ED and Hospital Care Can Improve Survival after Cardiac Arrest

1. ED and Hospital Care Can Improve Survival after Cardiac Arrest Ankur A. Doshi, MD FACEP Post Cardiac Arrest Service UPMC Presbyterian

2. Presenter Disclosure Information FINANCIAL DISCLOSURE: Employer: University of Pittsburgh/UPMC Grants/Research Support: Pittsburgh Emergency Medicine Foundation Ankur A. Doshi, MD FACEP ED and Hospital Care Can Improve Survival after Cardiac Arrest

3. Learning objectives • Discuss immediate steps shown to improve outcomes for patients with ROSC after cardiac arrest in the ED • List proven in-hospital medical therapies for post-cardiac arrest patients • Compare Targeted Temperature Management (TTM) with Induced Therapeutic Hypothermia (ITH)

4. What we won’t cover • Treatment during cardiac arrest • Detailed neuroprognostication • Seizure evaluation and treatment • Other therapies not yet proven to have benefit post-arrest

5. The good news Girotra 2012 – GWTG Data Daya 2013 – ROC Data

6. Opportunities Langhelle, 2003 % Survival (1 month) for OOHCA bystander witnessed and cardiac etiology Herlitz, 2006

7. What therapies can improve survival from cardiac arrest? • Blood pressure control / perfusion • Ventilator management (O2 and CO2) • Temperature management • Tertiary care • Cardiac catheterization • Delayed neuroprognostication • Post-discharge planning

8. 2015 Post-Arrest Guidelines Early Coronary Angiography Hemodynamic Goals Targeted Temperature Management Seizure Detection and Management Ventilation and Oxygenation Prognostication Organ Donation

9. Blood pressure management

10. Anoxic injury impairs cerebral autoregulation 100 Absent Normal “Pressure passive” Cerebral blood flow (ml/100g/min) 50 0 50 100 150 Mean arterial pressure (mmHg)

11. Hemodynamic goals Kilgannon. Crit Care Med, 2014 MAP > 80 mmHg Beylin. Int Care Med, 2013

12. Ventilation and oxygenation

13. Brain tissue hypoxia is bad and common • O2 delivery/diffusion impaired • Perivascular edema Menon. Crit Care Med, 2004

14. Is hyperoxia bad? • Drives oxidative injury, ROS generation, etc • Hyperoxia is common • Some OBSERVATIONAL data associate extreme hyperoxia with worse outcomes Kilgannon. JAMA, 2010

15. Oxygenation goals • Measure PaO2 • In vivo PaO2 5 mmHg lower per 1oC • Normoxia(PaO2 100-200) • Significant hyperoxia is (probably) bad and frequent • Brain tissue hypoxia is (probably) bad and often quite severe

16. Carbon dioxide goals • PaCO2 40mmHg (temp corrected)

17. Carbon dioxide goals • PaCO2 40mmHg (temp corrected) • Observational data Schneider. Resus, 2013 Roberts. Circ, 2013

18. Temperature management

20. HACA. NEJM, 2002 Bernard. NEJM, 2002

21. 950 patients, 36 ICUs in Europe and Australia • GCS <8 after OHCA due to “presumed cardiac” etiology, regardless of rhythm (except exclude unwitnessedasystolic arrests)

22. Nielsen. NEJM, 2013.

23. Temps in RCTs

24. Outcomes in RCTs • TTM results in good outcomes (50-60% survival) 32- 34ºC 36ºC 33ºC 33ºC 37ºC 37ºC

25. What does the data tell us? • TTM is another way of performing temperature management • Anywhere 33 deg– 36 deg C is reasonable • DOING NOTHING IS NOT AN OPTION!

26. Tertiary care

27. Systems of Care A comprehensive, structured, multidisciplinary system of care should be implemented in a consistent manner for the treatment of post–cardiac arrest patients (Class I, LOE B). AHA Guidelines 2010

28. Volume matters Callaway. Resuscitation, 2013

29. Volume ~ Survival Hospitals treat an average of 17 / year Callaway. Resuscitation,2013

30. Tertiary center effect • Survival different for first 5 days • More intensive cardiac AND ICU interventions Søholm. CircCardiovascQual Outcomes, 2015

31. Tertiary centers in CA • N=7,725 OOHCA cases adjusted for all covariates • OR (good neurological recovery) compared to non-STEMI center at • STEMI center (>40 cases/yr) 1.32 (1.06-1.64) • STEMI center (<40 cases/yr) 1.63 (1.35-1.97) Mumma. Am Heart J, 2015

32. Pittsburgh outcomes N=987 persons discharged from 7 hospitals. Link to National Death Index to determine survival time. Center 1 has a dedicated post-arrest service line with >250 patients per year

33. Cardiac catheterization

34. Non ST Elevation 60% survival; 86% with favorable neurological function Kern. JACC, 2012

35. Reynolds. Resuscitation, 2014

36. Delayed neuroprognostication

37. Time to awakening Grossestreuer. Resuscitation, 2013

38. Why do patients die after CA? • 2,137 non-survivors after OHCA • Largest cause of in-hospital death was WLST for “neurological” reasons (61.2%) Callaway. Resuscitation, 2014

39. When do patients die? • 151 ROC research hospitals across North America Elmer. Resuscitation, 2016

40. Prognostication Delay neuro-prognostication for 72 hours

41. Post-discharge planning

42. Anxiety and depression Anxiety in 24% of survivors Depression in 13%

43. Cognitive Function Cognitive dysfunction in 50%

44. Long term function Modified Rankin Scale Reintegration to Normal Living Index Cerebral Performance Category Raina. Biomed Research International, 2015

45. Summary of in-hospital care • BP • MAP > 80 • Vent • PaCO2 ~ 40 • Normoxia (PaO2 100-200) • TTM • 33-36 deg C for 24 hr • Tertiary center • Cardiac catheterization “early” • Delay neuroprognostication > 72 hrs • Functional recovery takes 12 months • Watch for depression / anxiety / cognitive deficits