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Post Resuscitation Syndrome

Restart the heart and keep it restarted

Andrianto
Ruthvi Adriana

CARDIOVASCULAR EMERGENCIES COURSE

Bumi Surabaya Hotel, November 7-8th, 2015

Scenario
45 y.o man admitted to the ER
Chief complaint : ischemic chest pain since an
hour ago, ST elevation in ECG.

Immediately

unconscious

with

ventricle

fibrillation in ECG monitoring

CPR was performed and ROSC in 10 minutes


CARDIOVASCULAR EMERGENCIES COURSE

Bumi Surabaya Hotel, November 7-8th, 2015

Patient is ROSC

Whats happen?

CARDIOVASCULAR EMERGENCIES COURSE

Bumi Surabaya Hotel, November 7-8th, 2015

Post Resuscitation Syndrome


To minimize
Brain injury

To correct
Myocardial dysfunction

To manage
Systemic ischemia reperfusion response

To detect and treat


Persistent precipitating
pathology

Robert W. Neumar et al. 2008. PostCardiac Arrest Syndrome. (Circulation. 2008;118:2452-2483.)

CARDIOVASCULAR EMERGENCIES COURSE

Bumi Surabaya Hotel, November 7-8th, 2015

CARDIOVASCULAR EMERGENCIES COURSE

Bumi Surabaya Hotel, November 7-8th, 2015

Not only
Return of Spontaneous Circulation (ROSC)

but
Return to Pre Arrest Status

CARDIOVASCULAR EMERGENCIES COURSE

Bumi Surabaya Hotel, November 7-8th, 2015

Post Resuscitation Syndrome


To minimize
brain injury

To correct
myocardial dysfunction

To manage
systemic ischemia reperfusion response

To detect and treat


persistent precipitating
pathology

Robert W. Neumar et al. 2008. PostCardiac Arrest Syndrome. (Circulation. 2008;118:2452-2483.)

CARDIOVASCULAR EMERGENCIES COURSE

Bumi Surabaya Hotel, November 7-8th, 2015

Our approach should be:


Comprehensive
Structured
Multidisciplinary system of care

CARDIOVASCULAR EMERGENCIES COURSE

Bumi Surabaya Hotel, November 7-8th, 2015

Management
ROSC

In field: - Maintain C-A-B - Oxygenation


- IV access
- ECG 12 leads
- Monitor rhythms

In ED & ICU: Access vital sign, airway, and mental status

Ashvarya Mangla et al. 2014. Post-resuscitation care for survivors of cardiac arrest. Indian Heart Journal 66 (2014) S105-S112.

CARDIOVASCULAR EMERGENCIES COURSE

Bumi Surabaya Hotel, November 7-8th, 2015

Patient comatose

Patient non comatose

Therapeutic
hypothermia

Focused history and physical examination


Laboratory & imaging examination
Initiate cardiopulmonary and metabolic stabilization
Treat precipitating cause

Multidisciplinary System of Care


Ashvarya Mangla et al. 2014. Post-resuscitation care for survivors of cardiac arrest. Indian Heart Journal 66 (2014) S105-S112.

CARDIOVASCULAR EMERGENCIES COURSE

Bumi Surabaya Hotel, November 7-8th, 2015

Multidisciplinary System of Care


Ventilation
Cardiovascular and Hemodynamic
Metabolic
Neurological

Ashvarya Mangla et al. 2014. Post-resuscitation care for survivors of cardiac arrest. Indian Heart Journal 66 (2014) S105-S112.

CARDIOVASCULAR EMERGENCIES COURSE

Bumi Surabaya Hotel, November 7-8th, 2015

Multidisciplinary System of Care


Ventilation
Cardiovascular and Hemodynamic
Metabolic
Neurological

Ashvarya Mangla et al. 2014. Post-resuscitation care for survivors of cardiac arrest. Indian Heart Journal 66 (2014) S105-S112.

