ROSC! Now what??!! An EMS Guide to the Management of Post Cardiac Arrest Syndrome Jay Lance Kovar,...
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- Slide 2
- ROSC! Now what??!! An EMS Guide to the Management of Post
Cardiac Arrest Syndrome Jay Lance Kovar, MD, FACEP Montgomery
County Hospital District PHI Air Medical Texas
- Slide 3
- Objectives o Review o Background and Epidemiology of Cardiac
Arrest Survival o Detail o Pathophysiology of Post Cardiac Arrest
Syndrome o Discuss o Monitoring, Therapeutic Strategies, and
Protocols they apply to the Pre-Hospital Environment o Propose o
Integrated EMS Protocols for Improved Intact Neurologic
Survivability
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- Background o 1966Nat'l Academy Sciences Nat'l Research Council
on CPR describes ABCDs o 1972Dr Valdimir Negovsky The Second Step o
Advances in CPR and cardiac care has not resulted in improved
survivability in 50 years o Post Cardiac Arrest Syndrome o Brain
Injury o Myocardial Dysfunction o Systemic Ischemia/Reperfusion
Response o Unresolved Pathological Process
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- Background o Barriers to Optimal Outcomes o Multiple
Teams/Hand-0ffs o Wide variation in Treatments (multicenter trials)
o Early Prognostication Inaccuracies < 72 hrs o Research focus
on ROSC o Improved ROSC w/o Improved Survival
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- Epidemiology o Early Mortality rates after ROSC varies greatly
between studies, regions, and hospitals indicating variability in
Post Cardiac Arrest Care o Advances in Critical Care over past 5
decades fails to produce improved outcomes o Data Definition
Confusion o ROSC o Mortality Location o OOH/IH o Mortality
Time
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- Epidemiology o Physiologic Phases of Post Cardiac Arrest Care o
Immediate = 0-20 minutes o CPR interventions o Early = 20 minutes 6
to 12 hours o Early interventions most effective o Intermediate = 6
to 12 hours 72 hours o Aggressive management of Injury pathways o
Recovery = beyond 3 days o Prognostication Reliable o Outcomes
Predictable
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- Epidemiology o Mortality Rates Inadequate o Neurologic and
Functional Outcomes o Cerebral Performance Category
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- Epidemiology Quality of Life? o Limitation and Withdrawal of
Therapy o 63% made DNR, 43% withdrew Therapy in Early and
Intermediate time periods
- Brain Injury o Protracted Injury Phase opens Broad Therapeutic
Window o Cerebral Perfusion becomes dependent upon CePP not
Autoregulation or Neuronal Activity o Migratory Intravascular
Thrombosis with CPR > 15 minutes (No Reflow) o Hyperemic Flow
increases Edema o Luxuriant Hyperperfusion o Excessive Oxygen Free
radical Formation
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- Brain Injury o Global CBF is reduced but adequate to meet
Oxidative Metabolic Demands in first 48 hours o Transient Edema
common post Arrest but rarely increases ICP o Delayed Edema
attributable to Ischemic Neurodegradation o Pyrexia o Poor Outcome
Increases with each degree > 37 0 C o Hyperglycemia o Common and
Potentially Mitigated with Insulin Rx o Seizures o Associated with
Worst Prognosis o -- Caused by and Exacerbates Injury
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- Myocardial Dysfunction o Responsive to Therapy and Reversible o
Detectible within minutes of ROSC o Decreased EF (stunned) o
Increased LVEDP (stiff) o Coronary Blood Flow Normal = Myocardial
Stunning o Nadir @ 8 Hrs, Improve @ 24 Hrs, Normal @ 72+ Hrs o
Dobutamine improves LVEF and Diastolic Dysfunction
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- Systemic Response o CPR generates poor Cardiac Output, O 2
delivery, and Metabolite Clearance o Oxygen Debt leads to
Endothelial Activation and Systemic Inflammation o Predictive of
MOSF and Death o Common Sepsis Features o Adrenal Insufficiency o
Responsive to Therapy and Reversible o Early Goal Directed Therapy
may Optimize Outcomes
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- Persistent Pathology o Precipitating or Contributory Pathology
o ACS o AMI >50% OOH Adult Arrests o 48% Acute Coronary
Occlusion w/o apparent STEMI o Biomarker Specificity Reduced yet
96% Sensitive for AMI
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- Persistent Pathology o Precipitating or Contributory Pathology
o Pulmonary Embolism o Up to 10% Incidence in Sudden Death o
Unknown ROSC Rate o COPD, Asthma, or Pneumonia o Pulmonary Function
often Worsens post ROSC o Brain Injury and Edema more common after
Asphyxic Arrest o Sepsis o Infections more common cause of In
Hospital Arrests o Toxins o Environmental
