Arrêt cardio-respiratoire : La prise en charge évolue!
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1 Marseille, 09 avril 2015 Arrêt cardio-respiratoire : La prise en charge évolue! Alain Cariou Intensive Care Unit - Cochin Hospital Paris Descartes University INSERM U970 Centre d Expertise Mort Subite - Paris
2 Presenter Disclosure Information Alain Cariou Arrêt cardiaque : La prise en charge évolue! FINANCIAL DISCLOSURE: Bard France (consulting) Lilly France (consulting) UNLABELED/UNAPPROVED USES DISCLOSURE: none
3 Jean-Christophe A., 29 ans Antécédents personnels : Epilepsie temporale non traitée Antécédents familiaux : Un cas de mort subite inexpliqué
4 14/11/ h55 : syncope avec reprise de conscience 21h56 : appel des secours 22h03 : 2 ème syncope 22h04 : arrivée des premiers secours avec début du MCE et mise en place du défibrillateur
5 Tracé initial
6 Choc électrique externe
7 Activité cardiaque spontanée No-flow = 1 minute, low-flow = 4 minutes
8 Arrivée du SMUR à 22h14 SpO2 = 95 %, 103/55 mmhg, FC = 105 /min En ventilation spontanée, Glasgow 3 Sédation pour intubation et ventilation mécanique ECG initial : pas de signe ischémique franc (mais tracé difficile à interpréter )
9 Centre d Expertise de la Mort Subite (CEMS) Alerte RCP immédiate Défibrillation précoce Prévention secondaire Soins post-arrêt cardiaque
10 Registre du CEMS Du 15 mai 2011 au 15 mai AC extra-hospitaliers 1048 étiologies non-cardiaques étiologies cardiaques probables (100 %) non réanimés avec tentative de réanimation (62 %)
11 «Portrait Robot» Registre CEMS Du 15 May 2011 au 15 mai % 45 % 26% 31% 28 % 72 %
12 A l hôpital Registre CEMS Du 15 May 2011 au 15 mai 2013 Coronarographie 702 (55 %) Hypothermie thérapeutique 704 (55 %) Survie hospitalière 250 (7 %) Récupération neurologique - CPC 1/2 - CPC 3/4 - inconnue 232 (93 %) 11 (4 %) 7 (3 %)
13 A l hôpital Registre CEMS Du 15 May 2011 au 15 mai 2013 Coronarographie 702 (55 %) Hypothermie thérapeutique 704 (55 %) Survie hospitalière 250 (7 %) Récupération neurologique - CPC 1/2 - CPC 3/4 - inconnue 232 (93 %) 11 (4 %) 7 (3 %)
14 Survival from OHCA has not significantly improved in almost 3 decades, despite enormous efforts in research spending and the development of novel drugs and devices Currently, 92% of individuals who experience OHCA each year do not survive to hospital discharge. This dismal statistic can be improved. Data extracted from 79 studies involving patients
15 2015 Bystander CPR 2010 Early defibrillation CPR efficiency 2010 Postresuscitation care 2015
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18 Association of National Initiatives to Improve Cardiac Arrest Management With Rates of Bystander Intervention and Patient Survival After Out-of Hospital Cardiac Arrest Wissenberg M et al. JAMA 2013
19 Eur Heart J Aug 4
20 Chest compression alone cardiopulmonary resuscitation is associated with better long-term survival compared with standard cardiopulmonary resuscitation Dumas F et al. Circulation 2012 Bystanders can proceed with the chest compression alone approach with the appreciation that this strategy on average provides optimal long-term survival benefit.
