Presented by: Dr. Niccole Bart
Summary by: Dr. Kaycie Corburn
The Case: 70 year old female with a long past medical history including a previous heart block with a pacemaker placed 20 years ago presents to the ED following a witnessed VF arrest with ROSC in the field within 5 minutes of EMS arrival. The history is limited, but supposedly the patient screamed and then collapsed. EMS initiated ACLS, intubated the patient, and after 1 defibrillation shock and one cycle of CPR, obtained ROSC. Upon arrival to the ED, the patient was bradycardic and hypotensive. Important stuff on ED arrival: check ET tube/lines/IV/O2/Monitor. In this case, immediate transcutaneous pacer pads should be placed – especially as the initial ECG showed an incomplete trifascicular block.
-for more information on trifascicular blocks look at this resource:
http://lifeinthefastlane.com/ecg-library/trifascicular-block/
Follow-up EKG: 3rd degree AV block, rate in the 40s. Transvenous pacer and hypothermia protocol was initiated, and the patient was admitted to MICU with cardiology consultation.
-for a great review video on placing transvenous pacers visit:
*Note: This video forgets to mention deflating the balloon once the transvenous pacer is in place; always remember to deflate the balloon (which initially helped to “float” the pacer).
Post Cardiac Arrest Care
• Post Arrest Syndrome
• AHA recommendations
• Therapeutic Hypothermia: what is the evidence?
• When should cooling start? How cold?
• Role of PCI
• Prognosis in setting of hypothermia
• Take home points
Post Arrest Syndrome: Priorities within the minutes, hours, and days post ROSC.
-0-20 minutes: the immediate phase, limit ongoing injury and prevent reoccurrence.
-20 minutes-6-12 hours: the early phase, limit ongoing injury and prevent
reoccurrence.
-6-12 hours-72 hours: the intermediate phase, limit ongoing injury and prevent
reoccurrence, begin prognostication around 72-hour mark.
-72 hours- disposition: the recovery phase, prevent reoccurrence, prognostication, start rehabilitation.
-Disposition and onward: the rehabilitation phase, focus on rehabilitation, prevent reoccurrence.
Post Arrest Syndrome: Pathophysiology
-Post cardiac arrest syndrome is a complicated compilation of maladaptive physiologic processes experienced after cardiac arrest.
-It involves:
-Ongoing brain injury
-Impaired CNS auto regulation
-Transient myocardial global dysfunction
-Systemic ischemia: including a “sepsis-like” response
AHA recommendations for post cardiac arrest care
1) Obtain ROSC
2) Optimize ventilation and oxygenation: maintain oxygenation >94%, consider an advanced airway and waveform capnography, avoid hyperventilation.
3) Treat hypotension (SBP <90mmHg): IVF bolus, vasopressors, treat reversible causes, obtain 12 lead EKG.
4) If the patient is not following commands consider induction of therapeutic
hypothermia.
5) If STEMI, consider PCI.
6) Prepare patient for critical care setting
If you prefer a visual algorithm:
http://circ.ahajournals.org/content/122/18_suppl_3/S768/F1.expansion.html
Curious about the Evidence For Therapeutic hypothermia?
-3 phases: induction, maintenance, re-warming
-Induce hypothermia fast, re-warm slowly
-Hypothermia after cardiac arrest (HACA) trial, 2002:
-275 patients resuscitated after VF or non-perfusing ventricular tachycardia
cardiac arrest were randomly assigned to normothermia versus hypothermia
(to 32°C-34°C)
-Primary end point was favorable neurologic outcomes within 6 months
-Secondary end point was mortality at 6 months
-55% of hypothermia patients had favorable neurologic outcomes versus
39% of the normothermia group
-Concluded that after VF/VT arrest with successful ROSC, mild hypothermia.
increased the rate of favorable neurologic outcome and reduced mortality.
-Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia, 2002, Bernard et al:
-77 patients resuscitated after VF cardiac arrest randomly assigned to
normothermia versus hypothermia to 33°C.
-Primary outcome measure was survival to hospital discharge with
sufficiently good neurologic outcome to be discharged home or to rehab
facility.
