ROSC! Now what??!!

ROSC! Now what??!!An EMS Guide to the Management of Post Cardiac Arrest Syndrome

Jay Lance Kovar, MD, FACEPMontgomery County Hospital DistrictPHI Air Medical TexasObjectivesReviewBackground and Epidemiology of Cardiac Arrest SurvivalDetailPathophysiology of Post Cardiac Arrest SyndromeDiscussMonitoring, Therapeutic Strategies, and Protocols they apply to the Pre-Hospital EnvironmentProposeIntegrated EMS Protocols for Improved Intact Neurologic SurvivabilityBackground1966Nat'l Academy Sciences Nat'l Research Council on CPR describes ABCDs 1972Dr Valdimir Negovsky The Second StepAdvances in CPR and cardiac care has not resulted in improved survivability in 50 yearsPost Cardiac Arrest SyndromeBrain InjuryMyocardial DysfunctionSystemic Ischemia/Reperfusion ResponseUnresolved Pathological Process

BackgroundBarriers to Optimal OutcomesMultiple Teams/Hand-0ffsWide variation in Treatments (multicenter trials)Early Prognostication Inaccuracies < 72 hrsResearch focus on ROSCImproved ROSC w/o Improved Survival

EpidemiologyEarly Mortality rates after ROSC varies greatly between studies, regions, and hospitals indicating variability in Post Cardiac Arrest CareAdvances in Critical Care over past 5 decades fails to produce improved outcomesData Definition ConfusionROSC Mortality LocationOOH/IH Mortality Time

EpidemiologyPhysiologic Phases of Post Cardiac Arrest CareImmediate = 0-20 minutesCPR interventionsEarly = 20 minutes 6 to 12 hoursEarly interventions most effectiveIntermediate = 6 to 12 hours 72 hoursAggressive management of Injury pathwaysRecovery = beyond 3 daysPrognostication ReliableOutcomes Predictable

EpidemiologyMortality Rates InadequateNeurologic and Functional OutcomesCerebral Performance Category

EpidemiologyQuality of Life?Limitation and Withdrawal of Therapy63% made DNR, 43% withdrew Therapy in Early and Intermediate time periods 15 minutes (No Reflow)Hyperemic Flow increases EdemaLuxuriant HyperperfusionExcessive Oxygen Free radical FormationBrain InjuryGlobal CBF is reduced but adequate to meet Oxidative Metabolic Demands in first 48 hoursTransient Edema common post Arrest but rarely increases ICPDelayed Edema attributable to Ischemic NeurodegradationPyrexia Poor Outcome Increases with each degree > 370CHyperglycemia Common and Potentially Mitigated with Insulin RxSeizures Associated with Worst Prognosis-- Caused by and Exacerbates InjuryMyocardial DysfunctionResponsive to Therapy and ReversibleDetectible within minutes of ROSCDecreased EF (stunned)Increased LVEDP (stiff)Coronary Blood Flow Normal = Myocardial StunningNadir @ 8 Hrs, Improve @ 24 Hrs, Normal @ 72+ HrsDobutamine improves LVEF and Diastolic Dysfunction

Systemic ResponseCPR generates poor Cardiac Output, O2 delivery ,and Metabolite ClearanceOxygen Debt leads to Endothelial Activation and Systemic InflammationPredictive of MOSF and DeathCommon Sepsis FeaturesAdrenal InsufficiencyResponsive to Therapy and ReversibleEarly Goal Directed Therapy may Optimize Outcomes

Persistent PathologyPrecipitating or Contributory PathologyACS AMI >50% OOH Adult Arrests48% Acute Coronary Occlusion w/o apparent STEMIBiomarker Specificity Reduced yet 96% Sensitive for AMI

Persistent PathologyPrecipitating or Contributory PathologyPulmonary EmbolismUp to 10% Incidence in Sudden DeathUnknown ROSC RateCOPD, Asthma, or PneumoniaPulmonary Function often Worsens post ROSCBrain Injury and Edema more common after Asphyxic ArrestSepsisInfections more common cause of In Hospital ArrestsToxinsEnvironmental

Therapeutic StrategyCritical Care Standards for EMS and EDTime SensitiveAccount for In/Out of Hospital SettingsSequential care by multiple Diverse TeamsAccommodate Spectrum of patientsAwake, Stable to Unstable Comatose

Out-of-Hospital Cardiac Arrest Survival after the Sequential Implementation of 2005 AHA Guidelines for Compressions, Ventilations, and Induced Hypothermia J. Brent Myers, MD MPH Medical Director Wake County EMS System4.6%7.3%8.2%11.6%* when compared with baselineP