Benjamin S. Abella, MD, Mphil, FACEP, and Mary Kay Bader, RN, MSN, CCNS, FNCS, FAHA, discuss the body of evidence surrounding TTM, then review the practical side of bedside care, describe new trends and present case studies.
Hello everyone. My name is Dr Benjamin Abella. I'm a faculty member at the University of pennsylvania where I'm an emergency physician there. And also the director of an entity called the Center for Substation Science which has been devoted to cardiac arrest and post arrest care for some 15 years now. I'm very proud to be sharing the stage here with my good friend and colleague mary Kay Bader who is a superb nursing educator and leader in the neuro critical care society. And we're gonna be talking to you today about one of our favorite topics which is how to think about post cardiac arrest care and specifically how to think about targeted temperature management or T. T. M. That is to say the use of cooling technology to improve care for patients after cardiac arrest. Mhm. Now if you want to follow me on twitter got some twitter handles, they're happy to interact if you have messages that you want to share or questions that you have after the talk. Now I'm giving this talk today as a paid consultant of B. D. Um however the opinions are mine and hopefully they will all be backed up as much as possible by science. But I'll be clear to share with you whenever I'm sharing something that is just my opinion alone and not necessarily backed by science. So we'll we'll try to be clear on that. It's also important to mention that I've received research funding from a number of entities but I have no stock or equity or company ownership and anything related to anything I'm going to be sharing with you today. Now I'd like to start off with a cardiac risk case an example of something that we all deal with on a regular basis. And I do this for several reasons. One is to remind us that it's all about the patients and we'll start and end with patient stories but also just to get us on the same page about what we're talking about when we talk about cardiac arrest because sometimes there's different viewpoints about what really is a typical cardiac recitation. So in this case we have a 57 year old male who's in cardiac arrest, they collapsed at home and in this case the patient's wife witnessed the arrest and performed Bystander CpR. So already this is good news in that whether an arrest is witnessed and whether bystander CPR is provided are two of the most important determinants of outcome from cardiac arrest. So this is the sort of patient that we now have a fighting chance as opposed to someone who has an unwitting arrest with no bystander Cpr there, it's possible to still get a return of spontaneous circulation and survival discharge but it's less probable. Alright, so the patient is found in ventricular fibrillation, a shock, herbal rhythm. They try to shock the patient doesn't work and they bring them to the emergency department. So already you have the sense that this patient down for a while here because they're down in the house there, down in transport. Now when they get to the E. D. They're still in ventricular fibrillation and after a period of time with a CLS delivery eventually we get their pulse back R. O. S. C. Return of spontaneous circulation. However the patient is comatose which is common for patients after cardiac arrest at this point the E. D. Does two things that are on sort of the key checklist of activities that should be done in the first hour for every patient after out of hospital cardiac arrest. One of them is an E. C. G. That actually usually comes first to evaluate for whether the patient's having a stem or not because that is a different trajectory, a different protocol and in this case the patient is not having a stem E. And also a head ct. Now there's a little confusion often about the head C. T. The main reason to get a head C. T. For out of hospital rest is actually the value for blood in the head. We don't know if the patient fell if they hit their head on the coffee table if they fell down the stairs and we don't want to be embarrassed several days later by missing a subdural. So in this case head CT is negative negative for stem E. And the patient is Miku bound. So this is a fairly typical vignette of a cardiac arrest patient. You've probably had cases like this. So and and someone like this really has a real fighting chance of survival. The shock double rhythm witnessed arrest and a person who is not particularly old now after resuscitation. The key issue of course is brain recovery. Uh, schema and re perfusion can often lead to brain injury, sometimes significant brain injury. And that's really what we're trying to avoid in a patient like this and for a number of years, the main therapy, the main conceptual modality to improve outcome from cardiac arrest is the use of targeted temperature management and it looks a little bit like this. You have a patient, this is just showing you bladder temperature and hours. You cool patient, keep them cool for a while and then rewarm them. So this is several day process usually starts in the emergency department and ends in the ICU. And the general notion here is that in the first few days there's a massive amount of inflammatory injury, mitochondrial injury, Other cell injury processes that cooling can mitigate cooling can minimize those injuries. And this has been very well established in the animal laboratory. And I'll show you some laboratory data a little bit later. Very little, I promise you. But one slide of of laboratory results. But suffice it to say this was well established in the lab and then it was brought to humans and in human trials from about 20 years ago and we go through this little quickly to get to the newer stuff. But I just wanted to share with you the foundational trials. So you knew where this all came from. These three studies here were all randomized trials that evaluated targeted