Transcript Video Targeted Temperature Management for Cardiology Practitioners My name is Paul Fiorilli. I'm an interventional cardiologist at the University of Pennsylvania. Today I have the honor of introducing dr carl kern. Dr kern is a professor of medicine at the University of Arizona, where he served as the chair of cardiovascular medicine, corn is the co director of the Sarver Heart Center at the University of Arizona. He graduated from Brigham Young University and subsequently Hahnemann Medical College, where he graduated with honors. He completed his cardiology fellowship at the University of Arizona and he is a member of numerous professional organizations in cardiology and received countless teaching awards throughout his career. Dr. is an active interventional cardiologist and has been named one of the best doctors in America since 1996. A mere 25 years. He tells high level leadership positions within the american college of Cardiology and the American Heart Association And oversaw the publication of the guidelines for CPR and emergency cardiovascular care. In 2000, His research interests have centered on cardiopulmonary resuscitation and he has been an active investigator of CPR since 1983. It has over 275 publications, with the majority of them in the field of resuscitation science. Dr kern has won several lifetime achievement awards in the arena of resuscitation science and recently received the prestigious 2019 complex cardiovascular method of therapeutics. Lifetime career achievement award for his work on PC. I after cardiac arrest. It is my distinguished honor today to welcome dr carl corn. I would like to address the topic of targeted temperature management, specifically for cardiologist or those who practice whether nurse practitioners or other physician extenders dealing with the cardiology population. As mentioned, I'm dr kern from the University of Arizona and I've had a long standing interest in cardiac arrest and in the last two decades in the importance of post arrest care, specifically targeted temperature management combined with PC for those adults who are successfully resuscitated from out of hospital cardiac arrest. My disclosures are shown here. I am on an educational advisory board for B and D. Well, why should cardiologist and those who care for cardiac patients even care about cardiac arrest? I think these two photos really show how it begins and where it goes. So for the out of hospital cardiac arrest population, bystander help is still critical and a quick response from professionals. As you see here, paramedics or M. S. Personnel on the scene doing their best to quickly restore spontaneous circulation. But what happens to that patient after their successful they have a pulse and hopefully even a decent blood pressure. As they arrive at the hospital, there's a whole new group that now are assuming more and more care for these patients. That's specifically the cardiology groups. Certainly they'll go through the emergency room and those specialists will help stabilize them. But ultimately, cardiology has a great role to play in establishing the ideology of the arrest and treating its immediate cause. Typically an acute coronary syndrome problem. I believe cardiac arrest is actually called cardiac arrest because it's a cardiac issue. We all understand that major effects happen for both the brain and the heart when blood flow is disturbed by cardiac arrest and basically ceases the most effective post event strategies to date are these two outlined on this slide, targeted temperature management, an early re perfusion for those who have an acute coronary problems. And I'll cover both of those today. This era really started in 2002 with the publication of these two randomized clinical trials of out of hospital cardiac arrest, treated after resuscitation with hypothermia or what we now term targeted temperature management. Both of these, published in the New England Journal in February 2002 were relatively small studies, the one about 240 patients, the other less than 100 but both found a positive effect, albeit slightly different. I'll review those in general as we go forward, But this is one typical slide in the first article, the Haka group or the hypothermia for cardiac arrest performed in europe. As you can see here, overall survival was statistically better when such patients were treated with hypothermia upon arrival at the hospital than those who were not treated or left to be normal. Thermic. The next major step forward was about a decade later. Again, a european trial this time, much bigger the TT. M trial 1000 patients this time not randomized to hypothermia or targeted temperature management versus no such treatment, but rather to different target temperatures 33 C versus 36 in this case again, Wonderful survival rates for this group around 50-55%. But no difference whether you cool to 33 Or 2 36. About a month later published in Jama was this Randomized clinical trial of about 500 patients from the university of Washington in Seattle. This group has been obviously very active for decades. These investigators, plus even there for bears have done great things for the field of resuscitation science. This was a trial in the Seattle area of beginning mild hypothermia or targeted temperature management in the field by administering intravenous, ice cold saline versus beginning that cooling process once they