The presentation by Professor Anne-Maree Kelly focuses on the management of post-cardiac arrest syndrome and highlights interventions to improve outcomes after out-of-hospital cardiac arrest, including therapeutic hypothermia and hemodynamic optimization. Key evidence supports structured care approaches, referred to as bundles of care, which enhance patient outcomes when implemented consistently. The potential benefits of specialized care systems for time-critical illnesses are also discussed, alongside suggestions for improving these systems in the Australian context.

1. Professor Anne-Maree Kelly
Western Health
@kellyam_jec

2.  This presentation may be reproduced in part or
whole for education purposes on the condition that
each reproduced slide contains the following:
‘Reproduced with permission of Professor Anne-
Maree Kelly, Joseph Epstein Centre for Emergency
Medicine Research @Western Health, Melbourne,
Australia’

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 & of
some of the research mentioned in this talk
 Editorial boards of:
◦ Annals of Emergency Medicine
◦ Emergency Medicine Australasia
◦ Hong Kong Journal of Emergency Medicine

4.  My Colleagues Dr Stephen Bernard, Dr Karen Smith and
colleagues for the ongoing, world leading body of work in this
space

5.  To review the pathophysiology of post-cardiac arrest
syndrome
 To summarize the evidence for a variety of interventions to
improve outcome after out of hospital cardiac arrest
 To propose the concept of a bundle of care approach to
management of these patients

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.  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) prognostication
ROSC rate = 24%
Survival to discharge =7.6%
Sasson et al. Circ Cardiovasc Qual Outcomes 2010:3:63-812.

8.  Cerebral and cardiac dysfunction due to prolonger whole
body ischaemia
 Elements
◦ Anoxia brain injury
◦ Myocardial dysfunction
◦ Systemic ischaemia/ reperfusion response
◦ Persistent precipitating pathology
 Contribution of the elements varies between individuals

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.  High oxygen concentration may increase free radical
production
 Some observational data (from ICU) that higher oxygenation
is harmful
 Each 100mmHg increase in pO2 (on ICU admission) associated
with 24% increase in mortality
 Currently the subject of RCT proposals
Kilgannon et al. JAMA 2010;123:2717-2722

11.  Avoidance of both hyperoxia and hypoxia
 SpO2 target 94-96%
 Avoid hypocarbia as it:
◦ Causes cerebral vasoconstriction
◦ Hyperventilation decreases cardiac output

12.  Increased blood pressure may improve cerebral perfusion,
BUT
 Inotropes/ pressors may cause additional cardiac injury
 Observational data only suggesting ~30% improvement in
outcome with achievement of haemodynamic stability
 Studies used different targets
 MAP 80-100mmHg vs 65-70mmHg
 Optimal MAP target remains unclear
Gaieski et al. Resuscitation; 2009;80:418-24.
Sunde et al. Resuscitation 2007; 73:29-39.

13.  Aim for mean arterial pressure of 65-100mmHg
 Taken into consideration ‘usual’ BP and severity of
myocardial dysfunction

14.  Judicious fluid loading
 Inotropic drug therapy
 Mechanical support devices e.g.
◦ IABP
◦ ECMO

15.  Anoxic brain injury responsible for ~2/3rds of deaths
post cardiac arrest
 Therapeutic hypothermia is a major recent advance in
neuroprotection
 How it works?
◦ Multifactorial?
◦ Decreases cerebral oxygen demand
◦ ? Direct cellular effects
◦ Reduction in reactive oxygen species generation

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.  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 neurological
outcome
HACA 59% vs 45% 55% vs 39%
Bernard 49% vs. 32% 49% vs. 26%
HACA. NEJM 2002;346:549-56
Bernard et al. NEJM 2002; 346:557-63
Haschimi-Idrissi et al. Resuscitation 2001; 51:275-81.

18.  Cooled IV fluids (40ml/kg)
 Surface cooling
 Intravascular cooling

19.  Persuasive animal data that the earlier the better
 Two RCT have demonstrated that pre-hospital cooling
using 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.  STEMI unconscious post cardiac arrest were excluded from
PCI vs. thrombolysis trials
 Initial ECG shows STEMI in 30-60% of patients with ROCS after
OHCA
 Good evidence that early angiography with view to PCI
improves outcome for patients with STEMI (RCT and
observational)

21.  Recent study showed significant coronary lesions
present in up to 66% of patients with OHCA without
ST elevation.
 Registry data has reported primary PCI as an
independent predictor of survival regardless of initial
ECG (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.  2902 post arrest patients in Victoria
 Transported to one of 70 hospitals
 1816 (63%) of patients were treated at hospitals with 24 hour
cardiac interventional services
 After adjusting for differences in baseline characteristics,
treatment at hospitals with 24 hour cardiac interventional
services was significantly associated with survival (odds ratio
1.40; 95% CI 1.12-1.74, p=0.003)
Stub D et al. Heart. 201197:1489-94.

23.  Bundles of care are a structured way of improving
processes of care and patient outcomes
 3-5 components performed collectively and reliably
 ALL OR NONE
 The power comes from the evidence-base and the
consistency of implementation
 Examples:
◦ Central line bundle IHI
◦ Goal-directed sepsis therapy

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 support
the concept.

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.  Systems of care for time critical illness improves
outcomes
 Emerging evidence of improved outcomes in OHCA in
specialized centres (Japan and Sweden)
◦ OR improved survival ~3.4
 Is this workable in the Australian context?