglet model of prolonged VF (8
min + 20 min CPR),
• Combination VP (0.8 IU/kg) +Epi (45 g/kg) :
higher left ventricular myocardial blood flow
than VP or Epi alone
• VP+Epi and VP alone : higher cerebral blood
flow than Epi alone
• ROSC ns
VP + Epi 6/6
VP5/6
Epi 2/6.
•
Mann K, Berg RA, Nadkarni V. Beneficial effects
of vasopressin in prolonged pediatric cardiac
arrest: a case series. Resuscitation
2002;52(2):149-56.
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



6 long lasting CA in 4 children after > 2
doses adrenaline
VP as rescue therapy
3 ROSC (>1h)
1 withdrawal therapy (>24 h)
1 survivor
High dose versus low dose
adrenaline
• Author A
• « High dose of adrenaline
is harmful in children with
in-hospital and out-ofhospital cardiac arrest »
• Search strategies
• 209 articles excluded
• 40 articles analysed : 25
human and 15 animal
model studies
• Author B
• « The recommended
resuscitation dose of
adrenaline for children (0.01
mg/kg) should be increased
• Search strategies
• Age less than 18 years
• 5 articles met full criteria
Refractory CA is > 2 doses of adrenaline
•
Goetting MG, Paradis NA. High dose epinephrine in refractory pediatric
cardiac arrest. Crit Care Med. 1989;17:1258-62
• 7 children received 0.2 mg/kg adre : 6 ROSC
Compared to 20 historic controls (SDE): no
ROSC
• LOE 5 (fair)
•
Goetting MG, Paradis NA. High-dose epinephrine improves outcome from
pediatric cardiac arrest. Ann Emerg Med. 1991;20:22-6.
• Prospective intervention group versus historic
control group (20 in each). HDE : 14 ROSC
(70%), 8 long term survival, 3 intact
• LOE 3
• No difference in survival at discharge
• LOE1 (excellent)
Compression / Ventilation Ratio
• Author A
• Author B
• A universal compressionventilation ratio should be
used for infants and
children irrespective of
their age, etiology of
arrest and number of
rescuers
• Scientific evidence
supports the superiority of
a 5:1 CV ratio in children
rather than the 15:2 CV
ratio recommended for
adults
• Search strategies
• Search strategies
• 9 articles
• 20 articles used for
discussion
• 9 articles in grid
In children
• Metabolic rates, CO2 production,
ventilatory needs are higher in the nonarrest setting
• Pediatric CA are precipitated by asphyxia
or shock
• In-hospital HCP are accustomed to a 5:1
rather than 15:2
• time to BLS in asphyxial CA vs Time to
defibrillation in VF are crucial
• Rescue breathing is critically important for
asphyxial arrest (inadequate O2 content
and high CO2 in the lungs at the time of
CA) but not necessary for VF
• VF has a normal O2 / CO2 content in
lungs and hyperventilation is deleterious
• BLS not necessary fort short duration VF
• BLS crucial for prolonged duration VF
Evidence Of Science
• Manikin studies or animal studies
(LOE 6)
• Mathematical model (LOE 6)
• Berg RA, Sanders AB et al. Adverse
hemodynamic effects of interrupting chest
compressions for rescue breathing during
cardiopulmonary resuscitation for VF cardiac
arrest. Circ 2001;104:2465-2470
• Interrupting CC for rescue breathing
decreases mean coronary perfusion, LV
blood flow & number of compression in
swine.
• Dorph E, Wik L, Steen PA. Effectiveness of
ventilation-compression ratios 1:5 and 2:15 in
simulated single rescuer paediatric resuscitation.
Resuscitation. 2002;54:259-64
• 1 lay rescuer – child sized manikin – 2
ratios 5:1 or 15:2
• Same minute ventilation; Better
compression with 15:2
C/V ratios
5:1
10:2
15:2
Tidal volume
121
117
115
Breaths/min
18
17
12
MV
2.2
2.0
1.4
Total
compressions/min
% effective chest
compression
87.9
78.9
83.7
84.6
84.6
84.6
Kinney SB, Tibballs J. An analysis of the efficacy of bag-valve-mask ventilation and
chest compression during different compression–ventilation ratios in manikinsimulated paediatric resuscitation. Resuscitation 2000;43:115-120.
Mean number of correct compression
Ratio 5/1
Ratio 15/2
Min 1
58
59
Min 2
55
41
Min 3
53
40
Min 4
60
47
Min 5
56
34
J. L. Greingor. Quality of cardiac massage with ratio compression–ventilation 5/1 and 15/2.
Resuscitation 2002; 55:263-267
•
Babbs CF,
Nadkarni V.
Optimizing chest
compression to
rescue
ventilation ratios
during onerescuer CPR by
professionals
and lay persons:
children are not
just little adults.
Resuscitation
2004;61:173-81.
Optimum C/V ratios in pediatric basic life support
5 + AGE for Pro
5 + AGE/2 for LAY
DO2
DO2
Blood flow
Blood flow
Alv O2
Alv O2
Oxygen delivery function of C/V ratio
(a) professionally trained rescuers (2 rescue breaths in 5 s)
(b) lay rescuers, (2 rescue breaths in 16 s)
Babbs CF, Kern KB. Optimum compression to ventilation ratios in CPR under realistic, practical
conditions: a physiological and mathematical analysis. Resuscitation. 2002 Aug;54(2):147-57.
Optimal combined flow/DO2
For 10 000 simulations
OPTIMAL RATIO between 30:2 and 50:2
• Simplicity of teaching is crucial
• Do we need an universal ratio?
Biphasic defibrillation
Number of shocks
that failed to
terminate the initial
VF episode for
monophasic weightbased and
attenuated adult
biphasic shocks in
the 4, 14 and 24 kg
weight categories.
*P<0.01.
ROSC and 4 &
24 h survival
Berg RA, Chapman FW et al Attenuated
adult biphasic shocks compared with
weight-based monophasic shocks in a
swine model of prolonged pediatric
ventricular fibrillation.Resuscitation 2004,
61:189-197
Ventricular
function
Automated External
Defibrillator (AED)
•
•
•
•
•
Evaluates the victim’s ECG
Determines if a “shockable” rhythm is present
Charges the “appropriate” dose
When activated by operator, delivers a shock
Provides synthetised voice prompts to assist
the operator
AED in children?
• Experience limited
• Recommended (Class IIb) for children older
than 1 year in the pre-hospital setting (circulation 2003)
• Remember:
– Most arrests in children are respiratory in origin
– The most frequent arrest rhythms are Asystole and
PEA
– Prompt defibrillation is the definitive treatment for
VF and pulseless VT
– Basic life support sequence
Conclusion
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Ongoing process
Evidence of science
Guidelines
Courses
Evidence Based Medicine