De (on)zin van reanimeren

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2 De (on)zin van reanimeren
Refereeravond SEH artsen Regio Amsterdam 18 juli 2013 Maartje Kruithof, SEH arts Vumc

3 Hoe de buitenwereld aankijkt tegen ‘reanimeren’

4 Definitie van "Reanimatie" Regelmatig krijgt de Nederlandse Reanimatie Raad vragen over wat nu precies wordt bedoeld met het begrip Reanimatie. In mei 2009 heeft de Wetenschappelijke Raad zich gebogen over deze vraag en kwam daarbij na veel afwegingen tot de volgende definitie: "Reanimatie is het geheel van handelingen voor het herstel van spontane circulatie en/of ademhaling"

5 De shockroom

6 Wat te doen als SEH arts? Zorgen dat je kennis up-to-date is
Wat nog te verbeteren?

7 S.G. Beesems*, J.A. Zijlstra*, R. Stieglis, R.W. Koster
Afdeling cardiologie, Academisch Medisch Centrum, Amsterdam AmsteRdam REsuscitation STudies (ARREST)

8 Historie Dood geaccepteerd als wil van God tot renaissance Anekdotes:
1e “ooggetuigenverslag” geslaagde reanimatie 1237 v. Chr. : Koning Chyryba van Aleppo gered van de verdrinkingsdood. 1100 v Chr verslag vroedvrouw (dmv beademen) Hippocrates ( v. Chr.) rietstengel Asklepiades ( v. Chr.) luchtpijpsnede. Paracelsus ( ) Attempted the resuscitation of a corpse using bellows (Arabic medical writings) Andreas Vesalius ( ) successfully using bellows to resuscitate asphyxiated dogs Vesalius: intra tracheal respiration and knowledge of VF. But his conservative colleagues declared him mad. To avoid execution by the Inquisition, he made a pilgrimage and died in a shipwreck

9 Societies for Saving “persons apparently drowned”  Amsterdam, Milan, Venice, Hamburg, Paris, St. Petersburg, Berlin, and Boston Rond 1740s, verschillende casus mond-op-mond resuscitatie. 1767 in Amsterdam de “Maatschappij tot behoudnis van den Drenkeling” richtlijnen:hoe te handelen bij een schijnbaar overleden drenkeling. (ook mond-op-mond beademing en het duwen op de borstkas vermeld) 1774 Cogan and Hawes: (Royal) Humane Society, London 'The Institute for Affording Immediate Relief for Persons Apparently Dead from Drowning'. the society would pay anyone who attempted the treatment for two hours —and pay twice as much if the patient survived. 

10 Overige methoden Drogen en opwarmen door wrijving over de huid
Houten pijpen om lucht in de neus en longen te blazen en reukzout Houten blaasbalg om tabaksrook in ingewanden te blazen via de anus Met mes in anus steken Tot ~1811 Therefore, if the intestines could be stimulated properly, they could revive the rest of the body.  The bellows were used to drive tobacco smoke, a known irritant, into the intestine through the anus. The idea that the function of the lungs was to cool the heart was widely accepted 1811 enema abolished

11 1788 elektriseermachine 1809 gesuggereerd om elektriciteit toe te passen op “newly dead people” 1861 eerste succesvolle defibrillatie Prevost en Batelli Electrische stroom en VF 1947 Gurvich en Yuniev: discharge sent through chest of dog followed bij resumption of cardiac function Belangrijke verbeteringen van defibrillator in 1933 (Kouwenhoven) en 1947 (Beck).

12 Wetenschappelijk onderzoek
1848: Eerste dood door algeheleaneshesie 1856 Airway clearance (Marshall Hall) 'Asphyxia, its rationale and its remedy‘ advies chest-pressure-arm-lift

13 J Physiol Jul 18;18(3):

14 1906

15 ‘Closed’ chest compressions
1892 Maass (Goetingen): Eerste gedocumenteerde succesvolle gesloten hartmassage …helaas in vergetelheid geraakt………. Open chest CPR tot ~ 1950

16 Experiences with cardiac arrest, FH Lahey and ER Ruzicka; Surgery, gynecology and obstetrics, 1950; 90/1,

17 Herontdekking closed chest compressions

18 1950 American Medical Association
Manual techniques of artificial respiration

19 Safar Safar en Elam :mond-op-mond-beademing

20 Vrijwilligers ! > 30 artsen en medisch studenten vrijwilliger gedurende aantal uren, dmv curare verslapt

21 Begin 1900 meeste CPR stappen bekend, maar geen effectief systeem, 1960-1970 onderwijs

22 Groepstraining

23 1966 AMA 1e ACLS richtlijn The ABCs of resuscitation Zonder adrenaline
1974 Adrenaline in protocol ACLS Geinitieerd door Jude, Elam, Safar, Gordon

24 1963 Dierproeven!

25 DESIGN: Systematic review of randomised controlled trials.
BMJ Dec 20;327(7429): Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trials. Smith GC, Pell JP. Source: Department of Obstetrics and Gynaecology, Cambridge University, Cambridge OBJECTIVES: To determine whether parachutes are effective in preventing major trauma related to gravitational challenge. DESIGN: Systematic review of randomised controlled trials. CONCLUSIONS: As with many interventions intended to prevent ill health, the effectiveness of parachutes has not been subjected to rigorous evaluation by using randomised controlled trials.

