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The Key to Survival

The Key to Survival. Dr Tong WL Associate Consultant Intensive Care Unit. 17 March 2009. Case 1. Male, 49 yr old Chronic smoker and drinker P/H DM on Mixtard HM for 2 years Newly diagnosed HT in China few months ago, on amlodipine 5mg QD. Case 1. Admitted on 5 June 2008

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The Key to Survival

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  1. The Key to Survival Dr Tong WL Associate Consultant Intensive Care Unit 17 March 2009

  2. Case 1 • Male, 49 yr old • Chronic smoker and drinker • P/H • DM on Mixtard HM for 2 years • Newly diagnosed HT in China few months ago, on amlodipine 5mg QD

  3. Case 1 • Admitted on 5 June 2008 • Sudden collapse on Nathan Road • No pulse on ambulance at 1305 • CPR with AED connected (not fired) • A&E at 1319: asystole • Intubated • Adrenaline x 3 + atropine 3mg + IV NaHCO3 • ROSC at 1330

  4. Case 1 A&E  ICU • pH 6.77 HCO3 7.2 BE -28.4 PaO2 14.2 PaCO2 6.7 • RFT 120/6.1/10.9/235 • Glucose 32.7 ( H’stix in A&E 26.3) • Urine ketone 4+ • Temp 35. 6 C

  5. Case 1

  6. CK 1041 LDH 948 • Tn I 12.5ng/ml • Bedside echo: inferior posterior wall hypokinesia, satisfactory biventricular systolic fx

  7. Case 1 Diagnosis • Post cardiac arrest • Acute inferior MI • DKA • Aspiration pneumonia

  8. Case 2 • F/44 • A cleansing worker, NDNS • P/H: R hemiparesis in China , good recovery 1992 • Travel: returned to HK 2 days ago from China, where she developed diarrheoa and dizziness. IV medication was given.

  9. 04 Jan 2008 • Sudden collapse while at work • Asystole at the scene • Started CPR upon EMS arrival • Ambulance: VF, defibrillation x 2 Case 2

  10. A&E Dept • VF, adrenaline 8mg, defibrillation x 3, Amiodarone IV • Intubation • CPR x 30min • Temp 34.8C • Pupils fixed and dilated • BP157/105 Case 2

  11. Case 2 A&E to ICU • pH 7.08 HCO3 16.4 BE –14.0 PaO2 34.8 PaCO2 7.5 • RFT 140/2.8/4.9/126 • Glucose 18.4 (H’ stix in A&E 8.8) • CK 317 LDH 493 Case 2

  12. Case 2 QTc 0.45 msec

  13. Case 2

  14. Case 2 • Bedside echo: 4 chambers normal size, satisfactory biventricular systolic fx ; mild AR; no RWMA • TnI 0.2 ng/ml (D1) • CT brain: hypodensity over left frontal lobe otherwise unremarkable

  15. Case 2 Diagnosis • VF • Post cardiac arrest • Aspiration pneumonia

  16. Outlines • Cases 1 & 2 (part 1) • Mortality data • Post cardiac arrest syndrome • Post cardiac arrest care • Cases 1 & 2 (part 2) • Prognostication • Summary

  17. In-hospital mortality • JAMA 2006, 295:50-57 • Anaesthesia 2007, 62:1207-1216 • Crit Care Med 2007, 35:836-841 UK study: ICU mortality 55-60%

  18. KWH ICU 2007 & 2008 Post cardiac arrest patients ICU mortality 58% In-hospital mortality 79%

  19. Outcome of in-hospital cardiac arrest is very poor The goal of treatment should be to intervene early before the patient deteriorates to develop unexpected arrest

  20. 2007 AHA Statistics Adult OOH cardiac arrest survival = 6.3%Australian OOHCA data:

  21. Survival of OOH CA patients in HK • Journal of Accident and Emergency Medicine 12, 34-39 • Hong Kong Med J Vol 8 No 5 October 2002 • Hong Kong J. Emerg. Med. Vol. 12(3) Jul 2005

  22. Variability between reports on in-hospital mortality • Brief, fleeting or sustained ROSC • Care during transport, ED or ICU • Limitation set on subsequent resuscitation efforts • Timing of therapy withdrawal

  23. ROSC • Resumption of spontaneous circulation (ROSC) after prolonged, complete, whole-body ischemia is an unnatural pathophysiological state created by successful CPR

  24. over the past half-century, focus was on improving the rate of ROSC interventions improve ROSC without improving long-term survival translation of optimized BLS and ALS interventions into the best possible outcomes is contingent on optimal post– cardiac arrest care

  25. Post-cardiac arrest syndrome • brain injury • myocardial dysfunction • systemic ischemia/reperfusion response • the unresolved pathological process that caused the cardiac arrest

  26. Post-cardiac arrest syndrome • brain injury • myocardial dysfunction • systemic ischemia/reperfusion response • the unresolved pathological process that caused the cardiac arrest

  27. Anoxic brain injury ( 3 phases) Cardiac Arrest ROSC CPR High, normal or low flow Low flow No flow Cerebral blood flow

