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Objectives

Brain Injury due to Cardiac Arrest: Neuropsychological Outcomes and a Model for Early Rehabilitation Management Kyle Harvison, PhD, LP, ABPP-CN Cindy Kosek, OT. Objectives. Review of cardiac arrest and associated mechanisms of brain injury

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Objectives

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  1. Brain Injury due to Cardiac Arrest: Neuropsychological Outcomes and a Model for Early Rehabilitation ManagementKyle Harvison, PhD, LP, ABPP-CN Cindy Kosek, OT

  2. Objectives • Review of cardiac arrest and associated mechanisms of brain injury • Overview of therapeutic hypothermia as a neuroprotective strategy post-cardiac arrest • Overview of neuropsychological outcomes and early non-cardiac rehabilitation needs • Introduce a model of care focused on these rehabilitation issues

  3. Cardiac Arrest • Sudden Cardiac Arrest • Notalways “heart attack” • Cessation of productive cardiac mechanical activity • Defined by absence of palpable pulse and spontaneous respiration (Tiainen et al., 2007)

  4. Cardiac Arrest: Causes In Cohen and Gunstad (2010), pp. 127-28 • Problems with heart rhythm • Myocardial infarction • Coronary artery disease • Respiratory arrest • Enlarged heart • Valve disease • Congenital heart defect • Coronary artery dissection • Severe physical stress (e.g., blood loss) • Electrocution • Trauma • Fluid buildup • Hypothermia • Overdose • Metabolic disruption • ……

  5. Cardiac Arrest: Causes Electrophysiologically, most common underlying problems are: • Ventricular fibrillation (VF)- Quivering of the heart’s lower chambers or • Pulseless ventricular tachycardia- Extremely rapid but ineffective beating of the heart’s lower chambers

  6. Out of Hospital Cardiac Arrest: Annual U.S. Incidence (Schulman, Hartman, & Geocadin, 2006; Holzer, 2010)

  7. Cardiac Arrest: Management and Survival Young (2009) • Interventions include cardiopulmonary-cerebral resuscitation, defibrillation, intubation, and heart stimulating drugs, as well as management of underlying causes • Crucial prognostic factors: • Whether a heart rhythm is detected early • Whether underlying causes of arrest been identified and treated

  8. Post Cardiac-Arrest Syndrome (Holzer, 2010) • Includes: • Brain Injury • Myocardial Dysfunction • Systemic ischemia • Reperfusion responses • Consequences of disorder that caused CA

  9. How does cardiovascular disease affect the brain? Primary Secondary • Cardioembolic stroke • Global cerebral ischemia • Cerebrovascular disease associated with systemic vascular changes • Metabolic disruption from injury to other organs • Psychiatric comorbidities • Medication effects • Adverse postsurgical effects Cohen (2010), pp. 21-22

  10. Cardiac arrest and Brain Injury: Where? More vulnerable Less vulnerable • Cerebral cortex • Cerebellum • Hippocampus • Basal ganglia • Brainstem • Thalamus/hypothalamus -Memory impairment in out-of-hospital cardiac arrest survivors has been associated with global cerebral atrophy, rather than selective hippocampal damage (Grubb et al., 2000) Geocadin et al. (2008), p. 489

  11. Cardiac Arrest and Brain Injury: How? (Holzer, 2010) • Immediate: • Oxygen and energy stores deplete quickly • Neuronal firing is disrupted • Excessive stimulation kills nerve cells • Reperfusion injury: • Initial increase in blood flow followed by delayed, prolonged hypoperfusion • Toxic cell injury due to oxidative stress • Inflammatory response can injure tissue and disrupt O2 delivery

  12. Cascade of events in Ischemia

  13. Cardiac Arrest: Neurological Prognosis Brain damage occurs quickly (seconds to minutes) and is permanent in half or more with conventional treatment (Young, 2009) Estimated 12,000 survivors with persistent neuro deficits/year with a prevalence of ~50,000 impaired survivors (Lim et al., 2004)

