brought to you by Scott Weingart, MD & the Division of
Emergency Critical Care of the Mount Sinai School of Medicine* and
Stephan Mayer, MD & the Division of Neurocritical Care of the New
York-Presbyterian Hospital*
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HACA Trial (NEJM 2002;346(8):549)
Bernard RCT (NEJM 2002;346(8):557)
ILCOR Post-Arrest Care Statement
Lancet Review by Kees Polderman
Nuts & Bolts Review by Kees Polderman (Crit Care Med 2009;37(3):1101-1120)
Mechanisms of Hypothermia by Kees Polderman
Study by Oddi ( )-Included Asystole and PEA
Oddi Crit Care Med 2008;36:2296. Time to ROSC, not rhythm was the best predictor.
Bundled Therapy after Arrest including Hypothermia Implementation of a standardized treatment protocol for post resuscitation care after out-of-hospital cardiac arrest (Resuscitation (2007) 73, 29-39)-Added EGDT to hypothermia, also aggressive PCI
Post resuscitation care What are the therapeutic alternatives and what do we know? Resus 2006;69:15
Cold simple intravenous infusions preceding special endovascular cooling for faster induction of mild hypothermia after cardiac arrest—a feasibility study Resus Volume 64, Issue 3, March 2005, Pages 347-351 no control group: Endovascular is quicker with 2 liter cold LR. 30 cc/kg takes you down ~2 C, 40 cc/kg ~2.5. 500 cc will take you down ~0.5 C
Cold infusions alone are effective for induction of therapeutic hypothermia but do not keep patients cool after cardiac arrest Resus Volume 73, Issue 1, April 2007, Pages 46-53
External Cooling Can Overcool used ice packs not applicable to current methods Therapeutic hypothermia after cardiac arrest: Unintentional overcooling is common using ice packs and conventional cooling blankets Critical Care Medicine:Volume 34(12) SupplDecember 2006pp S490-S494 overcooling with ice packs and blankets. flawed by use of tympanic temps and 20% received either saline augmentation or hemofiltration
Pilot study of rapid infusion of 2 L of 4 degrees C normal saline for induction
of mild hypothermia in hospitalized, comatose survivors of out-of-hospital
cardiac arrest. Circ 2005;112:715 CVP and PAWP went down after infusion, EF went
up
From evidence to clinical practice: Effective implementation of therapeutic hypothermia to improve patient outcome after cardiac arrest Crit Care Med 2006;34:1865 good outcome 55.8 vs 25.6, even in shock pts dramatic improvement 5/17 vs 0/14
A prospective, multicenter pilot study to evaluate the feasibility and safety of using the CoolGard System and Icy catheter following cardiac arrest. (Resuscitation 2004; 62:143-150)-Overcooling occurs with catheters as well
My Letter comparing Rectal vs. Esophageal Temp Probes--Rectal is no good
How long does it take to cool a bag of saline? 2 hours in the fridge
You can probably induce and maintain but not rewarm with ice packs and iced saline
In pigs at least, IO, PIV, and Central all worked equally well for induction with iced saline
In pigs, tracheal temp was accurate
Comparison of prophylactic use of midazolam, ketamine, and ketamine plus midazolam for prevention of shivering during regional anaesthesia: a randomized double-blind placebo controlled trial British Journal of Anaesthesia 2008 101(4):557-562 ketamine blunts shivering, add midaz and it works even better.
Review from SCCM Critical Connections on shivering prevention pharmacology
Surface warming ameloriates shivering Crit Care Med 37(6), June 2009, pp 1893-1897
Small study on hypothermia for inpatient arrest
Microcirculation during Cardiac Arrest
The Post-Arrest is a sepsis-like syndrome Successful Cardiopulmonary Resuscitation After Cardiac Arrest as a "Sepsis-like" Syndrome (Circ 2002;106;562-568)- it's big time SIRS
Long Term Sequelae
post-arrest
How deep to place the Esophageal probe
Myocardial dysfunction after resuscitation from cardiac arrest: An example of
global myocardial stunning JACC Volume 28, Issue 1, July 1996, Pages 232-240
Reversible myocardial dysfunction in survivors of out-of-hospital cardiac arrest JACC Volume 40, Issue 12, 18 December 2002, Pages 2110-2116
J Am Coll Cardiol 28 (1996), pp. 232–240, Crit Care Med 24 (1996), pp. 992–1000. J Am Coll Cardiol 40 (2002), pp. 2110–2116. Resuscitation 61 (2004), pp. 199–207. Circulation 95 (1997), pp. 2610–2613.
