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Abstract
Cardiac arrest is the most common cause of death in North America. An organized bundle of neurocritical care interventions can improve chances of survival and neurological recovery in patients who are successfully resuscitated from cardiac arrest. Therefore, resuscitation following cardiac arrest was chosen as an Emergency Neurological Life Support protocol. Key aspects of successful early post-arrest management include: prevention of secondary brain injury; identification of treatable causes of arrest in need of emergent intervention; and, delayed neurological prognostication. Secondary brain injury can be attenuated through targeted temperature management (TTM), avoidance of hypoxia and hypotension, avoidance of hyperoxia, hyperventilation or hypoventilation, and treatment of seizures. Most patients remaining comatose after resuscitation from cardiac arrest should undergo TTM. Treatable precipitants of arrest that require emergent intervention include, but are not limited to, acute coronary syndrome, intracranial hemorrhage, pulmonary embolism and major trauma. Accurate neurological prognostication is generally not appropriate for several days after cardiac arrest, so early aggressive care should never be limited based on perceived poor neurological prognosis.
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Affiliation(s)
- Jonathan Elmer
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Iroquois Building, Suite 400A, 3600 Forbes Avenue, Pittsburgh, PA, 15213, USA.
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| | - Kees H Polderman
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Darocha T, Kosiński S, Jarosz A, Podsiadło P, Ziętkiewicz M, Sanak T, Gałązkowski R, Piątek J, Konstanty-Kalandyk J, Drwiła R. Should capnography be used as a guide for choosing a ventilation strategy in circulatory shock caused by severe hypothermia? Observational case-series study. Scand J Trauma Resusc Emerg Med 2017; 25:15. [PMID: 28202085 PMCID: PMC5312422 DOI: 10.1186/s13049-017-0357-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Accepted: 01/31/2017] [Indexed: 11/16/2022] Open
Abstract
Background Severe accidental hypothermia can cause circulatory disturbances ranging from cardiac arrhythmias through circulatory shock to cardiac arrest. Severity of shock, pulmonary hypoperfusion and ventilation-perfusion mismatch are reflected by a discrepancy between measurements of CO2 levels in end-tidal air (EtCO2) and partial CO2 pressure in arterial blood (PaCO2). This disparity can pose a problem in the choice of an optimal ventilation strategy for accidental hypothermia victims, particularly in the prehospital period. We hypothesized that in severely hypothermic patients capnometry should not be used as a reliable guide to choose optimal ventilatory parameters. Methods We undertook a pilot, observational case-series study, in which we included all consecutive patients admitted to the Severe Hypothermia Treatment Centre in Cracow, Poland for VA-ECMO in stage III hypothermia and with signs of circulatory shock. We performed serial measurements of arterial blood gases and EtCO2, core temperature, and calculated a PaCO2/EtCO2 quotient. Results The study population consisted of 13 consecutive patients (ten males, three females, median 60 years old). The core temperature measured in esophagus was 20.7–29.0 °C, median 25.7 °C. In extreme cases we have observed a Pa-EtCO2 gradient of 35–36 mmHg. Median PaCO2/EtCO2 quotient was 2.15. Discussion and Conclusion Severe hypothermia seems to present an example of extremely large Pa-EtCO2 gradient. EtCO2 monitoring does not seem to be a reliable guide to ventilation parameters in severe hypothermia.
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Affiliation(s)
- Tomasz Darocha
- Severe Accidental Hypothermia Center, Cracow, Poland. .,Department of Anesthesiology and Intensive Care, John Paul II Hospital, Jagiellonian University Medical College, Cracow, Poland. .,Polish Medical Air Rescue, Warsaw, Poland.
