1. 20 ème Congrès du CREUF - Chartres Alain Cariou Intensive Care Unit - Cochin Hospital Paris Descartes University – INSERM U970 Centre d’Expertise Mort Subite - Paris La chaîne de survie

2. The chain of survival Cummins RO, Ornato J, Thies WH, Pepe P. Improving survival from sudden death cardiac arrest : “the chain or survival concept. A statement for health professionals from the Advanced Cardiac Life Support Subcommitee and the Emergency Cardiac Care Communitee, American Heart Association.”. Circulation 1991 ; 83 : 1832-47

3. Chaîne de survie Cummins RO et al. Circulation 1997 ; 95 : 2213-39 Alerte précoce RCP de base Défibrillation RCP spécialisée

4. Jean-Christophe A., 29 ans Antécédents personnels :  Epilepsie temporale non traitée Antécédents familiaux :  Un cas de mort subite inexpliqué

5. 14/11/2012 … 21h55 : syncope avec reprise de conscience 21h56 : appel des secours 22h03 : 2 ème syncope 22h04 : arrivée des premiers secours avec début du MCE et mise en place du défibrillateur

6. Tracé initial

7. Choc électrique externe

8. Activité cardiaque spontanée No-flow = 1 minute, low-flow = 4 minutes

9. Arrivée du SMUR à 22h14 SpO 2 = 95 %, 103/55 mmHg, FC = 105 /min En ventilation spontanée, Glasgow 3 Sédation pour intubation et ventilation mécanique ECG initial : pas de signe ischémique franc (mais tracé difficile à interpréter…)

10. Alerte RCP immédiate Défibrillation précoce Soins post-arrêt cardiaque Centre d’Expertise de la Mort Subite (CEMS) Prévention secondaire

11. Registre du CEMS Du 15 mai 2011 au 15 mai 2013 7 201 AC extra-hospitaliers 1048 étiologies non-cardiaques 6 153 étiologies cardiaques probables (100 %) 2 341 non réanimés 3 812 avec tentative de réanimation (62 %)

12. « Portrait Robot » 69 % 31% 72 %28 % 45 %26% Registre CEMS Du 15 May 2011 au 15 mai 2013

13. A l’hôpital Coronarographie702 (55 %) Hypothermie thérapeutique704 (55 %) Survie hospitalière250 (7 %) Récupération neurologique - CPC 1/2 - CPC 3/4 - inconnue 232 (93 %) 11 (4 %) 7 (3 %) Registre CEMS Du 15 May 2011 au 15 mai 2013

14. A l’hôpital Coronarographie702 (55 %) Hypothermie thérapeutique704 (55 %) Survie hospitalière250 (7 %) Récupération neurologique - CPC 1/2 - CPC 3/4 - inconnue 232 (93 %) 11 (4 %) 7 (3 %) Registre CEMS Du 15 May 2011 au 15 mai 2013

16. Défibrillation Automatisée Externe (DAE) 1. Connexion 2. Analyse

17. Défibrillation Automatisée Externe (DAE) 3. Choc4. Reprise immédiate RCP

20. Chest compression alone cardiopulmonary resuscitation is associated with better long-term survival compared with standard cardiopulmonary resuscitation Dumas F et al. Circulation 2012 “Bystanders can proceed with the chest compression alone approach with the appreciation that this strategy on average provides optimal long-term survival benefit.”

22. Association of National Initiatives to Improve Cardiac Arrest Management With Rates of Bystander Intervention and Patient Survival After Out-of Hospital Cardiac Arrest Wissenberg M et al. JAMA 2013 Introduction hypothermie (2004)Formation RCP à l’école (janv 2005) Recommandations (nov 2005) Formation RCP permis de conduire (2006) Amélioration dispatching (2009) Environ 175 000 personnes formées à la RCP (2001-2004) Distribution 150000 kits d’auto-formation (2005-2010)

23. Association of National Initiatives to Improve Cardiac Arrest Management With Rates of Bystander Intervention and Patient Survival After Out-of Hospital Cardiac Arrest Wissenberg M et al. JAMA 2013

24. Pre-hospital period Post-resuscitation:  Post-cardiac arrest shock  Brain damages  Cardiovascular diseases ≈ 40.000 SCA/yrs 60% CPR 15-20% ROSC… …and ICU admission 5-8 % survivors 5-6 % no or minor sequel Outcome of sudden cardiac arrest (SCA) victims Long-term ?

