Slides ROSC Lecture 3 Part 1
Transcript of Slides ROSC Lecture 3 Part 1
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Cardiac Arrest, Hypothermia and Resuscitation Science
Lecture 3: Cooling the body to save the heart and brain:Therapeutic hypothermia after cardiac arrest
Benjamin S. Abella, MD MPhilClinical Research Director Center for Resuscitation ScienceDepartment of Emergency MedicineUniversity of Pennsylvania
Coursera
July 2012
An introductory course for the educated lay public and health care providers
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Time
% S
u r v i v i n g
arrest
CPR
ROSC
hospitaldischarge
in-hospitalarrest data
52%
18%
The post-arrest problem
When do people die from cardiac arrest?
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Time
% S
u r v i v
i n g Damage observed after restoration
of blood flow to ischemic tissues
Reperfusion injury
Concept of REPERFUSION INJURY
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Reperfusion injury: clues from the laboratory
Can simulate cardiac arrest and resuscitation:
Bathe them in fluid without oxygen (cardiac arrest)Restore fluid with oxygen (resuscitation)
Heart cells (myocytes) grown in a petri dish
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ischemia
C e
l l D e a
t h ( % )
Time
Death during ischemia
Death during reperfusion
0
10
20 30
40
50 60
0 1 2 3 4 5
??
What will happen when you simulate ischemia and then reperfusion?
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ischemia
C e
l l D e a
t h ( % )
Time
Can we dosomething
here?
Vanden Hoek et al, AJP, 1996
What actually happens:
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Would you buy this car for $75,000 ?
One quirk: if you run out of gas,
And you then put gas in the car
What this means: imagine the following situation
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K A H B OOM
What this means: imagine the following situation
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What causes this problem?
free radicals
mitochondria
inflammation
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Ischemia(lack of blood flow)
Reperfusion(return of blood flow)
reactive oxygenspecies (ROS) inflammatory
cascades
energy processingdysfunction
blood vessel instabilitycell death
brain swelling
hypothermia
Reperfusion injury: how it happens
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Cardiac arrest epidemiology in the USEGYPT:
In the time of the Pharaohs
The remarkable history of therapeutic hypothermia
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Hesi Re, Physicianand scribe2650 BCE
Sekhmet,goddess ofdisease
Imhotep,the god ofhealing
AncientMedicinebottle
Medicine in ancient Egypt
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Ancient Egyptians documentedthe use of hypothermia for:
Pain control
Fever
Ice stored in straw, transportedLong distances or made inEgyptian winters
Medicine in ancient Egypt
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Cardiac arrest epidemiology in the USKOS:
Island home to the
Hippocratic tradition
Medicine in ancient Greece
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Hippocrates noted that injuries(traumatic wounds) often did better
when packed in ice or cooled
No shortage of experimentalsubjects: constant skirmishing of
Greek city states
Medicine in ancient Greece
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Cardiac arrest epidemiology in the US
France:The Age of Empire
Hypothermia in the modern era
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Baron Larrey (1766-1842)
Chief battlefield surgeon under Napoleon
Developed important military medicineinnovations:
The Flying Ambulance
Caring forenemies
(Prussians,seen here)
Baron Larrey: medical innovator
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Cold acts on the living parts[which] may remain in [a]state of asphyxia without losingtheir life (1814)
Baron Larrey observes hypothermia in action
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Benson DW, Williams GR Jr, Spencer FC, Yates AJ.The use of hypothermia after cardiac arrest.
Anes th A na lg 1959; 38: 423-8.
Comatose survivors
Asystole or VF31-32
CCooling until neurologicrecovery
(3 h to 8 days)water-filled blanket
The first study of hypothermia in cardiac arrest
0
10
20
30
40
50
60
Favorable neurologicrecovery
%
Hypothermia (n=12)
Normothermia (n=7)
http://images.google.com/imgres?imgurl=http://www.laxcast.com/images/Penn%2520Logo3.jpg&imgrefurl=http://www.laxcast.com/laxcasts.php&h=575&w=504&sz=86&hl=en&start=2&tbnid=FQB_-U94MtoUWM:&tbnh=134&tbnw=117&prev=/images?q=Penn+logo&svnum=10&hl=en&lr=&rls=DKUS,DKUS:2006-32,DKUS:en -
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Peter Safar, MD (1924-2003)
Anesthesia training at U Penn
Worked in Pittsburgh
Father of CPR AND also developedhypothermia as a science
The father of the science of hypothermia
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The father of the science of hypothermia