| | - Sylweriusz Kosiński
- Severe Accidental Hypothermia Center, Cracow, Poland.,Department of Anesthesiology and Intensive Care, Pulmonary Hospital, Zakopane, Poland Tatra Mountain Rescue Service, Zakopane, Poland
| | - Anna Jarosz
- Severe Accidental Hypothermia Center, Cracow, Poland.,Department of Anesthesiology and Intensive Care, John Paul II Hospital, Jagiellonian University Medical College, Cracow, Poland
| | - Paweł Podsiadło
- Severe Accidental Hypothermia Center, Cracow, Poland.,Polish Medical Air Rescue, Warsaw, Poland.,Polish Society for Mountain Medicine and Rescue, Szczyrk, Poland
| | - Mirosław Ziętkiewicz
- Severe Accidental Hypothermia Center, Cracow, Poland.,Department of Anesthesiology and Intensive Care, John Paul II Hospital, Jagiellonian University Medical College, Cracow, Poland
| | - Tomasz Sanak
- Severe Accidental Hypothermia Center, Cracow, Poland.,Department of Disaster Medicine and Emergency Care, Jagiellonian University Medical College, Krakow, Poland.,Department of Combat Medicine, Military Institute, Warsaw, Poland
| | - Robert Gałązkowski
- Polish Medical Air Rescue, Warsaw, Poland.,Department of Emergency Medical Services, Medical University of Warsaw, Warsaw, Poland
| | - Jacek Piątek
- Severe Accidental Hypothermia Center, Cracow, Poland.,Department of Cardiac, Vascular and Transplantation Surgery, John Paul II Hospital, Jagiellonian University Medical College, Cracow, Poland
| | - Janusz Konstanty-Kalandyk
- Severe Accidental Hypothermia Center, Cracow, Poland.,Department of Cardiac, Vascular and Transplantation Surgery, John Paul II Hospital, Jagiellonian University Medical College, Cracow, Poland
| | - Rafał Drwiła
- Severe Accidental Hypothermia Center, Cracow, Poland.,Department of Anesthesiology and Intensive Care, John Paul II Hospital, Jagiellonian University Medical College, Cracow, Poland
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Rittenberger JC, Friess S, Polderman KH. Emergency Neurological Life Support: Resuscitation Following Cardiac Arrest. Neurocrit Care 2016; 23 Suppl 2:S119-28. [PMID: 26438463 DOI: 10.1007/s12028-015-0171-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Cardiac arrest is the most common cause of death in North America. Neurocritical care interventions, including targeted temperature management (TTM), have significantly improved neurological outcomes in patients successfully resuscitated from cardiac arrest. Therefore, resuscitation following cardiac arrest was chosen as an emergency neurological life support protocol. Patients remaining comatose following resuscitation from cardiac arrest should be considered for TTM. This protocol will review induction, maintenance, and re-warming phases of TTM, along with management of TTM side effects. Aggressive shivering suppression is necessary with this treatment to ensure the maintenance of a target temperature. Ancillary testing, including electrocardiography, computed tomography and/or magnetic resonance imaging of the brain, continuous electroencephalography monitoring, and correction of electrolyte, blood gas, and hematocrit changes, are also necessary to optimize outcomes.
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Affiliation(s)
- Jon C Rittenberger
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA.
| | - Stuart Friess
- Department of Pediatrics, Washington University School of Medicine, St. Louis, St. Louis, MO, USA
| | - Kees H Polderman
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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Pang DSJ, Rondenay Y, Troncy E, Measures LN, Lair S. Use of end-tidal partial pressure of carbon dioxide to predict arterial partial pressure of carbon dioxide in harp seals during isoflurane-induced anesthesia. Am J Vet Res 2006; 67:1131-5. [PMID: 16817732 DOI: 10.2460/ajvr.67.7.1131] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To evaluate the relationship between end-tidal partial pressure of CO(2) (ETCO(2)) and PaCO(2) in isoflurane-anesthetized harp seals. ANIMALS Three 5-month-old 25- to 47-kg harp seals (Phoca groenlandica). PROCEDURES PaCO(2) was determined in serial arterial samples from isoflurane-anesthetized seals and compared with concomitant ETCO(2) measured with a side-stream microstream capnograph. Twenty-four paired samples were subjected to linear regression analysis and the Bland-Altman method for assessment of clinical suitability of the 2 methods (ie, PaCO(2) and ETCO(2) determinations). The influence of ventilation rate per minute (VR) on the ETCO(2) to PaCO(2) difference (P[ET-a] CO(2)) was examined graphically. RESULTS The correlation coefficient between the 2 measurements was 0.94. The level of agreement between ETCO(2) and PaCO(2) varied considerably. Values of ETCO(2) obtained with a VR of < 5 underestimated PaCO(2) to a greater degree (mean bias, -4.01 mm Hg) and had wider limits of agreement of -13.10 to 5.07 mm Hg (-4.01 mm Hg +/- 1.96 SD), compared with a VR of > or = 5 (mean bias, -2.24 mm Hg; limits of agreement, -7.79 to 3.30 mm Hg). CONCLUSIONS AND CLINICAL RELEVANCE These results indicate that a microstream sidestream capnograph provides a noninvasive, sufficiently accurate estimation of PaCO(2) with intermittent positive ventilation at a VR > or = 5 in anesthetized harp seals.
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Affiliation(s)
- Daniel S J Pang
- Département de sciences cliniques, Faculté de médecine vétérinaire, Université de Montréal, St-Hyacinthe, QC, Canada
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