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1
Controversies in
Post Resuscitation
After Cardiac Arrest
Andrea Gabrielli MD FCCM Departments of Anesthesiology and Surgery
Division of Critical Care Medicine
University of Florida
More News About Gainesville FL
bull 124354 souls
bull 2007 Best place to live and play in USA
ndash 2009 UF ranked 1 party school
ndash 2009 UF ranked 1 lowest number of hours
that students study
ndash Local marijuana is called ldquoGainesville Greenrdquo
and is the most potent strain growing in USA
No Conflicts of Interest
(Member ACLS subcommittee AHA-ECC) The Bow Tie Concept ldquoTierdquo
Evidence Based Medicine
Van de Wouw JACC 199730(3)780
PubMed End of 2013 16000 + manuscripts on CPR
500 + manuscripts on post ROSC care
3
Human Randomized Controlled 18 Human Clinical 34
Meta Analysis Practice Guidelines Review Systematic Reviews 200
1
2
Post Resuscitation Care
Epidemiology of CA bull 200000 out of hospital survival 8
bull Sudden Cardiac Death (Coronary) at least frac12
but still not well defined
bull 200000 in hospital survival 22
Merchant 2011 Nov39(11) 2401-6
Kong JACC 2011 57(7) 794
Grasner Eur H J 2011 (32) 1649 Girotra NEJM 20123671912-20
302 hypothermia
0
10
20
30
40
50
60
70
80
DC post ROSC Neuro OK (CPC 1-2)
Adults
NRCPR Data From About 400 US Hospitals
Larkin Resuscitation Volume 81 Issue 3 March 2010 Pages 302-311
Death or PVS Coma for at least a week
23
Cardiac Arrest and Post ROSC State
bull Cardiac Arrest is an
EVENT
ndash Dysrhythmic
ndash Asphyxial
bull CPR is the
Therapeutic Approach
to Cardiac Arrest
ndash Cardiovascular
recovery
ndash Brain recovery
bull Post ROSC is a
SYNDROME
1 Systemic
inflammatory response
triggered by
ischemiareperfusion
process
2 Brain injury
3 Myocardial
Dysfunction
4 ldquoOtherrdquo MOSF from
preexisting precipitating
pathology
2010 AHA
Guidelines
Post-ROSC Care An Opportunity to
Improve Outcome From Cardiac Arrest
bull Cerebral Protection
ndash Hypothermia and CMRO2
ndash CDO2 (CBF)
ndash O2 CO2 and Cerebro-Cardio-Pulmonary-Interactions
ndash ROSC Attack vs Head CT ROSC Attack
bull Cardiovascular Support
ndash PCI post-ROSC
ndash Myocardial dysfunction
bull Neurological prognostication
bull Systems of Care for post ROSC patients
3
Cardiac Arrest in 3 Phases
Weisfeld and Becker JAMA 2002 Rosomoff HL Ann Surg 1954 (179)85-88
Hypothermia and CMRO2
Peter Safar MD
Cardiac Arrest and Hypothermia
NEUROLOGICAL OUTCOME
0
10
20
30
40
50
60
Favorable
neuro
outcome
Death
Hypothermia
Normothermia
(p 0009 RR 140) (p 002 RR 074)
The Hypothermia after Cardiac Arrest Study Group
Mild therapeutic hypothermia to improve neurologic outcome after cardiac arrest
N Engl J Med 2002346549-556
Bernard SA Gray TW Buist MD et al
Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia
N Engl J Med 2002346557-63 Weisfeld and Becker JAMA 2002
Who is eligible A Case for the The ldquo Non Shockablerdquo Patient
1 A 60 yold with hypoxemic 15 minutes
PEA arrest from treating the ldquo6thrdquo vital sign
on a surgical floor Resuscitated -
transported in the ICU
2 A 60 y old patient with STEMI R
Ventricular MI followed by asystole
resolved after 20 minutes of CPR ACLS
protocol
Both pts 10 Min after ROSC occasionally
move spontaneously and are only
localizing to pain No evidence of seizure
Who is NOT going to survive
Acta Anaesthesioloica Scandinava 201357784-792
CMAJ Oct 4 2011183-14
4
Pulmonary Hypertension and Cardiac Arrest
Unlikely Long Term Survival
Hoeper AmJRCCM 2002165341-344
TH for PEA Small Case Series
Testori Resuscitation 2011 82 (9) 1162
OR184
TH and Non Shockable OOH
Dumas Circulation 2011123877-866
VFVT
PEA
Asystole
Soga T et al Circulation Journal 2012
All Comers
Post STEMI
2524 Perioperative CA in 234 Hospitals
Ramachandran SK et al Anesthesiology V119 (6) 2013
Can You Cool Here No Arguments Move Quickly
bull Persistent hypotension
bull Type of Rhythm
bull Pregnancy
bull Severe pre-admission morbidity
bull Age
bull Active bleeding Take care of it quickly but use common sense for contraindications
bull Reverse your anesthetic to assess neurological status Use Common Sense probably no
bull Cool ASAP but you have 4 hours time to get things organized by literature criteria (VF)
Polderman KH Crit Care 2007
5
TH How Soon and How Long 148 Hours Start and 24 vs 48 h Duration
Wolff International J Cardiol 2009 133 (2) 223
Best Way to Cool
Figure 1 Surface vs Endovascular
162 Patients 2003-8
Tomte CCM 2011 39(3)443
TH
1How soon
2How long
1 ASAP There is a Trauma STEMI and Stroke
alarm there should be a ROSC alarm
2 No human data Stay Tuned
An Automatic Cooling Device
Probably Improves Outcome
Which Device it is Unclear
How Deep Should I Cool 32 C By Evidence in Shockable Rhythm
6
bull Large study (950 pts)
bull 20 non shockable pts
bull Fever avoided X 3 days after rewarming
NEJM 20133692197-06
COLD Team STAT to the ED
EMTs Delivered a Post ROSC
V Fib Patient Ready for
Hypothermia
The patientrsquos wife tells you he had
sudden severe headache before
ldquogoing downrdquo
Post ROSC Head CT Scan CT pre TH and Prognostication
High sensitivity
Low Specificity
May Delay the TH Induction Process but
Good Info to RO Cerebral Pathology
bull SAH and OOHCA 4-15
bull Usually PEA Asystole
bull Unlikely survivable
Misuma Resuscitation 2011 82(10) 1294
In the ICU on Low dose Epinephrine
(BPS 80 mmHg) Cardiac Echo Global
LV Dysfunction EF 45
What pressure Doc
Cerebral Blood Flow After Cardiac Arrest
Sasser HC CCM 1999 Vol 27 No 12 A 29
7
BP post ROSC
Retrospective 2 hours after CA
Mullner M Stroke 19962759
Autoregulation in Cardiac Arrest
Sundgreen C Stroke 200132128-132
Pressure Cerebro-vascular
Reactivity Index and TCD
Lang EW J Neurol Neurosusg Psychiatry 2003741053-1059
Howells T J Neurosurg 102(2)317-7
Blood Pressure Goal May be the highest the L Ventricle can
tolerate without the risk of more cerebral
edema or myocardial dysfunction
MAP 80 + mmHg
NorepiEpi + Dobutamine
O2 Sat is 90 O2 during CA vs post ROSC
Pitcher Resuscitation 83 (4) 417-4222012
Kilgannon J JAMA 2010303(21) 2155-2171
Spindelboeck Resuscitation 84(2013)770-775
8
What PaCO2
0
200
250
20 40 100 80 60 PaCO2
