ECCU Survivor Workshop: Mosesso

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Expanding the Chain: The 7th Link--Rehabilitation and Recovery

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ECCU Survivor Workshop: Mosesso

  1. 1. Expanding the Chain:The 7th Link-Rehabilitation &RecoveryVince Mosesso, MDProfessor of Emergency MedicineUniversity of Pittsburgh School of Medicine
  2. 2. Disclosures  Prior grants from Medtronic Inc and Medtronic Foundation  Prior research support from Medtronic, Zoll, Philips, Heartsine, Cardiac Science, Welch- Allyn  Honorarium from Biotronik  Research support from Zoll LifeCor Corporation  Medical director and co-founder, Sudden Cardiac Arrest Association
  3. 3. When Survivors Speak, …
  4. 4. Post cardiac arrest syndromeNow recognized as specific condition with specific interventions
  5. 5. Post cardiac arrestsyndrome  Post cardiac arrest brain injury  Post cardiac arrest myocardial dysfunction  Systemic ischemia & reperfusion response  Underlying condition that caused arrest
  6. 6. CNS Loss of normal blood flow to brain  Overall blood flow/pressure control  Regional microvascular perfusion Neuronal cell death (necrosis/homicide) and triggering of self-death pathways (apoptosis/suicide) Clinical syndrome ranges from mild memory deficits to persistent vegetative state
  7. 7. Phases of post arrest care
  8. 8. After acute phase:Recovery & Rehabilitation  Less well understood  Most research has focused on severe neurological disabilities  Lack of providers to help survivors and love ones cope with emotional, psychological and more subtle cognitive changes
  9. 9. Symptoms and problemsnoted by survivors  Goes beyond typical organic dysfunction  Appears to be a unique spectrum of cognitive and emotional experiences  Many express need for support
  10. 10. Neuropsychological sequelaeafter cardiac arrest  155 survivors underwent neuro-psych evaluations 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.
  11. 11. Psychosocial distressafter ICD implantation 57 subjects surveyed every 6 months for 2 years Depression in 35% Anxiety in 45% Some decrease over time Thomas SA et al. Heart & Lung, 2009
  12. 12. SCAA: survey of survivors and theirloved onesBenjamin S. Abella, MD, MPhil Clinical Research Director CRS Center for Resuscitation Science Department of Emergency Medicine Center for Resuscitation Science University of PennsylvaniaSCAA Annual Meeting - October, 2008
  13. 13. Number responding 20 40 60 80 0 Touch Taste Smell 53% Sight Hearing MemoryCoordination None After SCA, what function has changed? Other
  14. 14. After SCA, what activity did you fear? 60 37% “holding loved ones” “swimming” “sleeping”Number responding 40 23% 30% 15% 20 5% 0 Driving Air travel Exercise Being alone Other
  15. 15. Emotional changes  Lability (marked fluctuations)  Spontaneous or easily-triggered crying  Increased sensitivity to others’ losses  Greater love of family and friends  Fear—of ICD firing, or of not having one and needing it.  Guilt—why did I survive, when so many others die?
  16. 16. Cognitive  Various types and duration of memory loss  Dementia (post-anoxic)  Variable degrees of loss of executive function  Continuous barrage of thoughts  Quicker, smarter brain function
  17. 17. Sensory / Perception  “Size up” people more quickly/easily  Heightened sense of smell  Altered pain tolerance / perception
  18. 18. Behavioral  Sleep disturbances  More outspoken when believe right  More risk-taking  “Been to the brink, nothing can hurt me more.”
  19. 19. Psychiatric/psychological  Depression and/or apathy  Perception of infallibility  Perception of vulnerability  Belief in destiny—things are happening for a purpose  Sense of urgency—must do as much as possible right now
  20. 20. Family & Loved ones  Also affected in many ways and to various degrees  Both similar and different challenges  One study:  60% with psychosomatic complaints  50% noted lack of social support  Pusswald G et al. Resuscitation, 2000.
  21. 21. Dual causation  Organic brain injury  Psychological stress Treatment must address both of these causes and the various components
  22. 22. “Post cardiac arreststress disorder (PCSD)” -?  Need to distinguish from PCAS  Labeling facilitates:  increasing awareness  advocacy for more research and clinical therapy
  23. 23. PCSD Components  Cognitive  Emotional  Perceptual  Behavioral  Psychiatric/Psychological
  24. 24. Needed Better understanding  Symptoms  Triggers  Spectrum of severity and scope Better therapy More access to therapy
  25. 25. Potential ways to address  Greater awareness of need  Research  Stakeholder forum  Meeting of experts to review current science and potential therapies  Professional education
  26. 26. The 7Link: thRecovery & Rehabilitation Stay tuned to www.suddencardiacarrest.org for further information.
  27. 27. The Defibrillators: Side Effects

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