CARDIOVASCULAR EMERGENCIES COURSE

Bumi Surabaya Hotel, November 7-8th, 2015

Ventilation
Maintain good airway
Adequate oxygenation and ventilation
Intubation if needed
Avoid hypo-hyperventilation
Reduce FIO2 as tolerated SPO2 94%
PaCO2 4045 mm hg

Ashvarya Mangla et al. 2014. Post-resuscitation care for survivors of cardiac arrest. Indian Heart Journal 66 (2014) S105-S112.

CARDIOVASCULAR EMERGENCIES COURSE

Bumi Surabaya Hotel, November 7-8th, 2015

Multidisciplinary System of Care


Ventilation
Cardiovascular and Hemodynamic
Metabolic
Neurological

Ashvarya Mangla et al. 2014. Post-resuscitation care for survivors of cardiac arrest. Indian Heart Journal 66 (2014) S105-S112.

CARDIOVASCULAR EMERGENCIES COURSE

Bumi Surabaya Hotel, November 7-8th, 2015

Cardiac and Hemodynamic


Maintain adequate tissue perfusion and prevent recurrent
hypotension (MAP 65 - 75 mm Hg; TDS >90 mm Hg)
Consider iv hydration with isotonic fluids and pressor support
Continues cardiac monitoring
Treat coronary ischemia with reperfusion
Treat arrhythmias as appropriate

Ashvarya Mangla et al. 2014. Post-resuscitation care for survivors of cardiac arrest. Indian Heart Journal 66 (2014) S105-S112.

CARDIOVASCULAR EMERGENCIES COURSE

Bumi Surabaya Hotel, November 7-8th, 2015

Multidisciplinary System of Care


Ventilation
Cardiovascular and Hemodynamic
Metabolic
Neurological

Ashvarya Mangla et al. 2014. Post-resuscitation care for survivors of cardiac arrest. Indian Heart Journal 66 (2014) S105-S112.

CARDIOVASCULAR EMERGENCIES COURSE

Bumi Surabaya Hotel, November 7-8th, 2015

Metabolic
Frequent electrolyte monitoring

Adequate repletion of K, Mg to keep K 3.5 mEq/L

Treat hypo-hyperkalemia

Avoid hypo/hyperglycaemia (target glucose 144180 mg/dL)

Monitor urine output

Ashvarya Mangla et al. 2014. Post-resuscitation care for survivors of cardiac arrest. Indian Heart Journal 66 (2014) S105-S112.

CARDIOVASCULAR EMERGENCIES COURSE

Bumi Surabaya Hotel, November 7-8th, 2015

Multidisciplinary System of Care


Ventilation
Cardiovascular and Hemodynamic
Metabolic
Neurological

Ashvarya Mangla et al. 2014. Post-resuscitation care for survivors of cardiac arrest. Indian Heart Journal 66 (2014) S105-S112.

CARDIOVASCULAR EMERGENCIES COURSE

Bumi Surabaya Hotel, November 7-8th, 2015

Neurological
Baseline neurological examination
Imaging of brain to assess for ischemia / haemorrhage
if clinically indicated

EEG to assess subclinical seizures


Therapeutic hypothermia

Ashvarya Mangla et al. 2014. Post-resuscitation care for survivors of cardiac arrest. Indian Heart Journal 66 (2014) S105-S112.

CARDIOVASCULAR EMERGENCIES COURSE

Bumi Surabaya Hotel, November 7-8th, 2015

The Use of Hypothermia


After Cardiac Arrest
60
50

Comatose survivors
Asystole or VF

40
% 30

20
10

31-32C

Cooling until neurologic recovery

Favorable neurologic
recovery

(3 hours to 8 days)
Hypothermia (n=12)

Water-filled blanket

Normothermia (n=7)

Benson et al,Anesth Analg 1959; 38: 423-8.

CARDIOVASCULAR EMERGENCIES COURSE

Bumi Surabaya Hotel, November 7-8th, 2015

Mild therapeutic hypothermia


to improve the neurologic outcome
P 0.02

Hypothermia

Normothermia

Mild therapeutic hypothermia to improve the neurologic outcome after cardiac


arrest. N Engl J Med. 2002;346:549-556.