PaCO2
0
50
100
150
PaCO2
Normal Individuals
CB
F
Leave the CO2 Alone
Cottrell JE Anesthesia and
Neurosurgery 3rd ed p23
Michard et al
Am J Respir Crit Care Med 159935-9 1999
To Cath or Not to Cath
STEMI and Cardiac Arrest
Post ROSC Head CT Scan STEMI and CA A Review
Kern K Cath and Cardiovascular Interv 75616-6242010
Survival
No
Hypothermia
60 (87 good outcome)
Hypothermia 70 (81 neuro intact)
9
STEMI and CA
The Real Controversy
Impact of Expected Increases Mortality
of the Cath Lab on Hospital $
Circulation 2013128762-773
What is a ldquoGood Outcomerdquo
Poor Agreement Between Currently
Used Estimates of ldquoGood Outcomerdquo
Rittenberger Resuscitation 2001 82(2011)1036
Neurological Prognostication
Post ROSC
bull Monitoring injury
bull Monitoring recovery
ndash Neuro exam
ndash Biomarkers
ndash EEG
ndash Neuroimaging
ndash SSEP Cortical Response
GCS 5
Neuro Exam + Severity Score 72 h post ROSC
Rittenberger JCResuscitation 2011 Nov82(11)1399-404
72
h No Survival
Rittenberger JC Resuscitation
2010 Nov81(10)1128-1132
+ SOFA
Myoclonic Status post ROSC
No Survival
English Anesthesia 2009 64908
Tomte Resuscitation 2011 Sep82(9)1186-93
10
EEG EKG
Drs Thomas Bleck and
Paul Vespa
UCLA Neuromeeting 2010
CT GWR (GrayWhite Ratio)
Inamasu J
Resuscitation 2010 (81)534
Torbey Stroke 2000312163
MRI
(Cortical and Basal Findings)
Post ROSC DWI MRI 72h and Outcome at 3 months
Highly sensitive (98) and poorly specific (462)
OK
NeuroCC Gree D 2012 17(2) 240-4
FOCAL 30 Survival DIFFUSE 7 survival
Beyond the EGG
(SSEP N2) Median Nerve response
bull Performed day 3-5 days of persistent coma
post hypothermia
Leithner Neurology 201074965-69
Withdrawal of Care in Most of the Studies is
Between 60 to 80 ROSC 48 Hours Day 3 and Beyond
Awaken
Neuro
Exam
Brain Death Persistent Vegetative State
MSE
COMA
Absent
N2O
Support
Withdrawal
11
My Hospital is Better Than Yours Resuscitation ldquoBest Standardsrdquo + Hypothermia
Ullevan University Oslo
Sunde Resuscitation 2007 7329-39
Better Survival
Better Neuro Outcome p lt 0001
Post ROSC Resuscitation Center of Excellence
Requirements
bull Strong EMS System short transit time
bull ROSC ALARM 247 therapeutic
hypothermia
bull STEMICA ROSC ALARM for PCI
bull ICU best evidence based practice
EMS+ED+Cardiac Cath+CCUICUNICU+Administration
Nichols G COCC 2010 16223-30
Conclusions Post-ROSC Care
bull Cerebral Protection
ndash Hypothermia and CMRO2
ndash CDO2 (CBF)
ndash O2 CO2 and Cerebro-Cardio-Pulmonary-Interactions
ndash ROSC Attack vs Head CT ROSC Attack
ndash Monitoring the close box
bull Cardiovascular Support
ndash PCI post-ROSC
ndash Myocardial dysfunction
bull Neurological prognostication
bull Systems of Care for post ROSC patients
For Those in Cardiac Arrest
The Future is Bright
TERIMA KASIH
2
Post Resuscitation Care
Epidemiology of CA bull 200000 out of hospital survival 8
bull Sudden Cardiac Death (Coronary) at least frac12
but still not well defined
bull 200000 in hospital survival 22
Merchant 2011 Nov39(11) 2401-6
Kong JACC 2011 57(7) 794
Grasner Eur H J 2011 (32) 1649 Girotra NEJM 20123671912-20
302 hypothermia
0
10
20
30
40
50
60
70
80
DC post ROSC Neuro OK (CPC 1-2)
Adults
NRCPR Data From About 400 US Hospitals
Larkin Resuscitation Volume 81 Issue 3 March 2010 Pages 302-311
Death or PVS Coma for at least a week
23
Cardiac Arrest and Post ROSC State
bull Cardiac Arrest is an
EVENT
ndash Dysrhythmic
ndash Asphyxial
bull CPR is the
Therapeutic Approach
to Cardiac Arrest
ndash Cardiovascular
recovery
ndash Brain recovery
bull Post ROSC is a
SYNDROME
1 Systemic
inflammatory response
triggered by
ischemiareperfusion
process
2 Brain injury
3 Myocardial
Dysfunction
4 ldquoOtherrdquo MOSF from
preexisting precipitating
pathology
2010 AHA
Guidelines
Post-ROSC Care An Opportunity to
Improve Outcome From Cardiac Arrest
bull Cerebral Protection
ndash Hypothermia and CMRO2
ndash CDO2 (CBF)
ndash O2 CO2 and Cerebro-Cardio-Pulmonary-Interactions
ndash ROSC Attack vs Head CT ROSC Attack
bull Cardiovascular Support
ndash PCI post-ROSC
ndash Myocardial dysfunction
bull Neurological prognostication
bull Systems of Care for post ROSC patients
3
Cardiac Arrest in 3 Phases
Weisfeld and Becker JAMA 2002 Rosomoff HL Ann Surg 1954 (179)85-88
Hypothermia and CMRO2
Peter Safar MD
Cardiac Arrest and Hypothermia
NEUROLOGICAL OUTCOME
0
10
20
30
40
50
60
Favorable
neuro
outcome
Death
Hypothermia
Normothermia
(p 0009 RR 140) (p 002 RR 074)
The Hypothermia after Cardiac Arrest Study Group
Mild therapeutic hypothermia to improve neurologic outcome after cardiac arrest
N Engl J Med 2002346549-556
Bernard SA Gray TW Buist MD et al
Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia
N Engl J Med 2002346557-63 Weisfeld and Becker JAMA 2002
Who is eligible A Case for the The ldquo Non Shockablerdquo Patient
1 A 60 yold with hypoxemic 15 minutes
PEA arrest from treating the ldquo6thrdquo vital sign
on a surgical floor Resuscitated -
transported in the ICU
2 A 60 y old patient with STEMI R
Ventricular MI followed by asystole
resolved after 20 minutes of CPR ACLS
protocol
Both pts 10 Min after ROSC occasionally
move spontaneously and are only
localizing to pain No evidence of seizure
Who is NOT going to survive
Acta Anaesthesioloica Scandinava 201357784-792
CMAJ Oct 4 2011183-14
4
Pulmonary Hypertension and Cardiac Arrest
Unlikely Long Term Survival
Hoeper AmJRCCM 2002165341-344
TH for PEA Small Case Series
Testori Resuscitation 2011 82 (9) 1162
OR184
TH and Non Shockable OOH
Dumas Circulation 2011123877-866
VFVT
PEA
Asystole
Soga T et al Circulation Journal 2012
All Comers
Post STEMI
2524 Perioperative CA in 234 Hospitals
Ramachandran SK et al Anesthesiology V119 (6) 2013
Can You Cool Here No Arguments Move Quickly
bull Persistent hypotension
bull Type of Rhythm
bull Pregnancy
bull Severe pre-admission morbidity
bull Age
bull Active bleeding Take care of it quickly but use common sense for contraindications
bull Reverse your anesthetic to assess neurological status Use Common Sense probably no
bull Cool ASAP but you have 4 hours time to get things organized by literature criteria (VF)
Polderman KH Crit Care 2007
