Penn Medicine's Ttm Academy Podcasts

A new multicenter trial published in NEJM, commonly known as the “TTM2” trial, evaluated treating patients resuscitated from out-of-hospital cardiac arrest with targeted temperature management to 33C versus controlled normothermia, and found that outcomes were equivalent.  Does this mean the end of TTM as we know it?  In this podcast, Dr. Benjamin Abella presents a comprehensive argument why he believes that such pronouncements are premature and not consistent with the larger body of laboratory and clinical science over the past 20 years. He discusses TTM2 in context of recent work from France (the Hyperion study), as well as work from the US and Japan, suggesting that patient selection is key.  TTM may not be needed for patients with favorable characteristics (witnessed arrest, bystander CPR, no evidence of shock) but still may be required for patients with less favorable characteristics (non-shockable arrest rhythms, no bystander CPR, evidence of shock).   Also join us for a free live Zoom webinar on Jun

Electrocardiography (ECG) represents a central diagnostic tool in the post-arrest evaluation of patients resuscitated from out-of-hospital cardiac arrest (OHCA), and it should be acquired immediately after achievement of ROSC to identify the need for an urgent coronary angiography, which is indicated only in the case of ST-segment elevation myocardial infarction (STEMI). While resuscitation guidelines are clear in the recommendation and importance of obtaining an ECG during the post-ROSC phase, they don’t provide specific instructions about the best time for ECG acquisition after ROSC.   In this context some have proposed that the timing of ECG post-ROSC may have an impact in the early post-ROSC phase, and that the ECG could reflect ischemia secondary to cardiac arrest more than or in addition to ischemia due to coronary artery pathology, possibly leading to overdiagnosis of STEMI.   In episode 24 of the TTM Academy Podcast we review a recent study published in JAMA Network Open, by authors Enrico Baldi,

While we have focused on the science of targeted temperature management and other care strategies for critically ill survivors, it is important for us to remember that real people experience cardiac arrest and the consequences. In this unique episode, Dr. Benjamin Abella interviews Kristin Flanary, who jumped into action to provide 10 minutes of bystander CPR to her husband, Dr. Will Flanary, who has thankfully made a full recovery. You may know Kristin and Will as @lglaucomflecken and @dglaucomflecken , well-known on twitter – we are grateful that Kristin has chosen to go public with her story and support advocacy for cardiac arrest and post-arrest care.   Suggested readings on bystander CPR and survivorship: Brian Anderson. The Conversation That Can Change the Course of a Cardiac Arrest. The Atlantic, 2021.   https://www.theatlantic.com/health/archive/2021/02/tcpr-telephone-cpr-can-save-lives/618145/ Riva G, et al. Survival after dispatcher-assisted cardiopulmonary resuscitation in out-of-hospital cardi

The role of oxygenation during critical illness remains a major question.  Is extra oxygen harmful or helpful? What oxygen levels should we target, both for respiratory failure and for patients after cardiac arrest? Dr. Benjamin Abella discusses these topics, and reviews a hot-of-the-press work from European investigators (the “HOT-ICU”) trial, published in New England Journal of Medicine this month. The paper evaluates two different oxygen targets for patients with respiratory failure – implications for this work as it pertains to cardiac arrest will be discussed.   Key publications: Schjørring OL, Klitgaard TL, Perner A et al. Lower or Higher Oxygenation Targets for Acute Hypoxemic Respiratory Failure. NEJM 2021; Jan 20. doi: 10.1056/NEJMoa2032510. Roberts BW, Kilgannon JH, Hunter BR, et al. Association Between Early Hyperoxia Exposure After Resuscitation From Cardiac Arrest and Neurological Disability: Prospective Multicenter Protocol-Directed Cohort Study. Circulation. 2018 May 15;137(20):2114-2124.

Critical illness from COVID19 remains a major challenge to health systems worldwide. When patients progress to in-hospital cardiac arrest (IHCA), what is the chance of survival?  Studies have so far revealing conflicting answers to this important question.  What is the role of post-arrest care bundles, including TTM, in the care process?  Dr. Felipe Teran will lead a conversation with Dr. Oscar Mitchell, who served as the lead author in a new multicenter study of COVID19 IHCA survival, to be presented as a late-breaking abstract at the Resuscitation Science Symposium.   Key publications: Girotra S, Tang Y, Chan PS, Nallamothu BK; American Heart Association Get With The Guidelines–Resuscitation Investigators. Survival After In-Hospital Cardiac Arrest in Critically Ill Patients: Implications for COVID-19 Outbreak? Circ Cardiovasc Qual Outcomes. 2020 Jul;13(7):e006837.   Thapa SB, Kakar TS, Mayer C, Khanal D. Clinical Outcomes of In-Hospital Cardiac Arrest in COVID-19. JAMA Intern Med. 2020 Sep 28:e204796. Hayek