CARDIOVASCULAR EMERGENCIES COURSE

Bumi Surabaya Hotel, November 7-8th, 2015

Cooling Technique
Cooling technique

Percentage of respondents
0%

Cooling blankets
Ice / cold liquid packing
Ice / cold liquid gastric lavage
IV cooling catheter
Cooling mist
Other method

10%

20%

30%

40%

50%

50%
15%
13%
2%
2%
17%

CARDIOVASCULAR EMERGENCIES COURSE

Bumi Surabaya Hotel, November 7-8th, 2015

Coolong Blankets

CARDIOVASCULAR EMERGENCIES COURSE

Bumi Surabaya Hotel, November 7-8th, 2015

Basics of Therapeutic Hypothermia:


Three phases of treatment
Induction
Rapidly bring the temperature to 32-34C
Sedate with propofol or midazolam during TH
Paralyze to suppress heat production
Maintenance
The goal temperature at 33C
Standard 12-24 hours (optimal duration is unknown)
Suppress shivering
Rewarming
Most dangerous period: hypotension, brain swelling,
Goal is to reach normal body temperature over 1224h
Stop all sedation when normal body temperature is
achieved

CARDIOVASCULAR EMERGENCIES COURSE

Bumi Surabaya Hotel, November 7-8th, 2015

Monitoring:

Seizure, shivering
Aritmia & unstable hemodinamic rewarmed
Electrolyte imbalance (Mg,K,P,Ca,Na )
Temperature check, skin care
Bleeding , dehydration, infection

Robert W. Neumar et al. 2008. PostCardiac Arrest Syndrome. (Circulation. 2008;118:2452-2483.)

CARDIOVASCULAR EMERGENCIES COURSE

Bumi Surabaya Hotel, November 7-8th, 2015

The 2005 AHA guidelines:

Comatose, ventricular fibrillation (VF) (class IIA)


Comatose, other rhythms (class IIB)

Robert W. Neumar et al. 2008. PostCardiac Arrest Syndrome. (Circulation. 2008;118:2452-2483.)

CARDIOVASCULAR EMERGENCIES COURSE

Bumi Surabaya Hotel, November 7-8th, 2015

Prognostication
Pre-Arrest

Arrest

Post - arrest

o Age

o Collapse to CPR time

o Clinical examination

o Comorbidities

o Prolonged CPR

o EEG

o Initial Rhythm

o Somatosensory

o CPR quality

evoked potential
o Neurological
biochemical marker

Robert W. Neumar et al. 2008. PostCardiac Arrest Syndrome. (Circulation. 2008;118:2452-2483.)

CARDIOVASCULAR EMERGENCIES COURSE

Bumi Surabaya Hotel, November 7-8th, 2015

Summary
The rate of ROSC continues to increase and proper postresuscitation care could reduce mortality and morbidity.

Managing the ROSC patients requires a multidisciplinary


system of care: including ventilation, cardiac, hemodynamic,
metabolic, and neurological approach.

Strong evidence that hypothermia theraupetic is neuroprotective after return of spontaneous circulation
CARDIOVASCULAR EMERGENCIES COURSE

Bumi Surabaya Hotel, November 7-8th, 2015

Thank You

CARDIOVASCULAR EMERGENCIES COURSE

Bumi Surabaya Hotel, November 7-8th, 2015

Outcomes of Therapeutic Hypothermia

Alive at hospital discharge - favorable neurological recovery


Hypothermia

Normothermia

HACA Study Group

72/136 (53%)

50/137 (36%)

Bernard

21/43 (49%)

9/34 (26%)

Hachimi-Idrissi

4/16 (25%)

1/17 (6%)

Alive at 6 months - favorable neurological recovery


HACA Study Group

Hypothermia

Normothermia

72/136 (52%)

50/137 (36%)

CARDIOVASCULAR EMERGENCIES COURSE

Bumi Surabaya Hotel, November 7-8th, 2015

CARDIOVASCULAR EMERGENCIES COURSE

Bumi Surabaya Hotel, November 7-8th, 2015

CARDIOVASCULAR EMERGENCIES COURSE

Bumi Surabaya Hotel, November 7-8th, 2015

CARDIOVASCULAR EMERGENCIES COURSE

Bumi Surabaya Hotel, November 7-8th, 2015