5
TH How Soon and How Long 148 Hours Start and 24 vs 48 h Duration
Wolff International J Cardiol 2009 133 (2) 223
Best Way to Cool
Figure 1 Surface vs Endovascular
162 Patients 2003-8
Tomte CCM 2011 39(3)443
TH
1How soon
2How long
1 ASAP There is a Trauma STEMI and Stroke
alarm there should be a ROSC alarm
2 No human data Stay Tuned
An Automatic Cooling Device
Probably Improves Outcome
Which Device it is Unclear
How Deep Should I Cool 32 C By Evidence in Shockable Rhythm
6
bull Large study (950 pts)
bull 20 non shockable pts
bull Fever avoided X 3 days after rewarming
NEJM 20133692197-06
COLD Team STAT to the ED
EMTs Delivered a Post ROSC
V Fib Patient Ready for
Hypothermia
The patientrsquos wife tells you he had
sudden severe headache before
ldquogoing downrdquo
Post ROSC Head CT Scan CT pre TH and Prognostication
High sensitivity
Low Specificity
May Delay the TH Induction Process but
Good Info to RO Cerebral Pathology
bull SAH and OOHCA 4-15
bull Usually PEA Asystole
bull Unlikely survivable
Misuma Resuscitation 2011 82(10) 1294
In the ICU on Low dose Epinephrine
(BPS 80 mmHg) Cardiac Echo Global
LV Dysfunction EF 45
What pressure Doc
Cerebral Blood Flow After Cardiac Arrest
Sasser HC CCM 1999 Vol 27 No 12 A 29
7
BP post ROSC
Retrospective 2 hours after CA
Mullner M Stroke 19962759
Autoregulation in Cardiac Arrest
Sundgreen C Stroke 200132128-132
Pressure Cerebro-vascular
Reactivity Index and TCD
Lang EW J Neurol Neurosusg Psychiatry 2003741053-1059
Howells T J Neurosurg 102(2)317-7
Blood Pressure Goal May be the highest the L Ventricle can
tolerate without the risk of more cerebral
edema or myocardial dysfunction
MAP 80 + mmHg
NorepiEpi + Dobutamine
O2 Sat is 90 O2 during CA vs post ROSC
Pitcher Resuscitation 83 (4) 417-4222012
Kilgannon J JAMA 2010303(21) 2155-2171
Spindelboeck Resuscitation 84(2013)770-775
8
What PaCO2
0
200
250
20 40 100 80 60 PaCO2
PaCO2
0
50
100
150
PaCO2
Normal Individuals
CB
F
Leave the CO2 Alone
Cottrell JE Anesthesia and
Neurosurgery 3rd ed p23
Michard et al
Am J Respir Crit Care Med 159935-9 1999
To Cath or Not to Cath
STEMI and Cardiac Arrest
Post ROSC Head CT Scan STEMI and CA A Review
Kern K Cath and Cardiovascular Interv 75616-6242010
Survival
No
Hypothermia
60 (87 good outcome)
Hypothermia 70 (81 neuro intact)
9
STEMI and CA
The Real Controversy
Impact of Expected Increases Mortality
of the Cath Lab on Hospital $
Circulation 2013128762-773
What is a ldquoGood Outcomerdquo
Poor Agreement Between Currently
Used Estimates of ldquoGood Outcomerdquo
Rittenberger Resuscitation 2001 82(2011)1036
Neurological Prognostication
Post ROSC
bull Monitoring injury
bull Monitoring recovery
ndash Neuro exam
ndash Biomarkers
ndash EEG
ndash Neuroimaging
ndash SSEP Cortical Response
GCS 5
Neuro Exam + Severity Score 72 h post ROSC
Rittenberger JCResuscitation 2011 Nov82(11)1399-404
72
h No Survival
Rittenberger JC Resuscitation
2010 Nov81(10)1128-1132
+ SOFA
Myoclonic Status post ROSC
No Survival
English Anesthesia 2009 64908
Tomte Resuscitation 2011 Sep82(9)1186-93
10
EEG EKG
Drs Thomas Bleck and
Paul Vespa
UCLA Neuromeeting 2010
CT GWR (GrayWhite Ratio)
Inamasu J
Resuscitation 2010 (81)534
Torbey Stroke 2000312163
MRI
(Cortical and Basal Findings)
Post ROSC DWI MRI 72h and Outcome at 3 months
Highly sensitive (98) and poorly specific (462)
OK
NeuroCC Gree D 2012 17(2) 240-4
FOCAL 30 Survival DIFFUSE 7 survival
Beyond the EGG
(SSEP N2) Median Nerve response
bull Performed day 3-5 days of persistent coma
post hypothermia
Leithner Neurology 201074965-69
Withdrawal of Care in Most of the Studies is
Between 60 to 80 ROSC 48 Hours Day 3 and Beyond
Awaken
Neuro
Exam
Brain Death Persistent Vegetative State
MSE
COMA
Absent
N2O
Support
Withdrawal
11
My Hospital is Better Than Yours Resuscitation ldquoBest Standardsrdquo + Hypothermia
Ullevan University Oslo
Sunde Resuscitation 2007 7329-39
Better Survival
Better Neuro Outcome p lt 0001
Post ROSC Resuscitation Center of Excellence
Requirements
bull Strong EMS System short transit time
bull ROSC ALARM 247 therapeutic
hypothermia
bull STEMICA ROSC ALARM for PCI
bull ICU best evidence based practice
EMS+ED+Cardiac Cath+CCUICUNICU+Administration
Nichols G COCC 2010 16223-30
Conclusions Post-ROSC Care
bull Cerebral Protection
ndash Hypothermia and CMRO2
ndash CDO2 (CBF)
ndash O2 CO2 and Cerebro-Cardio-Pulmonary-Interactions
ndash ROSC Attack vs Head CT ROSC Attack
ndash Monitoring the close box
bull Cardiovascular Support
ndash PCI post-ROSC
ndash Myocardial dysfunction
bull Neurological prognostication
bull Systems of Care for post ROSC patients
For Those in Cardiac Arrest
The Future is Bright
TERIMA KASIH
3
Cardiac Arrest in 3 Phases
Weisfeld and Becker JAMA 2002 Rosomoff HL Ann Surg 1954 (179)85-88
Hypothermia and CMRO2
Peter Safar MD
Cardiac Arrest and Hypothermia
NEUROLOGICAL OUTCOME
0
10
20
30
40
50
60
Favorable
neuro
outcome
Death
Hypothermia
Normothermia
(p 0009 RR 140) (p 002 RR 074)
The Hypothermia after Cardiac Arrest Study Group
Mild therapeutic hypothermia to improve neurologic outcome after cardiac arrest
N Engl J Med 2002346549-556
Bernard SA Gray TW Buist MD et al
Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia
N Engl J Med 2002346557-63 Weisfeld and Becker JAMA 2002
Who is eligible A Case for the The ldquo Non Shockablerdquo Patient
1 A 60 yold with hypoxemic 15 minutes
PEA arrest from treating the ldquo6thrdquo vital sign
on a surgical floor Resuscitated -
transported in the ICU
2 A 60 y old patient with STEMI R
Ventricular MI followed by asystole
resolved after 20 minutes of CPR ACLS
protocol
Both pts 10 Min after ROSC occasionally
move spontaneously and are only
localizing to pain No evidence of seizure
Who is NOT going to survive
Acta Anaesthesioloica Scandinava 201357784-792
CMAJ Oct 4 2011183-14
4
Pulmonary Hypertension and Cardiac Arrest
Unlikely Long Term Survival
Hoeper AmJRCCM 2002165341-344
TH for PEA Small Case Series
Testori Resuscitation 2011 82 (9) 1162
OR184
TH and Non Shockable OOH
Dumas Circulation 2011123877-866
VFVT
PEA
Asystole
Soga T et al Circulation Journal 2012
All Comers
Post STEMI