arrived at the hospital by whatever means was selected. Yeah, as you can see once again, there was no difference between starting in the field or starting at the hospital, But both resulted in excellent survival rates of over 60% in the ventricular fibrillation population. They actually treated a subgroup with non shock kable rhythms and again found no difference whether you started in the field or wait until the hospital. But if if you understand that typically Non VF patients have about a 5% survival rate, you can see that both groups achieved Twice or even three times that. Well, here's a summary slide that I've adapted from a original slide of Bene Bella, a emergency room physician and expert in the hypothermia and cardiac arrest at the University of Pennsylvania. Let me walk you through this because there's two things to learn here. Number one. Again, the red bars being obviously not cool, the blue bars being cooled and in a variety of ways to a variety of temperatures. The light blue, obviously to a lesser degree 36 degrees, the darker blue to 33 C In the Hawk. A trial the first one published in 2002 with a control group that was not cooled. You can see they found a significant difference in overall survival, 45% vs 59. It wasn't everybody survived who got cooled and everybody died who didn't get cooled. But there was a significant benefit from cooling. In that Trial of about 200 250 patients, The Bernard Group was much smaller, less than 100 patients. And they did not show an overall benefit for survival. But as I'll show you the next slide, they did show a neurologic benefit with more favorable neurologic status. After cooling the Tt M trial, as mentioned, tested two different temperatures, not treatment and no treatment, But 36 versus 33. And you can see again very equal groups at about 50, survival. And the kIM trial from Seattle 64 vs 63. But look at the red versus the blue regardless of what year or what study Using the two control groups that did not get cooled. The average Survival rate was somewhere between 35 and 45%. So the majority of those patients, we're not surviving in those who were randomized to cooling, whether it was in Hakka or Bernard, the Australian study or the TT M or the University of Washington study, all had survivals basically in the 50 to 60% range, a similar graft or schematic can be seen here for favourable neurologic outcome. In the Haka Group, a significant difference at the .009 level and in the Bernard group with the smaller patient size, a significant level Approximately less than .5. The Tt. M. And the kIM studies again, no difference but both equal numbers to the control to the treated group in the 2002 era. If not better, this analysis actually does so using the cerebral performance categories a commonly used scale for neurologic function after neurologic events, devastating neurological neurological events. In fact And it the scale is one is normal function to is moderate deficit, three is severe for his comatose and five is death. But in these studies, five included all this Clearly the majority of such deaths are neurologic but not all. And so I actually like to look at just the neurologic function of those who survived if in fact you don't survive. I think you're taken out of that dilemma. Did we do the right thing? Did we create a live heart or functional heart? But with such brain damage that the survival itself is questionable is a questionable value. And that's what this slide shows again. These are only those who survived but looks at the neurologic function of those survivors, not counting those who died. And you can see that there's actually no difference in the groups, but all of them that got treated have a survival, a favorable neurologic function in survivors Of between 93,- 100%. In other words, those who were treated who survived actually did very well neurologically. It's the very small minority who were left with significant deficits, particularly if you look at this type of data After 12 months post event. Well, all of that, with the exception of the kim who did have a subgroup of non shock cable was done in ventricular fibrillation. What we would consider the best possible rhythm for cardiac arrest whose patient prognosis patient population prognosis is substantially better than those with don chocola rhythms. But this is an interesting randomized clinical trial. Again, out of hospital cardiac arrest. Looking at that special subgroup of those without shock kable rhythms, who's prognosis is really much, much less. And using the same type of format. I've I put these three bars up To show that in this trial of about 500 patients all out of hospital arrest and resuscitated who were cooled or not cooled by randomization, no difference in outcome could be found 16.8 vs 18.7, but there was a significant difference in favorable neurologic function. Indeed, for the whole group, about six who were not treated, we're not cool, Had favorable neurologic function versus twice that, or 10.2%. And those who were actively treated if you look at the survival of favorite lodge favorable neurologic outcome and survivors, that turns out to be a third who don't get cooled. In other words, 2/3 have substantial challenges neurologically, vs 55% who were cool to have favorable or just under half. Uh a significant difference in that analysis as well. In summary in these randomized trials, Albeit with