Become a Creator today!Start creating today - Share your story with the world!
Start for free
00:00:00
00:00:01
Post ROSC Golden Hour
28 Plays3 years ago
In this episode of the podcast, we will discuss the first hour of clinical care post return of spontaneous circulation in cardiac arrest survivors. Our guest is Dr. Haney Mallemat a critical care intensivist and emergency medicine clinician at Cooper University Health. He is also an associate professor of medicine and of emergency medicine at Cooper Medical School of Rowan University, in Camden, New Jersey.
Additional Resources:
Critical Care Now: A site for intensivists and resuscitationists.: https://criticalcarenow.com/
RESUS-X: The ultimate resuscitation educational experience: https://www.resusx.com/
https://pubmed.ncbi.nlm.nih.gov/25599355/
European Resuscitation Council and European Society of Intensive Care Medicine guidelines 2021: post-resuscitation care: https://link.springer.com/article/10.1007/s00134-021-06368-4
Oxygen Targets in Comatose Survivors of Cardiac Arrest. BOX Trial: https://www.nejm.org/doi/full/10.1056/NEJMoa2208686
Blood-Pressure Targets in Comatose Survivors of Cardiac Arrest. BOX Trial: https://www.nejm.org/doi/full/10.1056/NEJMoa2208687
Books Mentioned in this Episode:
SmartLess. One of Haney’s favorite podcasts: https://podcasts.apple.com/us/podcast/smartless/id1521578868
How to win Friends & Influence People. By Dale Carnegie: bit.ly/3VVlTRQ
EMRAP. A leading educational platform recommended by Haney: https://www.emrap.org/
Recommended
Transcript
Introduction to Critical Care and the Golden Hour
00:00:06
Speaker
Welcome to Critical Matters, a sound podcast covering a broad range of topics related to the practice of intensive care medicine.
00:00:14
Speaker
Sound provides comprehensive critical care programs to hospitals across the country.
00:00:19
Speaker
To learn more about our programs and career opportunities, visit www.soundphysicians.com.
00:00:26
Speaker
And now your host, Dr. Sergio Zanotti.
The Golden Hour After Cardiac Arrest
00:00:33
Speaker
The golden hour is a concept we have adopted from the trauma literature.
00:00:37
Speaker
It defines the first hour post-traumatic event and highlights the importance specific interventions during this first hour have on the ultimate outcome of a patient.
00:00:46
Speaker
The golden hour is a critical window that requires systematic evaluation intervention with time-sensitive therapies.
00:00:53
Speaker
In today's episode of the podcast, we will discuss the first hour post-cardiac arrest with return of spontaneous circulation, the golden hour post-ROAC.
00:01:03
Speaker
Our guest is Dr. Haney Malamud.
00:01:05
Speaker
Dr. Malamud is a critical care intensivist and emergency medicine clinician at Cooper University Health.
00:01:10
Speaker
He is also associate professor of medicine and of emergency medicine at Cooper Medical School of Rowan University in Camden, New Jersey.
00:01:16
Speaker
Haney is a great Batesat clinician, an ultrasound guru, and a master educator.
00:01:21
Speaker
He is the editor-in-chief of Critical Care Now, an amazing educational platform from Critical Care.
00:01:26
Speaker
He is the founder of ResurceX, a conference focusing on state-of-the-art resuscitation.
00:01:31
Speaker
I encourage you to explore both.
Post-ROSC Critical Care Framework
00:01:33
Speaker
Haney, welcome back to Critical Matters.
00:01:37
Speaker
Hey, Sergio.
00:01:37
Speaker
Thanks for having me back on again.
00:01:40
Speaker
Well, today we're going to talk of a very important topic.
00:01:44
Speaker
I know dear to your heart, we've talked of different topics throughout the years on Critical Matters.
00:01:50
Speaker
And today we're going to really focus on a narrow time window, which is that first hour after we have success or we think we have success in a cardiac arrest and have
00:02:01
Speaker
return of spontaneous circulation or ROSC.
00:02:04
Speaker
So I guess the way we get started is you get ROSC, great job, now what?
00:02:11
Speaker
So I just want to hear your thoughts in terms of this critical hour, this, let's call it golden hour, and perhaps something that a lot of people are not paying as much attention to other topics, post-cardiac arrest, but that might have a very important impact on the ultimate outcome of our patients.
00:02:29
Speaker
Yes.
00:02:30
Speaker
The one thing that I noticed after many years of training and then being a young attending and being an older attending is that there's so much excitement.
00:02:39
Speaker
There's so much adrenaline.
00:02:41
Speaker
There's so much effort put into a cardiac arrest.
00:02:45
Speaker
And I don't want this to sound insincere or, you know, and insensitive.
00:02:50
Speaker
You know, downplaying the matter by any means, but the act of cardiac arrest, resuscitation is actually very, very simple.
00:02:57
Speaker
It's algorithmic.
00:02:58
Speaker
Certainly we can add things like ultrasound to help augment our decision making.
00:03:01
Speaker
But what I'm trying to say is that there's so many people who are in that room who are fighting for that person.
00:03:06
Speaker
And once we get ROSC, you'll see everyone just migrate out of the room.
00:03:11
Speaker
And the thing that I've noticed is that it's the things that we do post-RASC that probably matter the most to the patients, yet we have the greatest loss of resources right after.
00:03:22
Speaker
So what I have done is made a scheme or a framework where I could put into place what we're going to do for the first 15 minutes post-RASC, the next 45 minutes after-RASC.
00:03:35
Speaker
And then if your patient is stuck in the emergency room for a period after or even up in the ICU, the things we do for an hour and beyond.
00:03:43
Speaker
Because much of what we do is preventing the person from arresting again and ultimately improving their neurologic outcomes.
Monitoring and Stabilization Techniques
00:03:51
Speaker
And I believe that this whole idea of time-sensitive interventions is something that started in trauma but then became, I think, a common realization in cardiac care with STEMIs and time to balloon or door to balloon time, also with strokes.
00:04:10
Speaker
Then we talked about it in sepsis.
00:04:12
Speaker
But really, it's the...
00:04:15
Speaker
the realization that what we do early on in critical illness does have an impact downstream.
00:04:22
Speaker
And I think we're seeing that more and more in other areas.
00:04:25
Speaker
But today, I believe that, like you said, there's a lot going on post-cardiac arrest, and perhaps it's an area of opportunity for our listeners because it might be not something that they have systematically approached in that first hour.
00:04:39
Speaker
So I love your framework, and we'll start with the first 15 minutes.
00:04:43
Speaker
So we got ROSC.
00:04:45
Speaker
And the clock starts now.
00:04:46
Speaker
What do you do in those first 15 minutes, Haney?
00:04:50
Speaker
The first 15 minutes is about preventing that person from going back into cardiac arrest.
00:04:56
Speaker
I have looked for the statistic that I heard quoted, and I can't find the reference for it, but I heard it quoted once at a conference, and that is that 50% of people who get ROSC will go back into cardiac arrest.
00:05:07
Speaker
So again, I don't know how accurate it is, but based on my experience, it is a pretty high number of people who will flip back into cardiac arrest after we get our initial ROSC.
00:05:16
Speaker
So that first 15 minutes, everything in that package is done to prevent that person from slipping backwards and going into ROSC because, as you know, the more times you go into a rest, the worse off that person is.
00:05:30
Speaker
So we can go through these things, but again, the goal here is to push the patient forward to resuscitate them so we don't
00:05:37
Speaker
lose ROSC.
00:05:38
Speaker
Perfect.
00:05:39
Speaker
And I think it's important for our critical care listeners that you got ROSC.
00:05:44
Speaker
Your job is not to just go back to the ICU if you were in the ED or if you were on the floors, but really to keep leading the team in those first 15 minutes.
00:05:53
Speaker
So what's the first thing you would do, Changi?
00:05:56
Speaker
The first thing I do is I need some means of monitoring this person.
00:06:00
Speaker
And for me, if I'm, whether I'm on a rapid response on the floors or the person's in the ICU, doesn't have an A line or they're in the ED, I need to know what their blood pressure is constantly.
00:06:11
Speaker
The monitor's typically cycling every 15 minutes.
00:06:14
Speaker
That's not good enough for me.
00:06:15
Speaker
I need to know when this person is starting to lose their blood pressure.
00:06:18
Speaker
there's a higher likelihood that they're going to go back into a rest.
00:06:20
Speaker
So I cycle that cuff every one to two minutes.
00:06:23
Speaker
Now this is something you can tell your nurse to do, but I like to know how to do it because the nurses that I work with are probably doing other things that are important that they can only do.
00:06:32
Speaker
So I learned the monitors, I know how to adjust them, and I set the cycle time for every one to two minutes so I can constantly know what that blood pressure is.
00:06:40
Speaker
Excellent.
00:06:41
Speaker
And would you bring end tidal CO2 into the picture?
00:06:46
Speaker
Yeah, absolutely.
00:06:47
Speaker
Now, hopefully I'm using end tidal CO2 during the arrest for other things which are beyond the scope of this lecture, but I like end tidal CO2 to be on and waveform capnography for that matter because I'm not using it to see what their respiratory rate is or their CO2 necessarily is for ventilation.
