Cardio cerebral resuscitation

Cardio-cerebral resuscitation

Dr. Md.Toufiqur Rahman MBBS, FCPS, MD, FACC, FESC, FRCPE, FSCAI,

FAPSC, FAPSIC, FAHA, FCCP, FRCPG

Associate Professor of CardiologyNational Institute of Cardiovascular Diseases,

Sher-e-Bangla Nagar, Dhaka-1207

Consultant, Medinova, Malibagh branchHonorary Consultant, Apollo Hospitals, Dhaka and

STS Life Care Centre, Dhanmondi [email protected]

CRT 2014Washington DC, USA

Cardiovascular disease is the major cause of mortality in the United States, Canada, and Europe. Unfortunately, the first sign of cardiovascular disease is often the last, as the first sign is often sudden death. In the United States alone, thereare about 275,000 sudden deaths per year from out of­h ospital cardiac arrests (OHCAs). Despite national guidelinesand their near semi decennial update, the reported survival rates for OHCA between 1978 and 2008 remained unchanged at 7.6%. Obviously, OHCA is a major public health problem that has not previously been adequately addressed.Patients with OHCA are not a homogeneous group. Therefore, just looking at the overall survival of patients with OHCAmight not be the best indicator of the effectiveness of therapy.

Introduction

In hospital cardiac arrests are most often secondary to hypotension and shock, which is the end result of physiologicdeterioration from underlying medical conditions such as infections, renal failure, anemia, toxins, electrolyte imbalances,hypoxia, drugs, and trauma. In these cases, the best approach is prevention, by treating the underlying disease to prevent the cardiac arrest."cardiocerebral resuscitation" approachhas resulted in a significant improvement in the survival of patients with OHCA. Classic cardiopulmonary resuscitation(CPR) should be reserved for secondary cardiac arrest, secondary to respiratory insufficiency from conditions such as,drowning, drug overdose, or advanced pulmonary disease.

Introduction

The modern era of CPR began in 1960 at Johns Hopkins Hospital when Kouwenhoven (a retired engineer), Jude (asurgical resident), and Knickerbocker (an engineer) reported successful resuscitation of patients with cardiac arrest,without performing a thoracotomy. This approach was based on their experimental animal studies. There were norandomized clinical trials assessing this technique or comparing it to other approaches.In the beginning, these pioneers taught that assisted ventilations were not necessary during resuscitation efforts as theanimal gasped. However, others thought that assisted ventilation was necessary, so mouth to mouth "rescue breathing"interposed between closed chest compressions became cardiopulmonary resuscitation, known as CPR. Over the next50 years, using CPR meant performing chest compressions and assisted ventilations.It then became evident that most unexpected sudden deaths were not occurring in hospitals.

Historical Perspective

During the 1970s,researchers from Belfast, NY, and Seattle launched programs in which medical care was delivered in the field by trainedmedics who rode the ambulance services and were able to defibrillate patients in the community who were in cardiac arrest. This was a conceptual change in the way medical care for patients with OHCA was delivered; initial emergency care was delivered by nonphysicians (i.e., paramedics) in the community under physician guided protocols.Soon thereafter, researchers again changed the paradigm by initiating care for patients with cardiac arrest by laypersons. Again, these major advances in treating patients with OHCA were not subjected to randomized clinicaltrials. The ABCs (airway, breathing, compressions) of CPR became the standard of care for patients with cardiac arrest.Over approximately the past decade, the use of automated external defibrillators has gained increasing importance.

Historical Perspective

There are two general types of cardiac arrest. A primary cardiac arrest is an unexpected witnessed (seen or heard) collapse in a person who is not responsive.Gasping occurs in the majority (55%) of patients with OHCA, and is often interpreted as breathing. During primary cardiac arrest, the heart suddenly stops pumping blood andthe arterial blood is oxygenated at the time of the arrest.Secondary cardiac arrest is secondary to severe hypoxia, often from drowning, respiratory failure, drug overdose, or hypotension due to shock or hemorrhage.In patients with cardiac arrest, each chest compression is the patient's heart beat. If chest compressions areinterrupted for any reason, blood flow to the heart and brain essentially stops, decreasing the chance for neurologically intact survival.

The previous fixation on ventilations interrupted essential blood flow to the body, and in the excitement ofresuscitation efforts, hyperventilation was common.A new approach for patients with primary cardiac arrest, called cardiocerebral resuscitation, has been shown tosignificantly increase survival.Studies in Arizona have shown that the survival rate of patients with OHCA is significantly increased when CO CPR is advocated and taught to the public.For primary cardiac arrest, cardiocerebral resuscitation prohibits early intubation, advocates passive ventilation,emphasizes minimal interruptions of chest compressions, and encourages early administration of epinephrine.For patients with ROSC but in a coma following cardiac arrest, new approaches include therapeutic hypothermia,consideration of early cardiac catheterization for those with possible acute coronary occlusion as the etiology oftheir arrest, delay in terminating care, and appropriate intensive care.

Resuscitation science is a dynamic field. Resuscitation of patients in cardiac arrest is dependent on acarefully followed system of care and is no stronger than its weakest link. Cardiac arrest is a public health problem. Assuch, solutions depend upon accurate data measuring the effectiveness of the system of care. Resuscitation science,both in the laboratory and in clinical arenas, provides guides to developing the best models of care to fit each community.

Conclusion

Thank [email protected]

Asia Pacific Congress of Hypertension, 2014, FebruaryCebu city, Phillipines

Seminar on Management of Hypertension, Gulshan, Dhaka