26 The use of epinephrine is based on preclinical evidence of increased cerebral and coronary perfusion by redirected peripheral blood flow. Beneficial short-term effects of epinephrine have been shown in animal studies, but there is increasing concern for increased myocardial dysfunction and disturbed cerebral microcirculation after cardiac arrest. Epinephrine was an independent predictor of poor outcome in a large retrospective registry study

27 CPC: cerebral performance categorie
CONCLUSION: Patients receiving adrenaline during cardiac arrest had no statistically significant improvement in the primary outcome of survival to hospital discharge although there was a significantly improved likelihood of achieving ROSC

28 NAV van studies op varkens dat er een negatief effect van adrenaline op cerebrale bloedstroom is

29 Epinephrine for cardiac arrest. Callaway CW. Curr Opin Cardiol
Epinephrine for cardiac arrest. Callaway CW. Curr Opin Cardiol Jan;28(1):36-42 The available clinical data confirm that epinephrine during CPR can increase short-term survival (return of pulses), but point towards either no benefit or even harm of this drug for long-term survival or functional recovery

30 WR NRR conclusie

31 Jammer, helaas Cordarone Lidocaine NaBic Atropine Fibrinolyse Heparine
Vasopressine Magnesium Calcium Procainamide? 60-90 min Cordarone (vergroot overleving tot opname, niet tot ontslag) vs Lidocaine (alternatief) Magnesium: torsade, hypomagnesiemie of digitalis intox Natriumbic: wel bij TCA intox of hyperkaliemie Pronestyl: klasse 1 A antiarrhytmicum Onv. Bw Reden van niet-beschikbaarheid Om economische reden is dit product per uit het assortiment gehaald. [1]

32 Vlotte ontwikkeling Botnaald Interventies Echografie Therapeutische
Hypothermie

33 Toekomst LUCAS: (Nog) geen verbeterde survival Ononderbroken
compressie tijdens schok Continue aorta druk ( ) Prognose: Continue aorta druk: dierproeven (mn varkens)

34 Samenvatting Wetenschap via NRR Richtlijnen volgen Rol SEH arts
Up to date blijven

35 ?

36 Referenties Experiences with cardiac arrest, FH Lahey and ER Ruzicka; Surgery, gynecology and obstetrics, 1950; 90/1, Kouwenhoven, W.B.; Jude, J.R.; and Knickerbocker, G.G.:  Closed-Chest Cardiac Massage , JAMA : Weale, F., The efficiency of cardiac massage. Lancet, 1962 P.Safar, International Congress Series 1242 (2002) Richtlijnen Nederlandse Reanimatieraad ( Enkele fragmenten uit de geschiedenis van de reanimatie, Wulterkens; 10e Reanimatie Congres 2013 ( Effect of adrenaline on survival in out-of-hospital cardiac arrest: A randomised double-blind placebo-controlled trial, Ian G. Jacobsa et al; Resuscitation 82 (2011) 1138– 1143 Epinephrine in cardiac resuscitation, John W. Pearson, Joseph S. Redding; Experimental and laboratory reports 1962, Volume 66 Number 2 Prehospital Epinephrine Use and SurvivalAmong Patients With Out-of-Hospital Cardiac Arrest, Akihito Hagihara et al; JAMA. 2012;307(11): Reanimatie buiten het ziekenhuis in Noord-Holland en Twente: resultaten ARREST onderzoek over , S.G. Beesems*, J.A. Zijlstra*, R. Stieglis, R.W. Koster THE PHYSIOLOGICAL EFFECTS OF EXTRACTS OF THE SUPRARENAL CAPSULES. BY GEORGE OLIVER, M.D., AND E. A. SCHAFER, F.R.S.(From the Physiological Laboratory, University College.), J. Physiol, June 24, 1895. AN EXPERIMENTAL RESEARCH INTO THE RESUSCITATIONOF DOGS KILLED BY ANESTHETICS AND ASPHYXIA. BY GEORGE CRILE, M.D., AND DAVID H. DOLLEY, M.D., J. Exp Med, 1906 Intravenous Drug Administration during out-of-hospital cardiac Arrest, A randomized controlled trial, T M Olasveengen et al; JAMA. 2009; 302 (20): Epinephrine for cardiac arrest, CW Callaway; Curr Opin Cardiol 2013 Jan;28(1):36-42 Effects of sustained abdominal aorta compression on coronary pefusion pressures and restoration of spontaneous circulation during CPR in swine, Manhong Zhou et al; Resuscitation 82 (2011)

37 Objet d’arte Near the end of the 19th century, a mysterious young woman with a beguiling smile turned up in Paris. She became a huge sensation. She also happened to be dead. You'd probably recognize her face yourself. Death masks were a common way of preserving the faces. Known as "L'inconnue de la Seine" (the unknown woman of the Seine), The mask took on a life of its own, becoming a ‘must-have’ objet d’arte, several factories produced it in vast numbers. Laerdal en Dr Lind, and Safar: Fast forward to An Austrian doctor named Peter Safar was developing the basics of CPR, and he needed a way for people to practice his new method. He tracked down a toy maker in Norway, Asmund Laerdal, who had constructed prosthetic wounds for use in military training. Little did Safar know that Laerdal had a compelling, personal reason for getting involved. Ultimately, Laerdal decided the best way to learn artificial resuscitation would to practice on a dummy. All he needed was the perfect face.  >> Resusci Anne