temperature management at that time. It was called therapeutic hypothermia. So a little bit of a different terms to keep clear. But the idea was hypothermia to 33C. So we're not talking cold here, like freezing cold, 33 C is the target temperature that was well established. And you can see by looking at the red percentages that cooling 2 33 greatly improved neurologic outcome in all three of these studies. So it wasn't just survival. These studies scored neurologic recovery. So cerebral performance category of one or two. So people were walking and talking at discharge, which of course is our main goal. And you see all three studies supported the notion that cooling worked in the heck of study. They also looked six months later and they found indeed, if you made it to the hospital discharge walking and talking, you were alive at six months. This is of course an optimistic and hopeful note to strike here that if you can get people discharged in reasonable shape, they can actually do very well. And at Penn, we actually have an alumni club of many cardiac arrest survivors that we have followed for years. Our longest one is about 15 years out from his cardiac arrest. Can you imagine, you know, you're dead and you're alive for 15 more years. It's it's just a tremendous thing. And so this is something that gives us hope that we can do something for these patients. Now the three trials I shared with you looked at Shaka ble rhythms. It took a long time for the field to organize a randomized controlled trial to look at non shock kable rhythms of arrest. And there was a lot of controversy. Those of you have been in the field for some time about 10 years ago. The big debate was do we do this only for chocolate rhythms or what about non Chaka ble? Well, well this study took that out of the debate. This was a randomized trial. A big 1. 25. I see us in France where they cooled people either 33 or kept them normal thermic at 37 Celsius. And they did this for patients with non shock kable rhythms. So a sisterly or P. E. A. And just give you a little bit of a sense of their patients. The majority racist really. It's really remarkable to do a study of the sisterly patients, they tend to do very poorly and as you'll see overall survival was low. But the authors reasoned there's much to lose. But also much to gain. That is these people are really sick. So maybe they stand more to benefit from an aggressive therapy like T T. N. And indeed that's what was found. So the CPC one or two survival that is neurologically good survival was statistically significantly higher in the group that got cooled to 33. Now interestingly, survival didn't change. But neurologic recovery got better. Which is actually sort of the best thing you can hope for that is to say if you're neurologically devastated and you're going to die, the team will not save you. On the other hand, if you're going to live you will live better in your brain will recover better. So this was exciting because now the rhythm issue went away. We often wondered, oh they didn't write down the initial rhythm, was it shocking that non shackle now we don't care. And indeed the H. A. Guidelines which you know, get updated every five years, clearly indicated T. T. M. Was the right therapy for out of hospital cardiac arrest regardless of rhythm. Even suggested it might benefit some patients within hospital arrest. But that's a more complicated topic that we're going to mostly avoid today. Now one thing that happened in 2015, 20 though was they broadened the temperature recommendation. It used to be 32-34 and then they brought it up to 36 the question is why and we're going to get to that, it's because of this study here. This is at the time called the T T. M. Trial. Now it's known as the T T. M. One trial because there's a. T. T. M. Two and I'm gonna share with you that a little bit In the TT in one trial they did the following comparison. They compared 33 but not to know cooling. They compared it to temperature management at a different dose if you will. This is a dose finding trial. They compared 33 Celsius versus 36. Now why would you do this? Well it turns out patients after cardiac arrest. Get fevers very common and very difficult to control. These are neurogenesis. Fevers from brainstem dysfunction. These authors reasoned maybe the benefit of T. T. M. Is not the cooling but it's very careful avoidance of fever. And if you use the same technology to strictly avoid fever, maybe you get the same benefit without some of the side effects like shivering or bradycardia. But nonetheless they wondered if it was necessary and so they managed people at 33 or 36 to share with you a little bit of their patient cohorts. I show you here some characteristics note here that the bystander CpR rate was 73% and the witness rate was almost 90% 90% Witness arrest 73% by Senator CpR. And for those of you who are familiar with these kind of numbers, the lack date medium lacked. It was around 66 to 7 which is actually fairly low. So taken together. High rated by center cpr. High witness rest low lack date. These are not that sick of patients but we'll get to that As I said a little bit later when we try to interpret these trials. What they found was survival was the same at 36 or 37 which was a really big deal at the time. People were really befuddled by this result because so much science had supported 33. They wondered how this could be the case. It did definitely support that temperature management works but that fever avoidance may be a big part of why it works Now. These guys were not sad as guys and gals. These authors were not satisfied with stopping there and they did the TTM to trial and the team to trial. They said all right well 33 and 36 are equivalent. Now let's try 33 versus norma hermia. After all you could argue 36 is very mild hypothermia. Um so now they had a protocol where they said you have to keep the patients under 37 8, you have to keep them norma