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Transcript of Mind, Brain & Consciousness During Cardiac Arrest Sam Parnia MD, PhD Pulmonary & Critical Care...
![Page 1: Mind, Brain & Consciousness During Cardiac Arrest Sam Parnia MD, PhD Pulmonary & Critical Care Medicine State University of New York Stony Brook, USA University.](https://reader038.fdocuments.us/reader038/viewer/2022103122/56649ca65503460f94967c46/html5/thumbnails/1.jpg)
Mind, Brain & Consciousness During Cardiac Arrest
Sam Parnia MD, PhDPulmonary & Critical Care Medicine
State University of New York Stony Brook, USAUniversity of Southampton, UK
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• None
Disclosures
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What to do when someone dies? Historical Perspectives on Resuscitation
• Early in history – Galen: Life = Heat & Lifeless = Cold - Heat to prevent death from taking the person
• Bellows Method – started in 1530’s – lasted 300 yrs
- Flagellation – to stimulate a response
- Warm ash - Burning excrement or hot water on body
• Fumigation Method – 1700’s
• Inversion, Barrel, Trotting Horse - 1700- 1800’s
• Mouth-to-Mouth & Chest Compression- 1950-60’s
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Irreversible Death
Heart attack
Causes of death
Traffic accident
Dying Process – potentially reversible
Lasts: Few seconds – 10’s min’s – over an hour
Cardiac Arrest/Clinical Death
Impact of Resuscitation Science 50 Years on – Death not a “moment” it is a “reversible” process.
Uncharted Territory
Shock:02 delivery organs inadequate
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Cardiac Arrest “Global Stroke” Pathophysiology of Cardiac Arrest
• “Whole body ischemia”– lack oxygen
• Brain Oxygen & Energy Stores(ATP) depleted
– Accumulation toxins (adenosine, lactate, H+)
• Cells Dysfunction – massive intracellular Ca+ accumulation – toxicity - death
• Permanent Brain Cell Death – ? Hours later
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Does Brain Function During Cardiac Arrest?
• EEG during Cardiac Arrest – slowing - isoelectric (flatline) 10–20 s
• Remain flat – until resumption of heartbeat if early intervention
• Prolonged cardiac arrest - EEG returns “hrs” after.
• Animal study - 15 min cardiac arrest then resuscitation:
- EEG flat 21 ± 5.7 s (n=10) - 90 ± 24.7 min - bursts of slow waves
Kano T, Hashiguchi A, Sadanaga M. Resuscitation 1993; 25: 265-281
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So Why Does it Matter?
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What are the wider implications of cardiac arrest research?
- Can we bring people back safely?
- What happens after we die?
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What Happens When We Die? Near Death Experience (NDE)
• ‘Life after life’ Raymond Moody 1975
• Reactions -‘Life after life – Hallucination - Fabrication
• Retrospective Studies - Some describe negative NDE
• 4% prevalence of NDE in USA – Gallup 1982
• Problem: Social & Medical Perception of Death – Irreversible
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• 19th century Swiss accident survivors
• 15th century Dutch painting – H Bosch
• Plato’s Republic & many others…
Ascent to the Empyreon – H Bosch (1450 – 1516)
Cognitive & Mental Activity – Near Death Experience (NDE)
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• NDE described in Japan, China, India and ++++
• Consistent core features
• Studied in children
• Case of 3 year old sent to Southampton
Cognitive & Mental Activity – Near Death Experience (NDE)
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• Physiological
• Psychological
• Transcendental
WHY DO NEAR DEATH EXPERIENCES OCCUR?
• Other …
Anticipation of death - ? ‘fear death’ experience
Chemical changes in brain - hallucination
True separation of mind/soul from body
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WHY DO NEAR DEATH EXPERIENCES OCCUR? – Rumi’s Elephant in the Dark
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Near Death Experience – Problems!
• Cardiac arrest – Biologically = death
• What do we mean by near death?
