rosc! now what??!! an ems guide to the management of post cardiac arrest syndrome jay lance kovar,...
TRANSCRIPT
- Slide 1
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- ROSC! Now what??!! An EMS Guide to the Management of Post Cardiac Arrest Syndrome Jay Lance Kovar, MD, FACEP Montgomery County Hospital District PHI Air Medical Texas
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- Objectives o Review o Background and Epidemiology of Cardiac Arrest Survival o Detail o Pathophysiology of Post Cardiac Arrest Syndrome o Discuss o Monitoring, Therapeutic Strategies, and Protocols they apply to the Pre-Hospital Environment o Propose o Integrated EMS Protocols for Improved Intact Neurologic Survivability
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- Background o 1966Nat'l Academy Sciences Nat'l Research Council on CPR describes ABCDs o 1972Dr Valdimir Negovsky The Second Step o Advances in CPR and cardiac care has not resulted in improved survivability in 50 years o Post Cardiac Arrest Syndrome o Brain Injury o Myocardial Dysfunction o Systemic Ischemia/Reperfusion Response o Unresolved Pathological Process
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- Background o Barriers to Optimal Outcomes o Multiple Teams/Hand-0ffs o Wide variation in Treatments (multicenter trials) o Early Prognostication Inaccuracies < 72 hrs o Research focus on ROSC o Improved ROSC w/o Improved Survival
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- Epidemiology o Early Mortality rates after ROSC varies greatly between studies, regions, and hospitals indicating variability in Post Cardiac Arrest Care o Advances in Critical Care over past 5 decades fails to produce improved outcomes o Data Definition Confusion o ROSC o Mortality Location o OOH/IH o Mortality Time
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- Epidemiology o Physiologic Phases of Post Cardiac Arrest Care o Immediate = 0-20 minutes o CPR interventions o Early = 20 minutes 6 to 12 hours o Early interventions most effective o Intermediate = 6 to 12 hours 72 hours o Aggressive management of Injury pathways o Recovery = beyond 3 days o Prognostication Reliable o Outcomes Predictable
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- Epidemiology o Mortality Rates Inadequate o Neurologic and Functional Outcomes o Cerebral Performance Category
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- Epidemiology Quality of Life? o Limitation and Withdrawal of Therapy o 63% made DNR, 43% withdrew Therapy in Early and Intermediate time periods
- Brain Injury o Protracted Injury Phase opens Broad Therapeutic Window o Cerebral Perfusion becomes dependent upon CePP not Autoregulation or Neuronal Activity o Migratory Intravascular Thrombosis with CPR > 15 minutes (No Reflow) o Hyperemic Flow increases Edema o Luxuriant Hyperperfusion o Excessive Oxygen Free radical Formation
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- Brain Injury o Global CBF is reduced but adequate to meet Oxidative Metabolic Demands in first 48 hours o Transient Edema common post Arrest but rarely increases ICP o Delayed Edema attributable to Ischemic Neurodegradation o Pyrexia o Poor Outcome Increases with each degree > 37 0 C o Hyperglycemia o Common and Potentially Mitigated with Insulin Rx o Seizures o Associated with Worst Prognosis o -- Caused by and Exacerbates Injury
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- Myocardial Dysfunction o Responsive to Therapy and Reversible o Detectible within minutes of ROSC o Decreased EF (stunned) o Increased LVEDP (stiff) o Coronary Blood Flow Normal = Myocardial Stunning o Nadir @ 8 Hrs, Improve @ 24 Hrs, Normal @ 72+ Hrs o Dobutamine improves LVEF and Diastolic Dysfunction
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- Systemic Response o CPR generates poor Cardiac Output, O 2 delivery, and Metabolite Clearance o Oxygen Debt leads to Endothelial Activation and Systemic Inflammation o Predictive of MOSF and Death o Common Sepsis Features o Adrenal Insufficiency o Responsive to Therapy and Reversible o Early Goal Directed Therapy may Optimize Outcomes
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- Persistent Pathology o Precipitating or Contributory Pathology o ACS o AMI >50% OOH Adult Arrests o 48% Acute Coronary Occlusion w/o apparent STEMI o Biomarker Specificity Reduced yet 96% Sensitive for AMI
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- Persistent Pathology o Precipitating or Contributory Pathology o Pulmonary Embolism o Up to 10% Incidence in Sudden Death o Unknown ROSC Rate o COPD, Asthma, or Pneumonia o Pulmonary Function often Worsens post ROSC o Brain Injury and Edema more common after Asphyxic Arrest o Sepsis o Infections more common cause of In Hospital Arrests o Toxins o Environmental