thermic you can do that with the device or not. Most of the people ended up getting device either way. Um but compared to 33 with out of hospital arrest and this is a really big study with a lot of patients. And what they found was when they looked at survival at six months or death at six months if you will the survival was the same. So once again they found in their two groups, it didn't matter whether you're cool or cut people normal thermic some people have used this trial to argue that we should no longer do t t m that it doesn't work. I'm going to share with you. Hopefully some reasons why I think that's premature and not quite accurate. It has to do with generalize ability of patients. And I mentioned to you how the Tt in one trial at a high rate of by center CpR and a high rate of witness to rest. Exactly the same thing here, 80% by center CpR four and five people got by center CpR. I don't have it on the on the slide here but 90% of people had witnessed arrests and the rate of shock was very low. So these patients once again like the T. DM one trial are just very well cared for. I mean I congratulate these authors and I would ask you in your hospitals what is your rate of bystander CpR what is your rate of witnessed arrest? What is your rate of post arrest shock and hypertension Because if it's if it's if I see CpR rates and witness arrest rates are not as high as this. I worry that we're misapplying data and we're gonna get into that in more detail and the way we're going to do that is to go through four lines of argument. One I'm going to share with you some of the laboratory science two. I'm going to just review the positive R. C. T. S. three. I'm going to share with you some of the real world experiences from hospitals that implemented changes based on those trials and see how they did. And then in the end we're going to try to synthesize this and bring it together to try to give you a path forward on how to think about different temperature targets. To try to figure out what is the magic number Now. First let's start with the animal data. This is laboratory data and and this is one slide I could show you 20 slides on this topic Because T. T. M. has been studied in the lab for literally 50 years at this point um countless studies have been done in different animal models dogs, pigs, mice, rats, cell cultures And it's amazing how consistent the literature has been in the vast majority of the studies. Not only did t tm work to lessen injury, it worked in a dose effect manner. That is to say the deeper you go the better the outcome the longer you cool the better the outcome. And there's very good sort of dozing trials at different temperatures and different durations. So the studies are really quite clear and I just show you three older examples just to give you a sense of how old the literature is on this now I mentioned that there's positive R. C. T. S. That show that cooling works. And so if you think about it, the T. T. M. One and two trials did not show that cooling was harmful. They showed it was neutral meaning cooling versus no cooling, no difference. So if you think about the overarching scoreboard of trials, you have three trials that show a benefit, no trials that show harm In two trials that are tied so 3-0-2. And then you have to think you have a patient in front of you whose family is saying, Hey guys can you do everything you can to save my loved one. You have some trials that show benefit, no trials showing harm. It makes it very hard for me to consider not offering this therapy. And here's the summary of all of the randomized trials in this field. So this is a good slide to sort of keep handy and you can see that some of the studies show benefit with cooling but some show no difference but nothing shows that it's worse. So anyway, so that that's sort of the summary of all the trials thus far. Now, the other line of evidence that we need to consider is real world experiences with the use of T. T. M. And as you may appreciate sometimes RCT conditions. That is to say what we do in a strictly controlled randomized trial with protocol adherence and people monitoring may be very different from what people experienced during clinical care in their hospitals. And this is one such example. This work from Janet bray an excellent nursing investigator and friend of mine in Melbourne Australia. She let her hospital in a study of just their outcomes from a switch. So they read the T. T. M. One trial, they said, hey let's switch to 36 it seems it's equivalent and we may get the same outcomes. And then they found unfortunately that it wasn't the case. So here you see 33 and 36, they first had 33 and then they switched to 36 and indeed their CPC one and two survival fell. So their outcomes got worse. With this switch, they switch back to 33 they're they're real believers now including 2 33 after this experience. But again shows that that the real world is different now. Was this because more people in the 36 group had fevers. Was this because sometimes some other aspect of protocol adherence wasn't as good or was it that the T. T. M. One trial just had less sick patients than they see in Melbourne Australia. And maybe the patients in Melbourne needed 33 Celsius. If you need another example, here's one from the United States, another cautionary tale of a real role experience. Um This is from a team at the university of Washington harborview where they also switched from 33 to 36 based on the team one trial and what do they find again a big drop in CPC one to survival. A 25% relative drop. That's a big change if you think about it. Um, but this is just another example of how the real world is different and they have also switched back now 2 33. Now in the big picture, this is a cycle that we see in so many fields of medicine where you start off having amazing results in some area, you think it's the best thing in this case T Tm for everyone, then you fall into despair. Oh, nothing