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

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 Herlitz, 2006
% 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 50
100
150
Mean arterial pressure (mmHg)

11. Hemodynamic goals MAP > 80 mmHg Kilgannon. Crit Care Med, 2014
We aim for MAP > 80
A caveat – BP DOES NOT EQUAL PERFUSION
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
Exposure
Adjusted OR
(95% CI)
Arterial oxygen (per hour)
Severe hyperoxia (>300mmHg)
0.83 (0.72 – 0.98)
Moderate hyperoxia ( mmHg)
1.01 (0.96 – 1.05)
Normoxia (60-100mmHg)
1.01 (0.97 – 1.06)
Hypoxia (<60mmHg)
0.74 (0.47 – 1.16)
Drives oxidative injury, ROS generation, etc
Hyperoxia is common
Some OBSERVATIONAL data associate extreme hyperoxia with worse outcomes
Adjusted for arrest rhythm, location, hypothermia, Pittsburgh Cardiac Arrest Category, cumulative vasopressor index, time to first vent wean, number of vent weans in 24h, mean glucose
Kilgannon. JAMA, 2010

15. Oxygenation goals Measure PaO2 Normoxia (PaO2 100-200)
In vivo PaO2 5 mmHg lower per 1oC
Normoxia (PaO )
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. 6.4 4.5 7.0 HACA. NEJM, 2002 Bernard. NEJM, 2002 Hypotherm (%)
Normotherm (%) RR
[95% CI]
P value
NNT
Favorable neurologic recovery at discharge
HACA
75/136
(55%)
54/137
(39%)
1.40
[ ]
0.006
6.4
Bernard
21/43
(49%)
9/34
(26%)
2.65
[ ]
0.046
4.5
Favorable neurologic recovery at 6 months
71/136
(52%)
50/137
(36%)
1.44
[ ]
0.009
7.0
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 unwitnessed asystolic arrests)

22. Nielsen. NEJM, 2013.

23. Temps in RCTs

24. Outcomes in RCTs TTM results in good outcomes (50-60% survival) 32-

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!
There may be subgroups that benefit from more aggressive management – more research is needed

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 27

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
Norwegian study
2 Tertiary “Heart” Hospitals
6 Other “non-Heart Hospitals
N=1393 Cardiac Arrest with No STE
(STEMI automatically goes to heart center)
Søholm. Circ Cardiovasc Qual 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 ( )
STEMI center (<40 cases/yr) 1.63 ( )
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
151 ROC research hospitals across North America

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 Raina. Biomed Research International, 2015
Cerebral Performance Category
Modified Rankin
Scale
Reintegration to Normal Living Index
Recovery continues for up to 12 months
Raina. Biomed Research International, 2015

45. Summary of in-hospital careBP
MAP > 80
Vent
PaCO2 ~ 40
Normoxia (PaO )
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