Doctor: Romain Jouffroy

Title: Clinical and paraclinical criteria and risk factors for an unfavourable prognosis in the management of out-of-hospital cardiac arrest

Supervisor: Romain Pirracchio

Doctoral school: ED 393 Epidemiology and Biomedical Information Sciences, Université Paris Cité

Date of thesis defense: 12/2020

Jury: Romain Pirracchio, Benoît Vivien, Florence Dumas, Guillaume Debaty, Papa Ngalgou Gueye, Guillaume Geri, Nicole Karam, Agnès Ricard-Hibon.

Thesis summary:

Despite the progress made in improving its pre-hospital and then intra-hospital management, cardiac arrest remains a major public health problem, the prognosis for which has remained gloomy for some 30 years. Its treatment is based on the concept of the chain of survival, the absence of a single link destroying any hope of observing the effects of a treatment, however complex, introduced in the pre- or intra-hospital theather. Even with the best possible coordinated and optimised care, some patients present a picture of cardiac arrest that is refractory to well-managed therapies. In cardiac arrest secondary to a rhythmic disorder, the ineffectiveness of electrical and chemical antiarrhythmic agents has made it possible to open up a path of research towards the use of potassium salts under the cover of prior cardio-circulatory assistance, or as an alternative to pharmaceutical agents that have already been tried and tested. The effectiveness and the place of potassium salts in the therapeutic arsenal in the event of refractory cardiac arrest by shockable rhythm should be specified in the next years. Regarding refractory cardiac arrest by non-shockable rhythm, the fields of research remain wide, given the recent data suggesting the lack of superiority of adrenaline administration, and the questions about its safety at high doses. In the therapeutic arsenal for the management of refractory cardiac arrest, whatever the initial rhythm, shockable or not, the technological advent at the end of the last century made it possible to propose extracorporeal circulation outside operating theatres and in the out-of-hospital field. The latter makes it possible to prolong the symptomatic treatment of circulatory failure, but is not in itself the key to successful treatment. The Bispectral Index (BIS), a simple paraclinical tool, allows early detection of an unfavourable neurological evolution. Moreover, the impossibility of maintaining rheology, oxygenation and homeostasis within the limits of physiology is also associated with a pejorative prognosis in the short term. Research prospects in this field are still very numerous. Indeed, the implementation of extracorporeal circulation must be integrated within a global care strategy, from pre-hospital care to rehabilitation and social reintegration or towards an organ donation procedure in the event of an unfavourable evolution.

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