works because some studies contrary to that. But then you sort of reached this reality of, well, life is complicated. Not every therapy works for everybody. There's no magic bullets here and and maybe it works for some and I'm now going to share with you some of the studies that show that the answer is probably this complex muddy answer, which of course is less pleasant but may just be the reality. This is a study from Pittsburgh Clif Callaway colleagues where in their large hospital system, they had some teams that delivered care at 33 Celsius summer 36. So it's a natural experiment, but they looked based on injury severity and they used a scale that I won't bore you with, but they looked at increasing degrees of severity and what they fundamentally found was The less injured patients did better at 36, the more injured patients definitely did better at 33. This has a lot of reasonable consensus here sicker patients need more aggressive therapy. And in this case is what they found with T. T. M. So if these results are to be believed it's nice because it means the T. T. M. One and two trials are correct. The other trials are shared with you are correct. It just means they have different kinds of patients. Now if you need more examples of this to other studies here this out of Japan again they looked at stratify patients by their injury and they found that the moderately injured patients did better when they were managed at 33 versus higher temperature. A final example this very recently out of the Netherlands they stratified patients based on E. G. Which is kind of neat because it's real physiology here. And when they looked at the patients who had very little encephalopathy any E. G. Didn't matter at 33 or 36. Everyone did pretty well If they had moderate encephalopathy all of a sudden it mattered. And 33 was much better than 36. So three studies that to me say hey you know not so fast ditching T. T. M. They're definitely patients are sick enough that they need this therapy. So the issue really maybe one of generalize ability and I show you hear some of the statistics from the T T. M. To trial on the left and a number of United States studies and I'll focus on the ones on the far right columns. Because those are purely post arrest patient cohorts. So it's really apples to apples comparisons. And what you can see is that the bystander cpr witness rate is very different. The shock double rhythm rates very different and the survival rate is very different. So these are just very different patient populations. And I would ask you who are you taking care of? Because the patients I take care of don't look like T. T. M. Two. We do not have a high bystander witness rate. We do not have a behi bystander cpr rate. We do not have such a high survival or a high shock double rhythm. So I really worry about misapplying Swedish data to a U. S. Population uh inappropriately especially in light of those three trials looking at injury severity. Now there's another sort of key question that comes up that in a way relates to this issue of T. T. M. And whether it works or not. And that's when to start it. So as I see nurses, you know there's always this ongoing tension and debate with the D. O. Do we start T. Tm. In the E. D. Oh no wait till they get upstairs no certainty. D well this study sought to answer that question by looking at whether you needed to start it sooner. It looked at door to t T. M initiation time. So like door to balloon time. But T. T. M. Initiation time. And what they found was on the left is a history graham here of just how long it took people to cool. And some people got cooled in an hour or two. Someone took three or four hours. That's just real life. Um But when they ran the statistics they found it mattered survival was better if you got T. T. M. Start in the first two hours versus the next two hours versus the next two hours. So they sort of did in two hour blocks. Now this does two things. One it suggests that if a patient is going to be boarding for hours in the E. D. They really gonna start T. Tm. In the E. D. If you believe that the second important that tells me is if T. T. M. Didn't work it shouldn't matter how soon you get it started right? If it doesn't work and started early late it wouldn't matter the fact that they saw a very prominent survival benefit when I got out earlier. To me suggests that in this patient population it made a difference in outcome. Now another question of dose there's how quickly it takes to get started. Then there's also how long you use it. And and people have looked at this and this is the one study in the literature that's looked at duration and they looked at 24 versus 48 hours of cooling to see if you get a different benefit. And the reason for this study was a number of laboratory studies have suggested that longer cooling is better and that longer cooling increases survival, neurologic survival. And this makes sense because brain injury lingers for days and days following cardiac arrest. Well, they did not find a statistically significant difference, but there was a trend towards better survival. No longer cooling group. So I'm not here to tell you that you should call for 48 hours. 