Podcast 114 – Post-Arrest Care in 2013 with Stephen Bernard – Part II

I’ve been waiting for this one for a long time. I get to interview Dr. Stephen Bernard on the topic of post-arrest care.

 

Professor Stephen Bernard
Stephen BernardSenior Intensivist, The Alfred Hospital
Professor Stephen Bernard is a senior Intensive Care Physician at the Alfred Hospital and Director of Intensive Care at Knox Private Hospital in Victoria, Australia. He is also Medical Advisor to Ambulance Victoria.

 

Last Week, I posted Part I of this interview on Post-Arrest Care 2013

This is Part II.

My discussion with Dr. Bernard was based on a talk he gave at the Australasian College for Emergency Medicine

Photo by Brian Burns

Photo by Brian Burns

MAP Goals

SBP of 120 mm hg? The paper was just published ahead-of-print

The other paper Dr. Bernard Mentioned is Gaieski et al. (Resuscitation 2007;73:29-39)

Sedate

If cooling to 36, it is a lot easier to get away with standard sedation practice as the hypothermia-slowed metabolism is no longer a big problem

Cath lab with ECMO or LUCAS2 for refractory arrest

It can be done! And if we can do it, is “stay-and-play” on scene still a good strategy?

CHEER trial (CPR, Hypothermia, ECMO and Early Reperfusion)

CHEER Trial Protocol

15 F arterial cath and a 17-19 F venous catheter under ultrasound guidance, with the only pause during compressions being the initial vessel puncture and 1st wire advancement

Intraarrest Hypothermia?

The animal data look good, but need human trials that show benefit. If you do it, then these patients may need a deeper degree of hypothermia (33 C?).

Prehospital Hypothermia and is Quicker Better?

Dr. Bernard’s trial did not show benefit for prehospital cooling (20679551)

and the in-press study by Kim et al. showed the same (24240712)

Play

Bibliography

You finished the 'cast,
Now get CME credit

Already an EMCrit CME Subscriber?
Click Here to Get CME Credit for the Episode


Not a subcriber yet? Why the heck not?
By subscribing, you can...

  • Get CME hours
  • Support the show
  • Write it off on your taxes or get reimbursed by your department

Sign Up Today!

.

Subscribe Now

If you enjoyed this post, you will almost certainly enjoy our others. Subscribe to our email list to keep informed on all of the ED Critical Care goodness.

This Post was by , MD, published 9 months ago. We never spam; we hate spammers! Spammers probably work for the Joint Commission.

Comments

  1. don zweig says:

    can one do a cath with lucas on the patient operating? wouldnt that get in the way of the flouro?

  2. Greg Kelly says:

    Hi Scott

    My apologies, this is the third time I am posting this as the criteria for prognostication got cut out of the last two posts. I’ve deleted possibly offending formatting in this one. Please delete the other two posts or people will think I am a broken record.

    Great podcast as usual. However there are two points regarding prognostication that I want to discuss – timing and necessary tests.

    Prior to therapeutic hypothermia this was an area of great clinical certainty (maybe the only one in medicine!) The American Academy of Neurology published a guideline in 2006 (Wijdicks, Neurology, also see Young NEJM 2009 which is almost identical) that stated that the following were 100% accurate (0% false positive rate) for bad outcome i.e. death, persistent vegetative state or need for 24 hour nursing care at 6 months:

    Myoclonic status epilepticus in first 24 hours post arrest
    Bilaterally absent n20 SSEP between 24 and 72 hours
    Greater than 72 hours: motor response nil or extensor (Glasgow motor score 1-2) or absent pupillary or corneal reflex.

    There are of course other factors that are very strongly associated with bad outcome (unwitnessed asystole, etc) but are not 100%. Likewise there are lots of patients with bad outcomes who don’t meet the above criteria.

    With the advent of hypothermia reports of good outcome in patients who had met these criteria emerged (e.g. Young NEJM 2009, Al Thenayan Neurology 2008) and so it seemed reasonable to wait for 72 hours after the patient was rewarmed, which is what the Nielsen protocol was based on. Nielsen had an added safety margin of requiring 2 factors (e.g. Glasgow Motor Score 1 or 2 AND bilateral absence of N20 SSEP.)