  14. Cardiac Arrest: Neurological Prognosis • Early neurological prognosticating often occurs during coma or early stages of confusional state • Focused on likelihood that patient will achieve no better than vegetative state or severe disability (Young, 2009) • Some patients may remain comatose for extended periods but still have favorable neurological recovery • Assessment complicated by interventions (Holzer, 2010) • Difficult questions of when to withdraw care

  15. Cardiac Arrest: Neuropsychological Consequences • Roine, Kajaste, & Kaste (1993) published the first prospective, consecutive, community-based neuropsychological study of non-traumatic out-of-hospital VF cardiac arrest • Part of a larger investigation of nimodipine treatment to improve cognitive outcome • Occurred in Helsinki between 1986-88

  16. Roine, Kajaste, & Kaste (1993) • Follow-up assessments at 3 and 12 months • Of 155 who met entry criteria, 70 (45%) were alive at 3 months and 59 (38%) at 12 months • Descriptives: • Average age = 65 (range 36-85) • Approximately 70% were men • Average WAIS VIQs ~100

  17. Roine, Kajaste, & Kaste (1993): Summary • Moderate to severe deficits (i.e. < 2nd percentile) present in 60% at 3 months and 48% at 12 months • Findings generally stable between 3 and 12 months, but 23% improved and 8% declined (of those who survived) • Most common cognitive impairment was delayed memory, with visuoconstruction, psychomotor function, PIQ, and arithmetic also being commonly affected • Depression evident in 35% at 3 months and 31% at 12 months

  18. Cardiac Arrest: Neuropsychological Consequences • Subsequent studies (Grubb et al., 1996; Suave’ et al., 1996 ; van Alem et al, 2004) have demonstrated cognitive deficits in 28-50% of survivors at intervals ranging 6 -12 months • Most common pattern is combination of memory, psychomotor, and executive deficits(Lim et al., 2004) • Mayo study (Mateen et al., 2011) of survivors at 8 years found primarily memory difficulties but the group (n=47) retained strong verbal IQ, normal MMSE and high rates of functional independence

  19. 2002, Volume 346 (8) Mild Therapeutic Hypothermia to Improve the Neurologic Outcome after Cardiac ArrestThe Hypothermia after Cardiac Arrest Study Group Treatment of Comatose Survivors of Out-of-Hospital Cardiac Arrest with Induced Hypothermia Stephen A. Bernard, M.B., B.S., Timothy W. Gray, M.B., B.S., Michael D. Buist, M.B., B.S., Bruce M. Jones, M.B., B.S., William Silvester, M.B., B.S., Geoff Gutteridge, M.B., B.S., and Karen Smith, B.Sc.

  20. “Favorable” Neurological Outcome and Cerebral Performance Category Safar P. Resuscitation after Brain Ischemia, in Grenvik A and Safar P Eds: Brain Failure and Resuscitation, Churchill Livingstone, New York, 1981; 155-184. CPC1= Good outcome: conscious, alert, able to work, possible mild neurologic or psychologic deficit CPC2= Moderate disability: conscious, sufficient cerebral function for independent activities of daily life. Able to work in sheltered environment. CPC3 = Severe cerebral disability, functionally dependent; includes severe dementia states CPC4 = Coma or vegetative state CPC5 = Brain death

  21. Rates of favorable neurological recovery in survivors after therapeutic hypothermia (TH) “…hypothermia provides protection against numerous deleterious biochemical mechanisms” Safar & Kochanek (2002)

  22. TH Protocol Cooling initiated ASAP, typically within at least 4 hours of return of spontaneous circulation Target core body temperature is 33-36 degrees Celsius Hypothermia continued for 24 hours Followed by passive rewarming Broader care includes ventilation, hemodynamic support, cardiovascular intervention, dialysis, infection management, glucose management, etc…

