News Item written by Thomas Keeble Consultant Cardiologist and Senior Clinical Fellow
OHCA is common and outcomes remain sub-optimal despite better CPR education, greater availability of defibrillators in the community, better access to catheter labs and intensive care units, as well as aggressive temperature management, and improving neuro-prognostication tools.
OHCA patients represent a new and emerging population who present clinical challenges to prehospital staff, emergency departments, cardiologists and intensive care doctors in both district general hospitals and heart attack centres (HAC).
The purpose of the BCIS OHCA study day was to educate and inform BCIS Consultant and Specialist Registrar members to the optimal treatment strategies for this emerging cohort, focusing on the patient journey from cardiac arrest in the community, through emergency department and heart attack centre triage, cath lab based treatments, the intensive care stay, and finally discharge and physical and psychological follow up.
The BCIS cardiac arrest day while being hosted by the Consultants and staff of the Essex Cardiothoracic Centre was supported by world class faculty from both the UK and Europe. All lectures and discussion are available to view as a webcast and also as powerpoint slidesets.
The day was split into 3 main sessions:
Dr Paul Kelly – Introductory talk – OHCA the Essex CTC experience between 2012-2017.
Prof Nick Curzen discussed the current state of OHCA treatment across the UK. He utilised BCIS data returns to try to unravel the stark variations in treatment of these patients across PCI capable centres within the UK. Some HAC have an almost “open door” policy taking > 100 patients / year, while others never accept direct admissions of comatose survivors of cardiac arrest.
Dr Paul Rees went on to discuss the important pre-hospital interventions to improve patient outcomes. He stressed the importance of immediate by-stander recognition of cardiac arrest and CPR, followed by early access to defibrillation, and then transfer to definitive care within a hospital environment. He touched upon future technical developments to improve the pre-hospital phase including – drone assisted defibrillation, GoodSAM phone app, CPR adjuncts including mechanical CPR and pre-hospital cooling and ECMO technology.
Prof Simon Redwood discussed once the patient has return of spontaneous circulation (ROSC) or remains in cardiac arrest the data for what should happen next. Should all patients come to a cardiac arrest centre, and which patients should be taken immediately to the cardiac catheter lab. He introduced a case presentation of Patient “X” whose clinical course would run through all subsequent talks for the day to express the complicated nature of OHCA patients.
Dr John Davies explained his algorithm for the management of OHCA patients that he assesses in the cath lab to give a structure to management as these patients present many challenges to the interventional cardiologist not seen in conscious STEMI patients. He methodically breaks the assessment down into Airway and Access, Breathing and Blood gas, Circulation and Coronaries, Disability and Drugs, and finally Exposure and Exit. He also discussed the difficulties of drug administration and anti-platelet effects, risk of haemorrhage, lung and ventilation complications as well as the common difficulties of making a definitive diagnosis.
Prof Jacob Moller – Patients following OHCA are commonly shocked with hypotension, and metabolic derangements. Prof Moller from Denmark explained his vast ECMO and IMPELLA experience both in animal models and also in the DANSHOCK trial. He gave a state of the art lecture on the clinical value of both and how his unit methodically manages patients with OHCA and cardiogenic shock.
Dr Grigoris Karamasis – A consultant Cardiologist with a vast experience of both therapeutic hypothermia (TH) in OHCA and conscious STEMI presented the current literature for targeted temperature management (TTM) in patients following cardiac arrest. He expressed that many of the trials are flawed in that TH is implemented too late in the neurological injury making benefit less likely. He talked about pre-hospital and rapid intravenous temperature management, as well as TH and early waking trials.
Dr Jerry Sayer – In approximately one third of all OHCA patients we do not identify a “cause” for the cardiac arrest, which makes future management challenging. He went on to discuss additional diagnostic modalities including cardiac MRI, EP studies, CT scanning and advanced intra-coronary imaging to try and elucidate the underlying aetiology to better focus treatments.
- Intensive care therapies, neuro-prognostication, hospital discharge and beyond
Dr Guy Glover – Continued the complicated journey of Patient “X” through his 6 week intensive care stay highlighting the additional challenges of chest trauma, pulmonary haemorrhage, aspiration pneumonia, ventilatory and haemodynamic support, ARDS, and critical care neuropathy and myopathy.
Dr Max Damian – 60% of OHCA patients that do not survive die due to neurological injury often some days after the cardiac arrest event. It is vital that we have the tools to help understand and predict the likelihood and extent of neurological injury secondary to cardiac arrest. Max described in detail the prognostication tools including careful clinical examination, CT / MRI brain scanning, SSEP and EEG as well as biomarkers.
Paul Swindell (OHCA patient survivor) – bravely and passionately expressed the physical and psychological sequelae of cardiac arrest and the profound effect on both the patient and family. His powerful testimony highlighted the lack of proper neurological and psycho-social follow up for patients and care givers following cardiac arrest and how his peer to peer support group is trying to address these inadequacies.
Dr Thomas Keeble – Following up sequential OHCA patients and families from 2013 onwards it became clear that like Paul (above), many patients and families suffer considerable physical and psycho-social stresses. In an attempt to measure this burden and ameliorate the morbidity the Essex CTC set up the Care After REsuscitation (CARE) clinic to assess and offer neuro-psychological support to all sufferers and families of OHCA survivors.
Finally to round the day off Prof Marko Noc gave his key note lecture, where he summarised the current state of the art OHCA therapy for 2017, and what we can expect cardiac arrest management to look like in the years to come.