    Now that patients are not going to be cooled I believe that we can return to the established guidelines. We can prognosticate with certainty at least in the above situations, often earlier than the 5 days that you mention and we can do it with one test which might be a clinical exam. This is better both for families and for resource utilization.

    • Not sure we can say that Greg. Eelco’s paper was predicated on pts without targeted temp management. 36 is still mild hypothermia and the best evidence we have right now is the TTM Paper protocol. Would be easy for the authors to look at the 36 group retrospectively and compare the Wijdick’s recs vs. their own protocol to see if there is agreement. Worth an email to the authors by you.

  3. Ben Dowdy says:

    Man, now you folks are just coming up with reasons for us medics to not have any fun :)

    (I’m kidding.)

    Great topic to have listened to, especially since prehospital post-ROSC protocols tend to be a little generic (if the system even HAS one). I’m interested to see what impact PCI with ECMO/LUCAS will have, particularly for more rural EMS services. Traditionally, cardiac arrest has been a no-go for our airmedical folks….I wonder if some further development of who benefits most from the mCPR/PCI approach will change things.

  4. Brilliant series of podcasts, Scott.

    These have been particularly interesting for us pre-hospital folk and found myself thinking of several cases where transport under CPR to receive ECMO at ED may have made significant differences. I’m wondering if open cardiac surgery is something that is/could be undertaken with an appropriate history? The case I have in mind is a 16 y/o whom remained in PEA after non-traumatic catastrophic valve failure (history of valve defect).

    The use of mechanical CPR devices is also very exciting, especially for patient transport. Several colleagues were injured in a crash this year whilst transporting a patient under CPR, maximising everyone’s safety is so important.

    • Hey Andy,

      Yes a blown valve is a great case for ecmo. Pt has a reversible condition and should have good function after operative repair.

      As to cpr in the back of a moving bus, it is super-dangerous as you say. I want my medics seatbelted in as the bus is barreling through traffic.

  5. Scott Gallagher says:

    Scott,

    Wondering if you would be willing to speculate on why TTM study targeted mild/minimal hypothermia 36C instead of simply avoidance of fever, perhaps targeting 37C? Only talking about 37C) with antipyretics and no cooling? TTM study did not have third arm targeting normothermia. Maybe 33C, 36C and 37C with other advances in post-arrest care would all have same outcome?

    If you could, I would also love to hear your thoughts on the use of portable ECLS/ECMO in the ED. Would be interested whether you see small, portable ECMO/ECLS (extra-corporeal life support) devices as currently or on the horizon having any indication for routine use in the ED? Seems like could have enormous potential, perhaps for cardiac arrest patients (instead of prolonged CPR or LUCAS2 + intubation), hypotensive medical patients (sepsis, anaphylaxis), hypoxic medical patients (severe lung disease or difficult/can’t intubate/can’t ventilate patients)? I am not aware of the specific oxygenation and blood pressure support capabilities of portable ECLS devices (such as the CARDIOHELP – no affiliation whatsoever) to support blood pressure and oxygenation, nor of any good studies or routine use in the ED, but seems like a couple of cannulas and a portable ECLS device could be a game changer, particularly for those of us in rural ED settings will long transport times to tertiary center assistance.

    Scott Gallagher, MD FACEP
    Colorado

    http://www.cardiohelp-us.com/en/basic-knowledge/download-center/brochures/
    http://www.cardiohelp-us.com/en/basic-knowledge/download-center/images/

    • Scott Gallagher says:

      Sorry about typo, meant to say: “(Only talking about <1C from normotheric 37C)"

      • Scott,

        You might want to listen to this podcast. As to the temp choice, the surprise is not that they chose 36 instead of 37, but instead 36 instead of 35. 35 (and now 36) seems to be the temp where we get ICP reduction, fever prevention, and less side effects.

  6. Greg Kelly says:

    Hi Scott – I took your suggestion and wrote to Niklas Neilsen a while ago, he just got back to me saying that he has forwarded my question to the group neurologist. I’ll update you when I hear back from him.

Trackbacks

  1. […] is back — part 2 of EMCrit’s interview on post-arrest care is not to be missed. […]

  2. […] Post-arrest care: EMCrit interview with Stephen Bernard part 1 and  part 2 […]

Speak Your Mind (Along with your name, job, and affiliation)