Mind, Brain & Consciousness During Cardiac Arrest

Sam Parnia MD, PhDPulmonary & Critical Care Medicine

State University of New York Stony Brook, USAUniversity of Southampton, UK

• None

Disclosures

What to do when someone dies? Historical Perspectives on Resuscitation

• Early in history – Galen: Life = Heat & Lifeless = Cold - Heat to prevent death from taking the person

• Bellows Method – started in 1530’s – lasted 300 yrs

- Flagellation – to stimulate a response

- Warm ash - Burning excrement or hot water on body

• Fumigation Method – 1700’s

• Inversion, Barrel, Trotting Horse - 1700- 1800’s

• Mouth-to-Mouth & Chest Compression- 1950-60’s

Irreversible Death

Heart attack

Causes of death

Traffic accident

Dying Process – potentially reversible

Lasts: Few seconds – 10’s min’s – over an hour

Cardiac Arrest/Clinical Death

Impact of Resuscitation Science 50 Years on – Death not a “moment” it is a “reversible” process.

Uncharted Territory

Shock:02 delivery organs inadequate

Cardiac Arrest “Global Stroke” Pathophysiology of Cardiac Arrest

• “Whole body ischemia”– lack oxygen

• Brain Oxygen & Energy Stores(ATP) depleted

– Accumulation toxins (adenosine, lactate, H+)

• Cells Dysfunction – massive intracellular Ca+ accumulation – toxicity - death

• Permanent Brain Cell Death – ? Hours later

Does Brain Function During Cardiac Arrest?

• EEG during Cardiac Arrest – slowing - isoelectric (flatline) 10–20 s

• Remain flat – until resumption of heartbeat if early intervention

• Prolonged cardiac arrest - EEG returns “hrs” after.

• Animal study - 15 min cardiac arrest then resuscitation:

- EEG flat 21 ± 5.7 s (n=10) - 90 ± 24.7 min - bursts of slow waves

Kano T, Hashiguchi A, Sadanaga M. Resuscitation 1993; 25: 265-281

So Why Does it Matter?

What are the wider implications of cardiac arrest research?

- Can we bring people back safely?

- What happens after we die?

What Happens When We Die? Near Death Experience (NDE)

• ‘Life after life’ Raymond Moody 1975

• Reactions -‘Life after life – Hallucination - Fabrication

• Retrospective Studies - Some describe negative NDE

• 4% prevalence of NDE in USA – Gallup 1982

• Problem: Social & Medical Perception of Death – Irreversible

• 19th century Swiss accident survivors

• 15th century Dutch painting – H Bosch

• Plato’s Republic & many others…

Ascent to the Empyreon – H Bosch (1450 – 1516)

Cognitive & Mental Activity – Near Death Experience (NDE)

• NDE described in Japan, China, India and ++++

• Consistent core features

• Studied in children

• Case of 3 year old sent to Southampton

Cognitive & Mental Activity – Near Death Experience (NDE)

• Physiological

• Psychological

• Transcendental

WHY DO NEAR DEATH EXPERIENCES OCCUR?

• Other …

Anticipation of death - ? ‘fear death’ experience

Chemical changes in brain - hallucination

True separation of mind/soul from body

WHY DO NEAR DEATH EXPERIENCES OCCUR? – Rumi’s Elephant in the Dark

Near Death Experience – Problems!

• Cardiac arrest – Biologically = death

• What do we mean by near death?

– scientifically too vague

– led to much controversy

• New Term: Actual Death Experience

Irreversible Death

Heart attack

Causes of death

Traffic accident

Dying Process – potentially reversible

Lasts: Few seconds – 10’s min’s – over an hour

Cardiac Arrest

“Near Death” or “Actual Death” Experience

Parnia S, Waller D, Yeates R, Fenwick P, A qualitative and quantitative study of  incidence, features and aetiology of NDE's in cardiac arrest survivors Resuscitation Feb 2001 48, 149-156

What happens to mind and consciousness during cardiac arrest?

• 344 cardiac arrest survivors - 10 hospitals

Largest NDE Study in Cardiac Arrest

• 41 (12%) reported core NDEs - No association with:

• 8 year follow up - positive change in life

• Did not test physiological parameters

• ?? Account for NDE through brain processes?

• Transformation following NDE

Van Lommel P et al – Near-death experience in survivors of cardiac arrest: a prospective study in the Netherlands. Lancet 2001; 358:2039-2045

• Medication • Fear of death prior to cardiac arrest

Wider Implications of Consciousness During Cardiac Arrest

• ? Signify improved brain Resuscitation?

- Need to study “real time” brain resuscitation.

• When is human mind/consciousness lost permanently and cannot be retrieved after death?

Death – Physical Process

• Changes in Cells including Brain – Cell damage within minutes

• Brain Cells undergo Irreversible Damage

• Eventually leads to bodily destruction

Minutes

Hrs - Days

• When do the mind & consciousness cease existing?

• Scientific Paradox: ? mind/consciousness continue function when brain stopped working and reached the clinical criteria of death

• Five independent studies – published since 2001 UK, Holland, USA

• 10-20% people revived from cardiac arrest & clinical death – consciousness + thought processes + can “see” & “hear”

Death – What Happens to Mind & Consciousness?

Paradox:

Consciousness during Unconsciousness!

• Possible explanations:

- Arise just before or after cardiac arrest

- do not arise at all - Unlikely - ? millions of cases

- Need to re-examine mind/brain theories

The relationship of mind and brain:

Challenge for 21st century science?

• How do we have ‘consciousness’ (psyche or soul) from brain processes?

Mind and Brain - Problem of Consciousness, Psyche or Soul

• How do thoughts, feelings and all aspects of mind arise from brain processes?