limited patients, some having as few as 80 others, as many as 1000 active temperature control or targeted temperature management was able to show favorable advantages, either survival or neurologic function in those survivors. A representative meta analysis of this work is shown here, published before, actually, the last study with a non chocolate group, but in 19 in 2016 shows very clearly that indeed combining this group of of studies and data that therapeutic hypothermia or targeted temperature management is associated with the survival and a neurologic or neuro protective benefit after cardiac arrest. Well, the other critical part of post arrest care is, in my opinion, as an interventional cardiologist, early coronary angiography and PC? Why would I say that? Because we've known for decades that out of hospital cardiac arrest in adults at least is a coronary artery problem. 70% of adult victims of out of hospital cardiac arrest have demonstrated coronary artery disease in ongoing and geographic studies in pathology or Or postmortem studies. It's even higher, probably 80-85 from that comes an interesting concept that being a culprit vessel, is there an acute coronary issue that's the likely cause of this unexpected, out of hospital devastating event cardiac arrest, the potential value is apparent for coronary angiography. If such is the case number one, you could identify that coronary lesion restore coronary flow through per cutaneous coronary intervention, thereby salvaging mile cardi. Um Just as you might for both stem me and non stem e unstable patients, you should be able to reduce rearrest of such patients by fixing their underlying problem. And we hope and though yet to be proven, is that you could improve human dynamics enough to even improve brain blood flow and thereby in some improve overall survival. We'll come back to this theory or concept with some real data as we go on. But let me back up just a little bit and talk about those who have S. T. Elevation. M. I. Is complicated by cardiac arrest. For many years, we were not quite sure what to do with this group for. We knew that their overall expected expected mortality rate was really quite different than those without cardiac arrest and just stemming. But here's an interesting study now, almost 15 years ago in the ICUs of Scandinavia, where they looked at aggressive versus nonaggressive therapies, post arrest, as you can see on the left side in the control period without any particular effort at early coronary angiography or opening vessels. Um, there was in fact An overall survival rate of only 26% at one year. In other words, even though these patients have been successfully resuscitated, brought to the hospital by one year later, their survival rate was terrible, 75% had died. Buy aggressively treating them post event, whether that was angiography, controlling getting them off the ventilator quickly or cooling them. Whatever entailed that doubled 1-year survival rate in this before and after studying well, here's an interesting cardia graham actually taken in a patient's home in Tucson Arizona a few years ago, Paramedics were called to that home in 2003 for chest pain. Upon arrival they found the individual on the front room floor without a pulse and without response. Quickly hooking up this three lead system, they were able to show a ventricular fibrillation as you would expect. They quickly applied there automatic external defibrillator and the shock was given. You can see the response. There's an agonal almost looks like a P. Wave but it's a very wide QRS response if there even related. But eventually given A few seconds or 20 seconds later we see this now a narrow complex what looks like a perf using rhythm. And then they applied a 12 lead. Here's that 12 lead in the home in real life situation, As evidenced by the fact that v. five fell off. We don't have the five on this E. K. G. And you can see in the anti R. Leads dramatic S. T. Elevation consistent with an anti virus. To me as the most likely cause of this out of hospital cardiac arrest. That day in this patient's home, this patient was taken to the hospital and quickly passed through the er directly to the Cath lab where an an initial angiogram showed this. This is an L. A. Codel view showing the left main there in the middle, the circum flex coming off normally to the right, a small little diagonal branch but no left anterior descending coronary artery flush included right off the left main, as would be expected by the S. T. Elevation. 12 lead into your stemming here is just a few minutes later having restored that left anterior descending with first a balloon and then a stint just like we would for any stem me only this time in a steamy post cardiac arrest. Well, with that example in mind, who should go to the cath lab post arrest. And it's very clear that those with stem E. Are now included in the current. Both european and american heart guidelines. An american College of Cardiology guidelines for the care of stemming patients. Let me show you another interesting piece from europe. As I put this whole puzzle together. So this was 2400 Stem Ease. The vast majority did not have a cardiac arrest. As you can see on the left hand side of the slide, 94% had no cardiac arrest went for primary angioplasty. Not as often as today as you can see, we're probably still doing some intravenous thermal isIS then, But their