Clinical Issues- Monitoring - Aventri · • Ito N, Nishiyama K, Callaway GW, et al. Noninvasive regional cerebral oxy gen saturation for neurological prognostication of patients

Clinical Issues- Monitoring

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Presented by: Scott Johnson, MD FACEP

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1. Scott Johnson, MD FACEP

2. Clinical Issues- Monitoring

3. No relevant financial relationship (s) exist

Clinical Issues- Monitoring

• Ultrasound

• Cerebral oximetry

Cerebral Oximetry using NIRS (Near Infra Red Spectroscopy)

• Optical Monitoring technique of superficial brain tissue of frontal lobe

• Assesses regional O2 (rSO2%)

(balance O2 delivery & uptake) • Represents mostly cerebral

venous saturation • Acceptable Normal Values 60-

80%

NIRS

• based on spectroscopy technology that utilizes the near-infrared region of the electromagnetic spectrum to explore superficial tissue.

• Using the difference of absorption between oxy- and deoxy-hemoglobin, the NIRS technique allows continuous non-invasive monitoring of cerebral oxygenation in the frontal cortex (rSO2)

• dynamic measurement that reflects real-time changes in the balance between oxygen delivery and uptake in the frontal lobe of the brain

Cerebral Perfusion Targeted Resuscitation

30 mins CPR

The literature • In a feasibility study, Parnia et al reported on the use of cerebral

oximetry during 19 in-hospital cardiac arrests and showed significantly higher mean rSO2 values in those who achieved ROSC.

• In another study by the same group, involving 50 patients with either in- or out-of- hospital cardiac arrest, no subjects with a mean rSO2 value less than 30% achieved ROSC

• Singer, et al reported (in CS of 59 OHCA pts) that in ED patients with cardiac arrest. higher cerebral oxygen saturations are associated with higher rates of ROSC.

• A group from Japan reported that the rSO2 value recorded at admission to hospital after out-of- hospital cardiac arrest may help predict neurological outcome at hospital discharge

• Ito N, Nishiyama K, Callaway GW, et al. Resuscitation 2014;85:778–84.

*

Figure 1. The relationship between return of spontaneous circulation (ROSC) and mean regional cerebral saturation (rSO2) expressed as mean ± standard deviation (SD) during resuscitation of the total in patients with ROSC (n=26) vs. no ROSC (n=24).*p < 0.0001 using the Student’s t-test.

Ahn A, Nasir A, Malik H, et al. A Pilot Study Examining the Role of Regional Cerebral Oxygen Saturation Monitoring as a Marker of Return of Spontaneous Circulation in Shockable (VF/VT) and Non-Shockable (PEA/Asystole) causes of Cardiac Arrest. Resuscitation 2013;84:1713–16.

mean rSO2 (47.2% ±10.7

mean rSO2=31.7±12.8%

4 mins 6 mins 6 mins

10 mins 16 mins Up to22mins

ACLS: Manual CPR + U/S

Auto CPR Adjust to 5 cm

+ Auto-Vent

-Impedance Threshold Device

-High dose (5mg) epinephrine - Ca2+, Mg2+ IV - Cold Saline IV - Other CPR modes

ECMO Consult

STEP 1 STEP 2 STEP 3 STEP 4

Repeated 2 min cycle’s: (consider check pulse with U/S or doppler) pulse/rhythm check – defib/epi/ check: vent rate 8-10 /min

rSO2

Conclusions • real-time monitoring of rSO2 values is feasible during CPR • there is an association between higher values and ROSC • rSO2 may predict ROSC • rSO2 < 42% is highly predictive (positive predictive value 95%) of a

poor recovery. • Ito N, Nishiyama K, Callaway GW, et al. Noninvasive regional cerebral oxy gen saturation for neurological

prognostication of patients with out-of-hospital cardiac arrest: a prospective multicenter observational study. Resuscitation 2014;85:778–84.

• ROSC is associated with higher mean rSO2 and that ROSC rarely occurs when rSO2 remains below 30%.

• Possible guide to the quality and effectiveness of the CPR and as a prognosticator to indicate the likelihood of achieving ROSC and long-term survival.

