Prehospital Post Arrest Care AHA Strive to Revive 2017 November 3, 2017
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1 Prehospital Post Arrest Care AHA Strive to Revive 2017 November 3, 2017 Jon Rittenberger, MD, MS Department of University of Pittsburgh Employers: Disclosures - Rittenberger University of Pittsburgh UPMC Grants: Mallincrodt, LLC (inhaled NO study) BrainCool, LLC (surface cooling device study) Laerdal Foundation (early EEG study) AHA Innovation Award (Rehabilitation after cardiac arrest) AHA Grant in Aid (Neurostimulants after cardiac arrest) NIH/NINDS (NETT and SIREN research consortia) 1
2 Outline Preventing the Crump Treating the etiology Resuscitate the Brain 64M arrests on treadmill at YMCA Bystander calls 911, applies AED with shock *1 ALS arrives to find asystolic Receives 3mg IV epinephrine, shock *2 with ROSC 2
3 Why do patients die after CPR? Classify cause of death in 223 charts of non-survivors Deaths < 72 hours were mostly (50%) unstable Deaths > 72 hours were mostly (63%) neurological University of Pittsburgh 2011 Percent of Cases <72 hrs >72 hrs 3
4 The Crump! Goals? SBP>100mmH g SpO2>90% HR>0 4
5 Blood Pressure and Ventilation Auto-regulation Impaired / right-shifted CO2-reactivity Preserved CBF MAP pco2 Blood Pressure and Ventilation Auto-regulation Impaired / right-shifted CO2-reactivity Preserved CBF MAP pco2 5
6 Infused norepinephrine to increase CBF Blood pressure goal? We aim for MAP >80 mmhg Kilgannon, et al. Crit Care Med Threshold: MAP >70 Beylin, et al. Int Care Med Higher is better Regardless of pressor use 6
7 A bolt in the head Individual physiology varies Intact autoregulation Tissue hypoxia Pressure passive Hypoxia corrected Autoregulation essentially intact throughout No tissue hypoxia at any MAP 109mmHg 75mmHg 7
8 Hyperoxia Drives oxidative injury, ROS generation, etc Hyperoxia is common despite guideline recommendation SaO % Some OBSERVATIONAL data associate hyperoxia with worse outcomes PaO2 (mmhg) Severe hyperoxia Moderate hyperoxia Normoxia Hours after return of spontaneous circulation Kilgannon, et al. JAMA This effect varies across patients 8
9 Oxygenation goals In absence of monitoring, we aim for normoxia to mild hyperoxia (PaO ) With monitoring, PbtO 2 >20 mmhg Carbon dioxide goals We aim for PaCO 2 40mmHg (temp corrected) Observational data mixed Schneider, et al. Resus Roberts, et al. Circ
10 Blood Pressure and Ventilation This is scenario for first several hours after CPR CBF MAP pco2 WHY? 10
11 Minerals: Metabolic derangements (hypokalemia, DKA, etc) Toxicological Brain: Catastrophic CNS Event Heart: ACS -Primary Arrhythmia -Congenital/Structural Heart Disease -Secondary Arrhythmia (cardiomyopathy) -Cardiogenic Shock -Pulmonary Hypertension/RV Failure Lung: Large airway obstruction -Pulmonary failure (COPD, Asthma, etc) Blood: Trauma Non-traumatic exsanguination Bugs: Distributive Shock (sepsis) Environment: Electrocution -Hypothermia Blockages: PE -Obstructive shock Minerals: Metabolic derangements (DKA) Toxicological Brain: Catastrophic CNS Event Heart: ACS Blood: Trauma Non-traumatic exsanguination Environment: Electrocution -Hypothermia 11
12 Stenting or coronary bypass surgery (CABG) followed CATH 34/42 (81%) STEMI 30/54 (55%) nonstemi cases. Intraaortic Balloon Pump (IABP) was used 16/42 (38%) STEMI 18/54 (33%) nonstemi cases. LV assist device (LVAD), or transplantation for 4/42 (9.5%) STEMI 10/54 (19%) nonstemi cases. 12
13 Mortality 100% 90% 80% 70% 60% 50% 40% Hemodynamically unstable / intractable shock Multi-system organ failure CMO for non-neurologic prognosis Brain death / CMO for neurologic prognosis 30% 20% 10% 0% Early Delayed CATH + No CATH Early CATH Reynolds. Resuscitaiton 2014;85: Delayed + No CATH Early CATH Delayed + No CATH Early CATH Delayed + No CATH Early CATH All Type I Type II Type III Type IV Delayed + No CATH Examination AV fistula: Hyperkalemia Needle in arm: Overdose? Tracheostomy with mucous plug: Obstruction? Found in snowbank: Hypothermia? Blood on floor: Bleeding? Low glucose: Hypoglycemia? 13
14 Primum Non Nocere 14
15 TEMPERATURE? TTM better than no TTM Prehospital Cooling Circulation
16 Bernard Circulation Randomized 234 subjects to prehospital cooling or not Median fluid administration: 1900mL Bernard Circulation 16
17 Bernard Circulation Bernard Circulation 17
18 Bernard Circulation RCT of 1364 patients to prehospital TH or not VF survival 43% in TH and 50% in not Non VF survival 9% in TH and 9% in not More diuretics and CHF in TH group More re-arrest in TH group (early death not different) 18
19 19
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21 What is our Cardiac Arrest Center? Comprehensive post arrest care Early aggressive resuscitation Temperature management Coronary revascularization Prognostication Secondary prevention Rehabilitation Teach CPR to survivors and their families Feedback to providers and referring physicians Referral to survivor support groups Research infrastructure to generate new knowledge System-wide quality control and improvement Survivor celebrations Take Home First, prevent the re-arrest Optimize organ oxygenation/perfusion Start working on the etiology Fix what you can (i.e. bleeding, hypoglycemia, popsickles) Make sure they go to the right place 21
22 Thanks for your time! 22
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