A 55 year old business man collapses at work.This is witnessed by his colleagues who find him pulseless.They initiate CPR and call 911.
EMS arrive 5 minutes later.They confirm the pulseless state and place the patient on a monitor; he is in V. Fib.Standard ACLS protocols are initiated; the patient is intubated and transported to the closest ED.
The patient arrives at the ED 7 minutes later.He has received 2 doses of Epinephrine and one dose of Atropine.He has received 2 shocks and is currently in PEA arrest.
In the ERP confirms ETT placement, the rhythm of PEA, and performs a quick bedside ECHO, all the while continuing with CPR.The ECHO shows cardiac motion.
The patient is given another dose of Epinephrine and Atropine.By 6 minutes of his arrival, he is noted to have Return of Spontaneous Circulation and to have reverted to NSR.
Quick exam reveals: A: ETT in place.B:GBS x2.+ve ETCO2 Capnography. C: As above. N HS. D:GCS of 3T, absent gag/corneal/papillary response.E:Nothing obvious.And no calf edema.
Past medical history reveals a 30 pack-year smoking history.He is on no meds and has no known drug allergies.He is known to travel abroad frequently with his work.
5. Question 1
Please define Post-Cardiac Arrest Syndrome and its 4 pathophysiologic components. (Erik)
Post-cardiac arrest syndrome is a unique and complex combination of pathophysiological processes, which include
post-cardiac arrest brain injury,
post-cardiac arrest myocardial dysfunction, and
systemic ischemia/reperfusion response.
This state is often complicated by a fourth component:
4.the unresolved pathological process that caused the cardiac arrest.
7. Phases for Therapy & for Science
The immediate post-arrest phase could be defined as the first 20 minutes after ROSC.
The early post-arrest phase could be defined as the period between 20 minutes and 6 to 12 hours after ROSC, when early interventions might be most effective.
An intermediate phase might be between 6 to 12 hours and 72 hours, when injury pathways are still active and aggressive treatment is typically instituted.
Finally, a period beyond 3 days could be considered the recovery phase, when prognostication becomes more reliable and ultimate outcomes are more predictable.
The 4 key components of post-cardiac arrest syndrome are:
post-cardiac arrest brain injury,
post-cardiac arrest myocardial dysfunction,
systemic ischemia/reperfusion response, and
persistent precipitating pathology.
The unique features of post-cardiac arrest pathophysiology are often superimposed on the disease or injury that caused the cardiac arrest, as well as underlying comorbidities.
Therapies that focus on individual organs may compromise other injured organ systems.
The severity of these disorders after ROSC is not uniform and will vary in individual patients based on the severity of the ischemic insult, the cause of cardiac arrest, and the patients pre-arrest state of health.
10. 11. Foundation on which to grow
In a study of dogs with induced cardiac arrest
In a single observational human study
Biochemical and neurohormonal models suggest
A growing body of evidence
These findings suggest, in theory, that
These findings do not rule out the potential effect of
Limited evidence is available to guide
12. Forrest through the trees 13. Fundamentals
Who remembers 5:1, 15:2, 30:2, 10:1, vs continuous? (AHA, ACC, ILCOR)
ETT vs supraglottic device? (AHA, ACC, ILCOR)
BLS plus AED vs ACLS (OPALS, PAD)
Push hard, push fast, push often!(ROC-BC)
14. Question 2
How do you treat Post-Cardiac Arrest Syndrome. (Federico)