– scientifically too vague
– led to much controversy
• New Term: Actual Death Experience
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Irreversible Death
Heart attack
Causes of death
Traffic accident
Dying Process – potentially reversible
Lasts: Few seconds – 10’s min’s – over an hour
Cardiac Arrest
“Near Death” or “Actual Death” Experience
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Parnia S, Waller D, Yeates R, Fenwick P, A qualitative and quantitative study of incidence, features and aetiology of NDE's in cardiac arrest survivors Resuscitation Feb 2001 48, 149-156
What happens to mind and consciousness during cardiac arrest?
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• 344 cardiac arrest survivors - 10 hospitals
Largest NDE Study in Cardiac Arrest
• 41 (12%) reported core NDEs - No association with:
• 8 year follow up - positive change in life
• Did not test physiological parameters
• ?? Account for NDE through brain processes?
• Transformation following NDE
Van Lommel P et al – Near-death experience in survivors of cardiac arrest: a prospective study in the Netherlands. Lancet 2001; 358:2039-2045
• Medication • Fear of death prior to cardiac arrest
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Wider Implications of Consciousness During Cardiac Arrest
• ? Signify improved brain Resuscitation?
- Need to study “real time” brain resuscitation.
• When is human mind/consciousness lost permanently and cannot be retrieved after death?
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Death – Physical Process
• Changes in Cells including Brain – Cell damage within minutes
• Brain Cells undergo Irreversible Damage
• Eventually leads to bodily destruction
Minutes
Hrs - Days
• When do the mind & consciousness cease existing?
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• Scientific Paradox: ? mind/consciousness continue function when brain stopped working and reached the clinical criteria of death
• Five independent studies – published since 2001 UK, Holland, USA
• 10-20% people revived from cardiac arrest & clinical death – consciousness + thought processes + can “see” & “hear”
Death – What Happens to Mind & Consciousness?
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Paradox:
Consciousness during Unconsciousness!
• Possible explanations:
- Arise just before or after cardiac arrest
- do not arise at all - Unlikely - ? millions of cases
- Need to re-examine mind/brain theories
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The relationship of mind and brain:
Challenge for 21st century science?
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• How do we have ‘consciousness’ (psyche or soul) from brain processes?
Mind and Brain - Problem of Consciousness, Psyche or Soul
• How do thoughts, feelings and all aspects of mind arise from brain processes?
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Mind and Brain - Problem of Consciousness
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Mind and Brain - Problem of Consciousness
• Descartes - Cartesian model
From: Brain Atlas Harvard Medical School
• Ancient Greeks - Human Soul
• Cerebral localisation -19 - 20C
• Modern scanning techniques
- f MRI, PET
History
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Mapping the mind
• Complex thoughts = Activity in multiple areas of brain
• Identifying brain cell activity during thoughts – correlation NOT CAUSATION
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Mind and Brain - Problem of Consciousness
• Current Views -
- Others –
Quantum processes - Hameroff/Penrose
Irreducible entity: electromagnetic/mass/Gravity Chalmers
Mind/Brain – Separate – Eccles/ Elahi
- Conventional –
Neural Networks Greenfield/Crick/Koch/
Dennett
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• Reality of any experience is socially determined - not ‘neurologically’ – Whether NDE/Love or otherwise…
Are Experiences Real or Hallucinations?
• All experience mediated by brain pathways
• NDE – Out of body experiences - many claim objectively verifiable events – Can we test and determine its reality...?
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• First large scale study to examine claims to “see” and “hear”
AWARE STUDY (AWAreness during Resuscitation) - launched 2008.