24 hours is still the standard T. T. M. Maintenance duration. However, this is still a very active area of investigation and there's a study underway in the United States right now called Ice Cap where a site for it. A number of you may have heard of this NIH funded trial where we're going to be looking at duration of T. T. M. To see if we see a signal for longer cooling benefit. I just want to close with something that's important for all of us, which is for the very first time. The Joint Commission is including post arrest care quality of care and standards and guidelines in their accreditation process. So this report came out this year on this last year. So it's important, you're aware of it. It's important that your hospital leadership is aware of it, that, you know, they've always had some level of resuscitation standards. But now, and this is the specific standards for post arrest care that they if they come by they may ask you what are your post arrest care protocols and doesn't follow the current science. Um So for example do you use T. T. M. And I think any hospital that doesn't use T. T. M. May get in a little bit of Joint Commission trouble. Um Now that doesn't mean you have to do it to 33 but you have to have a T. T. M. Protocol available because the evidence suggests that many people do need T. T. M. So it's important to know about the Joint Commission because we all have to be aware of what they're what they're talking about now to bridge the gap of all this science. I mean I've shared with you a lot of stuff today and this is a short talk. You can imagine there's a lot more where this came from. We haven't even talked about your uh prognostication or the cardiac cath lab. And so we've established a program at Penn called the T. T. M. Academy to try to bridge this gap. This implementation gap where there's so much science, so much to know but yet there's a lot of confusion out there and a lot of these topics by the way, full disclosure. I make no money from this. It is a semi program purely. Uh so there's free podcast there's courses that we run. I'll show on the next slide. You're welcome to click on that Q. R. Code or follow us on twitter. Um But one of our flagship things is twice a year we run a live course last few years sadly because of covid it's been video. We used to do it live in person. I hope to go back to that one day but for safety we're gonna do october 7th 2022. As a video is a zoom course. You're welcome to check it out. There's our website, the registration is not open yet but we hope to get it open in the next month or two. I think it's a really good experience. People who join really like it. We get very case based. We do table top exercises. We go through a lot of things like how to neuro prognosticate how to handle shivering. Um All these sorts of topics on on post arrest care. So you're welcome to join our last one. We actually did in april and it was it was a big success. So in summary hopefully I've left you with a couple of thoughts that cardiac arrest is not hopeless. That at the very least strict fear of avoidance is critical that for many patients especially more injured patients T. T. M. 2 33 is important. It's very likely that you need to start in your E. D. If boarding times are excessive. And then finally with joint commission taking a look at this, it's important to have shared conference of protocols and be ready to talk about QA processes for your post arrest patients. Now, I'd like to end on a story as well. Um First thanks to members of my team and you see the tall gentleman with the I don't know if that's corduroy or khaki pants, I guess his corduroy pants there with the strawberry brown hair. He has a cardiac arrest survivor. Um His name is Zach. He had a cardiac arrest in his twenties while riding his bike. Uh He got cooled. Kath has made a full recovery. Is now a father of three doing well and we encourage our survivors to join us for cpR training events for other speaking events because the stories they have are so compelling and so important. And again they center us and remind us that why we're here is to have more people like Zach back home with his family after surviving cardiac arrest and with that I will stop. Um Thanks for your time today and I'll turn it over to my colleague. Mary Kay Bader, thanks Ben. My name is mary Kay Bader. I'm the neuro critical care clinical in their special submission hospital And I'm presenting part two Bundling care and post cardiac arrest syndrome patients. These are my disclosures. The objectives for this segment is to relate the impact of cardiac arrest to post cardiac arrest syndrome, identify some critical time elements and interventions delivered by the team to manage post cardiac arrest syndrome and then construct bundles of care in managing post cardiac arrest syndrome based on the literature and optimizing care for the heart, the brain and the body. Post cardiac arrest syndrome is defined by Nolan as a unique and complex combination of path of physiological processes, including four key elements systemic ischemia, re perfusion injury, hypoxic brain injury, myocardial dysfunction and then considering the underlying ideology of the cardiac arrest. There are published guidelines on how to best manage post cardiac arrest syndrome, the american heart association and ilK or have come up with published guidelines on managing the patient. One spontaneous circulation has returned. And when we focus in on the patient population following cardiac arrest, there is sort of an abc routine to how we stabilize that patient. The algorithm on the left hand side talks about the airway, breathing circulation, priorities, all the other things that are happening with 12 kg, identifying a potential stem E patient. But then when we're doing our Glasgow coma score and realized that our patient is comatose and has not awoken after their cardiac arrest. Our priorities are going to focus on targeted temperature management, system support and neurologic care. The guidelines also give very specific recommendations related to early post resuscitation care. They provide guidelines for targeted temperature management as well as priorities with oxygenation and ventilation, blood pressure management and then other priorities related to glucose management whether or not prophylactic antibiotics are indicated. Um also the other use of other medications which may or may not be indicated following the arrest. More importantly, there are some very specific guidelines on the neurologic management of these patients, including e E G monitoring. Now in January 2022, the Joint Commission published a performance standard document that focused on the post cardiac arrest