RAKESH GUPTA MD. Scope of the Problem History, Current Evidence and AHA Recommendations Physiology...
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RAKESH GUPTA MD. Scope of the Problem History, Current Evidence and AHA Recommendations Physiology of Cardiac Arrest Complications of Return of Spontaneous
Scope of the Problem History, Current Evidence and AHA
Recommendations Physiology of Cardiac Arrest Complications of
Return of Spontaneous Circulation (ROSC) Pathophysiology and
complications of Hypothermia Practical Aspects of Cooling
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Sudden cardiac arrest (SCA) is a leading cause of death in the
US Approximately 330,000 deaths annually in ED and out of hospital
from SCA 80% or more of initially comatose survivors will then die
or suffer debilitating neurologic outcomes AHA
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Of patients arresting out-of-hospital, 3.0% received bystander
cardiopulmonary resuscitation 9.1% had some prehospital CPR, 13.6%
had ventricular fibrillation (VF) on ED arrival. In the witnessed
arrests (80%), the estimated interval from arrest to initiation of
CPR was 21.1 14.7 min. Survival to hospital discharge from
out-of-hospital arrest was 5.1% for adults and 7.4% for children;
All had poor neurologic outcome. For patients arresting in the ED,
an initial rhythm of ventricular tachycardia (VT) or VF was
strongly correlated with survival. Survival from ED arrest was
30.4% in adults, 42.9% in children; all but one had normal
neurologic outcome. Cardiac arrest in Saudi Arabia: a 7-year
experience in Riyadh Volume 17, Issue 4, Pages 617-623 (July
1999)
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With n=19, survival was 6 of 12 in the cooled group and 1 of 7
without cooling with a target temperature of 31-32C.
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1961
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1980s Cardiac Arrest with Dogs
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2002s
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Can we safely cool patients? What is the best method? Evidence
for therapeutic hypothermia has lacked sufficient weight and the
advisory panel support that thereby follows to propel it into
common practice.
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77 patients 43 hypothermia 34 normothermia Results 49% of
hypothermia - good outcome compared to 26% of normothermia
(p=0.046) Bernard SA, et al. Treatment of comatose survivors of
out-of-hospital cardiac arrest with induced hypothermia. NEJM 2002;
346 (8): 546-556.
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5 Levels 1. Good 2. Moderate 3. Severe 4. Coma, Vegetative
State 5. Death The Brain Resuscitation Clinical Trial II Study
Group, Control Clin Trials 1991 Aug; 12 (4): 525-545
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Multi -Center Trial 275 patients 137 Hypothermia 138
Normothermia Results 55% Hypothermia group favorable outcome 39%
Normothermia group favorable outcome (p=0.009) The Hypothermia
After Cardiac Arrest Study Group. Mild therapeutic hypothermia to
improve the neurologic outcome after cardiac arrest. NEJM 2002; 346
(8): 549-556.
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Bernard et al. Resuscitation 2003: 22 post cardiac arrest,
comatose adults 30ml/kg LR at 4 C infused over 30 min via
peripheral IV then temp maintained at 33C Median temp decreased
1.6C after bolus (P=
Inclusion criteria Intubated patients with treatment initiated
within a 6- hour post cardiac arrest (nonperfusing ventricular
tachycardia [VT] or VF) Return of Spontaneous Circulation (ROSC)
within 60 minutes of cardiac arrest Those able to maintain a
systolic blood pressure >90 mm Hg, with or without pressors,
after cardiopulmonary resuscitation (CPR) Those in a coma at the
time of cooling. Brainstem reflexes and pathological/posturing
movements +/- Patients with a Glasgow Coma Score (GCS) of 3 are
eligible for hypothermia.
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Exclusion criteria Recent major surgery within 14 days -
Hypothermia may increase the risk of infection and bleeding.
Systemic infection/sepsis - Hypothermia may inhibit immune function
and is associated with a small increase in risk of infection.
Patients in a coma from other causes (drug intoxication,
preexisting coma prior to arrest) Patients with a known bleeding
diathesis or with active ongoing bleeding - Hypothermia may impair
the clotting system. Check prothrombin time/partial thromboplastin
time (PT/PTT), fibrinogen value, and D-dimer value at admission.
(Note: Patients may receive chemical thrombolysis, antiplatelet
agents, or anticoagulants if deemed necessary in the treatment of
the primary cardiac condition.) Patients with a valid do not
resuscitate order (DNR)
Intravenous cooling Mechanical or endovascular cooling Ice bags
during induction
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Bladder Rectal PA Catheter Esophageal Tympanic Axilla Monitor
every 15 minutes during induction until stabilized at goal
temperature 32-34C Avoid temperature
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