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

1. Expanding the Chain:
The 7th Link-
Rehabilitation &
Recovery
Vince Mosesso, MD
Professor of Emergency Medicine
University of Pittsburgh School of Medicine

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. When Survivors Speak, …

4. Post cardiac arrest syndrome
Now recognized as specific condition with
specific interventions

5. Post cardiac arrest
syndrome
 Post cardiac arrest brain injury
 Post cardiac arrest myocardial
dysfunction
 Systemic ischemia & reperfusion
response
 Underlying condition that caused arrest

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. Phases of post arrest care

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. Symptoms and problems
noted by survivors
 Goes beyond typical organic dysfunction
 Appears to be a unique spectrum of cognitive
and emotional experiences
 Many express need for support

10. Neuropsychological sequelae
after 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. Psychosocial distress
after 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. SCAA: survey of survivors and their
loved ones
Benjamin S. Abella, MD, MPhil
Clinical Research Director
CRS Center for Resuscitation Science
Department of Emergency Medicine
Center for
Resuscitation Science University of Pennsylvania
SCAA Annual Meeting - October, 2008

13. Number responding
20
40
60
80
0
Touch
Taste
Smell
53%
Sight
Hearing
Memory
Coordination
None
After SCA, what function has changed?
Other

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. 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. 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. Sensory / Perception
 “Size up” people more quickly/easily
 Heightened sense of smell
 Altered pain tolerance / perception

18. Behavioral
 Sleep disturbances
 More outspoken when believe right
 More risk-taking
 “Been to the brink, nothing can hurt me
more.”

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. 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. Dual causation
 Organic brain injury
 Psychological stress
Treatment must address both of these
causes and the various components

23. “Post cardiac arrest
stress disorder (PCSD)” -?
 Need to distinguish from PCAS
 Labeling facilitates:
 increasing awareness
 advocacy for more research and clinical
therapy

24. PCSD Components
 Cognitive
 Emotional
 Perceptual
 Behavioral
 Psychiatric/Psychological

25. Needed
 Better understanding
 Symptoms
 Triggers
 Spectrum of severity and scope
 Better therapy
 More access to therapy

26. Potential ways to address
 Greater awareness of need
 Research
 Stakeholder forum
 Meeting of experts to review current
science and potential therapies
 Professional education

27. The 7Link:
th
Recovery & Rehabilitation
Stay tuned to
www.suddencardiacarrest.org
for further information.

28. The Defibrillators: Side Effects