period of time and how care is delivered by the multidisciplinary team. Now the american Heart Association and E. C. C. Representatives had met with the Joint commission and discussed the priorities. They focused on the fact that many centers may not have comprehensive post cardiac arrest protocols that are based in the scientific evidence and so effective january one of this year, the Joint Commission published these performance standards. If you look at EPPC. The hospital implements processes for post resuscitation care and in these guidelines or standards, they say that the hospital develops and follows policies procedures or protocols based on current scientific literature for interdisciplinary post cardiac arrest care. So you may have a T. T. M. Guideline. But what this performance standard is asking is far more than T. T. M. It's looking at all the body systems and making sure that when reviewing the evidence, we have incorporated all the latest evidence based recommendation into our hospital based cardiac arrest protocol and E. P. Two states, the hospital develops and follows policies, procedures or protocols based on the current scientific literature to determine the neurologic prognosis for patients who remain comatose after cardiac arrest. Once again steering hospitals to look at the evidence and then construct in their protocol for post cardiac arrest care specific guidelines and interventions that help the team determine neuro prognostication standards that require hospitals to review all cardiac arrests in their center and also to look at certain factors. Did the hospital? Did the arrest occur outside of the ice? You what were the factors, Were there anything that contributed to that arrest? And then they also want to know about how effective was cpr how are we managing the post cardiac arrest patient? Did we get timeliness, good timing of care for the arrest and in the post resuscitation period. They're also asking us to collect outcomes on our patients who sustain in hospital cardiac arrest. At my hospital Mission Hospital in Mission Viejo California. I co chaired the resuscitation committee and we had a dialogue at the end of 2021 on how we're best going to meet these performance standards. So we decided to establish a post cardiac arrest project and we had physicians intensive ist cardiologists, neurologists, emergency department physicians leading advanced practice nurses from neuro critical care Critical care. We also engaged our epileptic ologists and neuro intensive ist and staff nurses from the cardiac intensive care unit, the surgical intensive care unit, the emergency department, our cardiac cath lab. We developed 23 PICO questions Reviewed 170 sources of evidence to come up with a guideline or protocol that would help us manage the post cardiac arrest patient. We put that into a comprehensive post cardiac arrest protocol. And what I'd like to do now is share with you some of the elements from the immediate stabilization through the entire how we're gonna manage the body systems. Our members of our team I'd like to recognize came from all the disciplines involved in post cardiac arrest care. And we had six or seven sub teams that looked at literature specific to that time period or that body system in the immediate stabilization period, which is the 1st 120 minutes after return of spontaneous circulation. We recognize that because of the period of ischemia that has occurred, there is this post cardiac arrest syndrome that occurs and that we have to focus in on optimizing cerebral perfusion pressure, managing oxygen and C. 02 levels controlling body temperature, detecting seizures and recognizing that we not only have the heart to take care of, we have the brain to take care of. So having a multidisciplinary team with expertise in cardiac arrest care is necessary. And then constructing a protocol based on the evidence will have shared agreement between all the practitioners. So we all know what the basic plan is for that post cardiac arrest care period. In the 1st 120 minutes after reviewing the literature, our team agreed on target goals for the emergency department oxygenation and ventilation. Spo2 goals of 92 to 98% P A. C. E. O. To between 35 45 P. 02 greater than 80. After reviewing the literature on blood pressure targets and looking at what produces optimal neurologic outcomes. Are teams selected a mean arterial pressure greater than 80 E. C. G. So having a comprehensive 12 lead E C. G within 10 minutes T T. M. So candidates who are comatose with meeting inclusion criteria would have their targeted temperature management instituted within 60 minutes of return of spontaneous circulation and then patients who have P. C. I. Candidates. So evidence of a stem E. Would be taken to the cath lab as rapidly as possible. So when the patients return to spontaneous circulation occurs, we have a quick airway breathing circulation and rhythm check. We're going to assess their neurologic deficit. If the Glasgow coma scores between three and eight we know that there's been a neuro hit. These patients are not responsive and that their brain has taken hits so they're probably going to benefit from some type of targeted temperature management intervention. We want to have our consults with our physician providers from pulmonary critical care cardiology neurology neuro critical care and hospitalists so that we can assess and manage the systems and also the providers are focusing in on a differential diagnosis. Work up In a reassessing airway breathing. We want to ensure. Is the patient intubated is their airway secured. The Glasgow Coma scores between three and 8. We have had perhaps using 100% F. I. 02 during resuscitation. We want to ensure that the resuscitation continues with tight trading down the F. I. 02 so that the patients not flooded with high amounts of oxygen which has been shown to be detrimental. We want to target the F. I. 02 based on the A V. G. Result and