00:07:06
Speaker
What I'm using it for is a surrogate for their cardiac output.
00:07:09
Speaker
And
00:07:10
Speaker
If you've paid attention to this and you've seen it before, you might have seen somebody's end tidal CO2 actually dropping right before they're about to code.
00:07:18
Speaker
And that's because their cardiac output is dropping and their CO2 is going down.
00:07:23
Speaker
I start to see their CO2 dropping.
00:07:25
Speaker
I know that I need to do something.
00:07:27
Speaker
If not, they're coding again.
00:07:30
Speaker
And I think that perhaps an underutilized tool, right, especially when you're outside of the ICU or in the initial phases, when you might not have an A-line, you might not have other hemodynamic monitoring, the end tidal CO2 in most of our patients with ROSC would be intubated.
00:07:45
Speaker
It's going to be very helpful in terms of giving us, like you said, that early warning sign, but also as a monitor of how we're perfusing, right?
00:07:56
Speaker
Absolutely.
00:07:56
Speaker
Absolutely.
00:07:57
Speaker
It's an underutilized tool I find in resuscitation.
00:08:01
Speaker
What comes next?
00:08:04
Speaker
The next thing I like to do is I'm probably going to be doing some procedures and managing my team.
00:08:09
Speaker
I don't want to lose sight of that patient and I can't constantly have my eyes
Medication and Team Debriefing
00:08:13
Speaker
glued to the monitor.
00:08:14
Speaker
So what I do is I set the pulse oximeter to have an auditory tone to that.
00:08:20
Speaker
And we all know how that sound is, the change in the pitch that we hear, you know, classically in the operating room.
00:08:25
Speaker
But this can be helpful when someone is for their heart rate.
00:08:28
Speaker
So the, the,
00:08:29
Speaker
The pace of the beeping is telling me what's happening to their heart rate.
00:08:32
Speaker
Are they getting more bradycardic?
00:08:34
Speaker
Is the signaling an appending arrest?
00:08:36
Speaker
Or are the SATs dropping indicating decreasing perfusion for the person?
00:08:41
Speaker
But this is just a nice auditory feedback that I have.
00:08:43
Speaker
And it's not blasting in the room because I don't want to distract the team and I don't want to have alarm fatigue.
00:08:49
Speaker
But it's just there enough so I can be doing other things, putting in lines, doing what I need to do, but I can constantly be monitoring the person with my ears when I'm not looking at that monitor.
00:08:59
Speaker
So really the initial interventions are all about being able to monitor that patient in a way that is sensitive in terms of potential changes that could indicate another cardiac arrest or the patient deteriorating once again.
00:09:15
Speaker
And you talked about cycling the blood pressure cuff, using entitled CO2 in these situations, and obviously setting up pulse hocks, alarms,
00:09:26
Speaker
to have that auditory feedback.
00:09:28
Speaker
And you did mention earlier, Haney, that other people can do this for you, but you obviously are a hands-on guy and knowing how to do it is probably something that we should all learn so we can teach other people, but make sure that our co-team takes these as ABC, right?
00:09:45
Speaker
We just do this, this, this, and this every single time and help the team understand how this can help us take care of this patient.
00:09:53
Speaker
I really like that.
00:09:58
Speaker
What would you be at this point considering once you've set up all these monitor devices?
00:10:05
Speaker
What's coming through your head right now, Hany?
00:10:09
Speaker
So my next step is why did this person arrest?
00:10:13
Speaker
And, you know, if we're looking at a out-of-hospital cardiac arrest, we want to look for things like ischemia.
00:10:20
Speaker
That would be the things that we would want to intervene on early on.
00:10:23
Speaker
Inpatient, we know it's more hypoxemia or something metabolic.
00:10:26
Speaker
But I want to know the why, because I have to fix that underlying problem, otherwise they're going to arrest again.
00:10:32
Speaker
And it seems very obvious, but I see this missed a lot.
00:10:36
Speaker
Look for ischemia.
00:10:37
Speaker
Try to be aggressive about finding it.
00:10:39
Speaker
Get your ECGs.
00:10:40
Speaker
Get serial ECGs.
00:10:42
Speaker
I actually call cardiology relatively early when I'm in the emergency department and I have these arrests because I want them on board and I want them to know about this patient.
00:10:51
Speaker
So ischemia, being aggressive about it.
00:10:53
Speaker
And again, if you're thinking about hypoxic or metabolic causes, get the diagnostics.
00:10:58
Speaker
And we'll go into that a little bit later.
00:11:00
Speaker
But that needs to be the next step because if you just worry about fixing numbers and doing things and you don't fix that problem, they almost certainly will go back into arrest again.
Advanced Cardiac Care Strategies
00:11:10
Speaker
And I think that an important point that often is missed by our clinical colleagues is that having the right information and the basic information and being able to share that with people we're consulting is very important, right?
00:11:26
Speaker
So if you were to call a cardiologist, the first thing they would ask you, what did the EKG show, right?
00:11:32
Speaker
So making sure that you're getting the EKG, that you're making sure those are going to be serial, that you get whatever tests you need to get, but that you have the available information.
00:11:41
Speaker
I think a lot of people are very eager to put a probe on somebody's chest, but that EKG can actually determine if the patient goes to the ICU or goes to the cath lab first.
00:11:53
Speaker
Yeah, you find STEMI, STEMI equivalents.
00:11:56
Speaker
And frankly, even if you don't find something that is a smoking gun, getting cardiology involved early in some centers might be the key to that patient's survival because they are the gatekeepers to things like intra-aeric balloon pumps, impellas, and VA ECMOs, things that will sustain that person.
00:12:12
Speaker
So getting the team involved and knowing that this patient exists in your center in some places is the way to start moving things forward.
00:12:23
Speaker
Excellent.
00:12:24
Speaker
In previous podcasts, we have discussed the use of ultrasound during cardiac arrest.
00:12:30
Speaker
What's the role of ultrasound in this phase?
00:12:34
Speaker
Well, hopefully people are using ultrasound during the code to try and find reversible causes.
00:12:39
Speaker
But even then, I want people to take away that you shouldn't be doing a detailed exam during arrest.
00:12:45
Speaker
The studies show that people spend more time than they should looking at ultrasound rather than getting the hands back on the chest.
00:12:52
Speaker
So our ultrasound during arrest is looking for immediately reversible causes, and we covered that before.
00:12:57
Speaker
What I want to do now that we got ROSC is now is the time we do a detailed exam.
00:13:02
Speaker
You can pick the exam that you want to do, but essentially I like to do a high map exam or a rush exam.
00:13:07
Speaker
That's looking at the heart.
00:13:08
Speaker
I'm looking at the right ventricle.
00:13:10
Speaker
I'm looking at the left ventricle.
00:13:11
Speaker
I'm looking for pericardial infusions.
00:13:13
Speaker
I'm looking for a hemothorax, a pneumothorax, blood in the belly, anything that could explain why this person arrested if I don't have a cause already.
00:13:22
Speaker
But my point here is now is the time you're going to do a detailed exam with ultrasound, not during the cardiac arrest.
00:13:29
Speaker
Excellent.
00:13:30
Speaker
And I would imagine that while you're doing that ultrasound as the bedside clinician intensivist, hopefully somebody is trying some blood work and laboratory work that you've instructed them to.
00:13:43
Speaker
And what would those be?
00:13:46
Speaker
You know, and I'll speak more so from an out-of-hospital arrest because sometimes as intensive as we get consulted to these arrests, but I want to know lactate.
00:13:56
Speaker
I think that's something we're very comfortable and we know the reasons why.
00:13:59
Speaker
It tells us how sick this person is, how much resuscitation is needed.
00:14:02
Speaker
But I also like to get not only an ABG, but I call it an ABG plus, and that is a lab with electrolytes.
00:14:10
Speaker
Some places have hemoglobin.
00:14:12
Speaker
I've seen some of these point-of-care ones even have
00:14:14
Speaker
creatinine, but it just gives me a little bit more data.
00:14:16
Speaker
And it is always perfect, as accurate as the serum tests, but it starts to tell me, oh, wow, the potassium is elevated.
00:14:23
Speaker
Maybe that's the reason why this person arrested.
00:14:26
Speaker
Then get your basic labs.
00:14:27
Speaker
I do like to get toxicology labs for patients who are out of hospital cardiac arrests.
00:14:32
Speaker
You know, we have this
00:14:34
Speaker
fixation when someone comes in cardiac arrest, it's got to be something cardiac, but we forget that people, they do stuff on the outside.
00:14:40
Speaker
Maybe it was a salicylate toxicity.
00:14:43
Speaker
Maybe it was acetaminophen.
00:14:45
Speaker
Maybe it was some other toxic congestion that may have led to this arrest.
00:14:48
Speaker
So I like to send those labs if I have no other reason why this person is arresting.
00:14:54
Speaker
And the final thing I get, I don't always send, but I draw is cultures because as I'm getting more history, which we'll talk about next from the family, I might find out that this person was actually very, very sick for the past couple of days, maybe even septic.
00:15:07
Speaker
And perhaps that's the reason this person arrested.
00:15:10
Speaker
So I'll pull those cultures while we're getting blood.
00:15:12
Speaker
I won't necessarily send them unless I have a history or a physical that leads to them being sent.