-49% of hypothermia patients survived to discharge versus 26% of the
normothermia group.
-Concluded that moderate hypothermia appears to improve outcomes in
patients with coma after resuscitation from out-of-hospital cardiac arrest.
-Therapeutic hypothermia: is it effective for non VF/VT cardiac arrest?, 2013,
Sandroni, et al:
-Pooled data shows that mild hypothermia in comatose patients after
resuscitation from non VF/VT cardiac arrest was associated with a 15%
reduction in hospital mortality.
-This data also showed a small, but clinically significant improvement in
neurological outcome at discharge.
-The quality of evidence is poor given that most evidence at this time is from
observational studies.
-AHA Guidelines 2010:
-Class I, LOE B: “Comatose (i.e lack of meaningful response to verbal
commands) adult patients with ROSC after out-hospital VF cardiac arrest
should be cooled to 32°C to 34°C for 12 – 24 hours.”
When should cooling start? How cold?
-Is sooner better?
-Induction of therapeutic hypothermia by paramedic after resuscitation from
out-of-hospital ventricular fibrillation cardiac arrest, 2010, Bernard, et al:
-234 patients with VF out-of-hospital cardiac arrest randomized to
pre-hospital cooling versus cooling after hospital admission.
-Primary outcome measure was functional status at hospital discharge.
-Concluded that for patients resuscitated from out-of-hospital VF
arrest, paramedic cooling decreased body temperature upon hospital
arrival, but did not improve outcome at hospital discharge compared
to cooling started in the hospital.
-How cold? What is the target temperature?
-Targeted temperature management at 33°C versus 36°C after cardiac arrest,
2013, Nielsen, et al:
-950 out-of-hospital cardiac arrest from presumed cardiac cause
randomized to hypothermia with target temperature 33°C versus
36°C.
-Primary outcome was all cause mortality up until the end of the trial
-Secondary outcome included composite of poor neurologic outcome
and death at 180 days.
-At the end of the trial, 50% of the 33°C patients had died versus 48%
of the 36°C.
-Concluded that for out-of-hospital cardiac arrest from a cardiac cause
33°C did not confer a benefit compared to 36°C.
Role of PCI
-AHA Class I:
-“A 12 lead ECG should be obtained as soon as possible after ROSC to determine where acute ST elevation is present.”
-PCI may be beneficial even in NSTEMI patients.
-Immediate percutaneous coronary intervention is associated with better survival after out-of-hospital cardiac arrest: insights from the PROCAT registry, 2010, Dumas et al:
-435 patients with out-of-hospital cardiac arrest were taken immediately to
coronary angiogram followed by angioplasty as indicated.
-At least one significant lesion was found in 70% of all patients; 96% of
patients who presented with ST segment elevations on EKG and 58% of
patient without ST segment elevations on initial EKG.
-Hospital survival overall was 40%
Prognosis in setting of hypothermia
-AHA CLASS I:
-Durations of observation greater than 72 hours after ROSC should be
considered before predicting outcome in patients treated with hypothermia.
Take home points:
1. Cardiac arrest with return of spontaneous circulation also includes a post arrest syndrome with maladaptive physiologic responses.
2. Based on several smaller studies there may be mortality and neurologic outcome benefits in patients with induced hypothermia.
3. Therapeutic hypothermia is currently the standard of care for patients with out-of-hospital cardiac arrest with return of spontaneous circulation.
4. Some patients may benefit from a cardiac catheterization with potential for
intervention.
5. Avoid assigning definitive prognosis on these patients in the ED
References
• Arntfield, et al. “Practical Aspects of Post Cardiac Arrest Therapeutic
Hypothermia” EB Medicine: EM Critical CARE, Vol. 3, Number 3.
• Ball, J. & Ranzani, O, “Hyeroxia following cardiac arrest.” Intensive Care
Medicine (2015) 41:534-536.
• Bandschapp & Iaizzo. “Induction of Therapeutic Hypothermia Requires
Modulation of Thermoregulatory Defense.” Therapeutic Hypothermia and
Temperature Management, Vol 1, no 2, 2001.
