Evaluation of the cognitive outcome after out-of-hospital cardiac arrest: The role of thalamus.

Cardiac arrest survivors develop a variety of neuropsychological impairments and neuroanatomical lesions. The goal of this study is to evaluate if brain voxel-based morphometry and lesional Magnetic Resonance Imaging (MRI) analyses performed in the acute phase of an Out-of-Hospital Cardiac Arrest (OHCA) can be sensitive enough to predict the persistence of neuropsychological disorders beyond 3 months. Survivors underwent a prospective brain MRI during the first month after an OHCA and performed neuropsychological assessments at 1 and 3 months. According to the second neuropsychological assessment, survivors were separated into two subgroups, a deficit subgroup with persistent memory, executive functions, attention and/or praxis disorders (n = 11) and a preserved subgroup, disorders free (n = 14). Brain vascular lesion images were investigated, and volumetric changes were compared with healthy controls. Correlations were discussed between brain MRI results, OHCA data and the second neuropsychological assessment. Analyses of acute ischemic lesions did not reveal significant differences between the two subgroups (p = .35), and correlations with cognitive impairments could not be assessed. voxel-based morphometry analyses revealed a global cerebral volume reduction for the two subgroups and a clear decrease of the right thalamic volume for the deficit subgroup. It was associated with a cognitive dysexecutive syndrome represented by four executive indexes according to the 'Groupe de Réflexion pour l'Evaluation des Fonctions EXécutives' criteria. The right thalamus atrophy seems to be more predictive than the vascular lesions and more specific than a global cerebral volume reduction of post-OHCA neuropsychological executive disorders.

Echocardiographic patterns of postresuscitation myocardial dysfunction.

BACKGROUND: Postresuscitation myocardial dysfunction (PRMD) can develop after successful resuscitation from cardiac arrest. However, echocardiographic patterns of PRMD remain unknown. This study aimed to investigate PRMD manifestations with serial echocardiography during the post-cardiac arrest period. METHODS: We enrolled non-traumatic out-of-hospital cardiac arrest patients older than 19 years who underwent successful cardiopulmonary resuscitation (CPR). We excluded patients with myocardial infarction or pre-existing cardiac disease, including heart failure or myocardial disease. Transthoracic echocardiography (TTE) was performed within 24 h, between 24 and 48 h, and between 72 and 96 h after restoration of spontaneous circulation (ROSC). RESULTS: Of 280 patients, 138 (93 men) were analysed. PRMD was observed in 45 patients (33%), including global dysfunction in 28 patients (20%), regional wall motion abnormalities (RWMA) in 10 (7%), and Takotsubo pattern in 7 (5%). There were no differences in clinical characteristics, laboratory findings, or hospital mortality according to PRMD pattern. Global left ventricular (LV) systolic function gradually improved with time and had recovered to normal by Day 3 in all patients except one with the Takotsubo pattern, which remained on follow-up echocardiography two weeks after ROSC. CONCLUSIONS: PRMD occurs in about one-third of patients resuscitated from cardiac arrest. Echocardiographic patterns of post-cardiac arrest LV dysfunction include global hypokinesia, regional wall motion abnormalities, and Takotsubo pattern.

Implementation of a standardized pathway for the treatment of cardiac arrest patients using therapeutic hypothermia: "CODE ICE".

Out-of-hospital cardiac arrest is common and is associated with high mortality. The majority of in-hospital deaths from resuscitated victims of cardiac arrest are due to neurologic injury. Therapeutic hypothermia (TH) is now recommended for the management of comatose survivors of cardiac arrest. The rapid triage and standardized treatment of cardiac arrest patients can be challenging, and implementation of a TH program requires a multidisciplinary team approach. In 2010, we revised our institution's TH protocol, creating a "CODE ICE" pathway to improve the timely and coordinated care of cardiac arrest patients. As part of CODE ICE, we implemented comprehensive care pathways including measures such as a burst paging system and computerized physician support tools. "STEMI on ICE" integrates TH with our regional ST-elevation myocardial infarction network. Retrospective data were collected on 150 consecutive comatose cardiac arrest victims treated with TH (n = 82 pre-CODE ICE and n = 68 post-CODE ICE) from 2007 to 2011. After implementation of CODE ICE, the mean time to initiation of TH decreased from 306 ± 165 minutes to 196 ± 144 minutes (P < 0.001), and the time to target temperature decreased from 532 ± 214 minutes to 392 ± 215 minutes (P < 0.001). There was no significant change in survival or neurologic outcome at hospital discharge. Through the implementation of CODE ICE, we were able to reduce the time to initiation of TH and time to reach target temperature. Additional studies are needed to determine the effect of CODE ICE and similar pathways on clinical outcomes after cardiac arrest.

Advances in the hospital management of patients following an out of hospital cardiac arrest.

The outcome for patients after an out-of-hospital cardiac arrest (OHCA) has been poor over many decades and single interventions have mostly resulted in disappointing results. More recently, some regions have observed better outcomes after redesigning their cardiac arrest pathways. Optimised resuscitation and prehospital care is absolutely key, but in-hospital care appears to be at least as important. OHCA treatment requires a multidisciplinary approach, comparable to trauma care; the development of cardiac arrest pathways and cardiac arrest centres may dramatically improve patient care and outcomes. Besides emergency medicine physicians, intensivists and neurologists, cardiologists are playing an increasingly crucial role in the post-resuscitation management, especially by optimising cardiac output and undertaking urgent coronary angiography/intervention.