2524 Perioperative CA in 234 Hospitals
Ramachandran SK et al Anesthesiology V119 (6) 2013
Can You Cool Here No Arguments Move Quickly
bull Persistent hypotension
bull Type of Rhythm
bull Pregnancy
bull Severe pre-admission morbidity
bull Age
bull Active bleeding Take care of it quickly but use common sense for contraindications
bull Reverse your anesthetic to assess neurological status Use Common Sense probably no
bull Cool ASAP but you have 4 hours time to get things organized by literature criteria (VF)
Polderman KH Crit Care 2007
5
TH How Soon and How Long 148 Hours Start and 24 vs 48 h Duration
Wolff International J Cardiol 2009 133 (2) 223
Best Way to Cool
Figure 1 Surface vs Endovascular
162 Patients 2003-8
Tomte CCM 2011 39(3)443
TH
1How soon
2How long
1 ASAP There is a Trauma STEMI and Stroke
alarm there should be a ROSC alarm
2 No human data Stay Tuned
An Automatic Cooling Device
Probably Improves Outcome
Which Device it is Unclear
How Deep Should I Cool 32 C By Evidence in Shockable Rhythm
6
bull Large study (950 pts)
bull 20 non shockable pts
bull Fever avoided X 3 days after rewarming
NEJM 20133692197-06
COLD Team STAT to the ED
EMTs Delivered a Post ROSC
V Fib Patient Ready for
Hypothermia
The patientrsquos wife tells you he had
sudden severe headache before
ldquogoing downrdquo
Post ROSC Head CT Scan CT pre TH and Prognostication
High sensitivity
Low Specificity
May Delay the TH Induction Process but
Good Info to RO Cerebral Pathology
bull SAH and OOHCA 4-15
bull Usually PEA Asystole
bull Unlikely survivable
Misuma Resuscitation 2011 82(10) 1294
In the ICU on Low dose Epinephrine
(BPS 80 mmHg) Cardiac Echo Global
LV Dysfunction EF 45
What pressure Doc
Cerebral Blood Flow After Cardiac Arrest
Sasser HC CCM 1999 Vol 27 No 12 A 29
7
BP post ROSC
Retrospective 2 hours after CA
Mullner M Stroke 19962759
Autoregulation in Cardiac Arrest
Sundgreen C Stroke 200132128-132
Pressure Cerebro-vascular
Reactivity Index and TCD
Lang EW J Neurol Neurosusg Psychiatry 2003741053-1059
Howells T J Neurosurg 102(2)317-7
Blood Pressure Goal May be the highest the L Ventricle can
tolerate without the risk of more cerebral
edema or myocardial dysfunction
MAP 80 + mmHg
NorepiEpi + Dobutamine
O2 Sat is 90 O2 during CA vs post ROSC
Pitcher Resuscitation 83 (4) 417-4222012
Kilgannon J JAMA 2010303(21) 2155-2171
Spindelboeck Resuscitation 84(2013)770-775
8
What PaCO2
0
200
250
20 40 100 80 60 PaCO2
PaCO2
0
50
100
150
PaCO2
Normal Individuals
CB
F
Leave the CO2 Alone
Cottrell JE Anesthesia and
Neurosurgery 3rd ed p23
Michard et al
Am J Respir Crit Care Med 159935-9 1999
To Cath or Not to Cath
STEMI and Cardiac Arrest
Post ROSC Head CT Scan STEMI and CA A Review
Kern K Cath and Cardiovascular Interv 75616-6242010
Survival
No
Hypothermia
60 (87 good outcome)
Hypothermia 70 (81 neuro intact)
9
STEMI and CA
The Real Controversy
Impact of Expected Increases Mortality
of the Cath Lab on Hospital $
Circulation 2013128762-773
What is a ldquoGood Outcomerdquo
Poor Agreement Between Currently
Used Estimates of ldquoGood Outcomerdquo
Rittenberger Resuscitation 2001 82(2011)1036
Neurological Prognostication
Post ROSC
bull Monitoring injury
bull Monitoring recovery
ndash Neuro exam
ndash Biomarkers
ndash EEG
ndash Neuroimaging
ndash SSEP Cortical Response
GCS 5
Neuro Exam + Severity Score 72 h post ROSC
Rittenberger JCResuscitation 2011 Nov82(11)1399-404
72
h No Survival
Rittenberger JC Resuscitation
2010 Nov81(10)1128-1132
+ SOFA
Myoclonic Status post ROSC
No Survival
English Anesthesia 2009 64908
Tomte Resuscitation 2011 Sep82(9)1186-93
10
EEG EKG
Drs Thomas Bleck and
Paul Vespa
UCLA Neuromeeting 2010
CT GWR (GrayWhite Ratio)
Inamasu J
Resuscitation 2010 (81)534
Torbey Stroke 2000312163
MRI
(Cortical and Basal Findings)
Post ROSC DWI MRI 72h and Outcome at 3 months
Highly sensitive (98) and poorly specific (462)
OK
NeuroCC Gree D 2012 17(2) 240-4
FOCAL 30 Survival DIFFUSE 7 survival
Beyond the EGG
(SSEP N2) Median Nerve response
bull Performed day 3-5 days of persistent coma
post hypothermia
Leithner Neurology 201074965-69
Withdrawal of Care in Most of the Studies is
Between 60 to 80 ROSC 48 Hours Day 3 and Beyond
Awaken
Neuro
Exam
Brain Death Persistent Vegetative State
MSE
COMA
Absent
N2O
Support
Withdrawal
11
My Hospital is Better Than Yours Resuscitation ldquoBest Standardsrdquo + Hypothermia
Ullevan University Oslo
Sunde Resuscitation 2007 7329-39
Better Survival
Better Neuro Outcome p lt 0001
Post ROSC Resuscitation Center of Excellence
Requirements
bull Strong EMS System short transit time
bull ROSC ALARM 247 therapeutic
hypothermia
bull STEMICA ROSC ALARM for PCI
bull ICU best evidence based practice
EMS+ED+Cardiac Cath+CCUICUNICU+Administration
Nichols G COCC 2010 16223-30
Conclusions Post-ROSC Care
bull Cerebral Protection
ndash Hypothermia and CMRO2
ndash CDO2 (CBF)
ndash O2 CO2 and Cerebro-Cardio-Pulmonary-Interactions
ndash ROSC Attack vs Head CT ROSC Attack
ndash Monitoring the close box
bull Cardiovascular Support
ndash PCI post-ROSC
ndash Myocardial dysfunction
bull Neurological prognostication
bull Systems of Care for post ROSC patients
For Those in Cardiac Arrest
The Future is Bright
TERIMA KASIH
4
Pulmonary Hypertension and Cardiac Arrest
Unlikely Long Term Survival
Hoeper AmJRCCM 2002165341-344
TH for PEA Small Case Series
Testori Resuscitation 2011 82 (9) 1162
OR184
TH and Non Shockable OOH
Dumas Circulation 2011123877-866
VFVT
PEA
Asystole
Soga T et al Circulation Journal 2012
All Comers
Post STEMI
2524 Perioperative CA in 234 Hospitals
Ramachandran SK et al Anesthesiology V119 (6) 2013
Can You Cool Here No Arguments Move Quickly
bull Persistent hypotension
bull Type of Rhythm
bull Pregnancy
bull Severe pre-admission morbidity
bull Age
bull Active bleeding Take care of it quickly but use common sense for contraindications
bull Reverse your anesthetic to assess neurological status Use Common Sense probably no
bull Cool ASAP but you have 4 hours time to get things organized by literature criteria (VF)
Polderman KH Crit Care 2007
5
TH How Soon and How Long 148 Hours Start and 24 vs 48 h Duration
Wolff International J Cardiol 2009 133 (2) 223
