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Mind, Brain & Consciousness During Cardiac Arrest

Mind, Brain & Consciousness During Cardiac Arrest. Sam Parnia MD, PhD Pulmonary & Critical Care Medicine State University of New York Stony Brook, USA University of Southampton, UK. Disclosures. None. What to do when someone dies? Historical Perspectives on Resuscitation.

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Mind, Brain & Consciousness During Cardiac Arrest

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  1. Mind, Brain & Consciousness During Cardiac Arrest Sam Parnia MD, PhD Pulmonary & Critical Care Medicine State University of New York Stony Brook, USA University of Southampton, UK

  2. Disclosures • None

  3. What to do when someone dies? Historical Perspectives on Resuscitation • Early in history – Galen: Life = Heat & Lifeless = Cold - Heat to prevent death from taking the person - Warm ash - Burning excrement or hot water on body - Flagellation– to stimulate a response • Bellows Method– started in 1530’s – lasted 300 yrs • Fumigation Method – 1700’s • Inversion, Barrel, Trotting Horse - 1700- 1800’s • Mouth-to-Mouth & Chest Compression- 1950-60’s

  4. Impact of Resuscitation Science 50 Years on – Death not a “moment” it is a “reversible” process. Irreversible Death Dying Process – potentially reversible Lasts: Few seconds – 10’s min’s – over an hour Uncharted Territory Cardiac Arrest/Clinical Death Shock: 02 delivery organs inadequate Heart attack Traffic accident Causes of death

  5. Cardiac Arrest “Global Stroke” Pathophysiology of Cardiac Arrest • “Whole body ischemia”– lack oxygen • Brain Oxygen & Energy Stores(ATP) depleted • – Accumulation toxins (adenosine, lactate, H+) • Cells Dysfunction – massive intracellular Ca+ accumulation – toxicity - death • Permanent Brain Cell Death – ? Hours later

  6. Does Brain Function During Cardiac Arrest? • EEG during Cardiac Arrest – • slowing - isoelectric (flatline) 10–20 s • Remain flat – until resumption of heartbeat if early intervention • Prolonged cardiac arrest - EEG returns “hrs” after. • Animal study - 15 min cardiac arrest then resuscitation: • - EEG flat 21 ± 5.7 s (n=10) - 90 ± 24.7 min - bursts of slow waves Kano T, Hashiguchi A, Sadanaga M. Resuscitation 1993; 25: 265-281

  7. So Why Does it Matter?

  8. What are the wider implications of cardiac arrest research? • Can we bring people back safely? • What happens after we die?

  9. What Happens When We Die? Near Death Experience (NDE) • ‘Life after life’ Raymond Moody 1975 • Reactions - ‘Life after life – Hallucination - Fabrication • Retrospective Studies - Some describe negative NDE • 4% prevalence of NDE in USA – Gallup 1982 • Problem: Social & Medical Perception of Death – Irreversible

  10. Ascent to the Empyreon – H Bosch (1450 – 1516) Cognitive & Mental Activity – Near Death Experience (NDE) • 19th century Swiss accident survivors • 15th century Dutch painting – H Bosch • Plato’s Republic & many others…

  11. Cognitive & Mental Activity – Near Death Experience (NDE) • NDE described in Japan, China, India and ++++ • Consistent core features • Studied in children • Case of 3 year old sent to Southampton

  12. WHY DO NEAR DEATH EXPERIENCES OCCUR? • Physiological Chemical changes in brain - hallucination • Psychological Anticipation of death - ? ‘fear death’ experience • Transcendental True separation of mind/soul from body • Other …

  13. WHY DO NEAR DEATH EXPERIENCES OCCUR? – Rumi’s Elephant in the Dark

  14. Near Death Experience – Problems! • What do we mean by near death? • – scientifically too vague • – led to much controversy • Cardiac arrest – Biologically = death • New Term: Actual Death Experience

