Cardiac Care Services

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 !!!!