Early HD optimization
No evidence based guidelines
Suggestion is to have a similar approach as EGDT for Sepsis
MAP goals undefined
Loss of Cerebral Autoregulation
CPP dependent on MAP
ICP generally not elevated
MAP Goals >65, 37C--> poor neuro outcomes), all patients
22. Bernard, 2002, NEJM 23. HACA, 2002, NEJM 24. What are the parameters of cooling protocol?
Target core temp: 33C, or 32-34C
Onset: variable, ASAP (2-8 Hr, up to 24Hr)
Duration: 12-24 Hr
Further data required
25. Complications of TH
Technical: Shivering, use of ongoing sedation and NMB, to prevent shivering (with 30% dec clearance with T=34C), fluctuations of temp
HD: inc SVR, dec COP, arrhythmias (esp brady)
Diuresis, hypovolemia, dec K, Ca, Mg, PO4 --> arrhythmia
MgSO4: NMDA blocker, so dec shivering, vasodilator, so facilitate cooling induction, antiarrhythmic, and ? additive Neuroprotective (animal data)
Impaired glucose tolerance (dec insulin level and sensitivity)
Lower immunity--> infections
Higher pneumonias in TH group in HACA, but NS
27. Should we cool this patient?
Yes! Out-of-hospital VF arrest
28. Question 4
His wife has just arrived with his 3 kids (16, 15, and 9 years old).They want to know what his prognosis is.What do you tell them and how do you prognosticate patients post arrest?Please discuss clinical and lab findingsand imaging modalities.Would things be looked at differently if he was cooled? (Neil)
29. .What do you tell them and how do you prognosticate patients post arrest?
What is a poor outcome?
Very difficult to prognosticate in the first 24 hours
Most evidence is derived on testing at 72 hours
Therapeutic hypothermia changes the timeline
31. What is a poor outcome? 32. What is a poor outcome?
Poor outcome is defined as death, unconsciousness after one month, or unconsciousness or severe disability after six months.
33. Clinical signs
Absence of pupillary light reflexes
100% specificity in meta analysis
LR+ 10.5 (CI 2.1-52.4)
Absence of motor response to pain
100% specificity in meta analysis
LR+ 16.8 (CI 3.4 84.1)
Myoclonic status epilepticus
Can be predictive early
Much worse than SE
34. Clinical Signs
Which are not good prognositcators
Cause of arrest
Type of arrhythmia
Total arrest time
Duration of CPR
35. 36. EEG
Overall prognostication ability is not strong
Variety of studies have looked into it
Lack of a standardized classification system
Nonreactive alpha and theta patterns
Generalized periodic complexes
Tests integrity of the neuronal pathways from peripheral nerve, spinal cord, brainstem, and cerebral cortex
Best studied waveform
Robust as it is not strongly influence by medsand metabolic derangements
LR+12 (CI 5.3-27.6)
39. 40. Biomarkers
Dead brain releases biomarkers
3 have been well studied
Neuron specific enolase (NSE)
Creatinine kinase BB isoenzyme(CK-BB)
41. 42. Imaging
Although not strong enough to prognosticate reliably,a bad scan is a bad scan
Problem lies in that a good scan may not be a good scan
43. 44. 45. Question 5
His EKG shows normal sinus rhythm with non-specific changes.Should he go to the cath lab?If so, what are the recommendations for cath post cardiac arrest?If he arrested again, would you thrombolyse him?What is the etiology of the vast majority of cardiac arrests? (Noamie)
His EKG shows normal sinus rhythm with non-specific changes.Should he go to the cath lab?
If so, what are the recommendations for cath post cardiac arrest?
If he arrested again, would you thrombolyse him?
What is the etiology of the vast majority of cardiac arrests?
47. Etiology of cardiac arrests 48. 65-70 % 10% 5-10% 15 to 35% 49. Etiology of Sudden Cardiac Death
Age < 20:
Myocarditis (22%), HCM (22%) and conduction system abnormalities (13%)
CAD (24%), myocarditis (22%) and
CAD (58%), myocarditis (11%).
Am J Cardiol 1991;689(13):1388-1392 50. Should he go to the cath lab?
Even if no evidence of an ACS, need to exclude stable/chronic CAD
Sudden cardiac arrest may be first indication of CAD
But, does he need it rightnow ?
Pt post cardiac arrest btw 30-75
Immediate cath if no obvious non-cardiac cause
1st rhythm recorded: 93% VF/VT
84% had 0 or 1 cardiac RF
71% had clinically significant CAD
NEJM 1997;336:1629-1633 52.
poor predictive value of CP and ECG changes for coronary-artery occlusion.
53. Recommendations for cath post cardiac arrest 54. Recommendations
Recommendations for Coronary Angiography in Patients With Known or Suspected CAD Who Are Currently Asymptomatic or Have Stable Angina.
Class I:Patients who have been successfully resuscitated from sudden cardiac death or have sustained (>30 s) monomorphic ventricular tachycardia or nonsustained (