00:15:17
Speaker
Okay.
00:15:18
Speaker
You mentioned obviously getting more history and that takes different forms.
00:15:23
Speaker
But this is usually the time when we might be asking if we were responding to a code on the floors, the nurse was caring for this patient, what else do you, can you tell me about this patient, why the patient was here, what was happening.
00:15:35
Speaker
But you also mentioned, obviously, a lot of times these patients come from outside of the hospital into the ED, and this is a time when you would try to touch base with family there at the unit or at the bedside and really try to get more information.
00:15:48
Speaker
Can you give us examples of things that you're always curious about or things that you should be asking?
00:15:54
Speaker
Exactly.
00:15:55
Speaker
I never take for granted that this person is just arresting.
00:15:58
Speaker
There has to be more to the story.
00:16:00
Speaker
So if they're inpatient, I take one of the thousands of people who are in the room just watching this cardiac arrest happening.
00:16:05
Speaker
I point to them.
00:16:06
Speaker
I say, I need you to go look at the chart and give me a little bit more history because I'm running the code.
00:16:11
Speaker
But there are lots of people who are just basically holding up the wall, if you will.
00:16:14
Speaker
They're just standing there watching.
00:16:16
Speaker
So I send them out to get more history.
00:16:19
Speaker
If they're out of hospital cardiac arrest, then I get that same person who's staying there to call the family to talk to paramedics.
00:16:26
Speaker
What was the scene like?
00:16:27
Speaker
What are we missing for this person?
00:16:29
Speaker
Sometimes you will find some valuable information there.
00:16:32
Speaker
And so that will help me to integrate why this person's arresting.
00:16:36
Speaker
The other thing is doing a physical exam.
00:16:39
Speaker
In the hospital, maybe a little less important.
00:16:42
Speaker
But I like to look and see if there's any lines.
00:16:44
Speaker
Is there an AV fistula that we missed?
00:16:47
Speaker
As a person comes from out of hospital cardiac arrest, don't forget about things like traumas.
00:16:52
Speaker
This often gets forgotten because you might have an older person who's having cardiac arrest, and the assumption is, well, this is just simply cardiac.
00:16:58
Speaker
But there are people that have MVCs who fall, they rupture their spleens, their own warfarin, they bleed, and that's why they're arresting.
24-Hour Post-Arrest Care and Systematic Approaches
00:17:06
Speaker
So a very good but very quick physical exam can help you.
00:17:11
Speaker
And again, I'm looking for lines.
00:17:12
Speaker
I'm looking for fistulas.
00:17:13
Speaker
I'm looking for any signs of trauma.
00:17:17
Speaker
Excellent.
00:17:18
Speaker
Now, as we're approaching, I guess, the 15-minute mark, are there any initial drips or therapies that you are concerned with at this point, Haney?
00:17:29
Speaker
I think at this point, what I'd like to do is I want to not forget that the person was getting pushes of epinephrine, and that's likely wearing off now.
00:17:39
Speaker
And now we want to get some continuous blood pressure going for this person in the sense that we want to maintain their map, essentially their coronary perfusion.
00:17:48
Speaker
So I'll make sure that we have a norepinephrine drip is what I like to do.
00:17:53
Speaker
Hanging at the bedside.
00:17:54
Speaker
And I'll even ask for that as we're getting ROSC because that still takes a few minutes.
00:17:58
Speaker
Let's run that peripherally and let's get the person's blood pressure better.
00:18:01
Speaker
If we were giving, you know, amiodarone or whatever antiarrhythmic, do we need to convert them to a drip to treat their arrhythmias that they had?
00:18:09
Speaker
And then the last thing not to forget is that this person very well might be aware as you're getting perfusion back, even though they may not be doing anything purposeful.
00:18:19
Speaker
Do we need to give that person some opioid?
00:18:21
Speaker
Do we need to give them something that's hemodynamically neutral as sedation?
00:18:25
Speaker
Maybe something like a ketamine type of drug, but always try to remember that there's a person there and they may be somewhat conscious of what's happening and making that person comfortable in a hemodynamically neutral way.
00:18:37
Speaker
Perfect.
00:18:38
Speaker
So I would like to take an imaginary pause here after the first 15 minutes.
00:18:45
Speaker
And there's something that we talked about offline and that I've heard you talk about a lot during cardiac arrest that I believe is crucial for our learning and improving what we do.
00:18:57
Speaker
But it's something that is not done routinely at all cardiac arrest.
00:19:00
Speaker
And that is debriefing the team.
00:19:02
Speaker
Could you talk about that?
00:19:03
Speaker
And is this the place where you might consider doing that and why?
00:19:09
Speaker
Every time I give this talk live and I talk about debriefing, if I listen very, very closely, I'll hear like 100 eyes clicking and rolling because people always say debriefing.
00:19:19
Speaker
There's no time to debrief.
00:19:21
Speaker
You know, we have to keep going and the department's falling apart and there's other patients to see.
00:19:26
Speaker
And I appreciate that.
00:19:27
Speaker
But if you don't strike when the iron is hot, you're never gonna change anything.
00:19:32
Speaker
And I just simply go for five minutes of a debrief for the people who are in the room.
00:19:37
Speaker
I pick one thing that could be done better, one thing that was really good, and some things to consider for the future.
00:19:44
Speaker
I just keep it as low-hanging fruit, and if it turns into a more formal discussion, that's great.
00:19:47
Speaker
We can do that later, but I can't let all the people who invested time, who have literally sweat over this patient, to walk out of there thinking that everything was great.
00:19:57
Speaker
And I choose this time, as we're doing things, just to say, let's go over this.
00:20:02
Speaker
And there have been times where we find some time later in the shift to go back and talk about more detailed things, but more times than not, that's the only time we'll debrief.
00:20:09
Speaker
So just take that time out with your team because you'll never make progress as a healthcare group.
00:20:15
Speaker
Just don't take those five minutes.
00:20:16
Speaker
And we always have five minutes to spare to talk to our team and make them better.
00:20:21
Speaker
And I think it's worth emphasizing that if you truly believe that you don't have time to debrief, what you're saying is we don't have time to learn
00:20:32
Speaker
And we don't have time to try to be better.
00:20:34
Speaker
So we're going to do whatever we do every single time with no intention of improving.
00:20:38
Speaker
And that obviously is something that most people would not want.
00:20:43
Speaker
I find it very interesting that when I think of a cardiac arrest team that really kicks ass, I would think of something equivalent to the Navy SEALs, right?
00:20:54
Speaker
The most proficient and efficient and badass unit within the military.
00:21:02
Speaker
And what I've read, Haney, is that the SEALs will have an after activity review for every single mission that they do, no matter what the nature of
00:21:13
Speaker
the outcome, the duration.
00:21:15
Speaker
And it's something that is really embedded in their DNA and they keep it simple, right?
00:21:21
Speaker
And they have a different algorithm, but I think that the three things that you mentioned are a perfect framework that we can apply to
00:21:30
Speaker
at any given time during our clinical shift.
00:21:33
Speaker
And we can definitely utilize for these cardiac arrests, which are, what did we do well?
00:21:38
Speaker
What could we do?
00:21:40
Speaker
What could we do better?
00:21:41
Speaker
Or what didn't go so well?
00:21:43
Speaker
And what are we going to do different next time?
00:21:45
Speaker
Three points that really can be discussed very quickly.
00:21:49
Speaker
It can help us.
00:21:51
Speaker
And I think it's also important to recognize that the reality for most of our intensivists is that they're not going to run cardiac arrest with the same people every single time.
00:21:59
Speaker
There might be some overlap, but if you go to the floor, the nature of what we're seeing in healthcare right now, it is very possible that there's new people there.
00:22:09
Speaker
And not only do you want to teach them, but you also want to learn from their perspective.
00:22:14
Speaker
Yeah, absolutely.
00:22:15
Speaker
And I'll tell you one more thing to build on that point.
00:22:20
Speaker
When you do that, when you plant that seed, you're teaching somebody else that person is going to teach the next person.
00:22:27
Speaker
And then it just spreads through the hospital.
00:22:29
Speaker
Because when I go to the floor, as you said, I might never see that person again.
00:22:34
Speaker
But that person...
00:22:36
Speaker
who you've taken the time to teach and you've changed them is going to teach the next person during a code.
00:22:41
Speaker
And I used to be very upset when I was a young attending, very hot headed when people didn't do the right things during the code.
00:22:47
Speaker
But it was only after a short period of time where I realized it's my fault that people aren't doing the right things because I'm not spending the time to teach them.
00:22:55
Speaker
We all know that we're time constrained.
00:22:57
Speaker
We all talk about sim, but the reality is, is that very few people get to do simulations.
00:23:02
Speaker
Very few people get to improve their practice.
00:23:04
Speaker
So that moment right there in real time might be the only education that that person gets on cardiac arrest.
00:23:11
Speaker
So it's up to us.
00:23:12
Speaker
It's up to us who are running the codes to spend that time and make the team better.
Reflective Practice and Learning from Events
00:23:17
Speaker
Not to mention that no matter how much you know,
00:23:21
Speaker
and how proficient you are, you have blind spots, and there's probably opportunities for you as the lead of that code to also improve.