Best Way to Cool
Figure 1 Surface vs Endovascular
162 Patients 2003-8
Tomte CCM 2011 39(3)443
TH
1How soon
2How long
1 ASAP There is a Trauma STEMI and Stroke
alarm there should be a ROSC alarm
2 No human data Stay Tuned
An Automatic Cooling Device
Probably Improves Outcome
Which Device it is Unclear
How Deep Should I Cool 32 C By Evidence in Shockable Rhythm
6
bull Large study (950 pts)
bull 20 non shockable pts
bull Fever avoided X 3 days after rewarming
NEJM 20133692197-06
COLD Team STAT to the ED
EMTs Delivered a Post ROSC
V Fib Patient Ready for
Hypothermia
The patientrsquos wife tells you he had
sudden severe headache before
ldquogoing downrdquo
Post ROSC Head CT Scan CT pre TH and Prognostication
High sensitivity
Low Specificity
May Delay the TH Induction Process but
Good Info to RO Cerebral Pathology
bull SAH and OOHCA 4-15
bull Usually PEA Asystole
bull Unlikely survivable
Misuma Resuscitation 2011 82(10) 1294
In the ICU on Low dose Epinephrine
(BPS 80 mmHg) Cardiac Echo Global
LV Dysfunction EF 45
What pressure Doc
Cerebral Blood Flow After Cardiac Arrest
Sasser HC CCM 1999 Vol 27 No 12 A 29
7
BP post ROSC
Retrospective 2 hours after CA
Mullner M Stroke 19962759
Autoregulation in Cardiac Arrest
Sundgreen C Stroke 200132128-132
Pressure Cerebro-vascular
Reactivity Index and TCD
Lang EW J Neurol Neurosusg Psychiatry 2003741053-1059
Howells T J Neurosurg 102(2)317-7
Blood Pressure Goal May be the highest the L Ventricle can
tolerate without the risk of more cerebral
edema or myocardial dysfunction
MAP 80 + mmHg
NorepiEpi + Dobutamine
O2 Sat is 90 O2 during CA vs post ROSC
Pitcher Resuscitation 83 (4) 417-4222012
Kilgannon J JAMA 2010303(21) 2155-2171
Spindelboeck Resuscitation 84(2013)770-775
8
What PaCO2
0
200
250
20 40 100 80 60 PaCO2
PaCO2
0
50
100
150
PaCO2
Normal Individuals
CB
F
Leave the CO2 Alone
Cottrell JE Anesthesia and
Neurosurgery 3rd ed p23
Michard et al
Am J Respir Crit Care Med 159935-9 1999
To Cath or Not to Cath
STEMI and Cardiac Arrest
Post ROSC Head CT Scan STEMI and CA A Review
Kern K Cath and Cardiovascular Interv 75616-6242010
Survival
No
Hypothermia
60 (87 good outcome)
Hypothermia 70 (81 neuro intact)
9
STEMI and CA
The Real Controversy
Impact of Expected Increases Mortality
of the Cath Lab on Hospital $
Circulation 2013128762-773
What is a ldquoGood Outcomerdquo
Poor Agreement Between Currently
Used Estimates of ldquoGood Outcomerdquo
Rittenberger Resuscitation 2001 82(2011)1036
Neurological Prognostication
Post ROSC
bull Monitoring injury
bull Monitoring recovery
ndash Neuro exam
ndash Biomarkers
ndash EEG
ndash Neuroimaging
ndash SSEP Cortical Response
GCS 5
Neuro Exam + Severity Score 72 h post ROSC
Rittenberger JCResuscitation 2011 Nov82(11)1399-404
72
h No Survival
Rittenberger JC Resuscitation
2010 Nov81(10)1128-1132
+ SOFA
Myoclonic Status post ROSC
No Survival
English Anesthesia 2009 64908
Tomte Resuscitation 2011 Sep82(9)1186-93
10
EEG EKG
Drs Thomas Bleck and
Paul Vespa
UCLA Neuromeeting 2010
CT GWR (GrayWhite Ratio)
Inamasu J
Resuscitation 2010 (81)534
Torbey Stroke 2000312163
MRI
(Cortical and Basal Findings)
Post ROSC DWI MRI 72h and Outcome at 3 months
Highly sensitive (98) and poorly specific (462)
OK
NeuroCC Gree D 2012 17(2) 240-4
FOCAL 30 Survival DIFFUSE 7 survival
Beyond the EGG
(SSEP N2) Median Nerve response
bull Performed day 3-5 days of persistent coma
post hypothermia
Leithner Neurology 201074965-69
Withdrawal of Care in Most of the Studies is
Between 60 to 80 ROSC 48 Hours Day 3 and Beyond
Awaken
Neuro
Exam
Brain Death Persistent Vegetative State
MSE
COMA
Absent
N2O
Support
Withdrawal
11
My Hospital is Better Than Yours Resuscitation ldquoBest Standardsrdquo + Hypothermia
Ullevan University Oslo
Sunde Resuscitation 2007 7329-39
Better Survival
Better Neuro Outcome p lt 0001
Post ROSC Resuscitation Center of Excellence
Requirements
bull Strong EMS System short transit time
bull ROSC ALARM 247 therapeutic
hypothermia
bull STEMICA ROSC ALARM for PCI
bull ICU best evidence based practice
EMS+ED+Cardiac Cath+CCUICUNICU+Administration
Nichols G COCC 2010 16223-30
Conclusions Post-ROSC Care
bull Cerebral Protection
ndash Hypothermia and CMRO2
ndash CDO2 (CBF)
ndash O2 CO2 and Cerebro-Cardio-Pulmonary-Interactions
ndash ROSC Attack vs Head CT ROSC Attack
ndash Monitoring the close box
bull Cardiovascular Support
ndash PCI post-ROSC
ndash Myocardial dysfunction
bull Neurological prognostication
bull Systems of Care for post ROSC patients
For Those in Cardiac Arrest
The Future is Bright
TERIMA KASIH
5
TH How Soon and How Long 148 Hours Start and 24 vs 48 h Duration
Wolff International J Cardiol 2009 133 (2) 223
Best Way to Cool
Figure 1 Surface vs Endovascular
162 Patients 2003-8
Tomte CCM 2011 39(3)443
TH
1How soon
2How long
1 ASAP There is a Trauma STEMI and Stroke
alarm there should be a ROSC alarm
2 No human data Stay Tuned
An Automatic Cooling Device
Probably Improves Outcome
Which Device it is Unclear
How Deep Should I Cool 32 C By Evidence in Shockable Rhythm
6
bull Large study (950 pts)
bull 20 non shockable pts
bull Fever avoided X 3 days after rewarming
NEJM 20133692197-06
COLD Team STAT to the ED
EMTs Delivered a Post ROSC
V Fib Patient Ready for
Hypothermia
The patientrsquos wife tells you he had
sudden severe headache before
ldquogoing downrdquo
Post ROSC Head CT Scan CT pre TH and Prognostication
High sensitivity
Low Specificity
May Delay the TH Induction Process but
Good Info to RO Cerebral Pathology
bull SAH and OOHCA 4-15
bull Usually PEA Asystole
bull Unlikely survivable
Misuma Resuscitation 2011 82(10) 1294
In the ICU on Low dose Epinephrine
(BPS 80 mmHg) Cardiac Echo Global
LV Dysfunction EF 45
What pressure Doc
Cerebral Blood Flow After Cardiac Arrest
Sasser HC CCM 1999 Vol 27 No 12 A 29
7
BP post ROSC
Retrospective 2 hours after CA
Mullner M Stroke 19962759
Autoregulation in Cardiac Arrest
Sundgreen C Stroke 200132128-132
Pressure Cerebro-vascular
Reactivity Index and TCD
Lang EW J Neurol Neurosusg Psychiatry 2003741053-1059
Howells T J Neurosurg 102(2)317-7
Blood Pressure Goal May be the highest the L Ventricle can