Dr. Felipe Teran joins Drs. Cindy Hsu and Hans van Schuppen to discuss recent guidance regarding cardiac arrest resuscitation during the COVID-19 pandemic. Key publications referenced in this episode:  Couper K, Taylor-Phillips S, Grove A, et al. COVID-19 in cardiac arrest and infection risk to rescuers: A systematic review. Resuscitation. 2020; 151:59-66. https://pubmed.ncbi.nlm.nih.gov/32325096/ Edelson DP, Sasson C, Chan PS, et al. Interim Guidance for Basic and Advanced Life Support in Adults, Children, and Neonates With Suspected or Confirmed COVID-19: From the Emergency Cardiovascular Care Committee and Get With the Guidelines-Resuscitation Adult and Pediatric Task Forces of the American Heart Association in Collaboration with the American Academy of Pediatrics, American Association for Respiratory Care, American College of Emergency Physicians, The Society of Critical Care Anesthesiologists, and American Society of Anesthesiologists: Supporting Organizations: American Association of Critical Care Nu

Dr. Felipe Teran discusses the recent studies pertainig to OHCA during the COVID-19 pandemic.   Key publications referenced in this episode: Baldi E et al. Out-of-hospital cardiac arrest during the Covid-19 outbreak in Italy. N Engl J Med 2020 Apr 29; [e-pub]. (https://doi.org/10.1056/NEJMc2010418) Marijon E, Karam N, Jost D, et al. Out-of-hospital cardiac arrest during the COVID-19 pandemic in Paris, France: a population-based, observational study. Lancet Public Health. 2020 Sayre MR, Barnard LM, Counts CR, et al. Prevalence of COVID-19 in Out-of-Hospital Cardiac Arrest: Implications for Bystander CPR. Circulation. 2020. DOI: 10.1161/CIRCULATIONAHA.120.048951

Dr. Abella discusses a very recent American Heart Association scientific statement on cardiac arrest survivorship, increasingly recognized as an important topic around the globe. While many studies have evaluated survival to hospital discharge, or even survival at 90 or 180 days post-arrest – survival is not enough. Increasing data suggest that even among “good” neurologic survivors (those with Cerebral Performance Category 1 or 2), life-limited challenges remain, including depression, PTSD, cognitive deficits and other challenges to quality of life.   Key readings:  Sawyer KN, et al. Sudden Cardiac Arrest Survivorship: A Scientific Statement From the American Heart Association. Circulation 2020 Feb 12 [epub ahead of print]. https://www.ncbi.nlm.nih.gov/pubmed/32078390   Lilja G, et al. Return to Work and Participation in Society After Out-of-Hospital Cardiac Arrest. Circ Cardiovasc Qual Outcomes. 2018 Jan;11(1):e003566. https://www.ncbi.nlm.nih.gov/pubmed/29326145   AHA Podcast on the Survivorship Scientific

Drs. Teran and Abella discuss a hot-off-the-press survey study by Maciel CB et al (Critical Care Medicine, 2020), probing physician perspectives and practice on post-arrest neurologic assessment and prognostication. Do all of us follow the international guidelines for this phase of care? What are points of confusion in current “real world” practice?  Join us to answer these questions and hear about key action items for all of us who manage post-arrest care. Key reading: Neuroprognostication Practices in Postcardiac Arrest Patients: An International Survey of Critical Care Providers. Maciel CB, Barden MM, Youn TS, Dhakar MB, Greer DM. Crit Care Med. 2020 Feb;48(2):e107-e114. https://www.ncbi.nlm.nih.gov/pubmed/31939809

Drs. Abella and Teran discuss the scientific literature surrounding gender differences in care during and following cardiac arrest. From differences in bystander CPR provision for public cardiac arrests to post-arrest DNR status and cardiac catheterization; listen to hear more.   Key publications for this episode: Lindgren E et al. Gender differences in utilization of coronary angiography and angiographic findings after out-of-hospital cardiac arrest: A registry study. Resuscitation. 2019 Oct;143:189-195. https://www.ncbi.nlm.nih.gov/pubmed/31330199 Perman SM et al. Sex Differences in "Do Not Attempt Resuscitation" Orders After Out-of-Hospital Cardiac Arrest and the Relationship to Critical Hospital Interventions. Clin Ther. 2019 Jun;41(6):1029-1037. https://www.ncbi.nlm.nih.gov/pubmed/31047712 Jeong JS et al. Gender disparities in percutaneous coronary intervention in out-of-hospital cardiac arrest. Am J Emerg Med. 2019 Apr;37(4):632-638. https://www.ncbi.nlm.nih.gov/pubmed/30563798 Blewer AL et al. Gender D