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- Therapeutic Strategy o Critical Care Standards for EMS and ED o Time Sensitive o Account for In/Out of Hospital Settings o Sequential care by multiple Diverse Teams o Accommodate Spectrum of patients o Awake, Stable to Unstable Comatose
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- Out-of-Hospital Cardiac Arrest Survival after the Sequential Implementation of 2005 AHA Guidelines for Compressions, Ventilations, and Induced Hypothermia J. Brent Myers, MD MPH Medical Director Wake County EMS System 4.6% 7.3% 8.2% 11.6% * when compared with baseline P 100 mmHg w/i 5 minutes of ROSC Bad o Cerebral perfusion dependant on MAP in Early Phase o No Reflow Phenomenon may require 90-100 mmHg Range o AMI or Myocardial Stunning maybe better at 65-75 mmHg Range
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- Optimal Hemodynamics o Post Cardiac Arrest Syndrome shares Characteristics with Sepsis o EGDT in Post Cardiac Arrest Syndrome o Optimal CVP 8 12 mmHg o Relative Intravascular Volume Depletion Exists post ROSC o Account for Pathologies causing Elevated CVPs o Cardiac Tamponade o RV Infarct o PE o Tension PTX o Poor Myocardial Compliance
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- Circulation Support o Hemodynamic instability manifests as Dysrhythmias, Hypotension, and poor Stroke Volume/Output o Early Reperfusion is Best AntiArhythmic Therapy o Optimize RV Filling Pressures 8 -12 mmHG o 3.5 6.5 Lt First 24 hours o Inotropes/Vasopressors After Volume Correction o Pressor Dependence up to 72 hours o Select Inotropes by BP, HR, CO, and S v O 2 o Dopamine??
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- Therapeutic Hypothermia o The Only Post Cardiac Arrest Therapy Show to Increase Survival o Ongoing Evaluation of benefit in Patient Populations, Induction Techniques, Target Temperature, Duration of Therapy, and Rewarming Techniques. o Benefit Related to Time of Initiation of Therapy o Induction o IV Fluids and Cooling Pads o Maintenance o Cooling Pads and Catheters o ReWarming o 0.25 0 C 0.5 0 C/hr Current Consensus
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- Therapeutic Hypothermia
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- Sedation and Paralysis o Indicated for Failure to return to Awake Status w/i 5-10 minutes Post ROSC o Sedation reduces oxygen Consumption o Opoids and Hypnotics Required o EEG Monitoring for Sustained Neuromuscular Blockade
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- Seizures o Increases Cerebral Metabolism 3 Fold o Exclude ICH & Electrolyte Imbalance o Myoclonus o Difficult to Control o Phenytoin Ineffective o Clonazepam most Effective o Improved Outcomes with Hypothermia despite Severe post Arrest Status Epilepticus
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- Prognostication o Pre-Cardiac Arrest Factors o Many Factors Associated with Poor Outcome o Advanced Age o Race o Poor Pre-Arrest health o Diabetes o Sepsis o Metastatic cancer o Renal failure o Homebound Status o Stroke o APACHE II & III Scores o None are Reliable Predictors
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- Prognostication o Intra-Cardiac Arrest Factors o Factors Associated with Poor ROSC o Time To CPR o Duration of CPR o Quality of CPR o Maximum ETCO 2 < 10 mmHg o Asystole o Non cardiac Causes o None are Reliable Predictors Post ROSC
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- Prognostication o PostCardiac Arrest Factors o Retention of Neurologic Function Immediately after ROSC Best Predictor o Absence of Neurologic Function Immediately after ROSC is Not a Reliable predictor of Poor Outcome o Reliable Predictors occur at 72 Hours
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- Prognostication In the Age of Hypothermia o Therapeutic Hypothermia Improves Survival and Functional Outcome for 1 in every 6 Cardiac Arrest Survivors treated (NNT=6) o Alters Progression of Neurological Injury o Changes the Evolution of Recovery o Changes in Timing and Interpretations are Needed o Do Not Withdraw Support Prematurely
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- Implementation o Clinical Guidelines Dont Change Practice o Barriers o Structural o Human and Financial Resources o Organizational o Leadership o Scientific o Personal o Intellectual o Attitudinal o Motivation o Environmental o Political o Economic o Cultural o Social
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- Implementation Protocol changes drop/downplay Epi Vasopressin early and repeat accept Pox 96-98% Follow eTCO2 Aim for MAP 65-95mmHg Volume resuscitate Dobutamine over Dopamine Induce Hypothermia Educate colleagues Demand Outcomes Transport to Resuscitation centers
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- Questions o What Will You Do Different Monday?