tolerate without the risk of more cerebral
edema or myocardial dysfunction
MAP 80 + mmHg
NorepiEpi + Dobutamine
O2 Sat is 90 O2 during CA vs post ROSC
Pitcher Resuscitation 83 (4) 417-4222012
Kilgannon J JAMA 2010303(21) 2155-2171
Spindelboeck Resuscitation 84(2013)770-775
8
What PaCO2
0
200
250
20 40 100 80 60 PaCO2
PaCO2
0
50
100
150
PaCO2
Normal Individuals
CB
F
Leave the CO2 Alone
Cottrell JE Anesthesia and
Neurosurgery 3rd ed p23
Michard et al
Am J Respir Crit Care Med 159935-9 1999
To Cath or Not to Cath
STEMI and Cardiac Arrest
Post ROSC Head CT Scan STEMI and CA A Review
Kern K Cath and Cardiovascular Interv 75616-6242010
Survival
No
Hypothermia
60 (87 good outcome)
Hypothermia 70 (81 neuro intact)
9
STEMI and CA
The Real Controversy
Impact of Expected Increases Mortality
of the Cath Lab on Hospital $
Circulation 2013128762-773
What is a ldquoGood Outcomerdquo
Poor Agreement Between Currently
Used Estimates of ldquoGood Outcomerdquo
Rittenberger Resuscitation 2001 82(2011)1036
Neurological Prognostication
Post ROSC
bull Monitoring injury
bull Monitoring recovery
ndash Neuro exam
ndash Biomarkers
ndash EEG
ndash Neuroimaging
ndash SSEP Cortical Response
GCS 5
Neuro Exam + Severity Score 72 h post ROSC
Rittenberger JCResuscitation 2011 Nov82(11)1399-404
72
h No Survival
Rittenberger JC Resuscitation
2010 Nov81(10)1128-1132
+ SOFA
Myoclonic Status post ROSC
No Survival
English Anesthesia 2009 64908
Tomte Resuscitation 2011 Sep82(9)1186-93
10
EEG EKG
Drs Thomas Bleck and
Paul Vespa
UCLA Neuromeeting 2010
CT GWR (GrayWhite Ratio)
Inamasu J
Resuscitation 2010 (81)534
Torbey Stroke 2000312163
MRI
(Cortical and Basal Findings)
Post ROSC DWI MRI 72h and Outcome at 3 months
Highly sensitive (98) and poorly specific (462)
OK
NeuroCC Gree D 2012 17(2) 240-4
FOCAL 30 Survival DIFFUSE 7 survival
Beyond the EGG
(SSEP N2) Median Nerve response
bull Performed day 3-5 days of persistent coma
post hypothermia
Leithner Neurology 201074965-69
Withdrawal of Care in Most of the Studies is
Between 60 to 80 ROSC 48 Hours Day 3 and Beyond
Awaken
Neuro
Exam
Brain Death Persistent Vegetative State
MSE
COMA
Absent
N2O
Support
Withdrawal
11
My Hospital is Better Than Yours Resuscitation ldquoBest Standardsrdquo + Hypothermia
Ullevan University Oslo
Sunde Resuscitation 2007 7329-39
Better Survival
Better Neuro Outcome p lt 0001
Post ROSC Resuscitation Center of Excellence
Requirements
bull Strong EMS System short transit time
bull ROSC ALARM 247 therapeutic
hypothermia
bull STEMICA ROSC ALARM for PCI
bull ICU best evidence based practice
EMS+ED+Cardiac Cath+CCUICUNICU+Administration
Nichols G COCC 2010 16223-30
Conclusions Post-ROSC Care
bull Cerebral Protection
ndash Hypothermia and CMRO2
ndash CDO2 (CBF)
ndash O2 CO2 and Cerebro-Cardio-Pulmonary-Interactions
ndash ROSC Attack vs Head CT ROSC Attack
ndash Monitoring the close box
bull Cardiovascular Support
ndash PCI post-ROSC
ndash Myocardial dysfunction
bull Neurological prognostication
bull Systems of Care for post ROSC patients
For Those in Cardiac Arrest
The Future is Bright
TERIMA KASIH
6
bull Large study (950 pts)
bull 20 non shockable pts
bull Fever avoided X 3 days after rewarming
NEJM 20133692197-06
COLD Team STAT to the ED
EMTs Delivered a Post ROSC
V Fib Patient Ready for
Hypothermia
The patientrsquos wife tells you he had
sudden severe headache before
ldquogoing downrdquo
Post ROSC Head CT Scan CT pre TH and Prognostication
High sensitivity
Low Specificity
May Delay the TH Induction Process but
Good Info to RO Cerebral Pathology
bull SAH and OOHCA 4-15
bull Usually PEA Asystole
bull Unlikely survivable
Misuma Resuscitation 2011 82(10) 1294
In the ICU on Low dose Epinephrine
(BPS 80 mmHg) Cardiac Echo Global
LV Dysfunction EF 45
What pressure Doc
Cerebral Blood Flow After Cardiac Arrest
Sasser HC CCM 1999 Vol 27 No 12 A 29
7
BP post ROSC
Retrospective 2 hours after CA
Mullner M Stroke 19962759
Autoregulation in Cardiac Arrest
Sundgreen C Stroke 200132128-132
Pressure Cerebro-vascular
Reactivity Index and TCD
Lang EW J Neurol Neurosusg Psychiatry 2003741053-1059
Howells T J Neurosurg 102(2)317-7
Blood Pressure Goal May be the highest the L Ventricle can
tolerate without the risk of more cerebral
edema or myocardial dysfunction
MAP 80 + mmHg
NorepiEpi + Dobutamine
O2 Sat is 90 O2 during CA vs post ROSC
Pitcher Resuscitation 83 (4) 417-4222012
Kilgannon J JAMA 2010303(21) 2155-2171
Spindelboeck Resuscitation 84(2013)770-775
8
What PaCO2
0
200
250
20 40 100 80 60 PaCO2
PaCO2
0
50
100
150
PaCO2
Normal Individuals
CB
F
Leave the CO2 Alone
Cottrell JE Anesthesia and
Neurosurgery 3rd ed p23
Michard et al
Am J Respir Crit Care Med 159935-9 1999
To Cath or Not to Cath
STEMI and Cardiac Arrest
Post ROSC Head CT Scan STEMI and CA A Review
Kern K Cath and Cardiovascular Interv 75616-6242010
Survival
No
Hypothermia
60 (87 good outcome)
Hypothermia 70 (81 neuro intact)
9
STEMI and CA
The Real Controversy
Impact of Expected Increases Mortality
of the Cath Lab on Hospital $
Circulation 2013128762-773
What is a ldquoGood Outcomerdquo
Poor Agreement Between Currently
Used Estimates of ldquoGood Outcomerdquo
Rittenberger Resuscitation 2001 82(2011)1036
Neurological Prognostication
Post ROSC
bull Monitoring injury
bull Monitoring recovery
ndash Neuro exam
ndash Biomarkers
ndash EEG
ndash Neuroimaging
ndash SSEP Cortical Response
GCS 5
Neuro Exam + Severity Score 72 h post ROSC
Rittenberger JCResuscitation 2011 Nov82(11)1399-404
72
h No Survival
Rittenberger JC Resuscitation
2010 Nov81(10)1128-1132
+ SOFA
Myoclonic Status post ROSC
No Survival
English Anesthesia 2009 64908
Tomte Resuscitation 2011 Sep82(9)1186-93
10
EEG EKG
Drs Thomas Bleck and
Paul Vespa
UCLA Neuromeeting 2010
CT GWR (GrayWhite Ratio)
Inamasu J
Resuscitation 2010 (81)534
Torbey Stroke 2000312163
MRI
(Cortical and Basal Findings)
Post ROSC DWI MRI 72h and Outcome at 3 months
Highly sensitive (98) and poorly specific (462)
OK
NeuroCC Gree D 2012 17(2) 240-4
FOCAL 30 Survival DIFFUSE 7 survival
Beyond the EGG
(SSEP N2) Median Nerve response
bull Performed day 3-5 days of persistent coma
post hypothermia
Leithner Neurology 201074965-69