survival rate was 95% very similar to what we see today. However, there was 6% of this population who with their stem e had cardiac arrest. It's about 1/3 of those 135 patients we're conscious by the time they reach the hospital. In other words, there treatment of their cardiac arrest was so quick and so effective that by the time they got to the hospital they were already responsive and conscious notice that their outcomes are identical to those who had no cardiac arrest. In fact, in this small series, 100% were alive. Now obviously if you do enough, some of them will not be alive but clearly not different than the 95% in the non cardiac arrest majority. But look at the outcomes for those two thirds 86 patients out of these 135 who were comatose By arrival at the hospital, so they were not responsive, 70% had primary angioplasty, But only 50%, to be totally correct. Were alive to discharge a dramatic difference From the 95 or 100 if they had no arrest or were awake from their arrest when they arrived. Here's a just a summary slide of some, a number of papers over the last several decades of this population stem ease cardiac arrest. Gone to the Cath lab early with re perfusion and you can see that instead of having um 95% survival at least, it's up to 60%. And again, euro neurologic function among those who survived was really quite excellent, 86. Not much different than what we're now seeing in the randomized trials. Again, averaging about 90%. Well, what if you combine these two treatments? What if you cooled and treated aggressively with early kath and angioplasty? Those lucky enough to be resuscitated post cardiac arrest in the field? Mm. That's this series again a bunch of different papers. Most of them not all of these in fact non randomised before and after experiences. But of these 4500 patients, you can see that again, 60% survived With good neurologic function somewhere between 85 and 86%. This is what I called Just a few years ago. The 60 90 club. Although non randomized data with all the biases that come in. Those kind of studies, 60% survival up from the 25% in the old days where we did very little for these patients except put them in the hospital and let them either declare that they were going to get better or die Now. Up to 60%. And of those who do survive excellent rates of good neurologic function going forward. That's been translated even before. Much of the randomized data to these guidelines. These are the ones from the American College of Cardiology. Mhm. That indeed for those who have a stem e combined with out of hospital cardiac arrest, that targeted temperature management should be started as soon as possible for those who remain comatose on arrival, at least for those in VF or pulseless VT. And again, I believe now that there's some supportive data to extend that to even the non shaka balls, realizing that their overall survival rate will be much less than the population with ventricular fibrillation. And second that immediate angiography and PC I when it's indicated by the and geographic findings should be performed in those resuscitated from out of hospital cardiac arrest who's E. C. G. Shows S. T. Elevation. This was given a Class one recommendation for both of these treatments. Meaning truthfully you should do this because the benefit clearly outweighs the risk. Another way to look at it is If it's class one and you don't do it, you should be able to explain in a logical fashion why you opted not to do it. Same exact data and conclusions though, in a different format by the european Society of Cardiology, a class one for the use of therapeutic hypothermia or again, what we now term targeted temperature management and for immediate angiography two with the eye towards doing primary PC. For those with an acutely included major coronary vessel. Well, what's the cost of following these guidelines to both cool and cast such patients with cardiac arrest and stemming. And there is a cost. Unfortunately, that cost is often in the public reporting statistics that have now become common as a way to let the public know who's doing a good job and who's not. Yeah, This was a paper that I was privileged to be part of back in 2013 simply looking at this concept and we didn't have a whole lot of data yet. But here's what we certainly emphasized the expected mortality rate for S. T. Elevation. Am I? Without cardiac arrest, as we've stated, is four or 5%. That in the best of hands Rises to 40 or 50%. If that stem me is associated with a cardiac arrest, particularly out of hospital cardiac arrest, that's a tenfold increase. And this is what happens to your centers mortality statistics for stem me when they're counted together, which they have been routinely in the past. If you did just let's say you do 100 cases a year of stemming and you did 10 that had associated out of hospital cardiac arrest with the increased 10 Fold mortality. Of those 10. instead of having a site mortality of 5%, the expected Your site mortality would be 9-10 a doubling. That has been a real challenge for some high volume centers and frankly, is the exact opposite of what we hope to accomplish. Indeed, those centers who are brave enough to do this, which clearly helps the cardiac arrest population, could be penalized, at least in public perception and in public reporting because of their willingness to take care of such patients. So the bottom line in