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ECCU Survivor Workshop: Mosesso
1. Expanding the Chain:
The 7th Link-
Rehabilitation &
Recovery
Vince Mosesso, MD
Professor of Emergency Medicine
University of Pittsburgh School of Medicine
2. Disclosures
Prior grants from Medtronic Inc and Medtronic
Foundation
Prior research support from Medtronic, Zoll,
Philips, Heartsine, Cardiac Science, Welch-
Allyn
Honorarium from Biotronik
Research support from Zoll LifeCor
Corporation
Medical director and co-founder, Sudden
Cardiac Arrest Association
4. Post cardiac arrest syndrome
Now recognized as specific condition with
specific interventions
5. Post cardiac arrest
syndrome
Post cardiac arrest brain injury
Post cardiac arrest myocardial
dysfunction
Systemic ischemia & reperfusion
response
Underlying condition that caused arrest
6. CNS
Loss of normal blood flow to brain
Overall blood flow/pressure control
Regional microvascular perfusion
Neuronal cell death (necrosis/homicide)
and triggering of self-death pathways
(apoptosis/suicide)
Clinical syndrome ranges from mild
memory deficits to persistent vegetative
state
8. After acute phase:
Recovery & Rehabilitation
Less well understood
Most research has focused on severe
neurological disabilities
Lack of providers to help survivors and
love ones cope with emotional,
psychological and more subtle cognitive
changes
9. Symptoms and problems
noted by survivors
Goes beyond typical organic dysfunction
Appears to be a unique spectrum of cognitive
and emotional experiences
Many express need for support
10. Neuropsychological sequelae
after cardiac arrest
155 survivors underwent neuro-psych
evaluations at 3 and 12 months
Moderate to severe cognitive dysfunction:
60% at three months
48% at one year
Depression in 45% at one year
Roine RO et al. JAMA. 1993.
11. Psychosocial distress
after ICD implantation
57 subjects surveyed every 6 months for
2 years
Depression in 35%
Anxiety in 45%
Some decrease over time
Thomas SA et al. Heart & Lung, 2009
12. SCAA: survey of survivors and their
loved ones
Benjamin S. Abella, MD, MPhil
Clinical Research Director
CRS Center for Resuscitation Science
Department of Emergency Medicine
Center for
Resuscitation Science University of Pennsylvania
SCAA Annual Meeting - October, 2008
13. Number responding
20
40
60
80
0
Touch
Taste
Smell
53%
Sight
Hearing
Memory
Coordination
None
After SCA, what function has changed?
Other
14. After SCA, what activity did you fear?
60 37%
“holding loved ones”
“swimming”
“sleeping”
Number responding
40
23%
30%
15%
20
5%
0
Driving
Air travel
Exercise
Being
alone
Other
15. Emotional changes
Lability (marked fluctuations)
Spontaneous or easily-triggered crying
Increased sensitivity to others’ losses
Greater love of family and friends
Fear—of ICD firing, or of not having one and
needing it.
Guilt—why did I survive, when so many others
die?
16. Cognitive
Various types and duration of memory
loss
Dementia (post-anoxic)
Variable degrees of loss of executive
function
Continuous barrage of thoughts
Quicker, smarter brain function
17. Sensory / Perception
“Size up” people more quickly/easily
Heightened sense of smell
Altered pain tolerance / perception
18. Behavioral
Sleep disturbances
More outspoken when believe right
More risk-taking
“Been to the brink, nothing can hurt me
more.”
19. Psychiatric/psychological
Depression and/or apathy
Perception of infallibility
Perception of vulnerability
Belief in destiny—things are happening
for a purpose
Sense of urgency—must do as much as
possible right now
20. Family & Loved ones
Also affected in many ways and to
various degrees
Both similar and different challenges
One study:
60% with psychosomatic complaints
50% noted lack of social support
Pusswald G et al. Resuscitation, 2000.
21. Dual causation
Organic brain injury
Psychological stress
Treatment must address both of these
causes and the various components
22.
23. “Post cardiac arrest
stress disorder (PCSD)” -?
Need to distinguish from PCAS
Labeling facilitates:
increasing awareness
advocacy for more research and clinical
therapy
25. Needed
Better understanding
Symptoms
Triggers
Spectrum of severity and scope
Better therapy
More access to therapy
26. Potential ways to address
Greater awareness of need
Research
Stakeholder forum
Meeting of experts to review current
science and potential therapies
Professional education
27. The 7Link:
th
Recovery & Rehabilitation
Stay tuned to
www.suddencardiacarrest.org
for further information.