• might be an additional useful value to guide the intensity of care • ? NIRS as marker of quality resuscitation compared to end tidal CO2

Ultrasound in cardiac arrest

Potential Usefulness of Ultrasound

• Tension Pneumothorax

• Pericardial Tamponade

• Hypovolemia

• Cardiogenic Shock

• Pulmonary Embolus

• Vascular access

• Confirmation of ETT position

• http://sinaiem.us/education/rush-in-arrest

Reprinted from: sinaiem.us/education/ultrasound-in-cardiac-arrest

Caleb Hernandez, Klaus Shuler, Hashibul Hannan, Chionesu Sonyika, Antonios Likourezos, John Marshall, C.A.U.S.E.: Cardiac arrest ultra-sound exam—A better approach to managing patients in primary non-arrhythmogenic cardiac arrest, Resuscitation, Volume 76, Issue 2, February 2008, Pages 198-206, ISSN 0300-9572,

Prior to Arrest Arrival 4 mins 6 mins 6 mins 6 mins 6 mins

10 mins 16 mins Up to22mins 23 min Onwards

Prepare Room & Set Up - Thumper backboard bed - Oximetry + ET CO2 ±port. EEG - Ensure feedback pads ready - Set up thumper+battery check - I/O+ CVP + art. line kits - Get Ultrasound ready

Arrival-first 4 mins – Turn on CPR Clock - Check rhythm on EMS stretcher Roll – if VT/VF – shock + one cycle CPR. - Roll pt onto hospital thumper board – continue manual CPR. - Attach SB CPR pads with accelerometer – A/P position – Rhythm check - Secure airway ET/LMA with capno – check vent rate 8-10 breaths/min - Give 1st epinephrine - Start oximetry/ETCO2 ±port. EEG (if available) - Start insert access– 18G peripheral+femoral line + art. Line (I/O if needed) - Send ABG with lytes and Labs (CBC/Biochem/Glc/lactate/neurone specific enolase)

Manual CPR +

RUSH U/S

May Consider:

Auto CPR Adjust to 5 cm

+ Auto-Vent

May Consider:

ResQ Pod

May Consider: ECMO

May Consider:

- RV lab results ? make changes

- High dose epinephrine (5mg) - Ca2+, Mg2+ IV - Cold Saline IV - ECMO - Other CPR modes Comp/Decomp CPR Nitroprusside

STEP 1 STEP 2 STEP 3 STEP 4 STEP 5

Repeated 2 min cycle’s: (consider check pulse with U/S or doppler)

pulse/rhythm check – defib/epi/ check: vent 8-10 bmp + compressions 100/min and no pauses.

rSO2

Sono during CPR

Cardiac Tamponade

Cardiac tamponade

IVC collapse = hypovolemia

Positive FAST- Morrison’s pouch

Normal lung sliding

NO lung sliding= Pneumothorax

NO lung sliding= Pneumothorax

M-mode

Normal= seashore sign PTX= stratosphere sign

Lung sliding

normal pneumothorax

Acute PE with RV strain

Acute PE with RV strain

AAA

http://www.em.emory.edu

Use of ultrasound imaging during advanced life support

• Several studies have examined the use of ultrasound during cardiac arrest to detect potentially reversible causes. • Although no studies have shown that use of this imaging modality

improves outcome, there is no doubt that echocardiography has the potential to detect reversible causes of cardiac arrest (e.g., cardiac tamponade, pulmonary embolism, hypovolemia, pneumothorax).

• When available for use by trained clinicians, ultrasound may be of use in assisting with diagnosis and treatment of potentially reversible causes of cardiac arrest.

• The integration of ultrasound into advanced life support requires considerable training if interruptions to chest compressions are to be minimized.

• Absence of cardiac motion on sonography during resuscitation of patients in cardiac arrest is highly predictive of death, although sensitivity and specificity has not been reported.

– Blaivas M, Fox JC. Outcome in cardiac arrest patients found to have cardiac standstill on the bedside emergency department echocardio- gram. Acad Emerg Med 2001;8:616-21.

Questions?