00:23:27
Speaker
So it's about learning as a team, right?
00:23:29
Speaker
And there might be things that you can actually take home to make your leadership or your cardiac arrest performance better.
00:23:40
Speaker
I'll give you, can I give you one quick example of that?
00:23:42
Speaker
Yes, absolutely.
00:23:44
Speaker
Oh, I should wait to get your response.
00:23:46
Speaker
Would you like to hear an example of that?
00:23:48
Speaker
Absolutely.
00:23:49
Speaker
Always.
00:23:51
Speaker
So last year, I was running a code with one of our fellows, and this fellow, getting ready for graduation, phenomenal, one of the nicest, kindest people, and we were doing this same exercise after a code.
00:24:07
Speaker
And, you know, me always wanting feedback was asking, you know, what could we do better?
00:24:12
Speaker
And in a circle of people, the fellow said to me, I think you could –
00:24:20
Speaker
you come across as very aggressive during the code barking orders, you could be a little kinder when you deliver your orders.
00:24:27
Speaker
You just don't have to be as aggressive during code.
00:24:30
Speaker
Everyone's listening to you anyway.
00:24:32
Speaker
And for all my years during a code with having that game face on that, like Kobe Bryant, you know, like stare during a code, all business, I realized that I could be doing things better.
00:24:44
Speaker
So
00:24:45
Speaker
What I'm trying to say is that this isn't just for you as the code leader imparting wisdom to others.
00:24:52
Speaker
There's very well changes that you could be making that you're not realizing that you're doing incorrectly for your team.
00:24:59
Speaker
Absolutely.
00:25:00
Speaker
So we've done the debrief and now we're embarking in the next 45 minutes.
00:25:05
Speaker
So what do we think about here, Haney?
00:25:07
Speaker
Haney.
00:25:09
Speaker
Well, there's one more thing that I put in the first 15 minutes that I'll just touch on briefly, and that's the airway.
00:25:16
Speaker
My personal belief, and this is backed by data, is that during a cardiac arrest, we shouldn't be doing endotracheal intubation.
00:25:24
Speaker
It's a talk for a different podcast.
00:25:27
Speaker
But I believe doing a supraglottic airway, whether that's an LMA, eye gel, whatever you want to do is the way to get your initial oxygenation and ventilation.
00:25:37
Speaker
But during that first 15 minutes, that's when we're going to change it out after we get ROSC and put in a definitive airway, whether they're pre-hospital or in-hospital.
00:25:46
Speaker
That's the only point I want to say to close out that first 15 minutes.
00:25:49
Speaker
Perfect.
00:25:49
Speaker
If you have other comments on that, we can go on to the next 45.
00:25:53
Speaker
Well, we could dive into that much deeper.
00:25:56
Speaker
And like you said, it might be a podcast for another day.
00:25:59
Speaker
But where the patient has been intubated or had an LMA, I think that your point is very well taken.
00:26:05
Speaker
During that first 15 minutes when we're going to probably eventually move the patient to diagnostics or the CT,
00:26:11
Speaker
to the cath lab, to the ICU, whatever, you want to make sure your airway is secured.
00:26:15
Speaker
So absolutely, I think that would fall in the first 15 minutes.
00:26:19
Speaker
So we debriefed the team, taking care of those critical items in the first 15 minutes.
00:26:24
Speaker
And now we're going to go to the next 45 of this golden hour.
00:26:30
Speaker
The first 15 minutes was about preventing the patient from going back into cardiac arrest.
00:26:34
Speaker
Now, hopefully, with the things that we've done and the patients more stable, we're moving into the fine-tuning phase of optimizing the patient for long-term success.
00:26:45
Speaker
I believe this starts at the ventilator.
00:26:47
Speaker
We've probably been bagging the patient or we've thrown the patient on some generic settings in the first 15 minutes.
00:26:53
Speaker
Now we have to start looking at the vent and saying, what's right for this person?
00:26:57
Speaker
Are we giving this person the appropriate amount of pee?
00:27:00
Speaker
Are we doing six to eight cc's per kg?
00:27:02
Speaker
Is the tidal volume appropriate?
00:27:04
Speaker
Now's the time we should be getting back our blood gases and avoiding things like hyperoxia or hypercarbia.
00:27:11
Speaker
And elevate the head of the bed.
00:27:13
Speaker
All these little things when it comes to respirations and ventilator are important.
00:27:17
Speaker
But I put this into the next portion of the 45 minutes because these are the things that are going to set the person up for success.
00:27:25
Speaker
Excellent.
00:27:26
Speaker
And what are things that you would consider important in the ventilator?
00:27:31
Speaker
Obviously, depending on what situation is, but as you think about what would be ideal settings, we talked a little bit pre-recording that there's been some new studies at the box trial that talks a little bit about this.
00:27:49
Speaker
But any specific recommendations that you have for our listeners?
00:27:58
Speaker
I think what we're looking for is we want to, the gas is going to help define.
00:28:03
Speaker
I think it starts there.
00:28:05
Speaker
We're going to look at the blood gas.
00:28:06
Speaker
Obviously, they're acidosis.
00:28:08
Speaker
We're going to increase our minute ventilation to adapt for that.
00:28:11
Speaker
But we just want to avoid doing too much for them.
00:28:14
Speaker
If you have a person whose blood gas is okay,
00:28:17
Speaker
We don't want to overventilate that person.
00:28:19
Speaker
We want to minimize the amount of positive intrathoracic breath to decrease coronary perfusion, all that usual stuff.
00:28:25
Speaker
So, you know, doing a normal respiratory rate anywhere between 12 to 14, I like to go for six to eight cc's per kg unless there's another reason to go above lung protective type strategies.
00:28:37
Speaker
And then, again, just aiming for a normal PCO2, if we allow them to be too hypercarbic, we run the risk of cerebral vasodilation and possibly increasing the ICP for that person, a person who might already have cerebral edema, reperfusion injury.
00:28:57
Speaker
Perfect.
00:28:58
Speaker
So we start with mechanical ventilation.
00:29:01
Speaker
Is this a time when you start thinking of what devices, catheters, this patient should have?
00:29:07
Speaker
Perhaps you're already in an ICU setting and start thinking about this.
00:29:12
Speaker
I know that there's been a huge push to not put central lines, to not do Foley catheters, but is this the right patient to have that attitude?
00:29:23
Speaker
What are your thoughts, Haney?
00:29:26
Speaker
My belief is that during a cardiac arrest and shortly thereafter, you don't need anything but a good peripheral line and an IO and an A-line.
00:29:37
Speaker
That's my personal belief.
00:29:38
Speaker
So if you're on the floor and you're getting this person resuscitated central line, there should be no triple lumen kit on the field.
00:29:45
Speaker
That's a lot of sharps and unnecessary when you can get two IOs in and now you have two central lines.
00:29:50
Speaker
When they get back to the ICU, sort of the home base where you can do stuff,
00:29:55
Speaker
My first go-to access would be to do an arterial line.
00:29:59
Speaker
There's a few reasons for this.
00:30:01
Speaker
The first is we already have a central line in the IOs and those can last for a good long time.
00:30:05
Speaker
The A-line is important because now it can monitor.
00:30:08
Speaker
We don't have to cycle that cuff every two minutes.
00:30:11
Speaker
Now on a second by second basis, we can know what the blood pressure is.
00:30:14
Speaker
I also know that if we lose ROSC,
00:30:18
Speaker
When we do a rhythm check, I don't need to go fishing around to feel for a palpable pulse.
00:30:23
Speaker
I have the arterial line there telling me what the blood pressure is or if there is in fact a pulse.
00:30:30
Speaker
And the last reason, well, there's actually two reasons.
00:30:32
Speaker
The second to last reason I like it is because I also have a measurement of the diastolic blood pressure.
00:30:38
Speaker
And we often don't think about looking at the diastolic blood pressure, but during cardiac arrest, having a diastolic blood pressure is going to estimate what the coronary perfusion pressure is
00:30:47
Speaker
That's really everything that we're doing in cardiac arrest is trying to get better perfusion to the coronaries.
00:30:53
Speaker
And the last reason is not for every center, but in some centers, you may be doing VA ECMO and getting an A-line in that patient.
00:30:59
Speaker
And we're talking femoral here, by the way.
00:31:01
Speaker
This is always a femoral A-line.
00:31:03
Speaker
Should have prefaced that.
00:31:04
Speaker
But when we get ephemeral A-line in, now we have a gateway to cannulate that person should we wind up doing VA ECMO for that person.
00:31:12
Speaker
So A-line is my first go-to procedure when we get that person in the first 45 minutes.
00:31:18
Speaker
And then after that, if you have the time and the means, you could put triple lube in catheters because certainly this person is going to require a lot of continuous drips.
00:31:26
Speaker
But that's my stance on A-lines and central lines.
00:31:29
Speaker
What about Foley catheters?
00:31:32
Speaker
You know, we talk about CAUTIs and all this work.
00:31:36
Speaker
This person just had a cardiac arrest.
00:31:38
Speaker
I need to know how well they're perfusing their kidneys, and I want a Foley catheter in.
00:31:43
Speaker
And we all know that the kidneys are great estimators for the internal physiology of a person.
