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

Post-cardiac Arrest Syndrome

Clinical Trials & Current Guidelines

What we will cover…

Clinical Implementation

? Potential applications in Sri Lanka

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

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

BRAIN INJURY IS EVOLVING

AFTER AN ANOXIC INSULT

UP TO 72 HOURS72 HOURS

AFTER THE EVENT

Brain

injury

free

radical

necrosis

apoptosis

edema

ICP

inflammatory

cascade

metabolic

demand

hyper-

excitability

TH prevents brain injury

Cool !!!Mechanisms

☺Hypothermia☺

Respir Care 2007

CA: Non-randomized studies

Polderman KH. Lancet 2008;371: 1955

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.

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

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

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

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

Survival

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

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

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

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.

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

Clinical Application

Cooling Options / Methods

Cold Fluids Surface Intravascular

Temperature Monitoring

Foley, rectal, esophageal, tympanic?If you can’t monitor the temperature, don’t manipulate

itFoley is better than rectal

Recommended Temperature Monitoring Sites

1. PA catheter2. Esophageal3. Bladder (unless anuric)4. Cranial or Nasopharyngeal5. Rectal

(Do not use axillary with surface cooling!)

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

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

Shivering

Increases metabolic demand (VO2); makes it hard to coolHeavy sedation is sufficient to suppress shiveringMuscle relaxants will be necessary only during induction

Cooling Lowers Heart Rate

Decline as low as 40/ mt, BP not affected

Cooling Prolongs QT interval

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

K+

Mg+ PO4-

K+K+

K+

Mg+ PO4-

Mg+ PO4-

K+

Fluids and Electrolytes

Lactate, Free fatty acids, Glycerol, Ketones, Osmolarity

Hypothermia Rewarming

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

What do they need to survive?

Most CA victims require Cardiac catheterization

Dead orAlive?

AfterCool !!!

Treat the reversible causes

• Hypovolemia

• Hypoxia

• Hydrogen ion (acidosis)

• Hypokalemia Hyperkalemia

• Hypothermia

• Tension pneumothorax

• Toxins

• Tamponade

• Thrombosis

pulmonary

• Thrombosis Cardiac

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

Video Clips

“The majority of patients who achieve ROSC are being

abandoned long before it is reasonable to predict neurological recovery”

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)

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

Arrest Rhythms

Shockable Non-shockable

VF / Pulseless VT Asystole / PEA

Goal of CPR • Improve neurologically intact survival to

hospital discharge following CA

CAB

• Compression

• Airway

• Breathing

• No more ABC

Chain of Survival

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

Thank You !!! Cool !!!!