ROSC! Now what??!! An EMS Guide to the Management of Post Cardiac Arrest Syndrome Jay Lance Kovar,...
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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
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
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
Slide 4
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
Slide 5
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
Slide 6
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
Slide 7
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
Slide 8
Epidemiology o Mortality Rates Inadequate o Neurologic and
Functional Outcomes o Cerebral Performance Category
Slide 9
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
Slide 13
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
Slide 14
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
Slide 15
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
Slide 16
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
Slide 17
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
Slide 18
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
Slide 19
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
Slide 36
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
Slide 37
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??
Slide 38
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
Slide 39
Therapeutic Hypothermia
Slide 40
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
Slide 41
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
Slide 42
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
Slide 43
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
Slide 44
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
Slide 45
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
Slide 47
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