target are cEO to between a P A C. 02 or 35 to 45 vital signs, blood pressure assessment E. K. G rhythm, assessing for the potential stem E patient and whether they need to go to cath lab is all done in the next steps. We also are going to be looking at with the blood pressure. Do we have enough support intravenously? Are they are they have they had enough volume? Are they hypovolemic? Do we need to give them a fluid bolus? If their blood pressure is a little low, do they need any kind of baser pressure support to support their blood pressure drawing labs and doing diagnostic studies are very important in that initial resuscitation period. Okay Now I'm sure Dr. Abella has been talking about the ideal temperature for targeted temperature management and our team took a look at the literature and we found that perhaps the burden of injury is an important factor in determining whether, 33 37 wherever the choice of temperature is by the team, there should be some type of risk analysis. So if the patient's Glasgow coma score is between three and eight and perhaps 3456 pupils are not reactive. There was a long time before. Bystander CpR was started. The patient when the medics arrived. Perhaps a Sicilian or P. A. Where you think that there's been a greater burden of neurologic injury. Perhaps 33 is the better target versus 36. And so the literature out there does support targeting a specific temperature and then having the providers look at the inclusion and the exclusion criteria when deciding what the proper temperature is. So our team recommended A. T. T. M. At 33 degrees for comatose post cardiac arrest patients unless they're unable to tolerate cooling, then consider 36. So if we have a bleeding patient, perhaps a trauma patient, maybe a subarachnoid hemorrhage patient from aneurysm rupture that had a cardiac arrest 36 because there's active bleeding, maybe the better potential target. And we also consider the risk stratification to guide selection of optimal T. T. M. So, in doing our neurologic assessment, we've now screened them for targeted temperature management. We want to ensure that interventions are occurring rapidly. So T. T. M. Intervention in the emergency department ensuring the temperature probe isn't getting the device on the patient initiating adequate analgesia and sedation. So you can get to your target temperature rapidly. And we set that goal is four hours from the initiation of T. T. M. The decision to use ice saline will be done by the providers based on if there's any evidence of cardiogenic shock. Now other priorities in that immediate stabilization period include seizure monitoring initiated within 30 minutes. We have a rapid response E. G. System that we can put on prior to the full montage E. G. Getting a ct contrast the brain and consider any c spine injury. If there's evidence of trauma, the cardiac evaluation in the emergency department focuses on if it's if you're able to get a stat echo to look at how the heart walls the the how the cardiac status is and then the cardiologist determining is this patient a candidate for Pc. I now the patients who are 9 to 15 following their cardiac arrest. So they're GCS is one in which they're awake. They generally don't need to be intubated. We stabilized provide supplemental oxygen if they're 02 status below 92%. We're going to evaluate blood pressure E. K. G. And proceed on. Is it possible that they need? Are the s Temi patient? Do they need to go to the cath lab? So addressing all those priorities but you'll notice T. T. M. Is not within this area. Although we would encourage that normal ther mia be maintained because having fever after cardiac arrest especially when there's been a prolonged period of no circulation or limited circulation can certainly cause some injury. So we created a bundle for this 1st 120 minutes that prioritizes oxygenation, ventilation, cardiac and hemo dynamics consults metabolic arrangements T. T. M. Early cardiac intervention, neurologic care and then family and caregivers. And this slide shares What are the interventions, what our target goals are parameters as we're managing this patient in the emergency department or in that 1st 120 minutes after the arrest the critical care management phase. Once again we have as a team to come to agreement on how we're going to manage the systems the body systems. So when we look at pulmonary the ventilation and sedation, we have established our target goals for S. A. 02 and P. A. C. 02. We're going to use low volume ventilation strategies for optimized ventilation. And if we have to provide sedation, propofol is a short acting agent is ideal. Not remember if amiodarone uses in and you have a prolonged Q. T. You might need to choose midazolam fentaNYL is an ideal short term agent, short acting agent for analgesia. And instead of putting people on continuous neuro muscular, if there's uncontrolled shivering, if you're having problems getting down to your target temperature, then using an intermittent neuromuscular blocker would be better than doing a continuous when it comes to supporting the blood pressure. There's a lot of literature in the last five years that looks at optimal mean arterial pressure And from the evidence we reviewed. We came up with the target of a map greater than 80 and so reassessing with a cardiac Echo assessing the patient's fluid volume status and then the use of pressers may be necessary to reach your target but take into consideration if your patients got cardiogenic shock or other the heart's not working as well. The cardiologists and intensive to collaborate on where the ideal target for the blood pressure is. Now consider inserting polarity catheters to monitor effectiveness especially in patients who might be in cardiogenic shock. And then the use of mechanical assist devices may be needed, nutrition recommends recommendations early entrant nutrition if the patient is intubated and then optimize hemoglobin, dVt prophylaxis, no