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- Therapeutic Strategy o Critical Care Standards for EMS and ED o
Time Sensitive o Account for In/Out of Hospital Settings o
Sequential care by multiple Diverse Teams o Accommodate Spectrum of
patients o Awake, Stable to Unstable Comatose
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- Out-of-Hospital Cardiac Arrest Survival after the Sequential
Implementation of 2005 AHA Guidelines for Compressions,
Ventilations, and Induced Hypothermia J. Brent Myers, MD MPH
Medical Director Wake County EMS System 4.6% 7.3% 8.2% 11.6% * when
compared with baseline P 100 mmHg w/i 5 minutes of ROSC Bad o
Cerebral perfusion dependant on MAP in Early Phase o No Reflow
Phenomenon may require 90-100 mmHg Range o AMI or Myocardial
Stunning maybe better at 65-75 mmHg Range
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- Optimal Hemodynamics o Post Cardiac Arrest Syndrome shares
Characteristics with Sepsis o EGDT in Post Cardiac Arrest Syndrome
o Optimal CVP 8 12 mmHg o Relative Intravascular Volume Depletion
Exists post ROSC o Account for Pathologies causing Elevated CVPs o
Cardiac Tamponade o RV Infarct o PE o Tension PTX o Poor Myocardial
Compliance
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- Circulation Support o Hemodynamic instability manifests as
Dysrhythmias, Hypotension, and poor Stroke Volume/Output o Early
Reperfusion is Best AntiArhythmic Therapy o Optimize RV Filling
Pressures 8 -12 mmHG o 3.5 6.5 Lt First 24 hours o
Inotropes/Vasopressors After Volume Correction o Pressor Dependence
up to 72 hours o Select Inotropes by BP, HR, CO, and S v O 2 o
Dopamine??
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- Therapeutic Hypothermia o The Only Post Cardiac Arrest Therapy
Show to Increase Survival o Ongoing Evaluation of benefit in
Patient Populations, Induction Techniques, Target Temperature,
Duration of Therapy, and Rewarming Techniques. o Benefit Related to
Time of Initiation of Therapy o Induction o IV Fluids and Cooling
Pads o Maintenance o Cooling Pads and Catheters o ReWarming o 0.25
0 C 0.5 0 C/hr Current Consensus
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- Therapeutic Hypothermia
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- Sedation and Paralysis o Indicated for Failure to return to
Awake Status w/i 5-10 minutes Post ROSC o Sedation reduces oxygen
Consumption o Opoids and Hypnotics Required o EEG Monitoring for
Sustained Neuromuscular Blockade
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- Seizures o Increases Cerebral Metabolism 3 Fold o Exclude ICH
& Electrolyte Imbalance o Myoclonus o Difficult to Control o
Phenytoin Ineffective o Clonazepam most Effective o Improved
Outcomes with Hypothermia despite Severe post Arrest Status
Epilepticus
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- Prognostication o Pre-Cardiac Arrest Factors o Many Factors
Associated with Poor Outcome o Advanced Age o Race o Poor
Pre-Arrest health o Diabetes o Sepsis o Metastatic cancer o Renal
failure o Homebound Status o Stroke o APACHE II & III Scores o
None are Reliable Predictors
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- Prognostication o Intra-Cardiac Arrest Factors o Factors
Associated with Poor ROSC o Time To CPR o Duration of CPR o Quality
of CPR o Maximum ETCO 2 < 10 mmHg o Asystole o Non cardiac
Causes o None are Reliable Predictors Post ROSC
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- Prognostication o PostCardiac Arrest Factors o Retention of
Neurologic Function Immediately after ROSC Best Predictor o Absence
of Neurologic Function Immediately after ROSC is Not a Reliable
predictor of Poor Outcome o Reliable Predictors occur at 72
Hours
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- Prognostication In the Age of Hypothermia o Therapeutic
Hypothermia Improves Survival and Functional Outcome for 1 in every
6 Cardiac Arrest Survivors treated (NNT=6) o Alters Progression of
Neurological Injury o Changes the Evolution of Recovery o Changes
in Timing and Interpretations are Needed o Do Not Withdraw Support
Prematurely
- Slide 46
- Implementation o Clinical Guidelines Dont Change Practice o
Barriers o Structural o Human and Financial Resources o
Organizational o Leadership o Scientific o Personal o Intellectual
o Attitudinal o Motivation o Environmental o Political o Economic o
Cultural o Social
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- Implementation Protocol changes drop/downplay Epi Vasopressin
early and repeat accept Pox 96-98% Follow eTCO2 Aim for MAP
65-95mmHg Volume resuscitate Dobutamine over Dopamine Induce
Hypothermia Educate colleagues Demand Outcomes Transport to
Resuscitation centers
- Slide 48
- Questions o What Will You Do Different Monday?