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DR. SOLOMON WAI-CHU WAI Training Coordinator COLLEGE OF EMERGENCY AND PARAMEDIC STUDIES,

CARDIAC ARREST AND RESUSCITATION SCIENCE; USING GLOBAL KNOWLEDGE & EXPERIENCE TO STRENGTHEN OUR PRACTICE. DR. SOLOMON WAI-CHU WAI Training Coordinator COLLEGE OF EMERGENCY AND PARAMEDIC STUDIES, PORT HARCOURT. OUTLINE. INTRODUCTION : What is Cardiac Arrest?

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DR. SOLOMON WAI-CHU WAI Training Coordinator COLLEGE OF EMERGENCY AND PARAMEDIC STUDIES,

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  1. CARDIAC ARREST AND RESUSCITATION SCIENCE;USING GLOBAL KNOWLEDGE & EXPERIENCE TO STRENGTHEN OUR PRACTICE DR. SOLOMON WAI-CHU WAI Training Coordinator COLLEGE OF EMERGENCY AND PARAMEDIC STUDIES, PORT HARCOURT

  2. OUTLINE INTRODUCTION: What is Cardiac Arrest? EPIDEMIOLOGY and CHAIN OF SURVIVAL: Incidence in Nigeria and Globally CARDIAC ARREST AS A DISEASE: the three-phase-model of Cardiac Arrest WHAT IS THE DEVELOPED WORLD DOING? Current trends in Management WHICH WAY NIGERIA? How do we improve outcome in Nigeria? THE FUTURE: New Treatments of Cardiac Arrest CONCLUSION: What is Death? When do we pronounce a patient dead?

  3. “The saddest aspect of life right now is that science gathers knowledge faster than society gathers wisdom” ~Isaac Asimov

  4. What is cardiac arrest? Electrical recording of the heart rhythm: Cardiac arrest rhythm: chaotic rhythm means no blood flow (no functional cardiac output) Normal rhythm: heart is moving blood (functional “cardiac output”) In cardiac arrest, the blood pressure quickly falls to zero Blood flow to the organs stops, abruptly and completely

  5. EPIDEMIOLOGY: Cardiac arrest is a massive public health problem Cardiac arrest is a leading cause of death in the developed world • No cohesive data in Nigeria • Over 300,000 people in the U.S. suffer OH cardiac plus over 200,000 IHCA each year • 95 persons per 100,000 worldwide per annum • Most victims die before hospital arrival • Less than 10% leave the hospital alive, but… Cardiac arrest commonly strikes people in their 50s and 60s – often active, generally healthy people – and strikes with few warning signs or symptoms

  6. Nihilism in cardiac arrest Culture of hopelessness common in healthcare providers regarding cardiac arrest Becomes a “self-fulfilling prophecy”: Pessimism about outcomes Lower quality care Poor survival

  7. CHAIN OF SURVIVAL: Why is cardiac arrest survival so variable? Cardiac arrest survival depends on the successful performance of the “chain of survival” Not all communities have the same strengths in this chain

  8. Survival from cardiac arrest is highly variable Survival from cardiac arrest depends on where you live From a large research study in 2008, showing survival to hospital discharge for victims of cardiac arrest: 16.3% 10.6% Survival to discharge 7.0% 4.5% Dallas Pittsburgh Portland Seattle Nichol et al, JAMA 2008

  9. Survival variability is from multiple factors Public knowledge about CPR, willingness to perform CPR varies from community to community Availability of automated external defibrillators (AEDs) differs widely as well Quality of Emergency Medical Services (EMS) response widely variable

  10. Example: variable public knowledge of AEDs A survey study conducted in a major European train station in 2011 queried members of the public about AEDs Findings from laypersons surveyed: •Only 38% could identify an AED •Only 46% could describe purpose of AED •Only 36% knew AEDs could be used by public If someone collapsed from cardiac arrest at your local bus station or airport, would people know to grab an AED and use it? Is one available? Schober et al, Ann Emerg Med 2011

  11. Timeline of survival from cardiac arrest Chance of survival falls by 7-15% for each minute of untreated cardiac arrest Early CPR alters this curve – survival increases by 2-3 fold in some studies Bottom line: public CPR matters! 100 80 60 40 20 0 CPR Survival 0 2 4 6 8 10 12 Minutes after cardiac arrest onset Valenzuela et al, Circulation 1997

  12. The DETAILS of CPR delivery makes a big difference CPR with chest compression alone or with rescue breathing T Rea et al, 2010 Bystander contacted 9-1-1 standard CPR (n=960) chest compression alone (n=981) 11.5% 14.4% survival to hospital discharge