  23. Cooling Methods • Include: • Surface cooling • Pre-cooled pads • Water-circulating pads • Core cooling • Cold IV fluids • Catheter based endovascular delivery of cool saline

  24. TH Mechanisms of Action (Hopkins, 2008, Holzer, 2010) • Reduced brain metabolism • Decreased levels of excitatory substances • Attenuated oxidative stress • Decreased inflammation • Better regulated cerebral microcirculation • Decreased cell death • Could also have beneficial effects on non-CNS aspects of post-CA syndrome

  25. Therapeutic hypothermia after cardiac arrest.An advisory statement by the Advanced Life Support Task Force of the International Liaison Committee on ResuscitationResuscitation 57 (2003) 231-235 • Unconscious adult patients with spontaneous circulation after out-of-hospital cardiac arrest should be cooled to 32-34 dgs. C for 12-24 hrs. when the initial rhythm was VF. • Such cooling may also be beneficial for other rhythms or in-hospital cardiac arrest.

  26. HACA Trial Neuropsychological Outcome (Tiainen et al., 2007) • 27 TH and 18 Normothermia (NT) at 3 months post • Most CPC 1 or 2 • Most living at home but only 25-33% back to work • Psychometric testing focused on memory, executive, and psychomotor speed • No significant group differences

  27. HACA Trial Neuropsychological Outcome (Tiainen et al., 2007) -”The use of therapeutic hypothermia was not associated with cognitive decline…” *<1.5 SDs

  28. Post TH outcomes: Study 2(Cronberg et al., 2009) • Prospective study of all patients with CA treated with hypothermia at intensive care units at two university hospitals and one regional hospital in Sweden • 43/48 survivors agreed to follow-up at ~7 months • Cognitive, mood, and quality of life measurement • Encouraging findings but let’s consider from a rehab lens

  29. Post TH outcomes: Study 2(Cronberg et al., 2009) “mild cognitive impairment is common”

  30. Cognitive Outcomes (Cronberg et al., 2009)

  31. Post TH outcomes: Study 2(Cronberg et al., 2009) “mild cognitive impairment is common” But moderate memory and executive impairment not uncommon

  32. Post TH outcomes: Study 2(Cronberg et al., 2009) “mild cognitive impairment is common” “high level of functioning as reflected in the CPC categories” Indeed, but meaning what? Also, moderate memory and executive impairment not uncommon CPC insensitivity

  33. Post TH outcomes: Study 2(Cronberg et al., 2009) “mild cognitive impairment is common” “high level of functioning as reflected in the CPC categories” “quality of life is good” But moderate memory and executive impairment not uncommon CPC insensitivity. QofL <90% with 1/4 below 70%; plus 14% depressed and 22% can’t sleep

  34. Post TH outcomes: Study 2(Cronberg et al., 2009) “mild cognitive impairment is common” “high level of functioning as reflected in the CPC categories” “quality of life is good” “Overt neurological findings are uncommon” But moderate memory and executive impairment not uncommon CPC insensitivity. QofL <90% with 1/4 below 70%; plus 14% depressed and 22% can’t sleep But ~25% showed motor difficulties causing difficulties in handling daily routines

  35. Post TH outcomes: Study 2(Cronberg et al., 2009) “mild cognitive impairment is common” “high level of functioning as reflected in the CPC categories” “quality of life is good” “Overt neurological findings are uncommon” “Clearly the outcome following TH-treated CA is dichotomized into survival with good neurological outcome or death” Indeed, but meaning what? Also, moderate memory and executive impairment not uncommon So what? We knew that. But most reported QofL <90% with 1/4 below 70%; plus 14% depressed and 22% can’t sleep But ~25% showed motor difficulties causing difficulties in handling daily routines Clearly it’s not that simple!

