Protease enzym that conducts proteolysis. (Breaks down protein, starves the cells)Free radicals are molecules with unpaired electrons. In their quest to find another electron, they are very reactive and cause damage to surrounding molecules.
Post Cardiac Arrest Syndrome
When you get one Back. Post Cardiac Arrest Syndrome! By Kane Guthrie S
Learning PointsS Cardiac arrest were are we at?S A case!S Post resuscitation care is it the answer?S A chilling look at the benefits of therapeutic hypothermia!
Cardiac Arrest the Stat’sS Generally 6-7% survival rate (worldwide)S 0nly 3-4% leave hospital with RONFS Early Defib/compressions make the differenceS Post resuscitation care is the answer to improving mortality and morbidity with ROSC.
Cardiac ArrestS We loose so many!S We need to focus on the ones we get back.S The REAL resuscitation starts once we get ROSC!S RONF or organ donation is the only good outcome’s!
The things that help get em back!The 3 things that have the evidence:1. Early high quality chest compressions2. Early defibrillation3. Therapeutic hypothermia
Case StudyS 68 male walking home from pubS Collapse > Cardiac Arrest >Bystander CPRS SJA arrive 13mins post arrestS In VF, Successful ROSC post x3 defibsS Arrives in T2 20 mins later with no RONFS What should we do now?
The Goals Post Arrest1. Induce Therapeutic Hypothermia2. Maximise Haemodynamic’s3. Optimise Oxygenation4. Advocate for Cardiac Catheterisation
Post Cardiac Arrest Syndrome!!S Thought to be RT production of free radicalsS Pathophysiology is very complex = BORINGS Hypoperfusion & Ischaemia cause cascade of events 1. Disruption of homeostasis 2. Free radical formation 3. Protease activation •Hypothermia helps slow down this cascade
The Patho1. Brain Injury S Cerebral oedema and ischaemia2. Myocardial dysfunction S Haemodynamically labile R/T global hypokinesis.3. Systemic ischemia/reperfusion response S SIRS response – looks like sepsis.4. Persistent precipitating pathology. S The underlying cause.
Oxygen and VentilationAvoid hyperoxia:S O2 toxicity detrimental to heart and brain.S Adjust 02 to keep spo2 >90.Avoid hyperventilation:S Hypocarbia causes cerebral vasoconstriction.
Circulatory SupportS Haemodynamic instability is the norm!S Each episode of hypotension worsens mortality & neuro function.S Aggressive IVF- replace volume depletionS Keep MAP- 65-100mmHg (adrenaline, noradrenaline or dopamine)
ICU via Cath Lab?S PCI improves survival and neurological function.S STEMI should go straight to CATH Lab.S Consider for all other survivors within 12-24 hours post ROSC – up to 40% have unstable plaques.S Can be difficult convincing cardiology!!!
Therapeutic HypothermiaS ‘Induced hypothermia” is were pt is deliberately cooled between 32-33.9°CS It aims to reduce hypoperfusion (& reperfusion) injury post arrest.S Focuses mainly on brain (neuroprotection), but offers protection to heart, liver, kidneys.S Current research shows no benefit of inducing TH before or during event. (RINSE trial ongoing)
Therapeutic Hypothermia S Therapeutic hypothermia is the first treatment that has proven effective for post-resuscitation reperfusion injury.S NNT 1:6 vs 1:42 for aspirin in STEMI
Who’s in? Whos Out? In. Out.S Cardiac arrest with ROSC. S Advanced directive or DNR.S Persistent significant altered S Traumatic arrest. GCS. S Active bleeding.S <12 since ROSC. S Pregnant, recent major surgery or severe sepsis.
3 phases of TH.1. Induction: •Aim reduce core temp to 32-34°C •Preferably within 2 hours2: Maintenance: •Maintain core temp 12-24 hours3:Rewarming: •controlled or passive rewarming to normothermia 37°C •0.2-0.5°C per hour –over 8- 12 hours
How to Cool!S Cold fluidsS ICE PacksS Machine’s
ED Management Airway •secure ETT, continuous EtCO2 Breathing •Prevent VILI Circulation •ECG (risk arrhythmias) •Monitor U/O (cold diuresis) Disability •Paralyze, sedate Exposure •Core temp monitoring •Monitoring skin integrity •Once at 34°C remove ICE packs & maintain •Monitor and prevent shivering•Prepare patient for T/F to ICU, Cath Lab
Take Home PointsS Good post resus care improves outcomes.S Therapeutic hypothermia should be done on all ROSC with-out RONF.S Maximise haemodynamic’s and oxygenation in ED.S Advocate for the early CATH Lab.