00:31:49
Speaker
So I'll put in a temperature-sensing Foley for this person because we'll be doing TTM on this person anyway.
00:31:57
Speaker
But I get a Foley catheter, and I do use it as a means to measure how well they're perfusing.
00:32:06
Speaker
Perfect.
00:32:06
Speaker
I think that the point also on the A-line is an important one, right?
00:32:09
Speaker
Because we see these pendulums.
00:32:11
Speaker
We go from one extreme to the other.
00:32:13
Speaker
In the past, everybody got lined up.
00:32:15
Speaker
And then people are moving away from that.
00:32:17
Speaker
But I do believe that, like you said, these patients just had a cardiac arrest.
00:32:21
Speaker
There is useful information.
00:32:23
Speaker
There are clinical reasons how this can be helpful for us.
00:32:27
Speaker
And doing it early is actually going to always have an impact.
00:32:31
Speaker
So definitely something to think about.
00:32:33
Speaker
And I just want to go back to your first point about the IOs, which, again, I believe are underutilized in many places.
00:32:42
Speaker
And the old days when I was an intern, when people were fumbling around during a cardiac arrest trying to get access,
00:32:48
Speaker
No excuse for that, right, Haney?
00:32:50
Speaker
Just put in the IOs, get it done with, and you can figure it out later.
00:32:55
Speaker
There's so many reasons to not do a triple lumen during a code.
00:32:59
Speaker
I've seen people getting stuck during a code.
00:33:02
Speaker
I've seen people stick the retroperitoneum during a code.
00:33:05
Speaker
I've seen people just fishing around with needles during a code.
00:33:09
Speaker
And it takes time.
00:33:10
Speaker
All of that takes time.
00:33:11
Speaker
IOs, you can put four central lines in, two in the shoulder and two in the tibia, and you have all the access you need.
00:33:19
Speaker
You can put anything you want in an I.O.
00:33:22
Speaker
And I agree with you.
00:33:23
Speaker
It is underutilized, but the good news is it's starting to pick up and more and more people are starting to go for that first.
00:33:29
Speaker
Excellent.
00:33:30
Speaker
So we've talked about the devices and catheters.
00:33:34
Speaker
We talked about mechanical ventilation.
00:33:36
Speaker
I would imagine that during this next 45 minutes, also understanding our strategy for hemodynamic support is going to be important.
00:33:46
Speaker
Absolutely.
00:33:46
Speaker
And we're going to go back now, now that we have an arterial line and an accurate assessment of blood pressure, we're going to make sure that we get to a MAP goal that's appropriate.
00:33:56
Speaker
You know, obviously there's data now that shows us that the previous thought was that patients who are hypertensive, we want to go for higher MAP goals.
00:34:03
Speaker
It turns out that 65 just seems to be good enough for most patients.
00:34:07
Speaker
So get the vasopressors on, go for a MAP goal of 65, and then be aggressive about sticking there.
00:34:14
Speaker
I will say this is one of my casual observations, and it's one of the things that I do.
00:34:20
Speaker
is I aim for a map that is a little bit higher than a map goal.
00:34:23
Speaker
I noticed that there's a hesitancy to, if I say a map goal is 65, there's a hesitancy to stay at 65.
00:34:31
Speaker
They'll always go to 63 or 60 because they don't want to go up on the vasopressors.
00:34:36
Speaker
So I'll ask for a map goal that's a little bit higher, 68 or even just 70 as a round number, because I know we're going to,
00:34:42
Speaker
fail to hit that 70 and get to 65.
00:34:45
Speaker
But our goal should be 65 for our maps using, you know, the usual suspects for vasopressors using norepinephrine as first line and then second line vasopressin.
00:34:55
Speaker
Now we'll talk a little bit about what happens if cardiogenic shock is at play, whether or not we need to introduce onotropes, but if we're just talking about vasodilatation, those are the agents and those are the goals.
00:35:06
Speaker
Perfect.
00:35:07
Speaker
And in terms of other concerns regarding hemodynamic support, is this a time that perhaps you would consider getting a formal echocardiogram or a full echocardiogram?
00:35:20
Speaker
Are these things that are at this time or are going to be later?
00:35:23
Speaker
I'm lucky in the sense that...
00:35:28
Speaker
I trained with ultrasound.
00:35:30
Speaker
I feel very good at looking at echoes.
00:35:31
Speaker
We also have fellows who are very good at echoes.
00:35:34
Speaker
I would say at this point, if you have the means to look at the heart again comfortably, take a look at the heart again.
00:35:41
Speaker
If you have a patient who's climbing up on vasopressors, this is the point in the resuscitation where you have to ask the question, did something else change or is there something else?
00:35:50
Speaker
Is there cardiogenic shock at play?
00:35:52
Speaker
At my institution, I feel comfortable looking with the fellows at it.
00:35:56
Speaker
If you don't, then I would get a cardiology echo or one with a sonographer so that they can come and take a look at the ventricles.
00:36:04
Speaker
More or less what we're looking for is to see if there's any RV or LV failure in this person, or if you didn't do it before, to see if there's any other reversible causes that were missed, like a tamponade, for example.
00:36:16
Speaker
Perfect.
00:36:16
Speaker
And you did mention a little bit of cardiogenic shock.
00:36:19
Speaker
So let's assume that you now are putting things together and you are believing that there's a component of cardiogenic shock going on.
00:36:28
Speaker
What are the type of inotropes that you would consider adding at this time?
00:36:33
Speaker
Post arrest, I'm a fan of low dose epinephrine.
00:36:38
Speaker
Dobutamine is okay, but there's arrhythmogenicity with it.
00:36:41
Speaker
And the last thing I want to do for this person is create an arrhythmia.
00:36:45
Speaker
So using a dose of 0.01 mics per kilo per minute to 0.05 mics per kilo per minute, you want to remember numbers anywhere between one and five for the average adult would be just fine as an anatrope for this person for support.
00:37:02
Speaker
Milrinone is okay, but you know, milrinone brings with its risks of hypotension.
00:37:08
Speaker
And the last thing I want to do for a person who's at rising vasopressors is create more vasodilation for that person.
00:37:13
Speaker
So that's my approach when it comes to inotropy chemically.
00:37:16
Speaker
The other thing to consider and doesn't happen that often is if the person is having refractory bradycardia.
00:37:24
Speaker
And is that the reason why the person is in shock?
00:37:26
Speaker
And is there a need to increase the heart rate?
00:37:29
Speaker
I see that more on the ED side when people come in with overdoses, calcium channel blockers or beta blockers.
00:37:36
Speaker
So maybe we'll keep that separate.
00:37:37
Speaker
But those would be the inotropies of choice using epinephrine at the bedside.
00:37:43
Speaker
Perfect.
00:37:43
Speaker
The other thing that you mentioned earlier, Hengi, when you were talking about the A-line was ECMO.
00:37:49
Speaker
Could you just give us some thoughts on terms of when to involve ECMO?
00:37:54
Speaker
Is this the time you're thinking about it and who?
00:37:56
Speaker
And obviously, this might also be very institution-specific based on your capacity, your capabilities to do ECMO.
00:38:03
Speaker
But you did mention that earlier, and I just wanted to kind of ask you, where would that fit?
00:38:10
Speaker
This is one of the reasons that I suggested getting cardiology involved early in the case, because if your institution
00:38:19
Speaker
does ECMO, there's going to be a team that has to be notified and involved.
00:38:23
Speaker
In our place, it's critical care as well as cardiac surgery.
00:38:28
Speaker
But if you get to the point where you are confident that the person is having ventricular dysfunction and ECMO could be helpful, call for that early.
00:38:38
Speaker
Call for it early even if you suspect it in the first 15 minutes because it takes time to generate the team.
00:38:44
Speaker
Even if you don't have the capabilities in your hospital, maybe it's time to start calling other hospitals and seeing what's available in terms of transport.
00:38:51
Speaker
All these things take time.
00:38:53
Speaker
It's very rare you can get ECMO instantly at the bedside.
00:38:57
Speaker
Even in a place that has ECMO, it's still going to take about 30 minutes to get the entire team and perfusionists and all the lines and cannulations to get going, in my experience.
00:39:06
Speaker
So think about it and then call early.
00:39:08
Speaker
And if you're wrong, at least the team is notified.
00:39:11
Speaker
But if you're right, you're not wasting any time with getting those resources to that patient.
00:39:16
Speaker
Perfect.
00:39:17
Speaker
Is there anything else that you would consider within that first 45 minutes?
00:39:22
Speaker
So obviously the focus has been on supporting the lungs and the hemodynamic support.
00:39:28
Speaker
So mechanical ventilation, hemodynamic support.
00:39:30
Speaker
We talk about the devices and catheters.
00:39:33
Speaker
What else would fall in that next 45 minutes?
00:39:37
Speaker
that that's pretty much it at this point we're just making sure we're setting this person up for success with their physiology getting them back to homeostasis post-arrest perfect and really all the things that we talked about doing them right and doing them systematically and we'll lead up that hour very quickly right we talked about it go ahead
00:40:01
Speaker
I was going to say most people will probably find that it goes over an hour and that's okay.
00:40:05
Speaker
These are just frameworks for what you should be doing for your patients post arrest.
00:40:10
Speaker
Perfect.
