Cardiac Arrest & Chain of Survival S. Sujanthy Rajaram MD, MPH, FCCM, FAASM Associate Professor of Medicine Division of Critical Care Medicine Cooper University Hospital Cooper Medical School of Rowan University University of Medicine & Dentistry Camden, New Jersey
What we will cover‌
Post-cardiac Arrest Syndrome
Clinical Trials & Current Guidelines
Clinical Implementation
? Potential applications in Sri Lanka
Cardiac Arrest (CA) Annually 450,000 Americans experience CA 80% out of hospital arrests Roughly 10% survive Majority of survivors are being abandoned long before it is reasonable to predict neurological recovery > 50% OF SURVIVORS HAVE SOME DEGREE OF PERMANENT BRAIN DAMAGE. Young GB, Clinical practice . Neurological prognosis after cardiac arrest NEJM 2009;361:605-611 Peberdy MA et al. CPR of adults in the hospital: a report Resuscitation. 2003;58:297-308
Prognostication
20 min
6-12 hours
72 hours
Rehabilitation
Intermediate
ROSC
Rehabilitation
Recovery
Early
Limit ongoing injury Organ support
Immediate
Goals Phase
Prevent Recurrence
Disposition
Circulation 2008
BRAIN INJURY IS EVOLVING AFTER AN ANOXIC INSULT UP TO 72 HOURS AFTER THE EVENT
â˜şHypothermiaâ˜ş
TH prevents brain injury Cool !!! Mechanisms
hypermetabolic
excitability
demand
necrosis apoptosis
Brain injury inflammatory
free
cascade
radical
edema ICP
Respir Care 2007
CA: Non-randomized studies
Polderman KH. Lancet 2008;371: 1955
Primary Outcome Good neurological outcome @ 6 mos
Hypothermia N = 137 N = 275 eligible Normothermia N = 138
Secondary Outcomes Mortality @ 6 mos. Complications @ 7 d.
HACA. N Engl J Med 2002;346 (8): 549-556
Method Target
Cooling blanket over whole body + released cool air. 32 to 34 째C
Induction
From ROSC to target T : median 8 hours
Duration
Median of 24 hours
Rewarming
Passive over 8 hours
HACA. N Engl J Med 2002;346 (8): 549-556
N Engl J Med 2002;346 (8): 549-556
Neurologic Outcome and Mortality at Six Months Outcome
Normothermia
Hypothermia
Risk Ratio (95% CI)
P Value
Favorable neurologic outcome
54 / 137 (39)
75 / 136 (55)
1.40 (1.08-1.81)
0.009
Death
76 / 138 (55)
56 / 137 (41)
0.74 (0.58-0.95)
0.02
N Engl J Med 2002;346 (8): 549-556
Survival
N Engl J Med 2002;346 (8): 549-556
Hypothermia N = 43 Primary Outcome Survival to DC with good neurological
N=77 Normothermia N = 34
Bernard SA et al. N Engl J Med 2002;346 (8): 55
Method Target
Ice packs placed around the head, neck, torso, and limbs 33 째C
Induction
From ROSC to target T : 2 hours
Duration
12 hours after target T achieved
Rewarming
Passive after 12 hours, active after 18 hours
Bernard SA et al. N Engl J Med 2002;346 (8): 55
Outcome of Patients at Discharge from the Hospital Outcome
Hypothermia (N = 43)
Normothermia (N = 34)
Normal or minimal disability
15
7
Moderate disability
6
2
Severe disability, awake but completely dependent
0
1
Severe disability, unconscious
0
1
Death
22
23
Bernard SA et al. N Engl J Med 2002;346 (8): 557
ACLS Guidelines • Unconscious patients with ROSC after out-of-hospital CA should be cooled to 32ºC to ºC 34 for 12-24 hours (I, B) • Similar therapy may be beneficial in patients with non–VT arrest (out-ofhospital) or for in-hospital arrest (IIb, B) Circulation 2010; 122: S768-786.
1. Use the term TTM rather than TH Out of hospital arrest: TT 89.6 -93.2 F, 32-34 C for ventricular fibrillation or pulseless v. tachycardia Newborns: 91.4-95.9 F (33-35.5 C) 2. Cool to a specific level, within a specific time frame, Specific warming protocols, gives a certain outcome Critical Care Med 2011; 39.
Clinical Application
Cooling Options / Methods
Cold Fluids
Surface
Intravascular
Temperature Monitoring
Foley, rectal, esophageal, tympanic? If you can’t monitor the temperature, don’t manipulate it Foley is better than rectal
Recommended Temperature Monitoring Sites 1. 2. 3. 4. 5.