Drs. Robert Neumar and Cindy Hsu (both at University of Michigan) continue their discussion with Dr. Felipe Teran following the plenary “Year in Review” presentation by Dr. Neumar at the American Heart Association Resuscitation Science Symposium (ReSS) in Philadelphia. If you missed ReSS, this is your chance to hear summaries of the top studies that impacted cardiac arrest and post-arrest care in the past 12 months. Note that this is the second part of a two-part podcast: Check your earlier in this feed for Episode 14 contains the first half of this conversation. Key readings for this podcast include: Nordberg P et al. Effect of Trans-Nasal Evaporative Intra-arrest Cooling on Functional Neurologic Outcome in Out-of-Hospital Cardiac Arrest: The PRINCESS Randomized Clinical Trial. JAMA2019 May 7;321(17):1677-1685. https://www.ncbi.nlm.nih.gov/pubmed/31063573 Lascarrou JB et al. Targeted Temperature Management for Cardiac Arrest with Nonshockable Rhythm. N Engl J Med. 2019 Dec 12;381(24):2327-2337. https://www.

Resuscitation Science Top Studies of 2019: Part 1 of 2 Drs. Robert Neumar and Cindy Hsu (both at University of Michigan) are guest presenters in this special TTM Academy Podcast, hosted by Dr. Felipe Teran. They recap the plenary “Year in Review” presentation by Dr. Neumar at the American Heart Association Resuscitation Science Symposium (ReSS) in Philadelphia. If you missed ReSS, this is your chance to hear summaries of the top studies that impacted cardiac arrest and post-arrest care in the past 12 months. Note that this is a two-part podcast: Episode 15 will present the second alf of this discussion in two weeks. Year in Review Slides Key readings for this podcast include: Jakkula P et al. Targeting low-normal or high-normal mean arterial pressure after cardiac arrest and resuscitation: a randomised pilot trial. Intensive Care Med. 2018 Dec;44(12):2091-2101. https://www.ncbi.nlm.nih.gov/pubmed/30443729 Ameloot K et al. Early goal-directed haemodynamic optimization of cerebral oxygenation in comatose surviv

Drs. Teran and Abella discuss the role of transesophageal echocardiography (TEE) in the resuscitation of cardiac arrest patients.  Listen for details of how this cutting-edge application of TEE could play a role in improving arrest diagnostics, CPR quality and possibly arrest outcomes.   Key Reading: Teran F et al. “Evaluation of out-of-hospital cardiac arrest using transesophageal echocardiography in the emergency department.” Resuscitation. 2019 Apr;137:140-147. https://www.ncbi.nlm.nih.gov/pubmed/30779977 Catena E et al. “Association between left ventricular outflow tract opening and successful resuscitation after cardiac arrest.” Resuscitation. 2019 May;138:8-14. https://www.ncbi.nlm.nih.gov/pubmed/30825552

Earlier this week, results from the HYPERION trial were published in the New England Journal of Medicine. Drs. Abella and Teran discuss the use of TTM for patients resuscitated from cardiac arrest with a non-shockable initial rhythm.   Suggested Readings: Lascarrou JB et at., “Targeted Temperature Management for Cardiac Arrest with Nonshockable Rhythm.” N Engl J Med. 2019 Oct 2.https://www.ncbi.nlm.nih.gov/pubmed/31577396 Perman SM et al., “The Utility of Therapeutic Hypothermia for Post-Cardiac Arrest Syndrome Patients With an Initial Nonshockable Rhythm.” Circulation. 2015 Dec 1;132(22):2146-51. https://www.ncbi.nlm.nih.gov/pubmed/26572795 Grossestreuer AV et al., “Magnitude of temperature elevation is associated with neurologic and survival outcomes in resuscitated cardiac arrest patients with postrewarming pyrexia.” J Crit Care. 2017 Apr;38:78-83. https://www.ncbi.nlm.nih.gov/pubmed/27866109 Neilsen N et al., “Targeted temperature management at 33°C versus 36°C after cardiac arrest.” N Engl J Med. 2013 De