Withdrawal of Care in Most of the Studies is
Between 60 to 80 ROSC 48 Hours Day 3 and Beyond
Awaken
Neuro
Exam
Brain Death Persistent Vegetative State
MSE
COMA
Absent
N2O
Support
Withdrawal
11
My Hospital is Better Than Yours Resuscitation ldquoBest Standardsrdquo + Hypothermia
Ullevan University Oslo
Sunde Resuscitation 2007 7329-39
Better Survival
Better Neuro Outcome p lt 0001
Post ROSC Resuscitation Center of Excellence
Requirements
bull Strong EMS System short transit time
bull ROSC ALARM 247 therapeutic
hypothermia
bull STEMICA ROSC ALARM for PCI
bull ICU best evidence based practice
EMS+ED+Cardiac Cath+CCUICUNICU+Administration
Nichols G COCC 2010 16223-30
Conclusions Post-ROSC Care
bull Cerebral Protection
ndash Hypothermia and CMRO2
ndash CDO2 (CBF)
ndash O2 CO2 and Cerebro-Cardio-Pulmonary-Interactions
ndash ROSC Attack vs Head CT ROSC Attack
ndash Monitoring the close box
bull Cardiovascular Support
ndash PCI post-ROSC
ndash Myocardial dysfunction
bull Neurological prognostication
bull Systems of Care for post ROSC patients
For Those in Cardiac Arrest
The Future is Bright
TERIMA KASIH
7
BP post ROSC
Retrospective 2 hours after CA
Mullner M Stroke 19962759
Autoregulation in Cardiac Arrest
Sundgreen C Stroke 200132128-132
Pressure Cerebro-vascular
Reactivity Index and TCD
Lang EW J Neurol Neurosusg Psychiatry 2003741053-1059
Howells T J Neurosurg 102(2)317-7
Blood Pressure Goal May be the highest the L Ventricle can
tolerate without the risk of more cerebral
edema or myocardial dysfunction
MAP 80 + mmHg
NorepiEpi + Dobutamine
O2 Sat is 90 O2 during CA vs post ROSC
Pitcher Resuscitation 83 (4) 417-4222012
Kilgannon J JAMA 2010303(21) 2155-2171
Spindelboeck Resuscitation 84(2013)770-775
8
What PaCO2
0
200
250
20 40 100 80 60 PaCO2
PaCO2
0
50
100
150
PaCO2
Normal Individuals
CB
F
Leave the CO2 Alone
Cottrell JE Anesthesia and
Neurosurgery 3rd ed p23
Michard et al
Am J Respir Crit Care Med 159935-9 1999
To Cath or Not to Cath
STEMI and Cardiac Arrest
Post ROSC Head CT Scan STEMI and CA A Review
Kern K Cath and Cardiovascular Interv 75616-6242010
Survival
No
Hypothermia
60 (87 good outcome)
Hypothermia 70 (81 neuro intact)
9
STEMI and CA
The Real Controversy
Impact of Expected Increases Mortality
of the Cath Lab on Hospital $
Circulation 2013128762-773
What is a ldquoGood Outcomerdquo
Poor Agreement Between Currently
Used Estimates of ldquoGood Outcomerdquo
Rittenberger Resuscitation 2001 82(2011)1036
Neurological Prognostication
Post ROSC
bull Monitoring injury
bull Monitoring recovery
ndash Neuro exam
ndash Biomarkers
ndash EEG
ndash Neuroimaging
ndash SSEP Cortical Response
GCS 5
Neuro Exam + Severity Score 72 h post ROSC
Rittenberger JCResuscitation 2011 Nov82(11)1399-404
72
h No Survival
Rittenberger JC Resuscitation
2010 Nov81(10)1128-1132
+ SOFA
Myoclonic Status post ROSC
No Survival
English Anesthesia 2009 64908
Tomte Resuscitation 2011 Sep82(9)1186-93
10
EEG EKG
Drs Thomas Bleck and
Paul Vespa
UCLA Neuromeeting 2010
CT GWR (GrayWhite Ratio)
Inamasu J
Resuscitation 2010 (81)534
Torbey Stroke 2000312163
MRI
(Cortical and Basal Findings)
Post ROSC DWI MRI 72h and Outcome at 3 months
Highly sensitive (98) and poorly specific (462)
OK
NeuroCC Gree D 2012 17(2) 240-4
FOCAL 30 Survival DIFFUSE 7 survival
Beyond the EGG
(SSEP N2) Median Nerve response
bull Performed day 3-5 days of persistent coma
post hypothermia
Leithner Neurology 201074965-69
Withdrawal of Care in Most of the Studies is
Between 60 to 80 ROSC 48 Hours Day 3 and Beyond
Awaken
Neuro
Exam
Brain Death Persistent Vegetative State
MSE
COMA
Absent
N2O
Support
Withdrawal
11
My Hospital is Better Than Yours Resuscitation ldquoBest Standardsrdquo + Hypothermia
Ullevan University Oslo
Sunde Resuscitation 2007 7329-39
Better Survival
Better Neuro Outcome p lt 0001
Post ROSC Resuscitation Center of Excellence
Requirements
bull Strong EMS System short transit time
bull ROSC ALARM 247 therapeutic
hypothermia
bull STEMICA ROSC ALARM for PCI
bull ICU best evidence based practice
EMS+ED+Cardiac Cath+CCUICUNICU+Administration
Nichols G COCC 2010 16223-30
Conclusions Post-ROSC Care
bull Cerebral Protection
ndash Hypothermia and CMRO2
ndash CDO2 (CBF)
ndash O2 CO2 and Cerebro-Cardio-Pulmonary-Interactions
ndash ROSC Attack vs Head CT ROSC Attack
ndash Monitoring the close box
bull Cardiovascular Support
ndash PCI post-ROSC
ndash Myocardial dysfunction
bull Neurological prognostication
bull Systems of Care for post ROSC patients
For Those in Cardiac Arrest
The Future is Bright
TERIMA KASIH
8
What PaCO2
0
200
250
20 40 100 80 60 PaCO2
PaCO2
0
50
100
150
PaCO2
Normal Individuals
CB
F
Leave the CO2 Alone
Cottrell JE Anesthesia and
Neurosurgery 3rd ed p23
Michard et al
Am J Respir Crit Care Med 159935-9 1999
To Cath or Not to Cath
STEMI and Cardiac Arrest
Post ROSC Head CT Scan STEMI and CA A Review
Kern K Cath and Cardiovascular Interv 75616-6242010
Survival
No
Hypothermia
60 (87 good outcome)
Hypothermia 70 (81 neuro intact)
9
STEMI and CA
The Real Controversy
Impact of Expected Increases Mortality
of the Cath Lab on Hospital $
Circulation 2013128762-773
What is a ldquoGood Outcomerdquo
Poor Agreement Between Currently
Used Estimates of ldquoGood Outcomerdquo
Rittenberger Resuscitation 2001 82(2011)1036
Neurological Prognostication
Post ROSC
bull Monitoring injury
bull Monitoring recovery
ndash Neuro exam
ndash Biomarkers
ndash EEG
ndash Neuroimaging
ndash SSEP Cortical Response
GCS 5
Neuro Exam + Severity Score 72 h post ROSC
Rittenberger JCResuscitation 2011 Nov82(11)1399-404
72
h No Survival
Rittenberger JC Resuscitation
2010 Nov81(10)1128-1132
+ SOFA
Myoclonic Status post ROSC
No Survival
English Anesthesia 2009 64908
Tomte Resuscitation 2011 Sep82(9)1186-93
10
EEG EKG
Drs Thomas Bleck and
Paul Vespa
UCLA Neuromeeting 2010
CT GWR (GrayWhite Ratio)
Inamasu J
Resuscitation 2010 (81)534
Torbey Stroke 2000312163
MRI
(Cortical and Basal Findings)
Post ROSC DWI MRI 72h and Outcome at 3 months
Highly sensitive (98) and poorly specific (462)
OK
NeuroCC Gree D 2012 17(2) 240-4
FOCAL 30 Survival DIFFUSE 7 survival
Beyond the EGG