  13. Breaths during public CPR don’t help, and they may hurt 80 60 40 20 0 Chest compressions only standard CPR with breaths Better survival with only chest compressions, no matter how long it took to respond! 30 day survival, % 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Minutes from bystander CPR to defibrillator SOS-KANTO et al, 2007

  14. Survival is also dependant on rapid defibrillation For shockable rhythms,with each passing minute without a shock, survival falls 40 30 20 10 0 Survival to discharge <1 2 3 4 5 6 7 minutes to defibrillation Chan et al, NEJM 2008 Should we have AEDs in our homes, like fire extinguishers? Large U.S. study showed no clear benefit from home AEDs Bardy et al, NEJM 2008

  15. Cardiac arrest heart rhythms summary ventricular ventricular pulseless asystole fibrillation tachycardia electrical activity Non-shockable rhythms; do not defibrillate PEA and asystole are more for cardiac arrest among hospitalized patients Shockable rhythms; need to defibrillate VF and VT are very common for cardiac arrest in the home or in public places

  16. Resuscitation in the media CPR in the workplace February 25, 1990 Terri Schiavo had cardiac arrest at home Was successfully revived by EMS team Suffered severe brain injury from the cardiac arrest event; after protracted legal battle, feeding tube was removed and she died on March 31, 2005

  17. Resuscitation in the media CPR in the home Friday, June 25, 2009 Michael Jackson had cardiac arrest at his home; physician performed CPR Presumed respiratory arrest from drug overdose Attempted resuscitation (CPR and defibrillation) failed CPR performed in the bed – not a hard surface

  18. Resuscitation in the media CPR in the workplace March 17, 2012 Fabrice Muamba had cardiac arrest while on English football field Was successfully revived after prolonged resuscitation efforts Brain injury was largely spared by the use of new treatment option known as “therapeutic hypothermia”

  19. Resuscitation in the media CPR in the workplace June 08, 2016 Stephen Keshi, a former Coach of Nigeria’s Super Eagles died of possible Cardiac Arrest. According to family sources, Keshi complained of being unwell just before midnight on Tuesday, June 7, and he was found to be gasping for breath very close to mid-night. He was rushed to Faith Hospital in the Benin Government Reservation Area, where he died around 00.30 in the morning of June 8. Not known if resuscitation efforts were made

  20. Resuscitation in the media CPR in the workplace June 12, 2016 Amodu Shuaibu, also a former Coach of Nigeria’s Super Eagles died of possible Cardiac Arrest in his sleep after complaining of chest pains before retiring to bed. Resuscitation attempts were not made

  21. The Three-Phase Model of the Disease, Cardiac Arrest And Reperfusion Injury

  22. Reperfusion injury: clues from the laboratory Heart cells (myocytes) – grown in a petri dish Can simulate cardiac arrest and resuscitation: Bathe them in fluid without oxygen (cardiac arrest) Restore fluid with oxygen (resuscitation)

  23. What will happen when you simulate ischemia and then reperfusion? Death during ischemia ischemia 60 ?? 50 40 Cell Death (%) 30 Death during reperfusion 20 10 0 0 1 2 3 4 5 Time

  24. What actually happens: Cell Death (%) Can we do something here? ischemia Time Vanden Hoek et al, AJP, 1996

  25. What this means: imagine the following situation Would you buy this car for $75,000 ? One quirk: if you run out of gas, And you then put gas in the car…

  26. What this means: imagine the following situation KAH BOOM

  27. ‘The most exciting phrase to hear in science, the one that heralds new discoveries, is not 'Eureka!' but 'That's funny...’ Isaac Asimov

  28. What causes this problem? free radicals inflammation mitochondria

  29. hypothermia Reperfusion injury: how it happens Reperfusion (return of blood flow) Ischemia (lack of blood flow) energy processing dysfunction reactive oxygen species (ROS) inflammatory cascades blood vessel instability cell death brain swelling

  30. Electrical Phase of VF Metabolic Phase Circulatory Phase Defibrillation Hypothermia Other Therapies ECPB Is the best treatment for VF here the same as here? Compression Defibrillation JAMA 2002,Weisfeldt & Becker Resuscitation After Cardiac Arrest A 3-Phase Time-Sensitive Model 4-10 min 0-4 min > 10 min

  31. Electrical Phase

  32. 3 Phases of Cardiac Arrest Electrical Phase of VF Metabolic Phase Circulatory Phase Defibrillation New therapy Compression Defibrillation AEDs

  33. Casino Study: Survival--Time is of the Essence Trained Security Officers in AEDs 105 patients, VF arrest 92 witnessed arrests Average time, collapse to shock: 4.4 minutes Valenzuela et al. NEJM, 2000

