Post cardiac arrest care in ED


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Survival after cardiac arrest is poor but some therapies can make a difference. This presentation discusses the evidence for therpauetic hypothermia, normoxia, management of blood pressure and early cardiac catherterisation. It also makes the case that these might be elements of a bundle of care.

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Post cardiac arrest care in ED

  1. 1. Professor Anne-Maree KellyWestern Health@kellyam_jec
  2. 2.  This presentation may be reproduced in part orwhole for education purposes on the condition thateach reproduced slide contains the following:‘Reproduced with permission of Professor Anne-Maree Kelly, Joseph Epstein Centre for EmergencyMedicine Research @Western Health, Melbourne,Australia’
  3. 3.  Support for this meeting and advisory boards from Astra Zeneca Travel support to speak at a conference (on blood gases) by Radiometer Advisory board membership MSD No relationships with manufacturers of hypothermia equipment Co-author of NHF guidelines for the management of ACS and addenda & ofsome of the research mentioned in this talk Editorial boards of:◦ Annals of Emergency Medicine◦ Emergency Medicine Australasia◦ Hong Kong Journal of Emergency Medicine
  4. 4.  My Colleagues Dr Stephen Bernard, Dr Karen Smith andcolleagues for the ongoing, world leading body of work in thisspace
  5. 5.  To review the pathophysiology of post-cardiac arrestsyndrome To summarize the evidence for a variety of interventions toimprove outcome after out of hospital cardiac arrest To propose the concept of a bundle of care approach tomanagement of these patients
  6. 6.  72% in the home Age 64 years (mean) 82% male Ventricular fibrillation 37% Pre-hospital -> advanced cardiac life support If return of pulse -> transport to nearest ED
  7. 7.  Ventilation on 100% oxygen Sedation to maintain ETT 12 lead ECG Cardiology referral ICU referral Chest Xray Arterial line and ABG Bloods Bladder catheter Early (pessimistic) prognosticationROSC rate = 24%Survival to discharge =7.6%Sasson et al. Circ Cardiovasc Qual Outcomes 2010:3:63-812.
  8. 8.  Cerebral and cardiac dysfunction due to prolonger wholebody ischaemia Elements◦ Anoxia brain injury◦ Myocardial dysfunction◦ Systemic ischaemia/ reperfusion response◦ Persistent precipitating pathology Contribution of the elements varies between individuals
  9. 9.  Ventilation◦ 100% oxygen or normoxia?◦ What pCO2 target? Blood pressure◦ What target and how? Cath lab◦ Just STEMI? Therapeutic hypothermia◦ If ‘Yes’, how?
  10. 10.  High oxygen concentration may increase free radicalproduction Some observational data (from ICU) that higher oxygenationis harmful Each 100mmHg increase in pO2 (on ICU admission) associatedwith 24% increase in mortality Currently the subject of RCT proposalsKilgannon et al. JAMA 2010;123:2717-2722
  11. 11.  Avoidance of both hyperoxia and hypoxia SpO2 target 94-96% Avoid hypocarbia as it:◦ Causes cerebral vasoconstriction◦ Hyperventilation decreases cardiac output
  12. 12.  Increased blood pressure may improve cerebral perfusion,BUT Inotropes/ pressors may cause additional cardiac injury Observational data only suggesting ~30% improvement inoutcome with achievement of haemodynamic stability Studies used different targets MAP 80-100mmHg vs 65-70mmHg Optimal MAP target remains unclearGaieski et al. Resuscitation; 2009;80:418-24.Sunde et al. Resuscitation 2007; 73:29-39.
  13. 13.  Aim for mean arterial pressure of 65-100mmHg Taken into consideration ‘usual’ BP and severity ofmyocardial dysfunction
  14. 14.  Judicious fluid loading Inotropic drug therapy Mechanical support devices e.g.◦ IABP◦ ECMO
  15. 15.  Anoxic brain injury responsible for ~2/3rds of deathspost cardiac arrest Therapeutic hypothermia is a major recent advance inneuroprotection How it works?◦ Multifactorial?◦ Decreases cerebral oxygen demand◦ ? Direct cellular effects◦ Reduction in reactive oxygen species generation
  16. 16.  32 C-34 C for 12-24 hours 24 hours is current recommendation In meta-analysis RR best cerebral performance categories 1.55 (95% CI 1.22-1.96) RR survival to hospital discharge 1.35 (95% CI 1.10-1.65)Arrich et al. Cochrane Database Syst Rev 2009; CD 004128
  17. 17.  Strong RCT evidence of OHCA with VF as initial rhythmEvidence less clear for PEA/ Asystole Lower overall survival Not all are cardiac in origin (? ~50%) Some trend towards benefit (one study) Survival 19% vs 7% Good outcome13% vs. 0%Study Survival Good neurologicaloutcomeHACA 59% vs 45% 55% vs 39%Bernard 49% vs. 32% 49% vs. 26%HACA. NEJM 2002;346:549-56Bernard et al. NEJM 2002; 346:557-63Haschimi-Idrissi et al. Resuscitation 2001; 51:275-81.
  18. 18.  Cooled IV fluids (40ml/kg) Surface cooling Intravascular cooling
  19. 19.  Persuasive animal data that the earlier the better Two RCT have demonstrated that pre-hospital coolingusing IV fluids is safe, feasible and effective No clinical outcome benefit shown compared to in-hospital cooling (yet)◦ Main (probable explanation): small difference in times
  20. 20.  STEMI unconscious post cardiac arrest were excluded fromPCI vs. thrombolysis trials Initial ECG shows STEMI in 30-60% of patients with ROCS afterOHCA Good evidence that early angiography with view to PCIimproves outcome for patients with STEMI (RCT andobservational)
  21. 21.  Recent study showed significant coronary lesionspresent in up to 66% of patients with OHCA withoutST elevation. Registry data has reported primary PCI as anindependent predictor of survival regardless of initialECG (odds ratio, 2.06; 95% CI, 1.16 to 3.66).Reynolds et al. J Intensive Care Med 2009; 24: 179-86.Dumas et al. Circ Cardiovasc Interv 2010; 3:200-7.
  22. 22.  2902 post arrest patients in Victoria Transported to one of 70 hospitals 1816 (63%) of patients were treated at hospitals with 24 hourcardiac interventional services After adjusting for differences in baseline characteristics,treatment at hospitals with 24 hour cardiac interventionalservices was significantly associated with survival (odds ratio1.40; 95% CI 1.12-1.74, p=0.003)Stub D et al. Heart. 201197:1489-94.
  23. 23.  Bundles of care are a structured way of improvingprocesses of care and patient outcomes 3-5 components performed collectively and reliably ALL OR NONE The power comes from the evidence-base and theconsistency of implementation Examples:◦ Central line bundle IHI◦ Goal-directed sepsis therapy
  24. 24.  Initiation of therapeutic hypothermia in ED (32-34 C). Maintain for 24 hours with slow re-warming Optimization of haemodynamic status (MAP 65-100mmHg) Transfer to cardiac catheter laboratory early Avoidance of hyperoxia (SpO2 94-96%)A number of ‘before-and-after’ studies supportthe concept.
  25. 25.  For patients with OHCA (?VF initial rhythm) SpO2 94-96% Core temperature <35 C MAP 65-100mmHg Transfer to cath lab within 110 mins.
  26. 26.  Systems of care for time critical illness improvesoutcomes Emerging evidence of improved outcomes in OHCA inspecialized centres (Japan and Sweden)◦ OR improved survival ~3.4 Is this workable in the Australian context?