Following the success of Episode 6, which discussed the scientific evidence for ECMO in cardiac arrest, we decided to take a deeper look at the implementation of ECMO in the ED. Drs. Felipe Teran and Joseph Tonna discuss the utilization of ECMO for refractory cardiac arrest, the expansion of hospital ECMO programs to the emergency department and implementation of an ECMO program for cardiac arrest. This episode was recorded on location in Salt Lake City, Utah.   Key Reading: Tonna JE et al., “Practice characteristics of Emergency Department extracorporeal cardiopulmonary resuscitation (eCPR) programs in the United States: The current state of the art of Emergency Department extracorporeal membrane oxygenation (ED ECMO).” Resuscitation. 2016 Oct;107:38-46. https://www.ncbi.nlm.nih.gov/pubmed/27523953 Tonna JE et al., “Development and Implementation of a Comprehensive, Multidisciplinary Emergency Department Extracorporeal Membrane Oxygenation Program.” Ann Emerg Med. 2017 Jul;70(1):32-40. https://www.ncbi.nlm.n

Drs. Teran and Abella discuss the role of TTM for patients following cardiac arrest caused by opioid overdose. Several recent observational studies are reviewed to understand the demographics of patients who suffer opioid-related cardiac arrest, their outcomes, and whether TTM may be beneficial during post-arrest for these patients.   Key readings: Salcido DD et al, “Regional incidence and outcome of out-of-hospital cardiac arrest associated with overdose.” Resuscitation 2016; 99:13-19.http://dx.doi.org/10.1016/j.resuscitation.2015.11.010 Katz AZ et al, “Outcomes of patients resuscitated from cardiac arrest in the setting of drug overdose.” Resuscitation 2015; 94:23-27.http://dx.doi.org/10.1016/j.resuscitation.2015.06.015 Khan S et al, “Impact of Targeted Temperature Management on ED Patients with Drug Overdose–Related Cardiac Arrest.”, Journal of Medical Toxicology 2019; 15:22–29. https://doi.org/10.1007/s13181-018-0686-0

Following resuscitation from cardiac arrest, accurate evaluation of neurological recovery can help guide patient care and family decisions. In this podcast, Drs. Teran and Abella discuss a recent investigation into the use of MRI imaging in prognostication following resuscitation from arrest.   Key reading for this podcast: Wallin E et al, "Acute brain lesions on magnetic resonance imaging in relation to neurological outcome after cardiac arrest."Acta Anaesthesiol Scand. 2018 May;62(5):635-647. doi: 10.1111/aas.13074. https://www.ncbi.nlm.nih.gov/pubmed/29363101

Episode 8 – Oxygen Delivery After Cardiac Arrest Resuscitation   During cardiac arrest resuscitation, most patients are intubated and placed on 100% oxygen. In this podcast, Drs. Teran and Abella discuss recent investigations that suggest that too much oxygen may worsen post-arrest injury. Global resuscitation guidelines suggest down-titration of oxygen as tolerated to maintain adequate O2 saturation, but it’s not clear how well this is done- many patients are left on high oxygen “dose” for hours.   Key readings for this podcast: Robert BW et al, “Association Between Early Hyperoxia Exposure After Resuscitation From Cardiac Arrest and Neurological Disability: Prospective Multicenter Protocol-Directed Cohort Study.” Circulation. 2018 May 15;137(20):2114-2124. https://www.ncbi.nlm.nih.gov/pubmed/29437118 Kilgannon JH et al, “Association between arterial hyperoxia following resuscitation from cardiac arrest and in-hospital mortality.” JAMA. 2010 Jun 2;303(21):2165-71. https://www.ncbi.nlm.nih.gov/pubmed/20516417

Drs. Felipe Teran and Ben Abella discuss an important recent publication in Annals of Emergency Medicine by Elmer et al, in which some of the strongest evidence to date are presented that support the concept of “cardiac arrest centers”, much like trauma or stroke centers. This has been proposed before (Nichol G et al, Circulation 2010 – see below) – but evidence is now accumulating in support of the idea. Key readings: Nichol G et al, “Regional systems of care for out-of-hospital cardiac arrest: A policy statement from the American Heart Association.”, Circulation 2010;121:709-29. https://www.ncbi.nlm.nih.gov/pubmed/20075331 Elmer J et al, “Long-Term Outcomes of Out-of-Hospital Cardiac Arrest Care at Regionalized Centers.”, Ann Emerg Med 2019; 73:29-39. https://www.ncbi.nlm.nih.gov/pubmed/30060961

Drs. Benjamin Abella, John Greenwood and Felipe Teran discuss the use of ECMO (extra corporeal membrane oxygenation) for cardaic arrest patients.    Referenced article: Weisfeldt ML, Becker LB.  Resuscitation after cardiac arrest: a 3-phase time-sensitive model. JAMA. 2002 Dec 18;288(23):3035-8. https://doi.org/10.1001/jama.288.23.3035