that paper was that we believe this is not the right way to do it, that it is important to track outcomes. But frankly, out of hospital stemming out of hospital cardiac arrest, Emmy and stem me without cardiac arrest should be tracked separately and reported separately. Finally, we've seen some traction in the last couple years up until 2018. This is an example of the database From the American College of Cardiology, which is probably used 90% of the time for such statistics Had only one question About cardiac arrest. And as you can see at the bottom here, it was, was cardiac arrest? Did it occur within the last 24 hours? Yes or no. That was the only day to gather. But in 2018, the most current version of the cath PC registry of the American College of Cardiology Added 20 questions for a total of 21 around the circumstances of cardiac arrest. Did it occur? Was it witnessed what was the time of arrival for ims what was the first cardiac arrest rhythm? Did it occur at another facility? Was there a transfer of this patient where they initially resuscitated? Did were they treated with targeted temperature management? To what temperature and so on? A great improvement In my opinion of gathering the data? The hope now is that such data will legitimately be used to report outcomes separately for this special subgroup with a much higher expected mortality than the standard stem E patient that has not yet been done. I'm aware of several groups who are currently working on that question, but we haven't seen those publications yet. Well, what about those who were not lucky enough to have S. T. Elevation? And I say that tongue in cheek because indeed, if you have a cardiac arrest and don't have S. T. Elevation, there is not a class one recommendation that you should go for any of these treatment. Let me tell you one more antidote if I could. This is a patient of mine a few years ago, 40 year old male at the time, very athletic swim in a master swimming program after his general workout which he did daily except on Sundays. He collapsed in the shower with cardiac arrest. He received chest compression only BLS almost immediately and Eddie was found although it took a few minutes to find it brought to the patient and he was given to shock simultaneous to all this. M. S. Was notified. 911 called and they arrived just after the second shock provided by the bystanders with the patient still comatose. It was a two minute ambulance ride to our hospital, the University of Arizona hospital there on campus and this was the first 12 lead E. K. G. taken in the emergency room. As you can see their sinus tack a Kardian and there's some non specific S. T. Changes, a little bit of depression maybe albeit upslope. And some. Yeah but nothing dramatic Certainly be 1234 and five. Look normal. But having been called to the emergency room for this patient I wondered how could this young man, middle aged man if you will. He's so active. Have a unexpected cardiac arrest with his usual workout. I wasn't sure that this E. K. G. Told the whole story so I elected back then in 2000 and 76 to take this individual to the catholic. We began to cool him in the emergency room and then did a stat echocardiogram showing decreased anti R. While motion and then went to the catholic. This is the first shot. I know this is dark, that's why I put the blue harrow. But this is the left main. You can see the puff of die in the coronary sinus and the cusp. And the left main is cut off within one cm of its origin from the left man. The L. E. D. The circum flexes there, but again, without any evidence of an anti R. Stem me. Within a few minutes of appropriate treatment that lady was reconstituted stinted and here you can see it flowing all the way to the apex. Well an echo the next day showed global hypothesis with an f of only 20%. The good news was this was stunning. A global phenomenon seen with cardiac arrest not infrequently. That can get better if the patient survives. We cooled, then re warmed this patient, he woke up and was completely normal discharge five days later and when he returned for a follow up appointment, a repeat echo showed it to be normal. I show this because this is public information. This is on the front page of the news newsweek in July 23, This is a patient of mine and it's actually a good friend of mine now brian Duffield and with his permission I tell his story over and over again. This is the exception, not the rule, but it happens enough that I believe that we need to strongly consider taking such patients even without S. T. Elevation early to the cath lab while we simultaneously cool them, just like we would a stem a patient. What are the guidelines say about that approach? Well they say this, it should be considered, obviously you don't have to do it. You you can consider doing it. It's given a to a recommendation in the Europeans and in the american heart and american College of Cardiology. So less emphatic, but at least consider it. Well since those guidelines in 2013 and 15 there are two randomized trials of this approach. that it would be unfair if I didn't share with you realizing that this population without S. T. Elevation, post resuscitation from out of hospital cardiac arrest. All in these two studies got cooled or all participated in target temperature management. So this was really just a look at early cath versus no early cath for this population and we take