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S. Sujanthy Rajaram MD, MPH, FCCM, FAASMAssociate Professor of MedicineDivision of Critical Care Medicine
Cooper University HospitalCooper Medical School of Rowan University
University of Medicine & DentistryCamden, New Jersey
Cardiac Arrest & Chain of Survival
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Post-cardiac Arrest Syndrome
Clinical Trials & Current Guidelines
What we will cover…
Clinical Implementation
? Potential applications in Sri Lanka
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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
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Imm
edia
te
Ear
ly
Inte
rmed
iate
Rec
ove
ry
Reh
abil
itat
ion
ROSC Disposition72 hours6-12 hours20 min
Ph
ase
Limit ongoing injuryOrgan support Rehabilitation
PrognosticationPrevent Recurrence
Go
als
Circulation 2008
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BRAIN INJURY IS EVOLVING
AFTER AN ANOXIC INSULT
UP TO 72 HOURS72 HOURS
AFTER THE EVENT
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Brain
injury
free
radical
necrosis
apoptosis
edema
ICP
inflammatory
cascade
metabolic
demand
hyper-
excitability
TH prevents brain injury
Cool !!!Mechanisms
☺Hypothermia☺
Respir Care 2007
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CA: Non-randomized studies
Polderman KH. Lancet 2008;371: 1955
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HACA. N Engl J Med 2002;346 (8): 549-556
N = 275 eligible
HypothermiaN = 137
NormothermiaN = 138
Primary OutcomeGood neurological outcome @ 6 mos
Secondary OutcomesMortality @ 6 mos.
Complications @ 7 d.
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Method Cooling blanket over whole body + released cool air.
Target 32 to 34 °C
Induction From ROSC to target T : median 8 hours
Duration Median of 24 hours
Rewarming Passive over 8 hours
HACA. N Engl J Med 2002;346 (8): 549-556
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N Engl J Med 2002;346 (8): 549-556
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Outcome Normothermia Hypothermia Risk Ratio (95% CI) P Value
Favorable neurologic outcome
54 / 137 (39) 75 / 136 (55) 1.40 (1.08-1.81) 0.009
Death 76 / 138 (55) 56 / 137 (41) 0.74 (0.58-0.95) 0.02
Neurologic Outcome and Mortality at Six Months
N Engl J Med 2002;346 (8): 549-556
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N Engl J Med 2002;346 (8): 549-556
Survival
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Bernard SA et al. N Engl J Med 2002;346 (8): 557-563
N=77
HypothermiaN = 43
NormothermiaN = 34
Primary OutcomeSurvival to DC with good neurological
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Method Ice packs placed around the head, neck, torso, and limbs
Target 33 °C
Induction From ROSC to target T : 2 hours
Duration 12 hours after target T achieved
Rewarming Passive after 12 hours, active after 18 hours
Bernard SA et al. N Engl J Med 2002;346 (8): 557-563
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Outcome Hypothermia(N = 43)
Normothermia(N = 34)
Normal or minimal disability 15 7
Moderate disability 6 2
Severe disability, awake but completely dependent
0 1
Severe disability, unconscious 0 1
Death 22 23
Outcome of Patients at Discharge from the Hospital
Bernard SA et al. N Engl J Med 2002;346 (8): 557-563
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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.
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Critical Care Med 2011; 39.
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
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Clinical Application
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Cooling Options / Methods
Cold Fluids Surface Intravascular
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Temperature Monitoring
Foley, rectal, esophageal, tympanic?If you can’t monitor the temperature, don’t manipulate
itFoley is better than rectal
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Recommended Temperature Monitoring Sites
1. PA catheter2. Esophageal3. Bladder (unless anuric)4. Cranial or Nasopharyngeal5. Rectal
(Do not use axillary with surface cooling!)
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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
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Benzodiazepine enhanced cooling
Shivering
Cold IV Saline + sedation (awake volunteers)
Valium 10 -20 mg
~2.5 liters (30ml/kg) of saline / 30 min
Holster et al. High dose diazepam facilitates core cooling during cold saline infusion in healthy volunteers. Appl Physiol Nutr Metab. 2009;34:582-586
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Shivering
Increases metabolic demand (VO2); makes it hard to coolHeavy sedation is sufficient to suppress shiveringMuscle relaxants will be necessary only during induction
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Cooling Lowers Heart Rate
Decline as low as 40/ mt, BP not affected
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Cooling Prolongs QT interval
PR=208, QTc=535 Be vigilant if etiology of CA or on agents prolongs QT(Amiadarone), electrolytes shift
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K+
Mg+ PO4-
K+K+
K+
Mg+ PO4-
Mg+ PO4-
K+
Fluids and Electrolytes
Lactate, Free fatty acids, Glycerol, Ketones, Osmolarity
Hypothermia Rewarming
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Potential Side Effects and Their Frequency
High Probability Coagulopathy
Hypovolemia (increased diuresis) Match the UOP
Electrolyte disorders
Hyperglycemia (Insulin resistance, low secretion, need more insulin)
Low Probability Manifest bleeding
Airway infections (with prolonged hypothermia)
Wound infections (transient immunomodulation)
Myocardial ischemia
Rare Manifest pancreatitis
Intracerebral bleeding
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What do they need to survive?
Most CA victims require Cardiac catheterization
Dead orAlive?
AfterCool !!!
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Treat the reversible causes
• Hypovolemia
• Hypoxia
• Hydrogen ion (acidosis)
• Hypokalemia Hyperkalemia
• Hypothermia
• Tension pneumothorax
• Toxins
• Tamponade
• Thrombosis
pulmonary
• Thrombosis Cardiac
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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 dysrhythmiaDespite 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 arrestNEJM. 1997;336:1629-1633Kurz et al. Periop. Normothermia NEJM. 1996;334:1209-1215Boddickee et al. Hypothermia improves defibrillation success from v.fibrillation in swine modelResuscitation, 2005; 65:79-85
Post arrest Cardiac Catheterization
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Video Clips
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“The majority of patients who achieve ROSC are being
abandoned long before it is reasonable to predict neurological recovery”
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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)
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Poor Prognosis
• Myoclonic twitching or jerking has no bearing on prognosis
• Atonic, sub clinical or focal seizures are unrelated to prognosis
• Neurologic specific enolase in serum or CSF
( Day 1-3, >33 microgram/dL )• CT – brain swelling or loss of grey white differentiation• MRI – 49-108 hours, MR spectroscopy for PH, N acetyl
aspartates, not widely available• Cannot apply these widely in hypothermia
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Arrest Rhythms
Shockable Non-shockable
VF / Pulseless VT Asystole / PEA
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Goal of CPR • Improve neurologically intact survival to
hospital discharge following CA
CAB
• Compression
• Airway
• Breathing
• No more ABC
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Chain of Survival
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Post-cardiac Arrest Syndrome
Clinical Trials & Current Guidelines
What was covered in CPR & Chain of Survival
Clinical Implementation
? Potential applications in Sri Lanka
Need BLS and ACLS with emergency response team
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Thank You !!! Cool !!!!