eccu survivor workshop: mosesso
TRANSCRIPT
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Expanding the Chain:Expanding the Chain:The 7The 7thth Link- Link-Rehabilitation &Rehabilitation &RecoveryRecovery
Vince Mosesso, MDVince Mosesso, MDProfessor of Emergency MedicineProfessor of Emergency MedicineUniversity of Pittsburgh School of MedicineUniversity of Pittsburgh School of Medicine
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DisclosuresDisclosures
Prior grants from Medtronic Inc and MedtronicPrior grants from Medtronic Inc and MedtronicFoundationFoundation
Prior research support from Medtronic, Zoll,Prior research support from Medtronic, Zoll,Philips, Heartsine, Cardiac Science, Welch-Philips, Heartsine, Cardiac Science, Welch-AllynAllyn
Honorarium from BiotronikHonorarium from Biotronik Research support from Zoll LifeCorResearch support from Zoll LifeCor
CorporationCorporation Medical director and co-founder, SuddenMedical director and co-founder, Sudden
Cardiac Arrest AssociationCardiac Arrest Association
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When Survivors Speak, When Survivors Speak, ……
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Post cardiac arrest syndromePost cardiac arrest syndromeNow recognized as specific condition withNow recognized as specific condition with
specific interventionsspecific interventions
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Post cardiac arrestPost cardiac arrestsyndromesyndrome
Post cardiac arrest brain injuryPost cardiac arrest brain injury Post cardiac arrest myocardialPost cardiac arrest myocardial
dysfunctiondysfunction Systemic ischemia & reperfusionSystemic ischemia & reperfusion
responseresponse Underlying condition that caused arrestUnderlying condition that caused arrest
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CNSCNS
Loss of normal blood flow to brainLoss of normal blood flow to brain Overall blood flow/pressure controlOverall blood flow/pressure control Regional microvascular perfusionRegional microvascular perfusion
Neuronal cell death (necrosis/homicide)Neuronal cell death (necrosis/homicide)and triggering of self-death pathwaysand triggering of self-death pathways(apoptosis/suicide)(apoptosis/suicide)
Clinical syndrome ranges from mildClinical syndrome ranges from mildmemory deficits to persistent vegetativememory deficits to persistent vegetativestatestate
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Phases of post arrest carePhases of post arrest care
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After acute phase:After acute phase:Recovery & RehabilitationRecovery & Rehabilitation
Less well understoodLess well understood Most research has focused on severeMost research has focused on severe
neurological disabilitiesneurological disabilities Lack of providers to help survivors andLack of providers to help survivors and
love ones cope with emotional,love ones cope with emotional,psychological and more subtle cognitivepsychological and more subtle cognitivechangeschanges
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Symptoms and problemsSymptoms and problemsnoted by survivorsnoted by survivors
Goes beyond typical organic dysfunctionGoes beyond typical organic dysfunction Appears to be a unique spectrum of cognitiveAppears to be a unique spectrum of cognitive
and emotional experiencesand emotional experiences Many express need for supportMany express need for support
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Neuropsychological sequelaeafter cardiac arrest
155 survivors underwent neuro-psychevaluations at 3 and 12 months
Moderate to severe cognitive dysfunction: 60% at three months 48% at one year
Depression in 45% at one year
Roine RO et al. JAMA. 1993.
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Psychosocial distressafter ICD implantation
57 subjects surveyed every 6 months for2 years
Depression in 35% Anxiety in 45% Some decrease over time
Thomas SA et al. Heart & Lung, 2009
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SCAA: survey of survivors and theirSCAA: survey of survivors and theirloved onesloved ones
Benjamin S. Abella, MD, MPhil
Clinical Research Director Center for Resuscitation Science
Department of Emergency Medicine University of Pennsylvania
SCAA Annual Meeting - October, 2008
CRSCenter for
Resuscitation Science
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After SCA, what function has changed?
Touc
h
Tast
e
Smel
l
Sigh
t
Hea
ring
Mem
ory
Coo
rdin
atio
n
Non
e
Oth
er
80
60
40
20
0Num
ber r
espo
ndin
g 53%
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After SCA, what activity did you fear?
Exer
cise
Driv
ing
Air
trav
el
Bei
ng a
lone
Oth
er
60
40
20
0Num
ber r
espo
ndin
g
23%
15%30%
37%
5%
“holding loved ones”“swimming”“sleeping”
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Emotional changesEmotional changes
Lability (marked fluctuations)Lability (marked fluctuations) Spontaneous or easily-triggered cryingSpontaneous or easily-triggered crying Increased sensitivity to othersIncreased sensitivity to others’’ losses losses Greater love of family and friendsGreater love of family and friends FearFear——of ICD firing, or of not having one andof ICD firing, or of not having one and
needing it.needing it. GuiltGuilt——why did I survive, when so many otherswhy did I survive, when so many others
die?die?
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CognitiveCognitive
Various types and duration of memoryVarious types and duration of memorylossloss
Dementia (post-anoxic)Dementia (post-anoxic) Variable degrees of loss of executiveVariable degrees of loss of executive
functionfunction Continuous barrage of thoughtsContinuous barrage of thoughts Quicker, smarter brain functionQuicker, smarter brain function
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Sensory / PerceptionSensory / Perception
““Size upSize up”” people more quickly/easily people more quickly/easily Heightened sense of smellHeightened sense of smell Altered pain tolerance / perceptionAltered pain tolerance / perception
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BehavioralBehavioral
Sleep disturbancesSleep disturbances More outspoken when believe rightMore outspoken when believe right More risk-takingMore risk-taking
““Been to the brink, nothing can hurt meBeen to the brink, nothing can hurt memore.more.””
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Psychiatric/psychologicalPsychiatric/psychological
Depression and/or apathyDepression and/or apathy Perception of infallibilityPerception of infallibility Perception of vulnerabilityPerception of vulnerability Belief in destinyBelief in destiny——things are happeningthings are happening
for a purposefor a purpose Sense of urgencySense of urgency——must do as much asmust do as much as
possible right nowpossible right now
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Family & Loved onesFamily & Loved ones
Also affected in many ways and tovarious degrees
Both similar and different challenges One study:
60% with psychosomatic complaints 50% noted lack of social support
Pusswald G et al. Resuscitation, 2000.
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Dual causation
Organic brain injury Psychological stress
Treatment must address both of thesecauses and the various components
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““Post cardiac arrestPost cardiac arreststress disorder (PCSD)stress disorder (PCSD)”” -? -?
Need to distinguish from PCASNeed to distinguish from PCAS Labeling facilitates:Labeling facilitates:
increasing awarenessincreasing awareness advocacy for more research and clinicaladvocacy for more research and clinical
therapytherapy
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PCSD ComponentsPCSD Components
CognitiveCognitive EmotionalEmotional PerceptualPerceptual BehavioralBehavioral Psychiatric/PsychologicalPsychiatric/Psychological
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NeededNeeded
Better understandingBetter understanding SymptomsSymptoms TriggersTriggers Spectrum of severity and scopeSpectrum of severity and scope
Better therapyBetter therapy More access to therapyMore access to therapy
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Potential ways to addressPotential ways to address
Greater awareness of needGreater awareness of need ResearchResearch Stakeholder forumStakeholder forum Meeting of experts to review currentMeeting of experts to review current
science and potential therapiesscience and potential therapies Professional educationProfessional education
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The 7The 7thth Link: Link:Recovery & RehabilitationRecovery & Rehabilitation
Stay tuned to
www.suddencardiacarrest.org
for further information.
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The Defibrillators: Side Effects