you through just briefly as I finish up these two studies. The first was published in the New England Journal in 2019 in about March and were presented at the American College of Cardiology meeting that March. This is from europe coronary angiography after cardiac arrest without S. T. Elevation and called the Co act trial. This was a large trial of about 540 patients randomized either immediate angiography or delayed angiography. This population in this study At the primary endpoint was 90 day survival. There was no difference in that survival, 67% versus 65 and both as as I'd hoped to have shown, you would be excellent survivals for out of hospital cardiac arrest. The interesting feature was in the previous non randomised work we had seen in most of those registry reports, with all the bias that can be introduced there. About a third of those patients without S. T. Elevation had a culprit lesion that was acutely occluded in this case. In the european study, they found that was very infrequent. In fact only about 3%. Indeed, that turns out to be one out of 29 patients that you take to the Catholic. It seems logical that if that's all the acute inclusions there are to save and reopen that it would be unlikely to show a benefit from early angiography or even perhaps late angiography and that's what they showed. I was the P. I. Of a smaller study that we just published in cirque. Um This last november presented at the american heart meetings called the Pearl Trial. Very similar design. Out of hospital cardiac arrest, resuscitated, brought to the hospital comatose without any S. T. Elevation on their E. K. G. We did the same. We randomized that population too early angiography or no such early angiography, but 85-90% of them received target temperature management. In our case, we included non shock herbal rhythms in the Co Act. They did not, My study was much smaller, about 50 patients in each arm. We also could not show a survival benefit. Not surprising with the small numbers, this was clearly an underpowered um study for that endpoint, but what we did find was a much more common culprit, vessel and acutely included culprit in those who went early to angiography In this case. In fact 14 are almost 15% of the population undergoing early calf had an acutely included culprit. Some minority for sure. It's not, it's but I think not an insignificant minority who deserve to be considered for early cath to re perf use them on a timely basis while they're still muscle to be saved. This is simply an example of such a patient without any S. T. Elevation, just like brian this time the search and who was, that was not apparent By the 12 ft but was very apparent by angiography. If it's 15% of the time, that's one out of seven Instead of one out of 29, it's still not the vast majority. But again, I believe an important minority. Mhm. Yeah. So what do we do with patients who in fact are successful resuscitated brought to the hospital and either have a stemming or don't. It's pretty easy if they have stem me of it Elevation, they should be treated aggressively. No question. Class one recommendation on both sides of the Atlantic. They should be cooled and they should be careful. And I believe immediately the good news is that these, this can be done simultaneously. There's no reason you have to do this sequentially. You can start that cooling process in the emergency room and continue right in the cath lab. It's not so easy if you use the old fashioned ice packs, it takes some real experience to know when to remove them and when to put more on. But it can be done. There are other systems, both non invasive and invasive, that can be used. And in fact, many of those devices, either or either radio lucents so you can see through the pads or in fact they're a catheter base that put in while you're in the cath lab into the in beer inferior vena cava. As shown here, you can even prepare knowing the patients coming from the M. S. Call by placing such pads and being ready to as you put the patient right on the table start that process likewise that most have found. You can put a catheter based system in in the E. D. But if you're going early to the cath lab it's much easier under floor. It literally takes minutes to put such a system in the inferior vena cava. Well let me just say if you have the right tools and I show this because I'm an avid fly fisherman and I simply get snowed on occasionally. Yellowstone. You can still get the job done if you do it simultaneously. That's why I'm a big fan of cooling and Kathleen together to help these unfortunate victims of sudden cardiac death who are lucky enough to be resuscitated and now need further care. In conclusion, let me just summarize, I believe that target temperature management after cardiac arrest is still a very important post resuscitation step. There is randomized data showing survival benefits as well as neurologic or brain benefits. Both the european Society of Cardiology and the American College of Cardiology have recommended This as a class one recommendation, meaning you should consider it strongly and you should do it. There's now data for both. Shock, double non shock will rhythms that benefit and they can be done simultaneously. I think that's the right thing for this right population. And hopefully as we go forward we'll even get more data about what to do for those without S. T. Elevation. Thank you