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When you get one Back.

Post Cardiac Arrest Syndrome!By Kane Guthrie

Learning Points

Cardiac arrest were are we at?

A case!

Post resuscitation care is it the answer?

A chilling look at the benefits of therapeutic hypothermia!

Cardiac Arrest the Stat’s

Generally 6-7% survival rate (worldwide)

0nly 3-4% leave hospital with RONF

Early Defib/compressions make the difference

Post resuscitation care is the answer to improving mortality and morbidity with ROSC.

Cardiac Arrest

We loose so many!

We need to focus on the ones we get back.

The REAL resuscitation starts once we get ROSC!

RONF or organ donation is the only good outcome’s!

The Approach

The things that help get em back!

The 3 things that have the evidence:

1. Early high quality chest compressions

2. Early defibrillation

3. Therapeutic hypothermia

Case Study

68 male walking home from pub

Collapse > Cardiac Arrest >Bystander CPR

SJA arrive 13mins post arrest

In VF, Successful ROSC post x3 defibs

Arrives in T2 20 mins later with no RONF

What should we do now?

Remember!

The Goals Post Arrest

1. Induce Therapeutic Hypothermia

2. Maximise Haemodynamic’s

3. Optimise Oxygenation

4. Advocate for Cardiac Catheterisation

Post Cardiac Arrest Syndrome!!

Thought to be RT production of free radicals

Pathophysiology is very complex = BORING

Hypoperfusion & Ischaemia cause cascade of events

1. Disruption of homeostasis

2. Free radical formation

3. Protease activation

• Hypothermia helps slow down this cascade

The Patho

1. Brain Injury Cerebral oedema and ischaemia

2. Myocardial dysfunction Haemodynamically labile R/T global hypokinesis.

3. Systemic ischemia/reperfusion response SIRS response – looks like sepsis.

4. Persistent precipitating pathology. The underlying cause.

Oxygen and Ventilation

Avoid hyperoxia:

O2 toxicity detrimental to heart and brain.

Adjust 02 to keep spo2 >90.

Avoid hyperventilation:

Hypocarbia causes cerebral vasoconstriction.

Circulatory Support

Haemodynamic instability is the norm!

Each episode of hypotension worsens mortality & neuro function.

Aggressive IVF- replace volume depletion

Keep MAP- 65-100mmHg (adrenaline, noradrenaline or dopamine)

ICU via Cath Lab?

PCI improves survival and neurological function.

STEMI should go straight to CATH Lab.

Consider for all other survivors within 12-24 hours post ROSC – up to 40% have unstable plaques.

Can be difficult convincing cardiology!!!

Therapeutic Hypothermia

‘Induced hypothermia” is were pt is deliberately cooled between 32-33.9°C

It aims to reduce hypoperfusion (& reperfusion) injury post arrest.

Focuses mainly on brain (neuroprotection), but offers protection to heart, liver, kidneys.

Current research shows no benefit of inducing TH before or during event. (RINSE trial ongoing)

Therapeutic Hypothermia

Therapeutic hypothermia is the first treatment that has proven effective for post-resuscitation

reperfusion injury.

NNT 1:6 vs 1:42 for aspirin in STEMI

Who’s in? Who's Out?

In.

Cardiac arrest with ROSC.

Persistent significant altered GCS.

<12 since ROSC.

Out.

Advanced directive or DNR.

Traumatic arrest.

Active bleeding.

Pregnant, recent major surgery or severe sepsis.

3 phases of TH.

1. Induction: •Aim reduce core temp to 32-34°C •Preferably within 2 hours

2: Maintenance: •Maintain core temp 12-24 hours

3:Rewarming: •controlled or passive rewarming to normothermia 37°C•0.2-0.5°C per hour –over 8-12 hours

How to Cool!

Cold fluids

ICE Packs

Machine’s

ED ManagementAirway • secure ETT, continuous

EtCO2

Breathing •Prevent VILI

Circulation •ECG (risk arrhythmias)•Monitor U/O (cold diuresis)

Disability •Paralyze, sedate

Exposure •Core temp monitoring•Monitoring skin integrity•Once at 34°C remove ICE packs & maintain•Monitor and prevent shivering•Prepare patient for T/F to ICU, Cath Lab

Monitoring the bloods

Remember the basics

Pressure area & skin care

Adequate sedation/analgesia

Lung protective ventilation

Seizure control

Social support (family)

Complications

Tachycardia > bradycardia

Hypertension

Diuresis (hypovolaemia)

Shivering (increases temp)

Arrhythmia's

Increase bleeding

Spiking temp’s look for signs of infection

Case Continued

Pt intubated and ventilated in ED

Cooling began.

Taken to CATH lab 90% occlusion to LAD.

Warmed and extubated 24 hours later in ICU.

GCS 15

Back at the pub 4/7 later.

The Future

Take Home Points

Good post resus care improves outcomes.

Therapeutic hypothermia should be done on all ROSC with-out RONF.

Maximise haemodynamic’s and oxygenation in ED.

Advocate for the early CATH Lab.

Thank-you