25. ICU mortality after cardiac arrest: the relative contribution of shock and brain injury in a large cohort Lemiale V, Dumas F, Mongardon N, Giovanetti O, Charpentier J, Chiche JD, Carli P, Mira JP, Nolan J, Cariou A Intensive Care Med 2013 n=499 n=269 n=768

26. Soreide et al. Resuscitation 2013

27. Immediate Early Intermediate Recovery Rehabilitation Phase ROSC 20 min 6-12 hours 72 hours Discharge Post-cardiac arrest disease ILCOR Consensus Statement Post-cardiac arrest disease Systemic ischemia- reperfusion

28. 1.Ischemia and reperfusion syndrome 2.Inflammatory response 3.Coagulopathy 4.Circulatory failure 5.Adrenal dysfunction Current Opinion in Crit Care. 2004

29. Six-month survival:  Controls 21%  HF alone 42%  HF + HT 32% Laurent I et al. JACC 2005 p=0.28 Death by intractable shock (IS):  Controls 42%  HF alone 10%  HF + HT 14% p=0.009 p=0.026 p=0.018 Relative risk of death by IS:  HF alone 0.21 (95% CI 0.5-0.85)  HF + HT 0.29 (95% CI 0.09-0.91) Controls n=19 HF alone n=20 HF + HT n=22 Multivariate analysis:  HF and six-month death: OR 0.21 (95% CI 0.5-0.85)  HF and death by IS: OR 0.29 (95% CI 0.09-0.91)

30. Recovery Rehabilitation Discharge Post-cardiac arrest disease ILCOR Consensus Statement Post-cardiac arrest disease Post-CA circulatory failure Immediate Early Intermediate Phase ROSC 20 min 6-12 hours 72 hours Systemic ischemia- reperfusion

31. Percutaneous Circulatory Support Bridges to neurological evaluation

33. Immediate Early Intermediate Recovery Rehabilitation Phase ROSC 20 min 6-12 hours 72 hours Discharge Post-cardiac arrest disease ILCOR Consensus Statement Post-CA circulatory failure Post-cardiac arrest Systemic ischemia- reperfusion Persistent precipitating pathology

35. Immediate percutaneous coronary intervention is associated with improved short and long-term outcome after out-of- hospital cardiac arrest Geri G, Dumas F, Bougouin W, Varenne O, Daviaud F, Pène F, Lamhaut L, Chiche JD, Spaulding C, Mira JP, Empana JP, Cariou A ESICM Barcelona 2014

36. Benefit of an early and systematic imaging procedure after cardiac arrest: insights from the PROCAT (Parisian Region Out of Hospital Cardiac Arrest) registry. J CHELLY, N MONGARDON, F DUMAS, O VARENNE, C SPAULDING, O VIGNAUX, P CARLI, J CHARPENTIER, F PENE, JD CHICHE, JP MIRA, A CARIOU Resuscitation 2009 Imaging procedures Cause identified? Family screening NoYes Inherited cause? Search for cardiac structural abnormalities: echo, MRI, (autopsy) Search for cardiac disease without structural abnormalities: repeated ECG, genetic test OHCA with ROSC

37. Répétition des ECG… Syndrôme de Brugada (Type 1)

38. Immediate Early Intermediate Recovery Rehabilitation Phase ROSC 20 min 6-12 hours 72 hours Discharge Post-cardiac arrest disease ILCOR Consensus Statement Post-cardiac arrest disease Post-CA myocardial dysfunction Systemic ischemia- reperfusion Treatment targets Post-anoxic brain injury Persistent precipitating pathology

40. Neuroprotection after cardiac arrest: what’s new? Calcium channel antagonists NMDA receptor antagonists Dexanabinol Lubeluzole (Nitrous oxide modulator) CDP-choline Tirilizad (free radical scavenger) Anti-ICAM-1 antibody GM-1 ganglioside Clomethiazole Fosphenytoin Piracetam Erythropoietin Selenium Ciclosporine ?