Myocardial Dysfunction starts in hours after arrest and lasts 24 hours (JACC Volume 40, Issue 12, 18 December 2002, Pages 2110-2116)
Cardiopulmonary resuscitation with assisted extracorporeal life-support versus conventional cardiopulmonary resuscitation in adults with in-hospital cardiac arrest: an observational study and propensity analysis (lancet 2008;372:554)- increased survival
Editorial about Extracorporeal Life Support
Analysis and results of prolonged resuscitation in cardiac arrest patients
rescued by extracorporeal membrane oxygenation J Am Coll Cardiol. 2003 Jan
15;41(2):197-203.Click here to read
Primary percutaneous coronary intervention and mild induced hypothermia in comatose survivors of ventricular fibrillation with ST-elevation acute myocardial infarction Resuscitation. 2007 Aug;74(2):227-34. Epub 2007 Mar 23
Mild therapeutic hypothermia in patients after out-of-hospital cardiac arrest
due to acute ST-segment elevation myocardial infarction undergoing immediate
percutaneous coronary intervention. Crit Care Med. 2008 Jun;36(6):1780-6
Extracorporeal membrane oxygenation support can extend the duration of cardiopulmonary resuscitation Crit Care Med Volume 36(9), September 2008, pp 2529-2535 incredibly impressive neurologic survival
Nagao - Japanese Study on IABP, Bypass, Cath
ST elev on post-arrest EKG actually represents STEMI (Ann Emerg Med. 2008;52:658-664)
Safety of Thrombolysis during CPR (Drug Safety 2003;26(6):367) Only small incremental risk from thrombolysis post-cpr as normal thrombolysis
Safety and Efficacy of Thrombolysis for Acute Myocardial Infarction in Patients with Prolonged Out of Hospital Cardiopulmonary Resuscitation (Am J Cardiol 73 (1994), pp. 953–955)-no increased risk, dramatic, but just under significant decrease in mortality
Thrombolytic therapy vs primary percutaneous intervention after ventricular fibrillation cardiac arrest due to acute ST-segment elevation myocardial infarction and its effect on outcome. (Am J Emerg Med. 2007 Jun;25(5):545-50)- Lysis appears as good as PCI
Thrombolytic therapy after cardiac arrest and its effect on neurological outcome. (Resuscitation. 2002 Jan;52(1):63-9)- After controlling for age, prehospital dosage of epinephrine, and the duration of cardiac arrest we found a non significant trend towards good neurological recovery when thrombolytic therapy was given (OR 1.9, 95% CI 0.8-4.6)
More on safety of lysis (Resuscitation (2007) 73, 189—201)
TROICA No benefit to empiric lytics in undifferentiated cardiac arrest after physicians stripped out the high-prob PE patients. No stat. sig increase in complications with lytics.
Propensity Analysis shows PCI after arrest improves survival (J Intens Care Med 209;24:179)
Out-of-hospital cardiac arrests in patients with acute ST elevation myocardial infarctions in the East Bohemian region over the period 2002-2004. (Cardiology. 2008;109(1):41-51.)-huge mortality difference that just missed stat. sig
Study of angiography after cardiac arrest. They claim they found a number of complete lesions without STEMI signs, but it is impossible to say if these were pre-existing clots or the cause of arrest. (NEJM 1997;336:1629)
Retrospective look at patients taking to cath after cardiac arrest. (JACC 2009;53(5):409)
It is worth performing PCI, many patients survive neurologically intact even if unresponsive on arrival
Prospective Analysis of the benefit of adding cath to hypothermia protocol
TEG of effects of Hypothermia Anesthesiology 2008;109:1465
SSEP Probably best means of prognostication
Neurologist 2007;13:369. Absence of brainstem at arrival did not preclude good outcome
Practice Parameters of the AAN. Lack of brainstem is not predictive in the first day, only on day 3. All bets are off if hypothermia used.
Myoclonic Status vs. Lance Adams
Very Small Data set on predicting outcome in TH patients (Neurology 2008;71:1535)
Perhaps in future CTA and CTP can predict early brain death
BIS/EEG markers of outcome
DW MRI for Prognosis beyond me but the neurocrit care folks seem to be using it
Why EM and CCM claim they can't do it
Am J Emerg Med. 2007 Jun;25(5):545-50. Links
Thrombolytic therapy vs primary percutaneous intervention after ventricular fibrillation cardiac arrest due to acute ST-segment elevation myocardial infarction and its effect on outcome.
Richling N
, Herkner H, Holzer M, Riedmueller E, Sterz F, Schreiber W.Department of Emergency Medicine, Medical University of Vienna, 1090 Vienna, Austria.