  15. “Near Death” or “Actual Death” Experience Irreversible Death Dying Process – potentially reversible Lasts: Few seconds – 10’s min’s – over an hour Cardiac Arrest Heart attack Traffic accident Causes of death

  16. What happens to mind and consciousness during cardiac arrest? Parnia S, Waller D, Yeates R, Fenwick P, A qualitative and quantitative study of  incidence, features and aetiology of NDE's in cardiac arrest survivors Resuscitation Feb 2001 48, 149-156

  17. Largest NDE Study in Cardiac Arrest • 344 cardiac arrest survivors - 10 hospitals • 41 (12%) reported core NDEs - No association with: • Medication • Fear of death prior to cardiac arrest • Transformation following NDE • 8 year follow up - positive change in life • Did not test physiological parameters • ?? Account for NDE through brain processes? Van Lommel P et al – Near-death experience in survivors of cardiac arrest: a prospective study in the Netherlands. Lancet 2001; 358:2039-2045

  18. Wider Implications of Consciousness During Cardiac Arrest • ? Signify improved brain Resuscitation? • - Need to study “real time” brain resuscitation. • When is human mind/consciousness lost permanently and cannot be retrieved after death?

  19. Death – Physical Process • Changes in Cells including Brain – Cell damage within minutes Minutes • Brain Cells undergo Irreversible Damage Hrs - Days • Eventually leads to bodily destruction • When do the mind & consciousness cease existing?

  20. Death – What Happens to Mind & Consciousness? • Five independent studies – published since 2001 UK, Holland, USA • 10-20% people revived from cardiac arrest & clinical death – consciousness + thought processes + can “see” & “hear” • Scientific Paradox: ? mind/consciousness continue function when brain stopped working and reached the clinical criteria of death

  21. Paradox: Consciousness during Unconsciousness! • Possible explanations: - do not arise at all - Unlikely - ? millions of cases - Arise just before or after cardiac arrest - Need to re-examine mind/brain theories

  22. The relationship of mind and brain: Challenge for 21st century science?

  23. Mind and Brain - Problem of Consciousness, Psyche or Soul • How do we have ‘consciousness’ (psyche or soul) from brain processes? • How do thoughts, feelings and all aspects of mind arise from brain processes?

  24. Mind and Brain - Problem of Consciousness

  25. Mind and Brain - Problem of Consciousness History • Ancient Greeks - Human Soul • Descartes - Cartesian model • Cerebral localisation -19 - 20C From: Brain Atlas Harvard Medical School • Modern scanning techniques • - f MRI, PET

  26. Mapping the mind • Complex thoughts = Activity in multiple areas of brain • Identifying brain cell activity during thoughts – correlation NOT CAUSATION

  27. Mind and Brain - Problem of Consciousness • Current Views - - Conventional– Neural Networks Greenfield/Crick/Koch/ Dennett - Others – Quantum processes - Hameroff/Penrose Irreducible entity: electromagnetic/mass/Gravity Chalmers Mind/Brain – Separate – Eccles/ Elahi

  28. Are Experiences Real or Hallucinations? • All experience mediated by brain pathways • Reality of any experience is socially determined - not‘neurologically’ – Whether NDE/Love or otherwise… • NDE – Out of body experiences - many claim objectively verifiableevents – Can we test and determine itsreality...?