21 Nationwide Improvements in Survival From Out-of-Hospital Cardiac Arrest in Japan Kitamura T et al. Circulation 2012
22 Improved Survival After Out-of-Hospital Cardiac Arrest and Use of AED Blom MT et al. Circulation 2014 Time to Shock (min) and Survival With Favourable Neurologic Outcome in Patients With Shockable First Rhythm (n=2858)
23 Improved Survival After Out-of-Hospital Cardiac Arrest and Use of AED Blom MT et al. Circulation 2014 Time to Shock (min) and Survival With Favourable Neurologic Outcome in Patients With Shockable First Rhythm (n=2858)
24 Comparison of Naive Sixth-Grade Children With Trained Professionals in the Use of an Automated External Defibrillator Gundry et al. Circulation 1999; 100: 1703
25 Improved Survival After Out-of-Hospital Cardiac Arrest and Use of AED Blom MT et al. Circulation
26 Cardiac Arrest Registry to Enhance Survival (CARES) 248 EMS systems across 23 states, representing a catchment area of >64 million people
27 Recent Trends in Survival From Out-of- Hospital Cardiac Arrest in the United States Chan PS et al. Circulation 2014 Bystander AED use
28 Association of National Initiatives to Improve Cardiac Arrest Management With Rates of Bystander Intervention and Patient Survival After Out-of Hospital Cardiac Arrest Wissenberg M et al. JAMA 2013 Introduction of therapeutic hypothermia (starting 2004) Mandatory education in resuscitation in elementary schools (Jan 2005) New guidelines for resuscitation (Nov 2005) Introduction of health care professionals at dispatch centers (starting 2009) Mandatory resuscitation course when acquiring a driver s license (Oct 2006) About first aid certificates distributed annually ( ) Distribution of about CPR self-instruction training kits ( )
29 Association of National Initiatives to Improve Cardiac Arrest Management With Rates of Bystander Intervention and Patient Survival After Out-of Hospital Cardiac Arrest Wissenberg M et al. JAMA 2013
30 European Resuscitation Council Guidelines for Resuscitation 2010 Section 4. Adult advanced life support Deakin CD, Nolan JP, Soar J, Sunde K, Kostere RW, Smith GB, Perkins GD Resuscitation 2010
31 Trends in Short- and Long-Term Survival Among OHCA Patients Alive at Hospital Arrival Wong MKY et al. Circulation days 1-year
32 Post-cardiac arrest disease ILCOR Consensus Statement ROSC 20 min 6-12 hours Phase Immediate Early Intermediate Systemic ischemiareperfusion 72 hours Recovery Post-cardiac arrest disease Discharge Rehabilitation
33 1. Ischemia and reperfusion syndrome 2. Inflammatory response 3. Coagulopathy 4. Circulatory failure 5. Adrenal dysfunction Current Opinion in Crit Care. 2004
34 Six-month survival: Controls 21% HF alone 42% HF + HT 32% p=0.28 Death by intractable shock (IS): Controls 42% HF alone 10% HF + HT 14% p=0.009 Controls n=19 HF alone n=20 HF + HT n=22 p=0.026 p=0.018 Relative risk of death by IS: HF alone 0.21 (95% CI ) HF + HT 0.29 (95% CI ) Multivariate analysis: HF and six-month death: OR 0.21 (95% CI ) HF and death by IS: OR 0.29 (95% CI ) Laurent I et al. JACC 2005
35 Etude HYPERDIA Etude de l intérêt d une membrane de filtration haute perméabilité dans le choc post ACR
36 Post-cardiac arrest disease ILCOR Consensus Statement ROSC 20 min 6-12 hours Phase Immediate Early Intermediate Systemic ischemiareperfusion 72 hours Recovery Post-cardiac arrest disease Discharge Rehabilitation Post-CA circulatory failure
37 Percutaneous Circulatory Support
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39 Cette assistance pourrait s envisager très précocement
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41 Post-cardiac arrest disease ILCOR Consensus Statement ROSC 20 min Phase Immediate 6-12 hours Early Intermediate Persistent precipitating pathology Systemic ischemiareperfusion 72 hours Recovery Post-cardiac arrest Discharge Rehabilitation Post-CA circulatory failure
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43 Immediate percutaneous coronary intervention is associated with improved short and long-term outcome after out-ofhospital cardiac arrest Geri G, Dumas F, Bougouin W, Varenne O, Daviaud F, Pène F, Lamhaut L, Chiche JD, Spaulding C, Mira JP, Empana JP, Cariou A 60 Percent death No immediate PCI Immediate PCI 0 At risk No PCI PCI logrank test p < 0.01 D Time (y) ESICM Barcelona 2014
44 Post-cardiac arrest disease ILCOR Consensus Statement ROSC 20 min 6-12 hours Phase Immediate Early Intermediate Persistent precipitating pathology Systemic ischemiareperfusion 72 hours Recovery Post-cardiac Treatment arrest targets disease Discharge Rehabilitation Post-CA myocardial dysfunction Post-anoxic brain injury
45 Spectrum of consciousness disorders after cardiac arrest Conscious wakefulness Normal consciousness Wakefulness (level of consciousness) MCS Severe disability Permanent MCS Coma Persistent VS Permanent VS Brain death Time Adapté de Stevens RD et al. Crit Care Med 2006