• Bernard, S. “Editorial: Inducing hypothermia after out of hospital cardiac
arrest.” BMJ 2014, 348.
• Bernard et al. “Induction of Therapeutic Hypothermia by Paramedics after
Resuscitation From Out of Hospital Ventricular Fibrillation Cardiac Arrest: A
Randomized Control Trial.” Circulation. 2010; 122: 737-742.
• Bernard et al. “Treatment of comatose survivors of out of hospital cardiac
arrest with induced hypothermia.” N Engl J Med. Vol 346; No 8. February 21,
2002.
• Bouwes et al, “Somatosensory evoked potentials during mild hypothermia
potentials during mild hypothermia after cardiopulmonary resuscitation.”
Neurology (73) Nov. 2009.
• Chelly, J, M.D et al, “Benefit of an early and systemic imaging procedure after
cardiac arrest: Insights from the PROCAT registry.” Resuscitation: 83, 2012,
1444-1450.
• DeBacker, et al. “Comparison of dopamine and norepinephrine in the
treatment of shock” NEJM, 2010, Vol 3, No 9.
• Dumas et al. “Immediate Percutaneous Coronary Intervention Is Associated
With Better Survival After Out-of-Hospital Cardiac Arrest Insights From the
PROCAT (Parisian Region Out of Hospital Cardiac Arrest) Registry.”
Circulation: Cardiac Interventions: 2010, 3, 200-207 .
• Friberg et al., “Continuous evaluation of neurological prognosis after cardiac
arrest.” Acta Anaesthesiol Scand 2013; 57: 6-15.
• Hollenbeck et al, “Early cardiac catheterization is associated with improved
survival in comatose survivors of cardiac arrest without STEMI”
Resuscitation 85 (2014) 88-95.
• Hypothermia after Cardiac Arrest Study Group. “Mild therapeutic
hypothermia to Improve the neurologic outcome after cardiac arrest.” N Engl
J Med, Vol. 346, no 8. February 21, 2002.
• Hubner, P. M.D. et al, “Neurologic causes of cardiac arrest and outcomes.”
JAMA Vol. 47 (6), 2014: 660-667.
• Little, N.E & Feldman E. “Viewpoint: Therapeutic hypothermia after cardiac
arrest without return of consciousness: Skating on Thin Ice.” JAMA Neurology,
2014, vol 71, no 7.
• Merchant et al. “Cost-Effectiveness of Therapeutic Hypothermia After Cardiac
Arrest.” Circulation: Cardiovascular Quality and Outcomes, 2009; 2; 421-428.
• Neumar et al. “Post Arrest Syndrome.” Circulation. October 23, 2008.
• Nielsen, et al. “Targeted temperature management at 33 C versus 36 C after
cardiac arrest.” N Engl J Med 369; 23. December 5, 2013.
• Nolan et al., “Editorial: Resuscitation highlights in 2013: Part 2” Resuscitation
85 (2014) 437-443.
• Noc, M. M.D. et al, “Editorial: Hunting for diagnosis of cardiac arrest.”
Resuscitation 83 (2012): 1423-1424.
• Oddo, et al. “Early predictors of outcome in comatose survivors of ventricular
fibrillation and non-ventricular fibrillation cardiac arrest treated with
hypothermia: A prospective study.” Crit Care Med, 2008, vol 36, no 8.
• Polderman, K.H. “Mechanism of action, physiologic effects, and complications
of hypothermia.” Crit Care Med 2009 Vol. 37, No. 7.
• Polderman & Herold. “Therapeutic hypothermia and controlled
normothermia in the intensive care unit: Practical considerations, side
effects, and cooling methods.” Cri Care Med 2009, Vol 37 No 3.
• Sandroni et al. “Therapeutic hypothermia: is it effective for non-VF/VT
cardiac carrest?” Critical Care 2013, 17:215.
• Storm et al. “Mild hypothermia treatment in patients resuscitated from non-
shockable cardiac arrest.” Emer Med J 2012; 29: 100-103.
• Taccone et al., “How to assess prognosis after cardiac arrest and therapeutic
hypothermia.” Critical Care 2014 (18): 202 .
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