  28. Brain injury

  29. Secondary brain injury • Hypotension • Hypercapnia • Impaired cerebrovascular autoregulation • Brain edema • Pyrexia • Hyperglycemia • Seizure

  30. Clinical manifestation • Coma • Seizures • Myoclonus • Cognitive dysfunction • Vegetative state • Secondary parkinsonism • Stroke • Brain death

  31. Post-cardiac arrest syndrome • brain injury • myocardial dysfunction • systemic ischemia/reperfusion response • the unresolved pathological process that caused the cardiac arrest

  32. Post-cardiac arrest myocardial dysfunction • detectable within minutes • manifest as hypotension, low CI, arrhythmia • stunning phenomenon rather than permanent injury or infarction • responsive to therapy and reversible • Cardiac index values reached their nadir at 8 hours after resuscitation, improved substantially by 24 hours, and almost uniformly returned to normal by 72 hours in survivors Reversible myocardial dysfunction in survivors of out-of-hospital cardiac arrest.J Am Coll Cardiol. 2002;40:2110 –2116

  33. Post-cardiac arrest syndrome • brain injury • myocardial dysfunction • systemic ischemia/reperfusion response • the unresolved pathological process that caused the cardiac arrest

  34. Systemic Ischemia/Reperfusion Response • represent the most severe shock state • inadequate tissue DO2 can persist even after ROSC because of myocardial dysfunction, pressor-dependent hemodynamic instability, and microcirculatory failure • generalized activation of immunologic and coagulation pathways  endothelial dysfunction, hypercytokinemia  increase risk of multiple organ failure and infection • manifest as intravascular volume depletion, impaired vasoregulation, impaired oxygen delivery and utilization, increased susceptibility to infection

  35. Post-cardiac arrest syndrome • brain injury • myocardial dysfunction • systemic ischemia/reperfusion response • the unresolved pathological process that caused the cardiac arrest

  36. Unresolved Precipitating Pathology • Cardiovascular disease • CAD accounts for two thirds of sudden cardiac deaths • Pulmonary disease (COPD, asthma) • CNS disease (CVA) • Thromboembolic disease (PE) • Toxicological (overdose, poisoning) • Infection (sepsis, pneumonia) • Hypovolemia (hemorrhage, dehydration)

  37. Post-cardiac arrest care • time sensitive, both in and out of the hospital • multidisciplinary team execute a comprehensive clinical pathway tailored to available resources • a spectrum of patients, ranging from the awake, hemodynamically stable survivor to the unstable comatose patient with persistent precipitating pathology • focus on reversing the patho-physiological manifestations of the post– cardiac arrest syndrome with proper prioritization • Avoid premature withdrawal of care before long-term prognosis can be established

  38. Therapeutic Strategies • General Measures • Monitoring • Oxygenation and Ventilation • Hemodynamic Optimization • Circulatory Support • Managing Underlying Pathology • Therapeutic Hypothermia • Seizure Control and Prevention • Glucose Control • Infection Management • Long-Term Rehabilitation

  39. Monitoring options General intensive care monitoring • Arterial catheter • Oxygen saturation by pulse oximetry • Continuous ECG • CVP • ScvO2 • Temperature • Urine output • Arterial blood gases • Serum lactate • Blood glucose, electrolytes, CBC, and general blood sampling • CXR More advanced hemodynamic monitoring • Echocardiography • Cardiac output monitoring (either noninvasive or PA catheter) Cerebral monitoring • EEG (on indication/continuously): early seizure detection and treatment • CT/MRI

  40. Management after cardiac arrest

  41. Airway and ventilation • Intubation / Airway protection • PaCO2 • Although cerebral autoregulation is either absent or dysfunction, cerebrovascular reactivity to changes in arterial carbon dioxide tension appears to be preserved • Minimal FIO2 to maintain SaO2 94-96%

  42. Circulation • early hemodynamic optimization • restoring and maintaining the balance between systemic oxygen delivery and demands • initiation of monitoring and therapy asap and achievement of goals within hours of presentation Early goal-directed hemodynamic optimization

  43. ↓

  44. EGDHO within 6 hr Resuscitation 2009,80: 418–424

  45. STEMI : Restoration of coronary perfusion is a priority • Primary PCI is preferred over thrombolysis • Prior CPR is not a contraindication to thrombolysis Non-cardiac arrest patient Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomised trials. The Lancet 2003; 361, 9351

  46. Management of STEMI in post cardiac arrest patient • early primary PCI • average intervals from symptom onset or CPR to balloon inflation : 2 to 5 hours • angiographic success rates : 78% to 95% • overall in-hospital mortality: 25% to 56% Circulation 2007;115:1354-1362 Resuscitation. 2007;74:227–234

  47. Post cardiac arrest patients with STEMI undergo PCI Resuscitation (2007) 72, 379—385

  48. Outcome of comatose & conscious survivors of cardiac arrest with STEMI Resuscitation (2007) 72, 379—385

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