Cardiac Arrest, Hypothermia and Resuscitation Science

Lecture 4: The future of cardiac arrest care

David F. Gaieski, MD
Clinical Director Center for Resuscitation Science Department of Emergency Medicine University of Pennsylvania

An introductory course for the educated lay public and health care providers

Coursera July 2012

JAMA 2002, Weisfeldt & Becker

Resuscitation After Cardiac Arrest A 3-Phase Time-Sensitive Model

0-4 min

4-10 min

> 10 min

Electrical Phase of VF
Defibrillation

Circulatory Phase
Compression Defibrillation

Metabolic Phase
Hypothermia Other Therapies ECPB

100 80 60 40 20 0 1 2 3 4 5 6

Is the best treatment for VF here the same as here?

9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

Electrical Phase

3 Phases of Cardiac Arrest

Electrical Phase of VF
Defibrillation

Circulatory Phase
Compression Defibrillation

Metabolic Phase
New therapy

AEDs

Casino Study: Survival--Time is of the Essence

Trained Security Officers in AEDs 105 patients, VF arrest 92 witnessed arrests Average time, collapse to shock: 4.4 minutes

Valenzuela et al. NEJM, 2000

Casino Study: Results

80% 70% 74%

60%
50% 40% 30% 20% 10% 0%

49%

All survivors neurologically intact

< 3 min >3 min

Survival to Hospital Discharge

Valenzuela et al. NEJM, 2000

Circulatory Phase

CPR Prior to Defibrillation

Shock patients as soon as recognized Efficacy decreases with each passing minute Study of immediate shock vs. 3 minutes of chest compressions prior to shock 200 out-of-hospital cardiac arrest patients 3 minutes of chest compressions offered no advantage in outcomes for population as a whole But
Wik et al. JAMA, 2003

Wik > 5 min ambulance response

89% of survivors good neurologic outcome

Wik et al. JAMA, 2003

Early Injury Mitochondrial Dysfunction

Metabolic Phase

Late Injury Apoptosis

ATP Depletion
Ion Pump Dysfunction Calcium Influx Metabolic Acidosis Free Radical Production

Inflammation Permeability of the Blood Brain Barrier Endothelial Dysfunction Procoagulation

To summarize: 3 phases of arrest

Arrest!

SHOCK < 3 min: 74%

% Surviving

CPR

> 5 min, CPR 1st: 22%

34% Penn Pre-TH OHCA Data

ROSC

M
Time

Hospital d/c, 10%

Valenzuela et al. NEJM, 2000

To summarize: reperfusion injury

Damage observed after restoration of blood flow to ischemic tissues What is happening?
Cellular level injury Endothelial damage Mitochondrial dysfunction

% Surviving

34%

Hypothermia
19%
10%

Time
Vanden Hoek et al. AJP, 1996