By Sarah Livesay, DNP, APRN Associate Dean, Rush University, President NCS
Mary Kay Bader, RN, MSN, Neurocritical Care CNS, Mission Hospital Mission Viejo CA, Past President NCS
Karen Hirsch MD, Associate Professor of Neurology, Division Chief Neurocriticial Care, Stanford University
Romer Geocadin MD, Professor of Neurology, Johns Hopkins University, Past President NCS
All who watched Monday Night Football this week were shocked and dismayed to witness Damar Hamlin collapse after experiencing a cardiac arrest, when the heart either stops beating or is no longer beating in a manner that allows blood to circulate effectively. We are thrilled to hear of his improvements and acknowledge the team of healthcare providers who intervened on the field and throughout his hospital stay. As healthcare providers who commonly care for patients who have survived a cardiac arrest, neurocritical care professionals are often asked how care during or after a cardiac arrest supports the brain and other critical body organs. Leaders from the Neurocritical Care Society have come together to highlight several important aspects of medical care during and after a cardiac arrest.
Importance of CPR
One of the best ways to support the brain and other critical organs during a cardiac arrest is to start cardiopulmonary resuscitation (CPR) as quickly as possible. After calling 911 (or your emergency response system if you are outside of the United States), CPR should be started right away. CPR includes chest compressions, which help to circulate blood while waiting for help to arrive. CPR can be done by anyone, and you can take a class in your local community to help you feel more comfortable performing CPR. Performing immediate and effective CPR can double or even triple a person’s chance of survival during cardiac arrest.
Key things to remember when performing CPR are to press in the center of the chest at a rate of 100-120 compressions per minute. In addition to pressing hard and fast, remember to allow the chest to return to its normal position between compressions. If you are trained and comfortable, you may also provide rescue breaths as a part of CPR in some situations. If there is an automated external defibrillator (AED) available nearby, follow the instructions on the device. AEDs work to correct the heart rhythm by administering an electrical shock. CPR keeps blood circulating to critical organs while waiting for help to arrive, and AEDs may help to correct the heart rhythm so that blood is circulating normally again. All of these actions help to protect the brain and other critical organs during the emergency.
For more information on CPR, visit https://www.cdc.gov/heartdisease/cpr.htm
Coordinated care between medical teams improves outcome
CPR is critical to support blood flow to vital organs like the heart and brain during cardiac arrest. When a person’s heart is re-started after CPR, electric shocks (ie by an AED) and/or advanced life support care, the hospital team manages the “aftershocks” of the event. Coordinated care in the emergency department and hospital intensive care unit (ICU) is important to improve patient outcomes.
After a patient with cardiac arrest arrives to an emergency department, the medical team focuses on two key things: (1) Identifying the cause of the cardiac arrest and preventing it from re-occurring, and (2) Supporting the body’s organs which may be in a state of shock and dysfunction from the period with lack of blood flow. These organs include the brain, heart, lungs, and others. Coordinated care between emergency medicine teams, heart teams (cardiology teams), brain teams (neurocritical care), and other experts starts as soon as a patient with cardiac arrest arrives to a hospital.
The brain is uniquely sensitive to injury after cardiac arrest. While other organs can tolerate longer periods without blood flow, the brain is injured within just a few minutes. The brain injury is evident as patients may initially be unresponsive or in a coma, and they can develop further complications of brain damage such as seizures and brain swelling. These neurologic manifestations usually occur during the first days after cardiac arrest. The management of this type of brain injury is complex and requires expertise as outlined below. The coordinated care of different experts, including the neurocritical care team, working together to treat a patient after cardiac arrest is key to improving patient outcomes.
Prevention of fever and other strategies to protect the brain
The lack of blood flow to the brain before CPR is started and the reduced blood blow that occurs during CPR leads to changes in the chemistry of the brain. These changes in the brain continue even after a pulse returns (for minutes, hours and even days after) and requires the ICU team to monitor the brain function and protect the brain from further damage. Patients who are not awake after the cardiac arrest is a signal to the medical team that the brain has suffered an injury from the heart stopping. These patients are often on machines (called ventilators) to support breathing and they will receive fluids and medications to support their blood pressure and provide the needed oxygen and glucose (sugar/food) to the brain. Special brain monitors are often used to obtain information about the brain’s electrical activity (ie by an electroencephalogram or EEG) and brain swelling (ie by a pressure monitor). The medical team uses this information to treat seizures and brain swelling in efforts to reduce further brain injury.
The healthcare team’s focus on preventing any further injury to the brain also includes controlling the body and brain temperature and avoiding fever. Medical teams may use machines to lower the body temperature (range 90 degrees F – 98 degrees F) which reduces the chemical changes in the brain, provides a “brain resting state” and allows the brain to begin to heal. Most temperature control strategies continue for at least 72 hours. Studies have demonstrated reduced injury to the brain when these strategies are used to maintain the body/brain temperature.
Recovering from cardiac arrest – a hard but rewarding path
The functional abilities of survivors of cardiac arrest are dependent on a few factors, mainly the level of brain injury, the underlying condition that led to the cardiac arrest, and the extent of injury to other organs that occurred during the cardiac arrest. Even after successful CPR, many people do not recover. In some cases, it may take days or even weeks to understand the long-term impact of the cardiac arrest.
Recovery from a cardiac arrest occurs at different rates and takes varying amounts of time (days, weeks, months, and in some cases even years) depending on the extent of brain injury. Medical teams rely on different tests to try to predict the degree of recovery that an individual patient might expect, but recent studies emphasize that those tests may not be reliable until several days after the cardiac arrest. As such, it is crucial that these patients continue to receive medical care and treatment of complications related to the brain, heart, and the rest of the body during the recovery period.
The degree of recovery is determined mainly by brain recovery. Almost all patients will be unresponsive initially and over a few days, some may remain unresponsive while others may quickly regain consciousness and respond to family and health care providers. As part of the recovery, patients will eventually leave the ICU and be transferred to the hospital wards, rehabilitation units, long-term care facilities, and/or even back to their homes. Overall, those who survive cardiac arrest will need rehabilitation and may need long-term neurologic care for problems such as memory issues, anxiety and depression, seizures, spasm, and walking difficulty. They will also need to be seen by healthcare providers that will manage problems that may have caused the cardiac arrest. For survivors, the process of recovery may be long and challenging and support from families and friends is critical. With proper care and support, some patients have good outcomes and regain good quality of life.
Read about another sports-related cardiac arrest case.