  29. AWARE STUDY (AWAreness during Resuscitation) - launched 2008. • International Multicentre Study of Consciousness during Cardiac Arrest • First large scale study to examine claims to “see” and “hear” • Aim to use Sophisticated Technology (cerebral oximetry) to study brain oxygen delivery with consciousness

  30. Cerebral Oximetry • Optical Monitoring technique using Beer Lambert law • Assesses regional O2 (rSO2%) (balance O2 delivery & uptake) • Represents mostly cerebral venous saturation • Acceptable Normal Values 60-80%

  31. Role of cerebral oximetry in predicting return of spontaneous circulation (ROSC) in cardiac arrest using manual CPR * * p = <0.0016 Mann-Whitney Test, ROSC = Return of Spontaneous Circulation(No ROSC n= 15, ROSC n= 7)

  32. Impact of Automated CPR (LifeStat) on rSO2 * * p= <0.0001 Mann-Whitney (Manual CPR n=22, Automated(LifeStat) CPR n=12)

  33. Illustration of the Impact of Manual & Automated Chest Compression on Cerebral Perfusion in Two Patients % rSO2 Automated CPR (patient 1) Manual CPR (patient 2) ROSC = Return of Spontaneous Circulation Time (mins)

  34. Automatic CPR leads to higher Return Spontaneous Circulation Following Cardiac Arrest * % Survival (ROSC) Manual CPR Automated CPR ROSC = Return of Spontaneous Circulation lasting > 20 mins. *p < 0.05 using Fischer's Exact test. (Manual CPR n=44, Automated CPR n=20)

  35. AWARE STUDY – Investigators/advisors University of Southampton, Dr Peter Fenwick (Psychiatry), Dr Charles Deakin (cardiac anesthesia), Dr Paul Little (research design), Professor Robert Peveler2 (Psychiatry), Ms Niki Fallowfield (Resuscitation) University of Cambridge: Ms Susan Jones (Resuscitation) Northampton Hospital:Ms Celia Warlow (Resuscitation), St Georges Hospital, London: Ms Leanne Smythe (Resuscitation), St Peters Hospital: Mr Paul Wills (Resuscitation), Mayday Hospital: LondonMr Russell Metcalfe Smith (Resuscitation), Royal Bournemouth Hospital: Ms Hayley Killingback (Resuscitation), Morriston Hospital: Dr Penny Sartori (Critical Care Unit), Stevenage Hospital: Ms Salli Lovett (Critical Care) Salisbury Hospital: Mr Iain Macleod (Resuscitation), East Sussex Hospitals, Dr Harry Walmsley (Anaesthetics & Resuscitation) Hammersmith HospitalLondon: Mr Ken Spearpoint, (Resuscitation), Indiana State University, Dr Mark Faber (Pulmonary & Critical Care), University of Virginia: Professor Bruce Greyson (Psychiatry), Dr Robert O’Connor (Emergency) Emory Medical Center:Dr Maziar Zafari (cardiology) University of Vienna: Professor Roland Beisteiner (Neurology), Dr Fritz Sterz (Emergency Medicine), Dr Michael Berger (Neuroscience)

  36. METHODS – Hidden Targets Southampton

  37. RESEARCH – Cardiac arrest – Humour!

  38. Near Death Experience Research How do we study human mind and consciousness during cardiac arrest

  39. METHODS • Open question - ? memory of consciousness • Study Experiences- Greyson scale • -Cognitive recollections (study) • -No cognitive recollections (control) • Study Brain & Resuscitation Processes: -Physiological– O2/ CO2– Electrolytes Drugs – Cardiac Rhythm - Psychological – ?Religion ? Practicing - Transcendental – Hidden targets…

  40. RESULTS – Physiological Southampton Southampton Study: NDE in cardiac arrest 150 130 Na 110 mmol/l 90 K mmol/l 70 PaCO2 50 KPa 30 PaO2 KPa 10 0 control study Parnia S, Waller D, Yeates R, Fenwick P, A qualitative and quantitative study of  incidence, features and aetiology of NDE's in cardiac arrest survivors Resuscitation Feb 2001 48, 149-156

  41. Current version – Fixed shelves with fixed images!

  42. Future Version - Random image generators

  43. Portable Brain (EEG) Monitor – during cardiac arrest

  44. Cerebral oximetry – Our experience so far! N=10 - Useful in cardiac arrest - results so far similar to previous - 02% <20% - non survivors ROSC

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