  34. Casino Study: Results • All survivors neurologically intact Valenzuela et al. NEJM, 2000

  35. Circulatory Phase

  36. Pause before a shock – it really makes a big difference! 100 90% 80 60 64% Shock success, % 55% 40 20 10% 0 ≤10.3 10.5-13.9 14.4-30.4 ≥33.2 Pre-shock pause, sec Edelson et al, 2006

  37. What can professional rescues do to improve CPR? Minimally interrupted cardiac resuscitation by emergency medical Services for out-of-hospital cardiac arrest Bobrow et al, 2008 Important to note: These were SIMPLE interventions without new drugs or new devices Only armed with new knowledge And education EMS leaders in Arizona recognized the Importance of high quality CPR Interventions: 1. Delay intubation 2. 200 compressions before first shock 3. Minimize pre and post shock pauses Tripled survival to hospital discharge (3.8%  9.1%)

  38. CPR Prior to Defibrillation • Shock patients as soon as recognized • Efficacy decreases with each passing minute • Study of immediate shock vs. 3 minutes of chest compressions prior to shock • 200 out-of-hospital cardiac arrest patients • 3 minutes of chest compressions offered no advantage in outcomes for population as a whole • But… Wik et al. JAMA, 2003

  39. Wik > 5 min ambulance response 89% of survivors good neurologic outcome Wik et al. JAMA, 2003

  40. Metabolic Phase Late Injury Early Injury Mitochondrial Dysfunction Apoptosis ATP Depletion Inflammation Ion Pump Dysfunction Permeability of the Blood Brain Barrier Calcium Influx Endothelial Dysfunction Metabolic Acidosis Pro-coagulation Free Radical Production

  41. To summarize: 3 phases of arrest Arrest! SHOCK < 3 min: 74% > 5 min, CPR 1st: 22% CPR % Surviving 34% ROSC Penn Pre-TH OHCA Data Hospital d/c, 10% M E C Time Valenzuela et al. NEJM, 2000

  42. To summarize: reperfusion injury Damage observed after restoration of blood flow to ischemic tissues What is happening? Cellular level injury Endothelial damage Mitochondrial dysfunction Hypothermia % Surviving 34% 19% 10% Time Vanden Hoek et al. AJP, 1996

  43. The first study of hypothermia in cardiac arrest Benson DW, Williams GR Jr, Spencer FC, Yates AJ.The use of hypothermia after cardiac arrest.Anesth Analg 1959; 38: 423-8. • Comatose survivors • Asystole or VF • 31-32°C • Cooling until neurologic recovery(3 h to 8 days) • water-filled blanket

  44. Three randomized trials evaluating therapeutic hypothermia What does a randomized trial of post-arrest cooling look like? ? ? cooling H arrest victim no cooling emergency department ambulance transport outcomes assessed patient treatment patient randomized

  45. Three randomized trials evaluating therapeutic hypothermia The Hypothermia after Cardiac Arrest (HACA) trial Target temperature: 32 oC Duration of cooling: 24 hours Bernard and colleagues post-arrest cooling trial Target temperature: 32 oC Duration of cooling: 12 hours Hachimi-Idrissi post-arrest cooling cap trial Target temperature: 32 oC Duration of cooling: 4 hours

  46. Three randomized trials evaluating therapeutic hypothermia The Hypothermia after Cardiac Arrest (HACA) trial Target temperature: 32 oC Duration of cooling: 24 hours Bernard and colleagues post-arrest cooling trial Target temperature: 32 oC Duration of cooling: 12 hours Key technical issue: These two trials only enrolled Patients who had SHOCKABLE arrest rhythms ventricular ventricular fibrillation tachycardia

  47. Summary of key therapeutic hypothermia trials Hypothermia trials: outcomes no cooling cooling 36% 53% 0 10 20 30 40 50 60 no cooling cooling 26% 49% no cooling cooling 6% 25%

  48. CPC5 CPC3 CPC2 CPC1 56% 19% 12% 14% CPC 5 .CPC3 CPC2 CPC1 40% 5% 14% 42% A real world example: cerebral performance category (CPC) outcomes Real world usage: Switzerland Outcome at discharge for out-of-hospital VF arrest baseline cooling

  49. CPC5 CPC3 89% 11% CPC5 CPC1 83% 17% Real world usage: Switzerland A real world example: cerebral performance category (CPC) outcomes Outcome at discharge for out-of-hospital asystole arrest baseline cooling

  50. Components of Comprehensive Care Bundle Heart Attack Early Cath Lab Early Hemodynamic Optimization Therapeutic Hypothermia Glucose Management Protocol Protect the Lungs Is the patient irreversibly injured?  Appropriate Neuroprognostication

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