(SSEP N2) Median Nerve response
bull Performed day 3-5 days of persistent coma
post hypothermia
Leithner Neurology 201074965-69
Withdrawal of Care in Most of the Studies is
Between 60 to 80 ROSC 48 Hours Day 3 and Beyond
Awaken
Neuro
Exam
Brain Death Persistent Vegetative State
MSE
COMA
Absent
N2O
Support
Withdrawal
11
My Hospital is Better Than Yours Resuscitation ldquoBest Standardsrdquo + Hypothermia
Ullevan University Oslo
Sunde Resuscitation 2007 7329-39
Better Survival
Better Neuro Outcome p lt 0001
Post ROSC Resuscitation Center of Excellence
Requirements
bull Strong EMS System short transit time
bull ROSC ALARM 247 therapeutic
hypothermia
bull STEMICA ROSC ALARM for PCI
bull ICU best evidence based practice
EMS+ED+Cardiac Cath+CCUICUNICU+Administration
Nichols G COCC 2010 16223-30
Conclusions Post-ROSC Care
bull Cerebral Protection
ndash Hypothermia and CMRO2
ndash CDO2 (CBF)
ndash O2 CO2 and Cerebro-Cardio-Pulmonary-Interactions
ndash ROSC Attack vs Head CT ROSC Attack
ndash Monitoring the close box
bull Cardiovascular Support
ndash PCI post-ROSC
ndash Myocardial dysfunction
bull Neurological prognostication
bull Systems of Care for post ROSC patients
For Those in Cardiac Arrest
The Future is Bright
TERIMA KASIH
9
STEMI and CA
The Real Controversy
Impact of Expected Increases Mortality
of the Cath Lab on Hospital $
Circulation 2013128762-773
What is a ldquoGood Outcomerdquo
Poor Agreement Between Currently
Used Estimates of ldquoGood Outcomerdquo
Rittenberger Resuscitation 2001 82(2011)1036
Neurological Prognostication
Post ROSC
bull Monitoring injury
bull Monitoring recovery
ndash Neuro exam
ndash Biomarkers
ndash EEG
ndash Neuroimaging
ndash SSEP Cortical Response
GCS 5
Neuro Exam + Severity Score 72 h post ROSC
Rittenberger JCResuscitation 2011 Nov82(11)1399-404
72
h No Survival
Rittenberger JC Resuscitation
2010 Nov81(10)1128-1132
+ SOFA
Myoclonic Status post ROSC
No Survival
English Anesthesia 2009 64908
Tomte Resuscitation 2011 Sep82(9)1186-93
10
EEG EKG
Drs Thomas Bleck and
Paul Vespa
UCLA Neuromeeting 2010
CT GWR (GrayWhite Ratio)
Inamasu J
Resuscitation 2010 (81)534
Torbey Stroke 2000312163
MRI
(Cortical and Basal Findings)
Post ROSC DWI MRI 72h and Outcome at 3 months
Highly sensitive (98) and poorly specific (462)
OK
NeuroCC Gree D 2012 17(2) 240-4
FOCAL 30 Survival DIFFUSE 7 survival
Beyond the EGG
(SSEP N2) Median Nerve response
bull Performed day 3-5 days of persistent coma
post hypothermia
Leithner Neurology 201074965-69
Withdrawal of Care in Most of the Studies is
Between 60 to 80 ROSC 48 Hours Day 3 and Beyond
Awaken
Neuro
Exam
Brain Death Persistent Vegetative State
MSE
COMA
Absent
N2O
Support
Withdrawal
11
My Hospital is Better Than Yours Resuscitation ldquoBest Standardsrdquo + Hypothermia
Ullevan University Oslo
Sunde Resuscitation 2007 7329-39
Better Survival
Better Neuro Outcome p lt 0001
Post ROSC Resuscitation Center of Excellence
Requirements
bull Strong EMS System short transit time
bull ROSC ALARM 247 therapeutic
hypothermia
bull STEMICA ROSC ALARM for PCI
bull ICU best evidence based practice
EMS+ED+Cardiac Cath+CCUICUNICU+Administration
Nichols G COCC 2010 16223-30
Conclusions Post-ROSC Care
bull Cerebral Protection
ndash Hypothermia and CMRO2
ndash CDO2 (CBF)
ndash O2 CO2 and Cerebro-Cardio-Pulmonary-Interactions
ndash ROSC Attack vs Head CT ROSC Attack
ndash Monitoring the close box
bull Cardiovascular Support
ndash PCI post-ROSC
ndash Myocardial dysfunction
bull Neurological prognostication
bull Systems of Care for post ROSC patients
For Those in Cardiac Arrest
The Future is Bright
TERIMA KASIH
10
EEG EKG
Drs Thomas Bleck and
Paul Vespa
UCLA Neuromeeting 2010
CT GWR (GrayWhite Ratio)
Inamasu J
Resuscitation 2010 (81)534
Torbey Stroke 2000312163
MRI
(Cortical and Basal Findings)
Post ROSC DWI MRI 72h and Outcome at 3 months
Highly sensitive (98) and poorly specific (462)
OK
NeuroCC Gree D 2012 17(2) 240-4
FOCAL 30 Survival DIFFUSE 7 survival
Beyond the EGG
(SSEP N2) Median Nerve response
bull Performed day 3-5 days of persistent coma
post hypothermia
Leithner Neurology 201074965-69
Withdrawal of Care in Most of the Studies is
Between 60 to 80 ROSC 48 Hours Day 3 and Beyond
Awaken
Neuro
Exam
Brain Death Persistent Vegetative State
MSE
COMA
Absent
N2O
Support
Withdrawal
11
My Hospital is Better Than Yours Resuscitation ldquoBest Standardsrdquo + Hypothermia
Ullevan University Oslo
Sunde Resuscitation 2007 7329-39
Better Survival
Better Neuro Outcome p lt 0001
Post ROSC Resuscitation Center of Excellence
Requirements
bull Strong EMS System short transit time
bull ROSC ALARM 247 therapeutic
hypothermia
bull STEMICA ROSC ALARM for PCI
bull ICU best evidence based practice
EMS+ED+Cardiac Cath+CCUICUNICU+Administration
Nichols G COCC 2010 16223-30
Conclusions Post-ROSC Care
bull Cerebral Protection
ndash Hypothermia and CMRO2
ndash CDO2 (CBF)
ndash O2 CO2 and Cerebro-Cardio-Pulmonary-Interactions
ndash ROSC Attack vs Head CT ROSC Attack
ndash Monitoring the close box
bull Cardiovascular Support
ndash PCI post-ROSC
ndash Myocardial dysfunction
bull Neurological prognostication
bull Systems of Care for post ROSC patients
For Those in Cardiac Arrest
The Future is Bright
TERIMA KASIH
11
My Hospital is Better Than Yours Resuscitation ldquoBest Standardsrdquo + Hypothermia
Ullevan University Oslo
Sunde Resuscitation 2007 7329-39
Better Survival
Better Neuro Outcome p lt 0001
Post ROSC Resuscitation Center of Excellence
Requirements
bull Strong EMS System short transit time
bull ROSC ALARM 247 therapeutic
hypothermia
bull STEMICA ROSC ALARM for PCI
bull ICU best evidence based practice
EMS+ED+Cardiac Cath+CCUICUNICU+Administration
Nichols G COCC 2010 16223-30
Conclusions Post-ROSC Care
bull Cerebral Protection
ndash Hypothermia and CMRO2
ndash CDO2 (CBF)
ndash O2 CO2 and Cerebro-Cardio-Pulmonary-Interactions
ndash ROSC Attack vs Head CT ROSC Attack
ndash Monitoring the close box
bull Cardiovascular Support
ndash PCI post-ROSC
ndash Myocardial dysfunction
bull Neurological prognostication
bull Systems of Care for post ROSC patients
For Those in Cardiac Arrest
The Future is Bright
TERIMA KASIH
