Cardiac Arrest & Chain of Survival

1. Cardiac Arrest & Chain of Survival S. Sujanthy Rajaram MD, MPH, FCCM, FAASM Associate Professor of Medicine Division of Critical Care Medicine Cooper University Hospital Cooper Medical School of Rowan University University of Medicine & Dentistry Camden, New Jersey

3. What we will cover… Post-cardiac Arrest Syndrome Clinical Trials & Current Guidelines Clinical Implementation ? Potential applications in Sri Lanka

4. Cardiac Arrest (CA) Annually 450,000 Americans experience CA 80% out of hospital arrests Roughly 10% survive Majority of survivors are being abandoned long before it is reasonable to predict neurological recovery > 50% OF SURVIVORS HAVE SOME DEGREE OF PERMANENT BRAIN DAMAGE. Young GB, Clinical practice . Neurological prognosis after cardiac arrest NEJM 2009;361:605-611 Peberdy MA et al. CPR of adults in the hospital: a report Resuscitation. 2003;58:297-308

5. Prevent Recurrence Prognostication Goals Limit ongoing injury Organ support Rehabilitation Phase Immediate Recovery Early Intermediate Rehabilitation ROSC 20 min 6-12 hours 72 hours Disposition Circulation 2008

6. BRAIN INJURY IS EVOLVING AFTER AN ANOXIC INSULT UP TO 72 HOURS AFTER THE EVENT

7. ☺Hypothermia☺ TH prevents brain injury Cool !!! Mechanisms hyper- excitability metabolic demand necrosis apoptosis Brain injury free radical inflammatory cascade edema ICP Respir Care 2007

8. CA: Non-randomized studies Polderman KH. Lancet 2008;371: 1955

9. Primary Outcome Good neurologicaloutcome @ 6 mos Hypothermia N = 137 N = 275 eligible Secondary Outcomes Mortality@ 6 mos. Complications @ 7 d. Normothermia N = 138 HACA. N Engl J Med 2002;346 (8): 549-556

10. HACA. N Engl J Med 2002;346 (8): 549-556

11. N Engl J Med 2002;346 (8): 549-556

12. Neurologic Outcome and Mortality at Six Months N Engl J Med 2002;346 (8): 549-556

13. Survival N Engl J Med 2002;346 (8): 549-556

14. Hypothermia N = 43 N=77 Primary Outcome Survival to DC with good neurological Normothermia N = 34 Bernard SA et al. N Engl J Med 2002;346 (8): 557-563

15. Bernard SA et al. N Engl J Med 2002;346 (8): 557-563

16. Outcome of Patients at Discharge from the Hospital Bernard SA et al. N Engl J Med 2002;346 (8): 557-563

17. ACLS Guidelines • Unconscious patients with ROSC after out-of-hospital CA should be cooled to 32ºC to ºC 34 for 12-24 hours (I, B) • Similar therapy may be beneficial in patients with non–VT arrest (out-of-hospital) or for in-hospital arrest (IIb, B) Circulation 2010; 122: S768-786.

18. 1. Use the term TTM rather than TH Out of hospital arrest: TT 89.6 -93.2 F, 32-34 C for ventricular fibrillation or pulseless v. tachycardia Newborns: 91.4-95.9 F (33-35.5 C) 2. Cool to a specific level, within a specific time frame, Specific warming protocols, gives a certain outcome Critical Care Med 2011; 39.

20. Clinical Application

22. Surface Intravascular Cooling Options / Methods Cold Fluids

24. Temperature Monitoring Foley, rectal, esophageal, tympanic? If you can’t monitor the temperature, don’t manipulate it Foley is better than rectal

25. Recommended Temperature Monitoring Sites • PA catheter • Esophageal • Bladder (unless anuric) • Cranial or Nasopharyngeal • Rectal (Do not use axillary with surface cooling!)

26. Why Sedation +/- Paralytics? • Needed for mechanical ventilation and shivering suppression • Propofol • Midazolam or other benzodiazepine • Fentanyl or other narcotic • Dexmedetomidine • Muscle relaxation / paralysis • Vecuronium / Pancuronium • Cisatracurium / etc. • Monitoring (TOF) / EEG

27. Cold IV Saline + sedation (awake volunteers) ~2.5 liters (30ml/kg) of saline / 30 min Shivering Valium 10 -20 mg Benzodiazepine enhanced cooling Holster et al. High dose diazepam facilitates core cooling during cold saline infusion in healthy volunteers. Appl Physiol Nutr Metab. 2009;34:582-586

28. Shivering Increases metabolic demand (VO2); makes it hard to cool Heavy sedation is sufficient to suppress shivering Muscle relaxants will be necessary only during induction

29. Cooling Lowers Heart Rate Decline as low as 40/ mt, BP not affected

30. Cooling Prolongs QT interval PR=208, QTc=535 Be vigilant if etiology of CA or on agents prolongs QT(Amiadarone), electrolytes shift

31. Fluids and ElectrolytesLactate, Free fatty acids, Glycerol, Ketones, Osmolarity Hypothermia Rewarming K+ K+ K+ K+ Mg+ PO4- Mg+ PO4- K+ Mg+ PO4-

32. Potential Side Effects and Their Frequency

33. Dead or Alive? After Cool !!! What do they need to survive? Most CA victims require Cardiac catheterization

34. Treat the reversible causes • Hypovolemia • Hypoxia • Hydrogen ion (acidosis) • Hypokalemia Hyperkalemia • Hypothermia • Tension pneumothorax • Toxins • Tamponade • Thrombosis pulmonary • Thrombosis Cardiac

35. Post arrest Cardiac Catheterization 85 CA victims, 71% had 1 or more vessels with at-least 50% stenosis (Spaulding et al.) 241 victims, 73% had 70% stenosis (Kurz et al.) Cold heart might be prone to more dysrhythmia Despite concerns, brief & long v.fib. Success of Shock is unchanged and even improves as Temperature drops from 96.6 -86 F (37-30) Sapulding CM et al. Immediate conronary angiography in survivors of out of hospital cardiac arrest NEJM. 1997;336:1629-1633 Kurz et al. Periop. Normothermia NEJM. 1996;334:1209-1215 Boddickee et al. Hypothermia improves defibrillation success from v.fibrillation in swine model Resuscitation, 2005; 65:79-85

36. Video Clips

49. “The majority of patients who achieve ROSC are being abandoned long before it is reasonable to predict neurological recovery”

50. Prognostic Tools • Clinical signs: Neither corneal reflex, nor motor response - Day 3 • Day 7 – no response to pain, discomfort • No pupillary reaction by Day 3 • Decerebrate rigidity (Extensor reaction) by Day 3 (35% of CA victims) • SSEPs – bsence of b/l N20 response is a reliable predictor (ideal timing is 24-72 hours, if present at 24 hrs, loss later) • EEG – myoclonic status (b/l repetitive motions of limbs, trunk or facial muscles, must confirm with EEG)