PA catheter Esophageal Bladder (unless anuric) Cranial or Nasopharyngeal Rectal
(Do not use axillary with surface cooling!)
Why Sedation +/- Paralytics? •
Needed for mechanical ventilation and shivering suppression
•
Propofol Midazolam or other benzodiazepine Fentanyl or other narcotic Dexmedetomidine
Muscle relaxation / paralysis
Vecuronium / Pancuronium Cisatracurium / etc. Monitoring (TOF) / EEG
Cold IV Saline + sedation (awake volunteers) ~2.5 liters (30ml/kg) of saline / 30 min Shivering
Valium 10 -20 mg
Benzodiazepine enhanced cooling
Holster et al. High dose diazepam facilitates core cooling during cold saline infusion in healthy volunteers. Appl Physiol Nutr Metab. 2009;34:582-586
Shivering
Increases metabolic demand (VO2); makes it hard to cool Heavy sedation is sufficient to suppress shivering Muscle relaxants will be necessary only during induction
Cooling Lowers Heart Rate
Decline as low as 40/ mt, BP not affected
Cooling Prolongs QT interval PR=208, QTc=535 Be vigilant if etiology of CA or on agents prolongs QT(Amiadarone), electrolytes shift
Fluids and Electrolytes Lactate, Free fatty acids, Glycerol, Ketones, Osmolarity
Hypothermia
Rewarming
K+ K+
K+
Mg+ PO4-
Mg+ PO4-
K+ Mg+ PO4-
K+
Potential Side Effects and Their Frequency High Probability
Coagulopathy Hypovolemia (increased diuresis) Match the UOP Electrolyte disorders Hyperglycemia (Insulin resistance, low secretion, need more insulin)
Low Probability
Manifest bleeding Airway infections (with prolonged hypothermia) Wound infections (transient immunomodulation) Myocardial ischemia
Rare
Manifest pancreatitis Intracerebral bleeding
Dead or Alive? After Cool !!!
What do they need to survive? Most CA victims require Cardiac catheterization
Treat the reversible causes • Hypovolemia • Hypoxia • Hydrogen ion (acidosis) • Hypokalemia Hyperkalemia • Hypothermia
• Tension pneumothorax • Toxins • Tamponade • Thrombosis pulmonary • Thrombosis Cardiac
Post arrest Cardiac Catheterization 85 CA victims, 71% had 1 or more vessels with at-least 50% stenosis (Spaulding et al.) 241 victims, 73% had 70% stenosis (Kurz et al.) Cold heart might be prone to more dysrhythmia Despite concerns, brief & long v.fib. Success of Shock is unchanged and even improves as Temperature drops from 96.6 -86 F (37-30) Sapulding CM et al. Immediate conronary angiography in survivors of out of hospital cardiac arrest NEJM. 1997;336:1629-1633 Kurz et al. Periop. Normothermia NEJM. 1996;334:1209-1215 Boddickee et al. Hypothermia improves defibrillation success from v.fibrillation in swine model Resuscitation, 2005; 65:79-85
Video Clips
“The majority of patients who achieve ROSC are being abandoned long before it is reasonable to predict neurological recovery�
Prognostic Tools • Clinical signs: Neither corneal reflex, nor motor response Day 3 • Day 7 – no response to pain, discomfort • No pupillary reaction by Day 3 • Decerebrate rigidity (Extensor reaction) by Day 3 (35% of CA victims) • SSEPs – bsence of b/l N20 response is a reliable predictor (ideal timing is 24-72 hours, if present at 24 hrs, loss later) • EEG – myoclonic status (b/l repetitive motions of limbs, trunk or facial muscles, must confirm with EEG)
Poor Prognosis • Myoclonic twitching or jerking has no bearing on prognosis • Atonic, sub clinical or focal seizures are unrelated to prognosis • Neurologic specific enolase in serum or CSF ( Day 1-3, >33 microgram/dL ) • CT – brain swelling or loss of grey white differentiation • MRI – 49-108 hours, MR spectroscopy for PH, N acetyl aspartates, not widely available • Cannot apply these widely in hypothermia
Arrest Rhythms Shockable
Non-shockable
VF / Pulseless VT
Asystole / PEA
Goal of CPR • Improve neurologically intact survival to hospital discharge following CA
• • • •
CAB Compression Airway Breathing No more ABC
Chain of Survival
What was covered in CPR & Chain of Survival
Post-cardiac Arrest Syndrome
Clinical Trials & Current Guidelines
Clinical Implementation
? Potential applications in Sri Lanka Need BLS and ACLS with emergency response team
Thank You !!!
Cool !!!!