Mind and Brain - Problem of Consciousness

Mind and Brain - Problem of Consciousness

• Descartes - Cartesian model

From: Brain Atlas Harvard Medical School

• Ancient Greeks - Human Soul

• Cerebral localisation -19 - 20C

• Modern scanning techniques

- f MRI, PET

History

Mapping the mind

• Complex thoughts = Activity in multiple areas of brain

• Identifying brain cell activity during thoughts – correlation NOT CAUSATION

Mind and Brain - Problem of Consciousness

• Current Views -

- Others –

Quantum processes - Hameroff/Penrose

Irreducible entity: electromagnetic/mass/Gravity Chalmers

Mind/Brain – Separate – Eccles/ Elahi

- Conventional –

Neural Networks Greenfield/Crick/Koch/

Dennett

• Reality of any experience is socially determined - not ‘neurologically’ – Whether NDE/Love or otherwise…

Are Experiences Real or Hallucinations?

• All experience mediated by brain pathways

• NDE – Out of body experiences - many claim objectively verifiable events – Can we test and determine its reality...?

• First large scale study to examine claims to “see” and “hear”

AWARE STUDY (AWAreness during Resuscitation) - launched 2008.

• International Multicentre Study of Consciousness during Cardiac Arrest

• Aim to use Sophisticated Technology (cerebral oximetry) to study brain oxygen delivery with consciousness

Cerebral Oximetry

• Optical Monitoring technique using Beer Lambert law

• Assesses regional O2 (rSO2%) (balance O2 delivery & uptake)

• Represents mostly cerebral venous saturation

• Acceptable Normal Values 60-80%

rSO

2%

0

20

40

60

80

No ROSC ROSC

Role of cerebral oximetry in predicting return of spontaneous circulation (ROSC)

in cardiac arrest using manual CPR

*

* p = <0.0016 Mann-Whitney Test, ROSC = Return of Spontaneous Circulation(No ROSC n= 15, ROSC n= 7)

*

0

20

40

60

80

rSO

2%

Manual CPR Automated CPR

Impact of Automated CPR (LifeStat) on rSO2

* p= <0.0001 Mann-Whitney (Manual CPR n=22, Automated(LifeStat) CPR n=12)

Time (mins)

% r

SO

2Illustration of the Impact of Manual & Automated

Chest Compression on Cerebral Perfusion in Two Patients

Automated CPR (patient 1) Manual CPR (patient 2)ROSC = Return of Spontaneous Circulation

Manual CPR Automated CPR

*

% S

urv

ival

(R

OS

C)

ROSC = Return of Spontaneous Circulation lasting > 20 mins. *p < 0.05 using Fischer's Exact test. (Manual CPR n=44, Automated CPR n=20)

Automatic CPR leads to higher Return Spontaneous Circulation Following

Cardiac Arrest

University of Southampton, Dr Peter Fenwick (Psychiatry), Dr Charles Deakin (cardiac anesthesia), Dr Paul Little (research design), Professor Robert Peveler2 (Psychiatry), Ms Niki Fallowfield (Resuscitation)

University of Cambridge: Ms Susan Jones (Resuscitation)

Northampton Hospital: Ms Celia Warlow (Resuscitation),

St Georges Hospital, London: Ms Leanne Smythe (Resuscitation), St Peters Hospital: Mr Paul Wills (Resuscitation), Mayday Hospital: London Mr Russell Metcalfe Smith (Resuscitation), Royal Bournemouth Hospital: Ms Hayley Killingback (Resuscitation), Morriston Hospital: Dr Penny Sartori (Critical Care Unit),

Stevenage Hospital: Ms Salli Lovett (Critical Care)

Salisbury Hospital: Mr Iain Macleod (Resuscitation),

East Sussex Hospitals, Dr Harry Walmsley (Anaesthetics & Resuscitation) Hammersmith Hospital London: Mr Ken Spearpoint, (Resuscitation),

AWARE STUDY – Investigators/advisors

Indiana State University, Dr Mark Faber (Pulmonary & Critical Care),

University of Virginia: Professor Bruce Greyson (Psychiatry), Dr Robert O’Connor (Emergency)

Emory Medical Center: Dr Maziar Zafari (cardiology)

University of Vienna: Professor Roland Beisteiner (Neurology), Dr Fritz Sterz (Emergency Medicine), Dr Michael Berger (Neuroscience)

METHODS – Hidden Targets Southampton

RESEARCH – Cardiac arrest – Humour!

Near Death Experience Research

How do we study human mind and consciousness during cardiac arrest

METHODS• Open question - ? memory of consciousness

• Study Experiences- Greyson scale - Cognitive recollections (study)

- No cognitive recollections (control)

-Physiological – O2 / CO2 – Electrolytes

Drugs – Cardiac Rhythm- Psychological – ? Religion ? Practicing

- Transcendental – Hidden

targets…

• Study Brain & Resuscitation Processes:

RESULTS – Physiological Southampton

Southampton Study: NDE in cardiac arrest

010

30

50

70

90

110

130

150

control study

Nammol/l

Kmmol/l

PaCO2KPa

PaO2KPa

Parnia S, Waller D, Yeates R, Fenwick P, A qualitative and quantitative study of  incidence, features and aetiology of NDE's in cardiac arrest survivors Resuscitation Feb 2001 48, 149-156

Current version – Fixed shelves with fixed images!

Future Version - Random image generators

Portable Brain (EEG) Monitor – during cardiac arrest

Cerebral oximetry – Our experience so far!

N=10 - Useful in cardiac arrest - results so far similar to previous - 02% <20% - non survivors

ROSC