slides rosc lecture 3 part 1

7/29/2019 Slides ROSC Lecture 3 Part 1

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Cardiac Arrest, Hypothermia and Resuscitation Science

Lecture 3: Cooling the body to save the heart and brain:Therapeutic hypothermia after cardiac arrest

Benjamin S. Abella, MD MPhilClinical Research Director Center for Resuscitation ScienceDepartment of Emergency MedicineUniversity of Pennsylvania

Coursera

July 2012

An introductory course for the educated lay public and health care providers


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Time

% S

u r v i v i n g

arrest

CPR

ROSC

hospitaldischarge

in-hospitalarrest data

52%

18%

The post-arrest problem

When do people die from cardiac arrest?


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Time

% S

u r v i v

i n g Damage observed after restoration

of blood flow to ischemic tissues

Reperfusion injury

Concept of REPERFUSION INJURY


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Reperfusion injury: clues from the laboratory

Can simulate cardiac arrest and resuscitation:

Bathe them in fluid without oxygen (cardiac arrest)Restore fluid with oxygen (resuscitation)

Heart cells (myocytes) grown in a petri dish


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ischemia

C e

l l D e a

t h ( % )

Time

Death during ischemia

Death during reperfusion

0

10

20 30

40

50 60

0 1 2 3 4 5

??

What will happen when you simulate ischemia and then reperfusion?


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ischemia

C e

l l D e a

t h ( % )

Time

Can we dosomething

here?

Vanden Hoek et al, AJP, 1996

What actually happens:


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Would you buy this car for $75,000 ?

One quirk: if you run out of gas,

And you then put gas in the car

What this means: imagine the following situation


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K A H B OOM

What this means: imagine the following situation


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What causes this problem?

free radicals

mitochondria

inflammation


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Ischemia(lack of blood flow)

Reperfusion(return of blood flow)

reactive oxygenspecies (ROS) inflammatory

cascades

energy processingdysfunction

blood vessel instabilitycell death

brain swelling

hypothermia

Reperfusion injury: how it happens


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Cardiac arrest epidemiology in the USEGYPT:

In the time of the Pharaohs

The remarkable history of therapeutic hypothermia


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Hesi Re, Physicianand scribe2650 BCE

Sekhmet,goddess ofdisease

Imhotep,the god ofhealing

AncientMedicinebottle

Medicine in ancient Egypt


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Ancient Egyptians documentedthe use of hypothermia for:

Pain control

Fever

Ice stored in straw, transportedLong distances or made inEgyptian winters

Medicine in ancient Egypt
http://en.wikipedia.org/wiki/File:Edwin_Smith_Papyrus_v2.jpg


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Cardiac arrest epidemiology in the USKOS:

Island home to the

Hippocratic tradition

Medicine in ancient Greece


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Hippocrates noted that injuries(traumatic wounds) often did better

when packed in ice or cooled

No shortage of experimentalsubjects: constant skirmishing of

Greek city states

Medicine in ancient Greece
http://upload.wikimedia.org/wikipedia/commons/6/6c/Medicine_aryballos_Louvre_CA1989-2183_n2.jpg


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Cardiac arrest epidemiology in the US

France:The Age of Empire

Hypothermia in the modern era
http://upload.wikimedia.org/wikipedia/commons/c/c1/Notre_Dame_Paris_France.JPGhttp://en.wikipedia.org/wiki/File:Jacques-Louis_David_017.jpg


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Baron Larrey (1766-1842)

Chief battlefield surgeon under Napoleon

Developed important military medicineinnovations:

The Flying Ambulance

Caring forenemies

(Prussians,seen here)

Baron Larrey: medical innovator
http://en.wikipedia.org/wiki/File:Anne-Louis_Girodet-Trioson_005.jpg


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Cold acts on the living parts[which] may remain in [a]state of asphyxia without losingtheir life (1814)

Baron Larrey observes hypothermia in action


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Benson DW, Williams GR Jr, Spencer FC, Yates AJ.The use of hypothermia after cardiac arrest.

Anes th A na lg 1959; 38: 423-8.

Comatose survivors

Asystole or VF31-32

CCooling until neurologicrecovery

(3 h to 8 days)water-filled blanket

The first study of hypothermia in cardiac arrest

0

10

20

30

40

50

60

Favorable neurologicrecovery

%

Hypothermia (n=12)

Normothermia (n=7)
http://images.google.com/imgres?imgurl=http://www.laxcast.com/images/Penn%2520Logo3.jpg&imgrefurl=http://www.laxcast.com/laxcasts.php&h=575&w=504&sz=86&hl=en&start=2&tbnid=FQB_-U94MtoUWM:&tbnh=134&tbnw=117&prev=/images?q=Penn+logo&svnum=10&hl=en&lr=&rls=DKUS,DKUS:2006-32,DKUS:en


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Peter Safar, MD (1924-2003)

Anesthesia training at U Penn

Worked in Pittsburgh

Father of CPR AND also developedhypothermia as a science

The father of the science of hypothermia


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The father of the science of hypothermia

slides rosc lecture 3 part 1

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