Expanding the Chain:Expanding the Chain:The 7The 7thth Link- Link-Rehabilitation &Rehabilitation &RecoveryRecovery

Vince Mosesso, MDVince Mosesso, MDProfessor of Emergency MedicineProfessor of Emergency MedicineUniversity of Pittsburgh School of MedicineUniversity of Pittsburgh School of Medicine

DisclosuresDisclosures

Prior grants from Medtronic Inc and MedtronicPrior grants from Medtronic Inc and MedtronicFoundationFoundation

Prior research support from Medtronic, Zoll,Prior research support from Medtronic, Zoll,Philips, Heartsine, Cardiac Science, Welch-Philips, Heartsine, Cardiac Science, Welch-AllynAllyn

Honorarium from BiotronikHonorarium from Biotronik Research support from Zoll LifeCorResearch support from Zoll LifeCor

CorporationCorporation Medical director and co-founder, SuddenMedical director and co-founder, Sudden

Cardiac Arrest AssociationCardiac Arrest Association

When Survivors Speak, When Survivors Speak, ……

Post cardiac arrest syndromePost cardiac arrest syndromeNow recognized as specific condition withNow recognized as specific condition with

specific interventionsspecific interventions

Post cardiac arrestPost cardiac arrestsyndromesyndrome

Post cardiac arrest brain injuryPost cardiac arrest brain injury Post cardiac arrest myocardialPost cardiac arrest myocardial

dysfunctiondysfunction Systemic ischemia & reperfusionSystemic ischemia & reperfusion

responseresponse Underlying condition that caused arrestUnderlying condition that caused arrest

CNSCNS

Loss of normal blood flow to brainLoss of normal blood flow to brain Overall blood flow/pressure controlOverall blood flow/pressure control Regional microvascular perfusionRegional microvascular perfusion

Neuronal cell death (necrosis/homicide)Neuronal cell death (necrosis/homicide)and triggering of self-death pathwaysand triggering of self-death pathways(apoptosis/suicide)(apoptosis/suicide)

Clinical syndrome ranges from mildClinical syndrome ranges from mildmemory deficits to persistent vegetativememory deficits to persistent vegetativestatestate

Phases of post arrest carePhases of post arrest care

After acute phase:After acute phase:Recovery & RehabilitationRecovery & Rehabilitation

Less well understoodLess well understood Most research has focused on severeMost research has focused on severe

neurological disabilitiesneurological disabilities Lack of providers to help survivors andLack of providers to help survivors and

love ones cope with emotional,love ones cope with emotional,psychological and more subtle cognitivepsychological and more subtle cognitivechangeschanges

Symptoms and problemsSymptoms and problemsnoted by survivorsnoted by survivors

Goes beyond typical organic dysfunctionGoes beyond typical organic dysfunction Appears to be a unique spectrum of cognitiveAppears to be a unique spectrum of cognitive

and emotional experiencesand emotional experiences Many express need for supportMany express need for support

Neuropsychological sequelaeafter cardiac arrest

155 survivors underwent neuro-psychevaluations at 3 and 12 months

Moderate to severe cognitive dysfunction: 60% at three months 48% at one year

Depression in 45% at one year

Roine RO et al. JAMA. 1993.

Psychosocial distressafter ICD implantation

57 subjects surveyed every 6 months for2 years

Depression in 35% Anxiety in 45% Some decrease over time

Thomas SA et al. Heart & Lung, 2009

SCAA: survey of survivors and theirSCAA: survey of survivors and theirloved onesloved ones

Benjamin S. Abella, MD, MPhil

Clinical Research Director Center for Resuscitation Science

Department of Emergency Medicine University of Pennsylvania

SCAA Annual Meeting - October, 2008

CRSCenter for

Resuscitation Science

After SCA, what function has changed?

Touc

h

Tast

e

Smel

l

Sigh

t

Hea

ring

Mem

ory

Coo

rdin

atio

n

Non

e

Oth

er

80

60

40

20

0Num

ber r

espo

ndin

g 53%

After SCA, what activity did you fear?

Exer

cise

Driv

ing

Air

trav

el

Bei

ng a

lone

Oth

er

60

40

20

0Num

ber r

espo

ndin

g

23%

15%30%

37%

5%

“holding loved ones”“swimming”“sleeping”

Emotional changesEmotional changes

Lability (marked fluctuations)Lability (marked fluctuations) Spontaneous or easily-triggered cryingSpontaneous or easily-triggered crying Increased sensitivity to othersIncreased sensitivity to others’’ losses losses Greater love of family and friendsGreater love of family and friends FearFear——of ICD firing, or of not having one andof ICD firing, or of not having one and

needing it.needing it. GuiltGuilt——why did I survive, when so many otherswhy did I survive, when so many others

die?die?

CognitiveCognitive

Various types and duration of memoryVarious types and duration of memorylossloss

Dementia (post-anoxic)Dementia (post-anoxic) Variable degrees of loss of executiveVariable degrees of loss of executive

functionfunction Continuous barrage of thoughtsContinuous barrage of thoughts Quicker, smarter brain functionQuicker, smarter brain function

Sensory / PerceptionSensory / Perception

““Size upSize up”” people more quickly/easily people more quickly/easily Heightened sense of smellHeightened sense of smell Altered pain tolerance / perceptionAltered pain tolerance / perception

BehavioralBehavioral

Sleep disturbancesSleep disturbances More outspoken when believe rightMore outspoken when believe right More risk-takingMore risk-taking

““Been to the brink, nothing can hurt meBeen to the brink, nothing can hurt memore.more.””

Psychiatric/psychologicalPsychiatric/psychological

Depression and/or apathyDepression and/or apathy Perception of infallibilityPerception of infallibility Perception of vulnerabilityPerception of vulnerability Belief in destinyBelief in destiny——things are happeningthings are happening

for a purposefor a purpose Sense of urgencySense of urgency——must do as much asmust do as much as

possible right nowpossible right now

Family & Loved onesFamily & Loved ones

Also affected in many ways and tovarious degrees

Both similar and different challenges One study:

60% with psychosomatic complaints 50% noted lack of social support

Pusswald G et al. Resuscitation, 2000.

Dual causation

Organic brain injury Psychological stress

Treatment must address both of thesecauses and the various components

““Post cardiac arrestPost cardiac arreststress disorder (PCSD)stress disorder (PCSD)”” -? -?

Need to distinguish from PCASNeed to distinguish from PCAS Labeling facilitates:Labeling facilitates:

increasing awarenessincreasing awareness advocacy for more research and clinicaladvocacy for more research and clinical

therapytherapy

PCSD ComponentsPCSD Components

CognitiveCognitive EmotionalEmotional PerceptualPerceptual BehavioralBehavioral Psychiatric/PsychologicalPsychiatric/Psychological

NeededNeeded

Better understandingBetter understanding SymptomsSymptoms TriggersTriggers Spectrum of severity and scopeSpectrum of severity and scope

Better therapyBetter therapy More access to therapyMore access to therapy

Potential ways to addressPotential ways to address

Greater awareness of needGreater awareness of need ResearchResearch Stakeholder forumStakeholder forum Meeting of experts to review currentMeeting of experts to review current

science and potential therapiesscience and potential therapies Professional educationProfessional education

The 7The 7thth Link: Link:Recovery & RehabilitationRecovery & Rehabilitation

Stay tuned to

www.suddencardiacarrest.org

for further information.

The Defibrillators: Side Effects