very much. It's been a real pleasure. Thank you so much, Doctor Kern for that fantastic presentation for those who don't know me. My name is Dr Benjamin Abella. I'm an emergency physician at the university of pennsylvania where I lead a team that's very much focused on cardiac arrest in post arrest care. No dr kern. We've known each other for some time and I always enjoy your lectures. Hope you don't mind if I ask a few questions. First off I'm curious and I'm sure some of the listeners are as well. What is the alert process like in your facility for patients who come in after cardiac arrest or are resuscitated? Who have a stem mean? And how do the emergency department, how do they collaborate with cardiologists to get steamy patients to the lab or at least make the decision about whether they need the lab. If you can tell us a little bit about that process, actually have just combined it with our stem the notification alert system. So if a patient comes in with the stem me, whether they had cardiac arrest or not, it's the same button, single page goes out and everybody responds the same. We've actually expanded that and we haven't really stopped it. Even with the newer data that may be it's not necessary to come in in the middle of the night for those without S. T. Elevation, we still actually notify the stem E. Team, the cardiology team on call because we're still strong believers that there's a benefit from early Cath, even if it's just to find those one out of seven with an acutely occluded vessel. You know what I didn't really emphasize, I should have is that though these two randomized trials, one in europe one here did not find a survival benefit for early cath for those without S. T. Elevation. They certainly didn't show any adverse increased events. So it's safe. In other words, you don't hurt the patient. And I believe again, if you could find that one out of 71 out of six that really does need that vessel reopened in a timely fashion, That's probably worth doing the other seven. And in truth you always learn something whether it's there in diastolic pressure well or even whatever. I just haven't seen a downside for Catherine people early if they've been lucky enough to be resuscitated. So that's still our approach. I wouldn't push than anybody else. I get it. There's randomized data suggests you could wait until the next day for those without SD, but I'm still worried about that one out of seven at least in my study. What we really need is another study because I'm not sure who's right are the Europeans right. It's one out of 28 or was my study right. It's actually four times that another question that comes up often relates to bradycardia after cardiac arrest. In your experience. How common is bradycardia? And what do you consider to Breda Kartik? What are the parameters that might govern whether you did something about it or have you just accepted it? And what are your perspectives about bradycardia during post arrest? Karen T. T. M. We typically say, you know it's all about symptoms. Now that's a little complicated. If the patient is comatose right, they can't tell you I'm feeling lightheaded. Um But we see everyone get a little break arctic. We've never seen one so far that we've had to pace. I would put the caveat to that though that if you had an inferior stem E and we're already having brady brady arrhythmias then I have a lower threshold and I wouldn't just sit tight. But I'll tell you for interiors They'll drop to the 50s, maybe even high 40's but they never get in trouble and it always gets better the minute you stop cooling. So it's it's almost the same as getting the benefit of a beta blocker early for preservation. In my opinion, Why would you want to disrupt that and raise their heart rate to 80 if their blood pressure and their profusion is okay. No if it's not then you know I get it. Some people with cardiogenic shock need more support might need a little higher heart rate. There's a statement coming out soon in a collaborative effort with the american heart and the Euro Critical care Society and we debated this back and forth because most of the cardiology world would want that to be on the lower side. So because we know that those hearts are stunned, they're bad, they're struggling to pump. And and that the neuro guys, they want 100 they want 90-100 mean arterial pressure for the brain profusion. So I don't know what the right answer is. And it all depends on who's in charge that day to be honest, not a very satisfying answer. But that's the reality of it. One issue that many providers worry about is this concept of cold diary sis or the fluid and electrolyte shifts that can occur during Tt. M. What are your thoughts about cold viruses? And what do you think is the ideal range for electrolytes and especially potassium, which is a big concern both hypo and hyper kelly mia uh concerned critical care providers quite a bit. So. So what's your take on cold diaries Is and how important is is again, I'm very cautious. So my advice to the house stuff is, you know, if it gets to 35 don't treat this 3433 because if you over treat it then you've got the opposite problem. This is a clear response to the cooling. And those potassium is pretty well normalize on their own with minimal replacement. So I don't mind some but I don't want them chasing and chasing and chasing this because that almost always leads to a worse problem