• International Multicentre Study of Consciousness during Cardiac Arrest
• Aim to use Sophisticated Technology (cerebral oximetry) to study brain oxygen delivery with consciousness
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Cerebral Oximetry
• Optical Monitoring technique using Beer Lambert law
• Assesses regional O2 (rSO2%) (balance O2 delivery & uptake)
• Represents mostly cerebral venous saturation
• Acceptable Normal Values 60-80%
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rSO
2%
0
20
40
60
80
No ROSC ROSC
Role of cerebral oximetry in predicting return of spontaneous circulation (ROSC)
in cardiac arrest using manual CPR
*
* p = <0.0016 Mann-Whitney Test, ROSC = Return of Spontaneous Circulation(No ROSC n= 15, ROSC n= 7)
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*
0
20
40
60
80
rSO
2%
Manual CPR Automated CPR
Impact of Automated CPR (LifeStat) on rSO2
* p= <0.0001 Mann-Whitney (Manual CPR n=22, Automated(LifeStat) CPR n=12)
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Time (mins)
% r
SO
2Illustration of the Impact of Manual & Automated
Chest Compression on Cerebral Perfusion in Two Patients
Automated CPR (patient 1) Manual CPR (patient 2)ROSC = Return of Spontaneous Circulation
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Manual CPR Automated CPR
*
% S
urv
ival
(R
OS
C)
ROSC = Return of Spontaneous Circulation lasting > 20 mins. *p < 0.05 using Fischer's Exact test. (Manual CPR n=44, Automated CPR n=20)
Automatic CPR leads to higher Return Spontaneous Circulation Following
Cardiac Arrest
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University of Southampton, Dr Peter Fenwick (Psychiatry), Dr Charles Deakin (cardiac anesthesia), Dr Paul Little (research design), Professor Robert Peveler2 (Psychiatry), Ms Niki Fallowfield (Resuscitation)
University of Cambridge: Ms Susan Jones (Resuscitation)
Northampton Hospital: Ms Celia Warlow (Resuscitation),
St Georges Hospital, London: Ms Leanne Smythe (Resuscitation), St Peters Hospital: Mr Paul Wills (Resuscitation), Mayday Hospital: London Mr Russell Metcalfe Smith (Resuscitation), Royal Bournemouth Hospital: Ms Hayley Killingback (Resuscitation), Morriston Hospital: Dr Penny Sartori (Critical Care Unit),
Stevenage Hospital: Ms Salli Lovett (Critical Care)
Salisbury Hospital: Mr Iain Macleod (Resuscitation),
East Sussex Hospitals, Dr Harry Walmsley (Anaesthetics & Resuscitation) Hammersmith Hospital London: Mr Ken Spearpoint, (Resuscitation),
AWARE STUDY – Investigators/advisors
Indiana State University, Dr Mark Faber (Pulmonary & Critical Care),
University of Virginia: Professor Bruce Greyson (Psychiatry), Dr Robert O’Connor (Emergency)
Emory Medical Center: Dr Maziar Zafari (cardiology)
University of Vienna: Professor Roland Beisteiner (Neurology), Dr Fritz Sterz (Emergency Medicine), Dr Michael Berger (Neuroscience)
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METHODS – Hidden Targets Southampton
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RESEARCH – Cardiac arrest – Humour!
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Near Death Experience Research
How do we study human mind and consciousness during cardiac arrest
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METHODS• Open question - ? memory of consciousness
• Study Experiences- Greyson scale - Cognitive recollections (study)
- No cognitive recollections (control)
-Physiological – O2 / CO2 – Electrolytes
Drugs – Cardiac Rhythm- Psychological – ? Religion ? Practicing
- Transcendental – Hidden
targets…
• Study Brain & Resuscitation Processes:
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RESULTS – Physiological Southampton
Southampton Study: NDE in cardiac arrest
010
30
50
70
90
110
130
150
control study
Nammol/l
Kmmol/l
PaCO2KPa
PaO2KPa
Parnia S, Waller D, Yeates R, Fenwick P, A qualitative and quantitative study of incidence, features and aetiology of NDE's in cardiac arrest survivors Resuscitation Feb 2001 48, 149-156
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Current version – Fixed shelves with fixed images!
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Future Version - Random image generators
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Portable Brain (EEG) Monitor – during cardiac arrest
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Cerebral oximetry – Our experience so far!
N=10 - Useful in cardiac arrest - results so far similar to previous - 02% <20% - non survivors
ROSC