41. Early high-dose erythropoietin therapy after out-of- hospital cardiac arrest: a multicentre, randomized controlled trial (EPO-ACR 02) EPO-ACR 02 Scientific committee: Alain Cariou (PI) Pierre Carli Christian Spaulding Olivier Hermine EPO-ACR 02 Executive committee: Nicolas Deye Maryline Delattre Benoit Vivien EPO-ACR 02 Investigators: P. Asfar (Angers) A. Bourg (Limoges) C. Buléon (Caen) JD. Chiche (Paris) A. Cravoisy (Nancy) C. Daubin (Caen) PF. Dequin (Tours) P. Ecollan (Paris) J. Frey (Nancy) L. Huet (Créteil) A. Khimoun (Nancy) L. Lamhaut (Paris) S. Legriel (Versailles) JS. Marx (Paris) A.Mathonnet (Orléans) JP. Mira (Paris) S. Narcisse (Orléans) D. Payen (Paris) F. Pène (Paris) N. Pichon (Limoges) K. Razazi (Créteil) O. Richard (Versailles) E. Wiel (Lille) Lille Orléans Nancy Limoges Caen Tours Paris Versailles Créteil Angers Statisticians: Myriam Ben Boutieb Joël Coste Funding: French Ministry of Health NCT00999583 Pharmacist: Florence Barat

42. CPC level at day 60 (%) P=0.90 EPO-ACR 02: primary endpoint OR 1.01 95%CI 0.68- 1.48 32.4 32.1

43. Spectrum of consciousness disorders after cardiac arrest Time Wakefulness (level of consciousness) Conscious wakefulness Coma Brain death Persistent VSPermanent VSSevere disabilityMCSPermanent MCS Adapté de Stevens RD et al. Crit Care Med 2006 Normal consciousness

44. What is the mode of death in post-cardiac arrest hospitalized patients? Lemiale V 1, Max A 1, Charpentier J 1, Kentish-Barnes N 2, Chiche JD 1, Mira JP 1, Cariou A 1. 1 Medical ICU, Cochin Hospital & Paris Descartes University 2 Famirea Group, Medical ICU, Saint Louis Hospital, Paris SRLF 2009 0 10 20 30 40 50 Brain damages Post-CA shock Brain death Other % Potentially Maastricht 3 Potentially brain dead donors

45. Evolution … favorable Score CPC = 1 à J6 Sortie en USIC Surveillance électrocardiographique Jean-Christophe A., 29 ans

46. Immediate Early Intermediate Recovery Rehabilitation Phase ROSC 20 min 6-12 hours 72 hours Discharge Post-cardiac arrest disease ILCOR Consensus Statement Que deviennent les « survivants » ?

47. Bunch TJ et al. NEJM 2003 « In summary, the rate of survival to hospital discharge was relatively high in a city that had a program of rapid defibrillation. The majority of survivors returned to work, and their quality of life was in most respects indistinguishable from that of the general population. The long-term survival rate was similar to that of age-, sex-, and disease-matched controls who did not have an OHCA. » Mean length of follow-up was 4.8±3.0 y Long-term outcomes of out-of-hospital cardiac arrest after successful early defibrillation. Bunch TJ, White RD, Gersh BJ, Meverden RA, Hodge DO, Ballman KV, Hammill SC, Shen WK, Packer DL. N Engl J Med. 2003

48. Inherited causes of Sudden Cardiac Death With structural abnormalities Coronary Artery Disease Cardiomyopathies (hypertrophic, dilated, ARVC) Without structural abnormalities Long QT syndrome, short QT syndrome, Brugada, catecholaminergic polymorph VT (CPVT)

49. Out-of-hospital cardiac arrest n = 7201 Cardiology n = 250 (7 %) Sudden Cardiac Death n = 3812 ICU n = 1340 (35 %) SDEC Registry From 15 th May 2011 to 15 th May 2013 Et si Jean-Christophe était mort ?

50. Prevention Research ICU Ethics EMS Genetics Cardiology Education

51. Prevention Research ICU Ethics EMS Genetics Cardiology Education