46
47 WHAT LEVEL? 33 C: the dogma
48
49 WHAT LEVEL? 36 C: the future? 33 C: the dogma
50 Nielsen N. NEJM 2013 Nielsen N et al. NEJM 2013
51 Is sooner really better?
52 Rearrest post-randomization Intervention (n=686) Control (n=671) P value 176 (26) 138 (21).008
53 Neuroprotection after cardiac arrest: what s new? Calcium channel antagonists NMDA receptor antagonists Dexanabinol Lubeluzole (Nitrous oxide modulator) CDP-choline Tirilizad (free radical scavenger) Anti-ICAM-1 antibody GM-1 ganglioside Clomethiazole Fosphenytoin Piracetam Erythropoietin Selenium Ciclosporine?
54 Jean-Christophe A., 29 ans Evolution favorable Score CPC = 1 à J6 Sortie en USIC Surveillance électrocardiographique
55 Benefit of an early and systematic imaging procedure after cardiac arrest: insights from the PROCAT (Parisian Region Out of Hospital Cardiac Arrest) registry. J CHELLY, N MONGARDON, F DUMAS, O VARENNE, C SPAULDING, O VIGNAUX, P CARLI, J CHARPENTIER, F PENE, JD CHICHE, JP MIRA, A CARIOU Resuscitation 2009 OHCA with ROSC Imaging procedures Cause identified? No Yes Search for cardiac structural abnormalities: echo, MRI, (autopsy) Search for cardiac disease without structural abnormalities: repeated ECG, genetic test Inherited cause? Family screening
56 Répétition des ECG Syndrôme de Brugada (Type 1)
57 Et après Pour Jean-Christophe? DAI Suivi régulier Famille?
58 Inherited causes of Sudden Cardiac Death With structural abnormalities Without structural abnormalities Coronary Artery Disease Cardiomyopathies (hypertrophic, dilated, ARVC) Long QT syndrome, short QT syndrome, Brugada, catecholaminergic polymorph VT (CPVT)
59 Pas plus de 25% des familles sont informées de la nécessité de consulter un cardiologue! Distribution by age of sports-related sudden deaths (SDs) in the overall population (blue) and among young competitive athletes (red).
60 Dépistage des causes : nous sommes tous concernés SCA/yrs 60% CPR 15-20% ROSC Période pré-hospitalière and ICU admission Période hospitalière 7-8 % survivors 6-7 % no or minor sequel Long-term? A distance de l évènement
61 Post-cardiac arrest disease ILCOR Consensus Statement ROSC 20 min 6-12 hours Phase Immediate Early Intermediate 72 hours Recovery Que deviennent les «survivants»? Discharge Rehabilitation
62 Long-term outcomes of out-of-hospital cardiac arrest after successful early defibrillation. Bunch TJ, White RD, Gersh BJ, Meverden RA, Hodge DO, Ballman KV, Hammill SC, Shen WK, Packer DL. N Engl J Med Mean length of follow-up was 4.8±3.0 y «In summary, the rate of survival to hospital discharge was relatively high in a city that had a program of rapid defibrillation. The majority of survivors returned to work, and their quality of life was in most respects indistinguishable from that of the general population. The long-term survival rate was similar to that of age-, sex-, and disease-matched controls who did not have an OHCA.» Bunch TJ et al. NEJM 2003
63 Prevention Research AED use Education ecognition ICU care Bystander CPR Cardiology
64 Recognition Prevention AED use Education Bystander CPR ICU care Research Cardiology
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