00:40:11
Speaker
So we've done all the things that we've talked about, Haney.
00:40:15
Speaker
We've taken care of those first 15 minutes.
00:40:18
Speaker
We've debriefed.
00:40:20
Speaker
We've brought the patient to the ICU.
00:40:22
Speaker
We've focused on mechanical ventilation, on hemodynamic support, and we've
00:40:27
Speaker
What happens afterwards?
00:40:29
Speaker
So beyond that first hour, let's talk about at a high level of some of the big things.
00:40:34
Speaker
The way I think about this, and please, I mean, comment and critique my framework, is that probably between that first hour or first 24 to 48 hours, we're working on supporting the patient, minimizing damage, protecting the brain, setting expectations for the family,
00:40:54
Speaker
really trying to figure out what else happened, any diagnostics.
00:40:58
Speaker
But the reality is that it would take some time for us to really figure out what the ultimate outcome of that patient is from neurologic status.
00:41:05
Speaker
So we would talk about prognostication 72 hours and beyond.
00:41:10
Speaker
And then there's a lot of things that happen after that.
00:41:12
Speaker
We don't want to go that far.
00:41:13
Speaker
But in that first 24 hours beyond the first hour, what are things or items that you would consider to be relevant?
00:41:22
Speaker
I call this ICU stuff because if they're stuck in the ED, these are things that should be done, will optimize the patient's success.
00:41:33
Speaker
But sometimes you feel like, oh, that can only be done in the ICU.
00:41:37
Speaker
So we'll go into that a little bit.
00:41:39
Speaker
And, of course, if they're in the ICU, these are things that certainly should be done.
00:41:42
Speaker
The first thing is for the person who's comatose is getting an EEG for that person.
00:41:49
Speaker
We want to make sure that that person's not having non-convulsive status epilepticus.
00:41:53
Speaker
In the ICU, I think we get that.
00:41:55
Speaker
In the ED, it's easily forgotten because that person's stable.
00:42:00
Speaker
We sort of say they're admitted to the ICU.
00:42:02
Speaker
But just getting on the phone with neurology and just asking them to do a spot EEG is so important.
00:42:09
Speaker
It's in the AHA guidelines.
00:42:11
Speaker
And device manufacturers have come along and made these point of care EEG devices that are extremely helpful at the bedside and can help tell you whether or not that person is seizing.
00:42:22
Speaker
Because again, we went through all this work to get this person alive.
00:42:26
Speaker
We'd like to get them back home to their families in the best neurologic shape possible.
00:42:30
Speaker
And so getting a point of care or a spot EEG would be one of those ways.
00:42:35
Speaker
So again, that's after the first hour stabilization, but that's the first part of my algorithm after that first hour.
00:42:42
Speaker
Perfect.
00:42:43
Speaker
What about fluids?
00:42:45
Speaker
We talked a little bit about hemodynamic support, but a lot of research over the last couple of years about types of fluids.
00:42:54
Speaker
We've talked with you about fluid responsiveness extensively, but do you have any particular comments on fluids for these patients?
00:43:04
Speaker
This is typically where I go around and turn off all the fluids.
00:43:07
Speaker
Someone somewhere is going to flick on a maintenance dose because the person's hypotensive.
00:43:13
Speaker
I try to just turn off all the fluids.
00:43:15
Speaker
This person in the first hour probably got...
00:43:18
Speaker
More than the volume that they needed with all the antibiotics and all the pushes and all the boluses.
00:43:23
Speaker
They don't need any more volume.
00:43:25
Speaker
They're likely fluid resuscitated and they're more likely to be volume overloaded.
00:43:30
Speaker
So here's where I try to cut off any exogenous fluids for this person and just focus on the vasopressor management if they're still hypotensive.
00:43:40
Speaker
Perfect.
00:43:42
Speaker
What about, I don't want to go too deep because we've talked about this in other episodes and there's obviously ongoing debate right now based on the TTM2 trial, but in terms of targeted temperature management, where do you fall?
00:43:57
Speaker
This obviously would be part of ICU stuff at this point for sure.
00:44:02
Speaker
Yeah, I'm in line with, you know, keeping people 36 degrees.
00:44:07
Speaker
Obviously, let me start off by saying you should probably have the whole hospital on the same page about what you're doing.
00:44:15
Speaker
I do know that there are some centers that still want certain patients to be 33, you know, people at high risk for dental neurologic injuries.
00:44:25
Speaker
There's the TTM2 trial that was published not too long ago that says maybe we can even get to avoiding fevers and just keeping people normal thermic.
00:44:35
Speaker
Whatever you decide to do, just be sure that everyone's on the same page and with a protocol in place.
00:44:41
Speaker
And that involves talking to all corners of the hospital, the ED, the ICU, the PACU, so everyone's on the same page.
00:44:49
Speaker
But we're at, and where I'm at is 36, works just fine.
00:44:54
Speaker
And so that's the protocol that we do.
00:44:55
Speaker
Perfect.
00:44:56
Speaker
And I think that what people forget is that
00:45:00
Speaker
The term that we've all grown up to talk about was therapeutic hypothermia, which for many reasons had deficits.
00:45:10
Speaker
And after an international consensus conference, the term of targeted temperature management was proposed.
00:45:16
Speaker
And definitely we should have a target and we should manage the temperature.
00:45:22
Speaker
And I agree 100% with you, Haney.
00:45:25
Speaker
that the most important thing is for people to look at the available literature pending, I mean, further changing the guidelines, although the ill court guidelines have changed a little bit and agree as a practice, as a team, as a hospital, this is what we do and do it well.
00:45:41
Speaker
But you are definitely setting a target and you're managing that temperature actively.
00:45:45
Speaker
So I think that that's an important point.
00:45:47
Speaker
And that would be part of that ICU stuff that you're doing in that post first hour.
00:45:51
Speaker
Is that correct?
00:45:54
Speaker
Absolutely.
00:45:55
Speaker
You know, there's enough things going on that if you're in the ED, don't be mad at your ED staff.
00:46:00
Speaker
If it's 30 minutes out, they're not being, you know, cooled, if you will.
00:46:04
Speaker
There's enough things that need to be done and you have time to get that TTM, but it's definitely part of my after the first hour bundle.
00:46:13
Speaker
The other thing that I wanted to ask you about, since you live in both worlds, the ED and the ICU, is the role of setting expectations for families early and how valuable that can be.
00:46:29
Speaker
And I guess that would be part of that golden hour as well, since it's likely that in that first hour you might touch base with the family for the first time.
00:46:40
Speaker
Right.
00:46:40
Speaker
We're going to meet the family.
00:46:42
Speaker
We're going to talk to them.
00:46:43
Speaker
And they have questions.
00:46:44
Speaker
And they want to know what's next and what's going to happen.
00:46:47
Speaker
What I've observed in my career so far is...
00:46:52
Speaker
a lot of passive conversations with family.
00:46:56
Speaker
This happens with nursing, with techs, with residents, even with attendings who use things like, you know, the person's not moving or they're fixed and dilated or terms are thrown around and it sends mixed signals to the families.
00:47:12
Speaker
What I've seen in the literature and what I've witnessed is that the best thing to do is just to give them the facts that are present.
00:47:18
Speaker
Your loved one was down for 45 minutes.
00:47:22
Speaker
CPR was done.
00:47:23
Speaker
We had ROSC four times.
00:47:26
Speaker
The chances are that this person is going to have neurologic survival.
00:47:30
Speaker
It's somewhat low, but we're going to keep doing everything that we can.
00:47:33
Speaker
But...
00:47:34
Speaker
to avoid putting too much stock into just things that are at the bedside or physical findings, because we do have to give this person a proper period of time, 72, 96 hours, before we can formally neuro-prognosticate that person.
00:47:51
Speaker
And then we'll see what happens.
00:47:53
Speaker
So it's a mixture of honesty with the family without giving them false, you know, false, um, uh,
00:48:00
Speaker
it's not false hope, but, you know, a sense of panic and doom just by things that are classically being found, like fixed and dilated, or they're not moving, or they had a seizure.
00:48:11
Speaker
Those things don't really communicate.
00:48:12
Speaker
The time to prognosticate is after this, when they're in the ICU for a few days.
00:48:17
Speaker
And it also allows time for you to build rapport with the family to better understand them.
00:48:22
Speaker
It also gives insight into what you think the next step for that patient would be should they not wake up neurologically viable.
00:48:30
Speaker
And I think that that's a key point, right?
00:48:32
Speaker
Setting the expectations.
00:48:33
Speaker
And the truth is that the first 24 hours or the first couple of hours, it's very difficult to figure out.
00:48:41
Speaker
Even if somebody had findings of brain death, you would have to make sure there's no confounders, right?
00:48:45
Speaker
Which are very common in these post-arrest situations.
00:48:49
Speaker
So I do believe that setting the tone, like you said, for what's next and what to expect is
00:48:54
Speaker
is very important.
00:48:55
Speaker
And to be honest, the outcome of these patients in general can be poor, but we still don't have enough information.
00:49:03
Speaker
We'll have to see what happens over the subsequent days.
00:49:07
Speaker
So is there anything that we missed in that golden hour, Haney, that you want to bring back or you want to make sure that we emphasize?