  36. Post TH outcomes: Study 3( Torgersen et al., 2010) • 24 CA survivors post TH with CPC 1 or 2; seen at 13–28 month follow up in university hospitals in Sweden • 52% showed deficits in memory and executive functioning on the CANTAB • Group level QoL consistent with population norms; QoL not correlated with cognitive outcomes • Mild cognitive deficits are common in OHCA survivors with a high functional status treated with TH but do not affect HRQOL. (p. 7). • Problems include small sample and poorly validated test which samples limited domains

  37. Post TH outcomes: Study 4( Fugate et al., 2013) • Prospective study from Mayo of OOH CA survivors post TH (n=56); short post-CA coma • Followed at 20 months using a telephone-based interview of cognitive status • 91% living independently • 40% cognitively impaired, primarily weak delayed recall • 79% of those employed at time of CA had returned to work • Long time to ROSC did not preclude good outcome (avg 20 mins in both groups)

  38. Post TH outcomes: Study 5( Larsson et al., 2014) • Quality of life and mood outcomes in 26 survivors post CA at discharge, one month and six months • Changes in reporting of low QofL from 73% at discharge to 50% at one month and 41% by six months • Physical problems most common complaint affecting QofL • Correlation with depressive symptoms; rates of clinically significant depressive symptoms 11% or lower

  39. Conclusions from literature • Cardiac arrest causes heterogeneous brain damage via global ischemia; injury continues through reperfusion • Usually fatal, but survival improving with community resources and improved treatments • TH associated with “favorable neurological outcome,” relatively speaking • Memory, psychomotor, and executive problems common but functional status often essentially normal • Quality of life improves over about first six months; longer-term outcome less clear • Need better operationalized definition of “impairment”

  40. Next Steps • From ICU to Discharge….. • The need for a program at ANW was identified by a previous patient • Therapeutic Hypothermia work group was established (Goal: no patient will slip through the cracks)

  41. Rehabilitation Approach Our challenges: Don’t let relief of survival overshadow need to focus on rehab-relevant adverse outcomes Select array of tests with validity and reliability in this population, acceptably easy to administer, broad yet focused Screening model: find survivors with any cognitive dysfunction after Cool-it knowing: would over-identify dysfunction not all dysfunction identified would necessarily be due to effects of CA-related global cerebral ischemia

  42. Work Group Outcomes for Rehabilitation • Routine orders sets now include: • Therapies • PM&R consult • Neuropsych consult • Discharge conference • Team and patient • Routine order for Outpt follow up • Neuropsych and OT

  43. Therapy Roles: ICU Typical Patient Profile Multiple lines Impulsive Emerging Alertness Amnesia around the event Decreased Fine Motor Control Family Relief of survival • PT: • Early mobilization OT: • Family Education • Early ADL’s • Min-stim protocol SLP:- Swallow screen Social Work: - Family connection

  44. Therapy Roles Telemetry Unit Typical Patient Profile Most lines removed Impaired Balance persists Impulsivity Decreased Attention Impaired short term memory Decreased Insight PT: • Progress Mobility OT: • Functional Cognition • Assess high risk ADL’s SLP /Neuropsych • Formal Cognitive Testing PM&R Consult Cardiac Rehab • Trains in CPR • Outpatient referral

  45. Patient Education:

  46. Other Defaulted Consults • Social work • Will follow patients from admission to discharge • Will coordinate Discharge Planning meeting • Case management • Will actively follow patients at time of transfer • Will coordinate required After Discharge appointments • Spiritual care • Smoking cessation (if appropriate) • Hospitalist/Cardiologist • Manages non-cardiac or cardiac issues

  47. Day of Discharge Patient Profile Up and moving independently Varying levels of insight Anxious and focused on discharge home

  48. Day of Discharge Cont. Discharge Conference • Patient & Family • Case Manager • Social Worker • Therapies • MD Providers • Physiatrist • Neuropsych • Discharge Recommendations • ADLs/mobility • Supervision • Driving • Working • Out patient therapies • Cardiac Rehab

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