The aim of this study was to evaluate the effect of thrombolytic therapy on neurologic outcome and mortality in patients after cardiac arrest due to acute ST-elevation myocardial infarction and to compare this with those in patients treated with primary percutaneous coronary intervention (PCI). We retrospectively examined patients after they had ventricular fibrillation cardiac arrests. To assess the effect of thrombolysis and PCI on outcome, we used odds ratios and their 95% confidence intervals and logistic regression modeling. Thrombolysis was applied in 101 patients (69%) and PCI in 46 patients (31%). More patients who received thrombolysis had favorable functional neurologic recovery (cerebral performance category 1 and 2) and survived to 6 months compared with patients with primary PCI (P = .38 and P = .13, respectively). In patients with cardiac arrest due to ST-elevation myocardial infarction, it may be acceptable to use thrombolysis as a reperfusion strategy. This applies especially in hospitals where immediate PCI is not available.
Resuscitation. 2008 Feb;76(2):180-4. Epub 2007 Aug 28. Links
Out-of-hospital thrombolysis during cardiopulmonary resuscitation in patients with high likelihood of ST-elevation myocardial infarction.
Arntz HR
, Wenzel V, Dissmann R, Marschalk A, Breckwoldt J, Müller D.Department of Medicine, Division of Cardiology/Pulmonology, Benjamin Franklin Medical Center, Charité, Berlin, Germany. hans-richard.arntz@charite.de
Up to 90% of cardiac arrests are due to acute myocardial infarction or severe myocardial ischaemia. Thrombolysis is an effective treatment for ST-elevation myocardial infarction (STEMI), but there is no evidence or guideline to put forward a thrombolysis strategy during cardiopulmonary resuscitation (CPR). In two physician-manned emergency medical service (EMS) units in Berlin, Germany, using thrombolysis is based on an individual judgment of the EMS physician managing the CPR attempt. In this retrospective analysis over 3 years (total 22.164 scene calls), thrombolysis was started at the scene in 50 patients during brief intermittent phases of spontaneous circulation, and in 3 patients during ongoing CPR. On-scene diagnosis of myocardial infarction was established in 45 patients (85%) by a 12-lead ECG, 5 (9%) patients had a left bundle branch block. Sixteen patients (30%) died at the scene, 37 patients
(70%) were admitted to a hospital. In-hospital mortality was 35% (13 of 37 patients), with cause of death being cardiogenic shock in nine patients, hypoxic cerebral coma in two and acute haemorrhage in two other patients. All 24 of 53 (45%) survivors were discharged with an excellent neurological recovery. CPR was started by an EMS physician in 18 of the 24 survivals (75%) and emergency medical technicians who arrived first in six (25%). Duration of CPR until return of spontaneous circulation was <10 min in 13 of 24 (54%) of the survivors. Thrombolysis was initiated during intermittent phases of spontaneous circulation in 50 (94%) of all patients and in 23 (96%) of the 24 survivors. In conclusion, this retrospective analysis shows excellent survival rates and neurological outcome in selected patients with a high likelihood of myocardial infarction, who develop cardiac arrest and are treated with thrombolysis.
Resuscitation. 2001 Jun;49(3):251-8. Links
Thrombolytic treatment of acute myocardial infarction after out-of-hospital cardiac arrest.
Voipio V
, Kuisma M, Alaspää A, Mänttäri M, Rosenberg P.Department of Anaesthesiology and Intensive Care, Helsinki University Central Hospital, P.O. Box 340, Helsinki, FIN-00029 HUS, Finland. ville.voipio@helsinki.fi
OBJECTIVE: To investigate the safety and efficacy of thrombolytic treatment for an acute myocardial infarction (AMI) immediately after resuscitation in the out-of-hospital setting. DESIGN: Retrospective. SETTING: A middle-sized urban city (population 540000) served by a single emergency medical system using a tiered response with physicians in field. PATIENTS AND METHODS: Sixty-eight patients with an initial diagnosis of AMI who received thrombolytic treatment in an out-of-hospital setting after cardiac arrest and cardiopulmonary resuscitation (CPR) between January 1st 1994 and December 31st 1998. An ECG and the myocardial enzymes (CK, CK-MB, Troponin-T) were used to diagnose AMI. Myocardial reperfusion was assessed by resolution of the ST-segment elevation. Side effects and complications were studied. The quality of secondary survival was evaluated. The Utstein style was used for a uniform style of reporting the cardiac arrest data. RESULTS: The accuracy of prehospital diagnosis was found to be excellent. Retrospective analysis revealed that thrombolytic therapy had been appropriately administered in 64 (94%) of the 68 patients actually treated. Reperfusion was achieved in 71% of the patients. Haemorrhagic complications were few, and included intracranial haemorrhage (one patient), gastrointestinal bleeding (two patients), bleeding from the puncture site (one patient) and epistaxis (one patient). The incidence of hypotension during streptokinase infusion was 22%. Sixty-three (93%) of the patients were admitted alive to the hospital, with 36 subsequently surviving to discharge. CONCLUSIONS: Thrombolytic treatment is a safe and effective treatment in AMI even after out-of-hospital cardiopulmonary resuscitation.