00:49:19
Speaker
The only thing that I'll say is I see this newer tendency for people to get CT scans during this period, which I'm okay with.
00:49:29
Speaker
But my stance on CT scans are they should be the thing that the patient gets after all these other things are started.
00:49:36
Speaker
So if I have a patient who's in the emergency department, I would not put this in the first 45 minutes of getting a head CT for that person, unless I think that that is the reason for the person's arrest.
00:49:48
Speaker
If we think that the person is having blood in the belly and we need to diagnose that, certainly get that initial CT scan as part of your management.
00:49:56
Speaker
But I see far too often people skipping over getting definitive vasopressors and fine-tuning things because we have to get over to the CT and do a pan scan for the person.
00:50:04
Speaker
If you have a good reason or a good hypothesis for why that person did a CT scan, don't take them out of that first 45 minutes and just get a CT scan just as a checkbox.
00:50:16
Speaker
I'm more than happy to get the CT scan on the way up to the ICU and put that into the next hour
00:50:22
Speaker
I know that's controversial.
00:50:23
Speaker
I know that people want to do that, but the data just doesn't play out to show that early CT scanning for people post-cardiac arrest is very fruitful or helpful unless you have a reason to do a targeted CT scan to diagnose that patient's cause for arrest.
00:50:38
Speaker
And in any event, it's probably not going to change management substantially in that one first hour, right?
00:50:45
Speaker
So one of the things that we've learned during the arrest itself is that anything that deviates our attention from
00:50:53
Speaker
effective CPR is a problem.
00:50:57
Speaker
And during this first hour, anything that deviates us from supporting the patient and establishing all the right therapies could be a problem and it's not going to change the care of that patient substantially.
00:51:08
Speaker
You can get the CT scan a little bit later.
00:51:12
Speaker
Exactly.
00:51:12
Speaker
Avoid distraction, focus at what's in front of you, and then get the other information later.
00:51:18
Speaker
The one thing that we didn't touch on specifically, but I guess would be part of hemodynamic support or even in the first 15 minutes for the initial drips, any comments on antiarrhythmics?
00:51:33
Speaker
Yeah, I mean, if the person had an arrhythmia that was defibrillated or required intervention, then the continued use of them is what I would do.
00:51:44
Speaker
I'm not aware of any data that says that prophylactic antirhythmics would be very helpful for a person.
00:51:50
Speaker
Perfect.
00:51:51
Speaker
Well, I think we covered a lot that has to be compressed in a short amount of period of time post-arrest.
00:51:59
Speaker
But I do believe, Haini, that as you've done, I mean, by highlighting this in some of your talks, that it is a danger area or a danger time period for our patients.
00:52:10
Speaker
And that instead of talking about obscure neurologic findings that have no relevance to
00:52:17
Speaker
In this time period, we should probably be focusing on what are the items that I need to get in place so that I can provide this patient the best chance they have of having a meaningful recovery, recognizing that in many cases that won't be the case.
00:52:35
Speaker
But focusing on these time-sensitive interventions, finding a way to do it in a systematic way, I think is very important.
00:52:43
Speaker
We want to do it every time that we have a cardiac arrest.
00:52:46
Speaker
And I find the framework very useful.
00:52:50
Speaker
I like threes.
00:52:51
Speaker
So the framework I'm taking home from you, Haynie, is the first 15 minutes, debrief the next 45 minutes, and really focus on what happens in that time period, no matter what
00:53:04
Speaker
what the location of the patient is at that time, because eventually they'll come to the ICU most likely, but they might not be in the ICU during that first hour.
00:53:15
Speaker
Exactly.
00:53:16
Speaker
Exactly.
00:53:16
Speaker
No matter the location, these are things that could be done anywhere in the hospital.
00:53:19
Speaker
I'm,
00:53:20
Speaker
My own personal thing is that I think critical care happens everywhere.
00:53:24
Speaker
It doesn't happen in the ICU, and if we want our patients to do best, then we start critical care where it's needed.
00:53:31
Speaker
And the last thing I'll say about this is, as you're listening to this podcast, just reflect, there's nothing that I taught new here.
00:53:38
Speaker
This is stuff that everyone knows how to do.
00:53:40
Speaker
These are all very simple interventions.
00:53:42
Speaker
It's just putting it in a framework and an organizational manner so that it can get done every single time.
00:53:49
Speaker
And to be honest with you, when I first started doing it like this, I would have a checklist in my pocket and I would just take a look down.
00:53:55
Speaker
I was like, okay, what's next?
00:53:57
Speaker
And feel free to write this down or write down the steps that you find are helpful in order.
00:54:02
Speaker
But we have to be task oriented because codes are chaotic.
00:54:06
Speaker
Codes are crazy.
00:54:08
Speaker
During the middle of a code, you're getting called to another consult, but you have to be laser focused on these steps so that you make sure that the person in front of you has every chance for the best neurologic outcome possible.
00:54:21
Speaker
I agree.
00:54:22
Speaker
And I think that also it talks about that whole idea that excellence is not a skill, it's an attitude, and that by really making sure that we excel at the basic level,
00:54:37
Speaker
skills post arrest, we can probably provide the best care for our patients.
00:54:43
Speaker
Well said.
00:54:44
Speaker
Perfect.
00:54:45
Speaker
So you've been on the podcast before and you know the drill.
00:54:48
Speaker
So I would like to close with some questions unrelated to the topic of the golden hour post ROAC.
00:54:55
Speaker
Would that be okay?
00:54:57
Speaker
Absolutely.
00:54:58
Speaker
It's my favorite part of the show.
00:55:00
Speaker
Excellent.
00:55:01
Speaker
So,
00:55:02
Speaker
With you, obviously, I have to talk about what has been called foam, free open access medical education.
00:55:09
Speaker
But I think really it's just medical education in different forms that has really permeated all sorts of platforms.
00:55:20
Speaker
And just interested, since you introduced me to this whole world, what are the things that you would tell other people to follow on different platforms?
00:55:28
Speaker
We can start there.
00:55:32
Speaker
Yeah.
00:55:33
Speaker
So, you know, this, this open access medicine thing is, is a community of people who are sharing information and trying to make each other better.
00:55:40
Speaker
One of the interesting things when I first started on medicine is Twitter was the place where everyone congregated and this whole Elon Musk buying Twitter and Twitter potentially collapsing has put a fright into people and said, where are we going to go now?
00:55:53
Speaker
Where are we going to go for our education?
00:55:56
Speaker
If it can't be Twitter, what I,
00:55:58
Speaker
Realizing what I tell people is that this foam ad concept is not a Twitter thing.
00:56:04
Speaker
It's not an Instagram thing.
00:56:05
Speaker
It's not even a TikTok or YouTube thing.
00:56:08
Speaker
It's a community, and people will find each other online in some way, shape, or form.
00:56:13
Speaker
What I'm getting at is that...
00:56:17
Speaker
try to find multitudes of platforms that give you information because you never know when one platform is going to be shut down one day or anything happens.
00:56:29
Speaker
The government shuts down a platform.
00:56:31
Speaker
So it's important to know content on all the different platforms and then also have other sources of information where you consume New England Journal, for example, puts out some very excellent short blogs.
00:56:41
Speaker
There's something called Journal Files.
00:56:42
Speaker
a journal feed, which is a summary of articles all day long.
00:56:47
Speaker
So besides platforms, there are lots of individuals or organizations who are putting out free content every day.
00:56:53
Speaker
And it's all about picking your preferences, subscribing to those so you can get the information efficiently and, uh, and never relying on one platform for that, for that data.
00:57:05
Speaker
Perfect.
00:57:05
Speaker
And well said.
00:57:06
Speaker
Yes, it is interesting how the whole Twitter med community has been proposing different ways.
00:57:14
Speaker
But like you said, it's not the platform.
00:57:16
Speaker
It's really the content that ultimately matters and that can be delivered in different ways.
00:57:20
Speaker
And I also believe that you have to understand as a learner what speaks to you.
00:57:26
Speaker
There might be some generational differences, people think.
00:57:29
Speaker
But at the end of the day, everybody has
00:57:31
Speaker
a style of learning and gravitate towards platforms that provide that.
00:57:35
Speaker
But I do believe, Haney, that you hit it on the nail.
00:57:39
Speaker
It's like your portfolio, right?
00:57:40
Speaker
You want it to be diversified.
00:57:43
Speaker
I can't tell you how many people give me a hard time about being on TikTok.
00:57:48
Speaker
And maybe less so in 2022 than in 2020.
00:57:52
Speaker
But who's on TikTok?
00:57:54
Speaker
Well, it's younger learners, it's students, it's nurses, it's young residents.
00:57:58
Speaker
That's where people are.
00:57:59
Speaker
They're not necessarily on Twitter.
00:58:01
Speaker
So finding your audience, your voice, the way you like to learn is the most important thing.
00:58:07
Speaker
So you said it perfectly.
00:58:08
Speaker
Excellent.
00:58:09
Speaker
What are some podcasts that you enjoy outside of medicine?
00:58:14
Speaker
Outside of medicine, there's a few, but I'll give you the one that I'm absolutely obsessed with.
00:58:21
Speaker
It's probably an unhealthy obsession, but it's called Smartless.