with hyper Colombia. You know, the 1st 24 hours while you're being cooled. That's really almost a vacation time because those patients are usually quite stable when you start to rewarm people's where you begin to see a little more instability with their human dynamics, their rhythms and that's not when you want A potassium of seven. Thanks dr kern. You know, it's interesting at penn. We also certainly worry about called diaries is, in theory, I agree with you that it's not actually so clear that hypo colima is such a big deal. Of course hyper killing me is more so in our pen protocol. We check electrolytes every six hours and we do replete, although we tend to be much more tolerant of hype vocally miA, which is certainly much less of a life threat than severe hyper Colombia. And indeed, actually, in my experience of cooling patients, I don't see much of either. That is to say when there are abnormalities of potassium or any electrolyte, they tend to be relatively modest. Well, dr kern, one important question that I'm sure you get posed all the time and is a big issue across the world is what to do with patients post arrest. If they don't have clear evidence of stem E in and E C. G. We all know that stem E N N E C. G. Means you should probably go to the Cath lab. The bigger population of post arrest patients don't have Steny criterion. BCG. So I'm curious to your thoughts. What do you do with those patients? Do they go to the Cath lab? How do you decide and what should the timing be? Should they go early right away later? Um I know that's a lot of questions bundled into one, but this is I think one of the biggest topics for out of hospital cardiac arrest management, the relationship with the Cath lab. And then as a related point, if you delay the catholic, would you do cooling first or T. T. M before the cath lab or at the same time? Um And what kind of factors, both from the patient or the history might help you tip you one or the other about early versus delayed cath or Catherine? All, if I knew that, I would publish that too. But that is the debate. There's no question. That's why I showed the randomized data versus the non randomized data, but I think that becomes a very personal decision at each medical center. I'm obviously still a champion that it's better to go than not go. We put out recently an algorithm with the american College of Cardiology interventional subgroup to help guide the people in the particularly emergency medicine physicians With 10 bad prognostic signs. It's interesting, you know, they're not, it's not Hard to figure out, but if it took you 30 minutes to get your pulse back, you had a non shock more rhythm And you're greater than 85 years old. Those people do badly. And we actually just validated that there's a we've just published in Jack last month that we went, we took a database of post arrest patients Applied that algorithm to them to kind of find the cut point. How many of the 10 do you need before you really say I'm not going meaning if you don't have that number you should go. And it turned out it was six six out of 10 if you have more than that that the outcomes are so bad. It's not good resource utilization to go to the catholic. But frankly that means five or less. It might be unless it was the big three. The ones I just mentioned If you're really old, 85 or greater. If it took you 30 minutes to get the pulse back or greater and they had a non chocolate rhythm to start with going to the Cath lab Still didn't make a big difference. And only 7% of those patients were discharged home, you know, in that group I'd say fine, we're not gonna do it. But that's it's the million dollar question today. No question. Thanks for that answer. And you know at at penn, we struggle a lot with the issue of who and when should go to the Cath lab if they don't have a steamy in any CG. What we found is given that there's not great evidence. It means that often cardiologists have their own individual opinions and and and we know that some have a much lower threshold to consider cardiac cath and some are very resistant to doing it and with good reason these are critically ill patients and they worry about outcomes. So, so I think this is an area that clearly needs more research to help define criteria for cath lab activation because I think it is clear and certainly in our hands, we've seen that some patients really do benefit from going to the Cath lab after resuscitation and probably more patients than we even recognize. Thank you for joining us today for this important topic of how to manage patients after cardiac arrest. I am sure that dr kern and I both agree that it's so important for all of you listening to be champions for cardiac arrest care and to advocate for this is an important therapy and for the fact that patients can survive and can do well after cardiac arrest. One of the things we've started at Penn is a program called the T T. M Academy to promote education on these topics. You can check out our website at Penn. T t M dot com and also we have podcast available on itunes under T TM Academy. I think this whole area of post cardiac arrest care and TPM implementation is so important. There is strong evidence, there's randomized trials, there's guidelines. What we really now need is better implementation and better education. And so I'm very glad that you did your part today by joining for this lecture. Created by