steroids, no antibiotics. The neuro assessment and the neuro monitoring. Care of the post cardiac arrest patient is very important. So your team needs to be assessing the neurologic status on a regular basis. We need to have strategies to reduce rebel edema and intracranial pressure. And we need to detect seizures if they are occurring which means early E. G. Monitoring. There are particular elements of your assessment that have been found in the literature, joke Aiden berg and panko. All make recommendations on clinical assessment documentation a level of consciousness, arouse ability awareness. Glasgow coma score assessment, pupil lama tree as an objective tool prefer people, dynamics, selected cranial nerves and motor response. The clinical management. We also can include non invasive monitors. So things like pupil mama tree near infrared spectroscopy E. G. Transcranial Doppler. And um if there are changes or significant changes in the normal values of these devices, you would want to report that to your provider keeping the head of bed at 30 to 45 degrees, keeping the neck midline uh and then administering medications as indicated there's a lot of street Galadima. Perhaps the provider may order some mannitol um if they're having seizures you might see some anti epileptic drugs ordered. Now the Occurrence of seizures in comatose, post cardiac arrest patients is significant. It's reported in 15-33% of post cardiac arrest patients because of that period where there's been depletion of ATP and insufficient energy. There is electrical systems that basically go haywire in the brain seizures can manifest itself in a convulsive state or it could be a non convulsive state meaning there E E. G. Demonstrates seizures but they aren't physically manifesting seizures and so we need to keep in mind that status and non convulsive status does happen in this population. The our awareness of non convulsive status, epileptic fits and seizures is rising quickly over the years. And there are recommendations by the neuro critical care society that E. G. Monitoring should be initiated within 15 to 60 minutes. Uh And the american heart association also recommends the continual assessment of E. E. G. And then the joint commission also recommends E. G. Monitoring as part of the multi modal neurologic prognostication that occurs by the providers 3 to 5 days after return of spontaneous circulation. So with E. E. G. And seizure monitoring the clinical team needs to be aware of the signs and symptoms. The neurologist neuro intensive ist the epileptic ologists will be monitoring the E. E. G. Looking for seizure activity and then ordering the appropriate medications as needed in your uh prognostication is an element that even in our own center we had never put down on paper. So when we reviewed the literature what was recommended as a multimodal approach, the clinical exam is paramount. Right so clinical exam is important. They recommend other modalities like S. S. C. P. S. E. E. G. Biomarkers such as neurons specific analysts and imaging C. T. And M. R. I. So we're not just making a decision based on one element but really looking at this patient from a multimodal perspective. And so in our protocol we have recommendations on putting on E. E. G. Monitoring within 30 to 60 minutes of return of spontaneous circulation and then as fast as we can getting the full montage E. E. G. Monitoring on the patient and then having your epileptic ologists neurologist neuro intensive ist monitor that E. G. Activity and when it comes to neuro prognostication. There are there's evidence and recommendations and literature that show what points to a more a poor neurologic outcome based on E. E. G. Now the critical care phase also has bundle elements oxygenation, ventilation, cardiac chemo dynamic optimization, T. T. M. Maintenance and re warm. So this is going to occur during the the critical care phase. So maintaining your target temperature for at least 24 hours. Uh making sure that the team is assessing and reassessing for shivering. Using the bedside shivering assessment score, maintaining electrolytes. And as you re warm, keeping in mind that the patients often Visa dilate their blood pressure may fall. They have electrolyte shifting So the potassium of three can become a potassium of 44.5 by the time you reach normal temperature the rewarming phase is a very vulnerable pay a phase for that patient. And we've often seen the emergence of seizures occurring during the re warm phase And then making sure that we have normal therm E. A. for 72 hours. Once we've got our patient back so continually to pay attention to where the temperature is and how the patient's reacting to their illness. Neurological care includes the neuro exam, pupil llama tree on an hourly basis uh measures to control I. C. P. E. G. Monitoring uh glycemic control. Remember that if you are doing T. Tm. Often their insulin resistant when they're cold and as they re warm they can have episodes of hypoglycemia. You want to be conducting the multimodal examined. Keeping in mind that neuro prognostication should not take place until 72 hours after they return to normal temperature. Or if you're not doing t T m 72 hours after return of spontaneous circulation. And don't forget shared decision making and supportive multidisciplinary team. So that interaction with the surrogate decision making makers is very important. The joint commission also has outlined certain performance metrics. So please keep this in mind. If you're looking for what data you should be collecting on all of your cardiac arrest patients, you want to be gathering this data on a constant basis and then reporting it to committees to see what opportunities for improvement may exist. Well, I'm happy to answer any questions in following this lecture. And if there is any information I can help new with, share my email. Bader. MK at AOL dot com is listed on this screen. Thank you for your time today.