00:58:25
Speaker
Have you heard of this podcast?
00:58:26
Speaker
I have not.
00:58:28
Speaker
It's Jason Bateman from, we all know Jason Bateman, Will Arnett, and Sean Hayes.
00:58:35
Speaker
The three of those guys are best friends in real life.
00:58:37
Speaker
And when COVID hit, they wanted to hang out with each other.
00:58:41
Speaker
So they just started doing Zoom and hanging out on Zoom.
00:58:44
Speaker
And then slowly, slowly, they just started asking some of their friends because they're best friends.
00:58:48
Speaker
movie stars, so they all have very wealthy and influential friends to come on the podcast.
00:58:53
Speaker
And then they finally just made a podcast where they did that.
00:58:56
Speaker
But the three of those goofballs together ragging on each other with guests that, you know, I think they had Kamala Harris on,
00:59:05
Speaker
And they have some really important people and influential people on there.
00:59:09
Speaker
But just to hear these three goofballs rag on each other while they're interviewing guests, it's the best mix of hysterical, heartfelt, honest podcasting that I've ever heard.
00:59:20
Speaker
And I'm now going through for the second time listening to all the podcasts.
00:59:23
Speaker
It's just endless enjoyment.
00:59:24
Speaker
Well, we'll definitely put a link in the show notes and we'll definitely take a listen.
00:59:29
Speaker
It sounds like something fun that we should be checking out.
00:59:35
Speaker
What are some platforms?
00:59:36
Speaker
What's that?
00:59:36
Speaker
I was going to say, you know, my second dream, my first dream was to be on your podcast.
00:59:41
Speaker
So I've already achieved that dream.
00:59:43
Speaker
There you go.
00:59:43
Speaker
My second dream is to be on SmartList.
00:59:45
Speaker
Well, maybe we'll pull some strings and get you on SmartList.
00:59:49
Speaker
If you could do that, I'd be indebted.
00:59:52
Speaker
Perfect.
00:59:54
Speaker
What about books, Haney?
00:59:56
Speaker
You know that I'm an avid reader, but is there any book that has had a big impact on you or a book that you have found you have gifted to other people on different occasions?
01:00:08
Speaker
This varies a lot, and I'll admittedly, I'm not like a huge book reader, so take that for what it's worth.
01:00:14
Speaker
The one book that early on in my career someone gifted to me and has been the most influential was Dale Carnegie's How to Win Friends and Influence People.
01:00:27
Speaker
As a young attending, getting started with a lot of nerves and sometimes
01:00:32
Speaker
being interpreted as being, you know, a little bit sharp or a little stern, learning how to influence your team and the people around you and just to be a good person.
01:00:44
Speaker
That book is something I give to residents and fellows and people that I mentor because there's just little things that we can do every single day.
01:00:52
Speaker
And it's not about –
01:00:54
Speaker
being a salesperson or to trick people.
01:00:56
Speaker
It's just little things that you can do to recognize what gets us to be better people and interact better as a community.
01:01:04
Speaker
And that could be in the hospital.
01:01:06
Speaker
It could be how you deal with your neighbor or someone at the store.
01:01:09
Speaker
But time and time again, I find myself listening to that audio book
01:01:14
Speaker
You know, I do it regularly, like every year or every year and a half.
01:01:18
Speaker
It just resets me and refocuses me and tells me the things that are important to just keep us all happy spinning on this rock as we fly through the universe.
01:01:26
Speaker
And I agree.
01:01:27
Speaker
And I think this is a book that has been mentioned by other podcast guests.
01:01:31
Speaker
And I've read it and find it very, very useful.
01:01:36
Speaker
And one of the things that my grandfather used to tell me is that read old books because only the good ones get to get old.
01:01:47
Speaker
And I think what he was really referring to is exactly what this book represents, right?
01:01:51
Speaker
It's been around for, I don't know, what do you think?
01:01:54
Speaker
Definitely more than 50 years, right?
01:01:55
Speaker
Probably even more than that.
01:01:57
Speaker
70, 80 years, who knows?
01:01:58
Speaker
But it's been around a while.
01:02:00
Speaker
And yet a lot of the points it makes...
01:02:04
Speaker
are probably true throughout time.
01:02:07
Speaker
They're universal.
01:02:08
Speaker
And like you mentioned, they're super, super helpful.
01:02:11
Speaker
And a lot of what we talked about today are the skills that are required to do our jobs from a clinical perspective.
01:02:18
Speaker
But ultimately, all that falls short if you are not able to engage people around you.
01:02:24
Speaker
So I definitely will put a link in the show notes.
01:02:27
Speaker
And if you don't like to read, it's a great listen.
01:02:29
Speaker
I've read it and listened to it.
01:02:31
Speaker
And I think it's a great audio book, as you mentioned.
01:02:35
Speaker
1936.
01:02:36
Speaker
Yeah, it wasn't too often.
01:02:39
Speaker
1936.
01:02:39
Speaker
Yeah.
01:02:41
Speaker
That is when that book was written, and I got to tell you, every time I listen to it, I got to say every single principle holds up.
01:02:49
Speaker
It's super actionable, and definitely there's some golden nuggets there for sure.
01:02:52
Speaker
Absolutely.
01:02:54
Speaker
Absolutely.
01:02:56
Speaker
Well, I would like to close with anything you would want our listeners to think about or to know as we end the year also and hopefully move towards 2023 and away from all the craziness of the last couple of years.
01:03:15
Speaker
Oh, man, there's so many things I could say.
01:03:19
Speaker
Yeah.
01:03:21
Speaker
So the one thing I would say is, you know, we are coming out of a time where people are so divided about everything.
01:03:32
Speaker
You know, you talk about vaccines and masks and politics.
01:03:38
Speaker
And the COVID pandemic truly showed the worst in people and not just in America, really worldwide.
01:03:47
Speaker
A lot of this behavior was happening online and social media.
01:03:52
Speaker
I'm trying myself personally to get back to a point where we just start to have dialogue with people again, where I will force myself to sit down with somebody who has very different views from me and just listen to what they have to say.
01:04:07
Speaker
I'm not trying to argue with them.
01:04:09
Speaker
I'm not trying to convince them.
01:04:11
Speaker
I want to start listening to people that differ from me so I can truly understand what they're saying.
01:04:17
Speaker
And this is a growth for me.
01:04:21
Speaker
Because for the past few years, spent a lot of time just saying why someone was wrong or listening to what they had to say just so I can provide my counter argument.
01:04:32
Speaker
But I think we have to get back to a point as human beings, not Americans, not any nationality, but as human beings get to a point where we just start being together and coming together as one and accepting people's differences, different viewpoints,
01:04:48
Speaker
and find ways to just all live cohesively and still have different viewpoints.
01:04:54
Speaker
I don't know what the best way is, but that's where I'm personally trying to head.
01:04:58
Speaker
And that's what I advise people to do.
01:05:00
Speaker
Well, it's a great point.
01:05:02
Speaker
I think it's a perfect place to not only end the podcast, but as we close the year, right?
01:05:08
Speaker
But, Haney, I think that the way I've thought about the same concept a lot over the last couple of years and
01:05:17
Speaker
What I try to do is to be more of an active listener with true curiosity and trying to figure out maybe what Haney is saying is right and what I'm thinking is wrong.
01:05:31
Speaker
How can I learn from this person?
01:05:32
Speaker
How can I understand why they think like this or why they could think like that as opposed to just either being polite and waiting for them to finish or tell them why they're wrong but really trying
01:05:43
Speaker
you're not listening with an open mind, right?
01:05:45
Speaker
So I think that we have to open our minds and our hearts to really understand that people are different for many reasons and that there's something that we probably can learn from that other person.
01:05:55
Speaker
Yeah, well said.
01:05:56
Speaker
We're just, this is so aged, but I really believe that we're more alike in so many ways than we are different.
01:06:04
Speaker
So just accept those little differences and let's move on.
01:06:08
Speaker
We just came through a couple of years of just the worst human behavior that I've ever seen.
01:06:14
Speaker
And yeah, I think that that's what I'm trying to do in 2023 and beyond.
01:06:21
Speaker
Perfect.
01:06:22
Speaker
Well, Haney, I am always a pleasure to have you on the podcast.
01:06:26
Speaker
I really appreciate you sharing your expertise and your time with us.
01:06:30
Speaker
We definitely will have you back again and I will work on getting you on smart list.
01:06:34
Speaker
I think if you do 10 critical matters, you get on smart list, but we'll get there.
01:06:40
Speaker
Then sign me up for as many as you can.
01:06:42
Speaker
I got to get on the podcast.
01:06:43
Speaker
Thank you, Sergio.
01:06:44
Speaker
Thank you for having me on.
01:06:45
Speaker
Always a pleasure to talk to you on this podcast.
01:06:49
Speaker
Thank you.
01:06:49
Speaker
Talk to you soon.
01:06:52
Speaker
Thank you for listening to Critical Matters, a sound podcast.
01:06:56
Speaker
Make sure to subscribe to Critical Matters on Apple or Google Podcasts and share with your network.
01:07:02
Speaker
Sound's transforming the way critical care is provided in hospitals across the country.
01:07:06
Speaker
To learn more, visit www.soundphysicians.com.