Post on 13-Jul-2016
CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
Post Resuscitation Syndrome“Restart the heart and keep it restarted”
AndriantoRuthvi Adriana
CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
Scenario
45 y.o man admitted to the ER
Chief complaint : ischemic chest pain since an
hour ago, ST elevation in ECG.
Immediately unconscious with ventricle
fibrillation in ECG monitoring
CPR was performed and ROSC in 10 minutes
CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
Patient is ROSC
What’s happen?
CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
Post Resuscitation Syndrome
To minimizeBrain injury
To correctMyocardial dysfunction
To manageSystemic ischemia -
reperfusion response
To detect and treatPersistent precipitating
pathology
Robert W. Neumar et al. 2008. Post–Cardiac Arrest Syndrome. (Circulation. 2008;118:2452-2483.)
CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
Not only
Return of Spontaneous Circulation (ROSC)
but
Return to Pre Arrest Status
CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
Post Resuscitation Syndrome
To minimizebrain injury
To correctmyocardial dysfunction
To managesystemic ischemia -
reperfusion response
To detect and treatpersistent precipitating
pathology
Robert W. Neumar et al. 2008. Post–Cardiac Arrest Syndrome. (Circulation. 2008;118:2452-2483.)
CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
Our approach should be:
Comprehensive
Structured
Multidisciplinary system of care
CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
ManagementROSC
In field: - Maintain C-A-B - Oxygenation- IV access - ECG 12 leads- Monitor rhythms
In ED & ICU: Access vital sign, airway, and mental status
Ashvarya Mangla et al. 2014. Post-resuscitation care for survivors of cardiac arrest. Indian Heart Journal 66 (2014) S105-S112.
CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
Patient comatose
• Focused history and physical examination• Laboratory & imaging examination
• Initiate cardiopulmonary and metabolic stabilization•Treat precipitating cause
Multidisciplinary System of Care
Patient non comatose
Therapeutichypothermia
Ashvarya Mangla et al. 2014. Post-resuscitation care for survivors of cardiac arrest. Indian Heart Journal 66 (2014) S105-S112.
CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
Multidisciplinary System of Care
Ventilation
Cardiovascular and Hemodynamic
Metabolic
Neurological
Ashvarya Mangla et al. 2014. Post-resuscitation care for survivors of cardiac arrest. Indian Heart Journal 66 (2014) S105-S112.
CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
Multidisciplinary System of Care
Ventilation
Cardiovascular and Hemodynamic
Metabolic
Neurological
Ashvarya Mangla et al. 2014. Post-resuscitation care for survivors of cardiac arrest. Indian Heart Journal 66 (2014) S105-S112.
CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
Ventilation
• Maintain good airway
• Adequate oxygenation and ventilation
• Intubation if needed
• Avoid hypo-hyperventilation
• Reduce FIO2 as tolerated → SPO2 ≥94%
• PaCO2 40–45 mm hg
Ashvarya Mangla et al. 2014. Post-resuscitation care for survivors of cardiac arrest. Indian Heart Journal 66 (2014) S105-S112.
CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
Multidisciplinary System of Care
Ventilation
Cardiovascular and Hemodynamic
Metabolic
Neurological
Ashvarya Mangla et al. 2014. Post-resuscitation care for survivors of cardiac arrest. Indian Heart Journal 66 (2014) S105-S112.
CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
Cardiac and Hemodynamic
Maintain adequate tissue perfusion and prevent recurrent
hypotension (MAP 65 - 75 mm Hg; TDS >90 mm Hg)
Consider iv hydration with isotonic fluids and pressor support
Continues cardiac monitoring
Treat coronary ischemia with reperfusion
Treat arrhythmias as appropriate
Ashvarya Mangla et al. 2014. Post-resuscitation care for survivors of cardiac arrest. Indian Heart Journal 66 (2014) S105-S112.
CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
Multidisciplinary System of Care
Ventilation
Cardiovascular and Hemodynamic
Metabolic
Neurological
Ashvarya Mangla et al. 2014. Post-resuscitation care for survivors of cardiac arrest. Indian Heart Journal 66 (2014) S105-S112.
CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
Metabolic• Frequent electrolyte monitoring
• Adequate repletion of K, Mg to keep K › 3.5 mEq/L
• Treat hypo-hyperkalemia
• Avoid hypo/hyperglycaemia (target glucose 144–180 mg/dL)
• Monitor urine output
Ashvarya Mangla et al. 2014. Post-resuscitation care for survivors of cardiac arrest. Indian Heart Journal 66 (2014) S105-S112.
CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
Multidisciplinary System of Care
Ventilation
Cardiovascular and Hemodynamic
Metabolic
Neurological
Ashvarya Mangla et al. 2014. Post-resuscitation care for survivors of cardiac arrest. Indian Heart Journal 66 (2014) S105-S112.
CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
Neurological
Baseline neurological examination
Imaging of brain to assess for ischemia / haemorrhage
if clinically indicated
EEG to assess subclinical seizures
Therapeutic hypothermia
Ashvarya Mangla et al. 2014. Post-resuscitation care for survivors of cardiac arrest. Indian Heart Journal 66 (2014) S105-S112.
CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
Benson et al,Anesth Analg 1959; 38: 423-8.
Comatose survivors
Asystole or VF
31-32°C
Cooling until neurologic recovery(3 hours to 8 days)
Water-filled blanket
0102030405060
Favorable neurologicrecovery
%
Hypothermia (n=12)
Normothermia (n=7)
The Use of HypothermiaAfter Cardiac Arrest
CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
Hypothermia
Normothermia
P 0.02
Mild therapeutic hypothermia to improve the neurologic outcome after cardiacarrest. N Engl J Med. 2002;346:549-556.
Mild therapeutic hypothermiato improve the neurologic outcome
CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
Cooling Technique
Cooling blankets
Ice / cold liquid packing
Ice / cold liquid gastric lavage
IV cooling catheter
Cooling mist
Other method
0% 10% 20% 30% 40% 50%
Cooling technique Percentage of respondents
50%
15%
13%
2%
2%
17%
CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
Coolong Blankets
CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
Basics of Therapeutic Hypothermia:Three phases of treatment
Induction Rapidly bring the temperature to 32-34C Sedate with propofol or midazolam during TH Paralyze to suppress heat production
Maintenance The goal temperature at 33C Standard 12-24 hours (optimal duration is unknown) Suppress shivering
Rewarming Most dangerous period: hypotension, brain swelling, Goal is to reach normal body temperature over 12-
24h Stop all sedation when normal body temperature is
achieved
CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
Monitoring:
Seizure, shivering
Aritmia & unstable hemodinamic → rewarmed
Electrolyte imbalance (Mg,K,P,Ca,Na ↓)
Temperature check, skin care
Bleeding , dehydration, infection
Robert W. Neumar et al. 2008. Post–Cardiac Arrest Syndrome. (Circulation. 2008;118:2452-2483.)
CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
The 2005 AHA guidelines:
Comatose, ventricular fibrillation (VF) (class IIA)
Comatose, other rhythms (class IIB)
Robert W. Neumar et al. 2008. Post–Cardiac Arrest Syndrome. (Circulation. 2008;118:2452-2483.)
CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
Prognostication
Pre-Arrest
o Age
o Comorbidities
Arrest
o Collapse to CPR time
o Prolonged CPR
o Initial Rhythm
o CPR quality
Post - arrest
o Clinical examination
o EEG
o Somatosensory
evoked potential
o Neurological
biochemical marker
Robert W. Neumar et al. 2008. Post–Cardiac Arrest Syndrome. (Circulation. 2008;118:2452-2483.)
CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
Summary
The rate of ROSC continues to increase and proper post-
resuscitation care could reduce mortality and morbidity.
Managing the ROSC patients requires a multidisciplinary
system of care: including ventilation, cardiac, hemodynamic,
metabolic, and neurological approach.
Strong evidence that hypothermia theraupetic is neuro-
protective after return of spontaneous circulation
CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
Thank You
CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
Outcomes of Therapeutic Hypothermia
Alive at hospital discharge - favorable neurological recovery
Alive at 6 months - favorable neurological recovery
Hypothermia NormothermiaHACA Study Group 72/136 (53%) 50/137 (36%)
Bernard 21/43 (49%) 9/34 (26%)
Hachimi-Idrissi 4/16 (25%) 1/17 (6%)
Hypothermia NormothermiaHACA Study Group 72/136 (52%) 50/137 (36%)
CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015
CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015