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Arrest
Case Presentation
ICU is consulted
Vital signs: HR – 112, RR – 6/poor effort, BP 65/40 (MAP
48), 36.5 Rectal Temp, Glucose 17.8, Sat’n 100%.
Volume resuscitate
Consider intropes/vasopressors
Treat for ACS
Noemie
Hypothermia
Ibrahim
Treat seizures
Increase cerebral metabolism
No Evidence for prophylaxis
Myoclonus
Clonazepam
Treat hyperglycemia
Adrenal dysfunction
Renal failure
Infection
More prone to aspiration pneumonia
Question 3
In-hospital VF Arrests
Small subset within HACA: favorable survival
Duration: 12-24 Hr
Coagulopathy
His wife has just arrived with his 3 kids (16, 15, and
9 years old). They want to know what his
prognosis is. What do you tell them and how do
you prognosticate patients post arrest? Please
discuss clinical and lab findings and imaging
modalities. Would things be looked at
differently if he was cooled? (Neil)
. What do you tell them and how
do you prognosticate patients
Timing
post arrest?
What is a “poor outcome”?
Prognostication
Clinical
EEG
Biomarkers
Imaging
Timing
Poor outcome is defined as death, unconsciousness after one month, or unconsciousness or severe disability after six months.
Clinical signs
Concerning features
Burst suppression
Nonreactive alpha and theta patterns
Generalized periodic complexes
SSEP’s
10%
5-10%
15 to 35%
Etiology of Sudden Cardiac
Death
Age < 20:
Myocarditis (22%), HCM (22%) and conduction
system abnormalities (13%)
Age 20-29:
CAD (24%), myocarditis (22%) and
HCM (13%).
Age 29-39:
CAD (58%), myocarditis (11%).
Am J Cardiol 1991;689(13):1388-1392
Should he go to the cath lab?
Yes
1994-1998
Lancet 2001
rt-PA vs placebo
Improved ROSC but no difference in 24HR survival or
survival to discharge
AJC 2006
No statistically significant benefit
Treatment recommendation:
“Fibrinolysis should be considered in adult patients with
cardiac arrest with proven or suspected pulmonary
embolism. There are insufficient data to support or refute the
routine use of fibrinolysis in cardiac arrest from other
causes.”
Question 6
Reversible causes:
Polymorphic VT/VF clearly due to ischemia that is amenable to
revascularization.
Polymorphic VT in the setting of reversible QT prolongation
Exceptions:
Wolff-Parkinson-White syndrome – tx is ablation
Fulminant myocarditis in which LVAD will be used as a bridge to recovery
Drug-induced arrhythmias
Electrolyte abnormalities (rarely an isolated cause however)
Epstein, AE, DiMarco, JP, Ellenbogen, KA, et al. ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities: a
report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Circulation 2008; 117:e350.
Question 8a: Are there any differences
between in-hospital and out-of-hospital
cardiac arrest?
VS
Differences between in-hospital
and out-of-hospital cardiac
Initial rhythm arrests
VT/VF is the first monitored rhythm in only 15-23% of in-
hospital cardiac arrests (IHCAs)
Sandroni C, et al. In-hospital cardiac arrest: incidence, prognosis and possible measures to improve survival. Intensive Care Medicine (2007)
33:237-245
Dichtwald S, et al. Improving the outcome of in-hospital cardiac arrest: the importance of being earnest. Seminars in Cardiothoracic and
Question 8b: What can be done to
improve the outcome of in hospital
cardiac arrest?
“Survival” post in-hospital
cardiac arrests
Between 25% and 67% of successfully resuscitated patients die within 24h of ROSC
Survival to discharge ranges from 0% to 28%%, with major studies reporting ~ 20% survival
to discharge rate.
Sandroni C, et al. In-hospital cardiac arrest: incidence, prognosis and possible measures to improve survival. Intensive Care Medicine (2007)
Strategies to improve outcomes
MET teams:
Sandroni C, et al. In-hospital cardiac arrest: incidence, prognosis and possible measures to improve survival. Intensive Care Medicine (2007)
Strategies to improve outcomes
DNR status:
Sandroni C, et al. In-hospital cardiac arrest: incidence, prognosis and possible measures to improve survival. Intensive Care Medicine (2007)
Strategies to improve outcomes
ACLS training
Sandroni C, et al. In-hospital cardiac arrest: incidence, prognosis and possible measures to improve survival. Intensive Care Medicine (2007)
33:237-245
Strategies to improve outcomes
CPR Adjuncts:
Dichtwald S, et al. Improving the outcome of in-hospital cardiac arrest: the importance of being earnest. Seminars in Cardiothoracic and
Vascular Anesthesia (2009) 13(1):19-30
Active
Compression/Decompression
CPR
Frascone RJ, et al. Combination of active compression decompression cardiopulmonary resuscitation and the inspiratory impedance threshold
device: state of the art. Curr Opin Crit Care.(2004): 10:193–201
Impedance threshold valve
Lurie K, Zielinski T, McKnite S, et al. Improving the efficiency of cardiopul- monary resuscitation with an inspiratory impedance threshold valve. Crit
Care Med 2000; 28:N207–N209.
Hemodynamic effects of
devices
Lurie K, Zielinski T, McKnite S, et al. Improving the efficiency of cardiopul- monary resuscitation with an inspiratory impedance threshold valve. Crit
Care Med 2000; 28:N207–N209.
Strategies to improve outcomes
Early defibrillation
Sandroni C, et al. In-hospital cardiac arrest: incidence, prognosis and possible measures to improve survival. Intensive Care Medicine (2007)
33:237-245
Strategies to improve outcomes
Post-resuscitation care
Therapeutic hypothermia
As opposed to out-of-hospital arrests, in-hospital
cardiac arrests are more often non-VT/VF.
Neurological injury less often a cause of death in
IHCA patients
Impact of therapeutic hypothermia may therefore
be reduced for in-hospital cardiac arrests
Sandroni C, et al. In-hospital cardiac arrest: incidence, prognosis and possible measures to improve survival. Intensive Care Medicine (2007)
The End