The document discusses refractory cardiac arrest and the CHEER protocol used in Victoria, Australia. It summarizes that the CHEER protocol involves using extracorporeal membrane oxygenation (ECMO) for patients under 70 years old who experience out-of-hospital cardiac arrest and do not achieve return of spontaneous circulation after 30 minutes of advanced cardiac life support at the scene. Patients are transported on mechanical CPR to the emergency department where intensivists perform percutaneous cannulation for veno-arterial ECMO. Coronary angiography and stenting of any blockages is then performed, after which the heart often regains rhythm. The patient is cooled for 24 hours and rewarmed slowly over 12 hours before transfer to the

1. Refractory Cardiac Arrest
The CHEER Protocol
Stephen Bernard
MD FACEM FCICM FCCM

2. The Victorian setting
•
•
•
•
000 call system
Computer aided dispatch
Post dispatch instructions (ECM only)
“3-tier” system
– PAD/ Firefighters/ CERT
– ALS paramedics
– Intensive Care Paramedics
• ACLS at scene
• Transport to ED if ROSC

3. The Victorian setting
• If no ROSC at ~30 minutes- declared
deceased
– All ACLS provided at scene
– Asystole as final rhythm
– No compelling other factors (hypothermia/ OD)
•
•
•
•
EMS transport with effective CPR not practical
Hazardous for EMS crew
No new therapy in ED
Considered futile

4. The Victorian setting
• Data from Victorian Ambulance Cardiac
Arrest Register for Melbourne
– 12 month period (2012)
– Age < 65 years
– VF as initial cardiac rhythm
• 222 patients
• 149 ROSC (Survival of these = 55%)
• 68 no ROSC
• 5/68 transported with CPR (Autopulse)
• 63 declared deceased at scene

5. The Victorian setting
• Data from Victorian Ambulance Cardiac
Arrest Register for Melbourne
– 12 month period (2012)
– Age < 65 years
– VF as initial cardiac rhythm
• 222 patients
• 149 ROSC (Survival of these = 50%)
• 68 no ROSC
• 5/68 transported with CPR (Autopulse)
• 63 declared deceased at scene

6. ECMO
• 2008 Swine flu
• Increasing experience in VV ECMO
• Intensivists at Alfred undertake training
program
– 2 day program
– Cannulation in dogs
– Circuit management

7. E-CPR
Reports from Japan in 2000-2012
J Am Coll Cardiol 2000; 36(3):776-83.

8. E-CPR
• January 2004 and May 2011
• E-CPR in 86 patients with ACS
• Median age 63 years/ 81% were male
• Intra-arrest PCI was performed in 61 patients (71%).
• ROSC 88%
• 30-day survival 29%
• Favorable neurological outcome 24%
Kagawa E, et al. Should we emergently revascularize occluded coronaries
for cardiac arrest?: Rapid-response extracorporeal membrane oxygenation
and intra-arrest percutaneous coronary intervention. Circulation 2012 Sep
25;126(13):1605-13

9. The CHEER Trial
– Pilot observational trial
– Post-VF arrest
– <70 years old
– No ROSC at 30 minutes
•
•
•
•
•
CPR to ED with Autopulse
Hypothermia
ECMO
Emergency
Reperfusion

10. The CHEER Trial
– Mechanical CPR to ED

11. The CHEER Trial
Cannulae
Cold fluid
Autopulse
Primed circuit
– Notification by AV
– Equipment
immediately
available in ICU
– Brought to ED by
ICU team
Drapes etc

12. In the ED
• Clearly defined roles to prevent chaos
–
–
–
–
–
–
–
–
–
ED Consultant manages airway/ventilator
No shocks or cannulation during ECPR
ED nurses (x 2) equipment and scribe
ICU SR pumps ice cold saline x 3L
ICU Consultants x 2 cannulate
ICU/ED manage U/S upper abdo for wires
ICU nurse manages Autopulse and ECMO circuit
Cardiology review need for PCI
All others stand back

13. In the ED
– Percutaneous
cannulation by
Intensivists x 2
– 15F arterial/ 17F venous
– Ultrasound of femoral
vessels
– Ultrasound of IVC
– No defibs/ CVC during
cannulation

14. VENO-ARTERIAL ECMO
V-A ecmo for CPR
Low flow configuration
(3-4L/min)
Oxygen vs Air?

15. The CHEER Trial
– Cold IV saline
– 3 L bolus IV
– Cools rapidly
Bernard SA, et al. Therapeutic hypothermia induced during
cardiopulmonary resuscitation using large-volume, ice-cold intravenous
fluid. Resuscitation 2008; 76:311-3

16. In the cath lab:
•Coronary angiogram
•Stent any blockages
•Then the heart will start!

17. To the ICU:
•Cooling for 24 hours
•33°C
•Slow rewarming over
12 hours @ 0.25°C/hr

18. In-hospital cardiac arrest
– Refractory cardiac arrest following in-hospital
arrest
– No ROSC at 30 minutes
– The “CHEER” approach
– Reversible cause
•
•
•
•
Age <70
ACS in ED
Reperfusion arrest in Cath lab
Pulmonary embolism

19. Experience to date
Definitions for this presentation
• OHCA- CPR into the ED and > 30 minutes
• IHCA- CPR > 30 minutes
• Excludes
– VA-ECMO for shock with arrest < 30 minutes
– IHT from other centre

20. Experience to date
Site
ECMO
Survival
OHCA
7/9
3/7
IHCA
13/13
8/13
E-CPR Good neurological outcome 11/20 (55%)

21. IHCA-1

22. IHCA-11
“Jenny thanks 'miracle workers'
who saved her life”

23. What we are doing now…
– Extra 10 Autopulses donated to AV by Zoll
– Covers most of Melbourne
– 24/7 ICU Consultant roster
– Strategy to move patients within 20 minutes of
arrest- ECMO < 60 minutes
– Scenario training for the team

24. Summary
– Every large city should have E-CPR available
– Safe transfer to hospital with CPR now possible
– Intensivist rapid percutaneous cannulation in ED
feasible
– Cooling during CPR is recommended (40mL/kg
cold fluid bolus)
– Normal neurological outcomes possible with up to
125 minutes of CPR
– 55% good outcomes at The Alfred (11/20)