Wednesday, December 30, 2009

Top 10 issues in hospital medicine for 2009, issue 6: resuscitation and post-resuscitation care

For several years I've been writing about aspects of resuscitation and post-resuscitation care starting with a post on Dr. Gordon Ewy's cardiocerebral resuscitation. Therapeutic hypothermia following cardiac arrest received increased attention this year and I posted on the subject here, here, here and here.

Accumulating evidence on other aspects of post resuscitation care, particularly aggressive coronary angiography and PCI strategies, has led to the notion of the post-cardiac arrest syndrome and post-resuscitation bundle, recently promulgated as an ILCOR consensus statement.

This Medscape Viewpoint piece provides a helpful perspective on the current evidence for the role of emergency PCI in resuscitated patients:

Reynolds' study further supports previously published reports encouraging urgent catheterization for survivors of cardiac arrest regardless of ECG evidence of STEMI. Recent publications also show that therapeutic hypothermia can be used safely in these patients during and after PCI without producing delays in time to balloon inflation.

The significance of this new literature cannot be overstated. If further studies confirm these findings, it would strongly argue for enormous changes in prehospital systems of care. All survivors of primary cardiac arrest would be recommended for immediate transport to hospitals that have the capability of performing urgent PCI in conjunction with therapeutic hypothermia. Based on the current literature, it certainly seems advisable that emergency healthcare practitioners who care for resuscitated victims of primary cardiac arrest should engage in conversations with cardiology consultants and urge them to take an aggressive approach to PCI in these patients.

This new integrated approach to cardiac arrest care will require changes in the way we assess neurologic prognosis after cardiac arrest. We won't be giving up so soon, because assessment of neurologic prognosis will have to be delayed in patients who receive therapeutic hypothermia. Again, from the Medscape article (my emphasis):

The authors determined that improved survival and good outcome were associated with coronary angiography regardless of the presence of new left bundle branch block or STEMI, and also regardless of presenting rhythm or neurologic status immediately after resuscitation.

A nice overview of resuscitation and post-resuscitation care is contained in this review from Current Opinion in Cardiology. According to that review post-resuscitation care should include:

...mild hypothermia (32–348C) for patients in coma after arrest. Urgent cardiac catheterizationand PCI unless contraindicated .

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