Emerge in EM

E2: Post-cardiac arrest care

• Mohamed Hagahmed, MD

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In the October episode, Dr. Ankur Doshi and I are discussing the care of the post cardiac arrest patient.

For the past 20 years, Dr. Doshi has been a clinician, educator, and researcher in the fields of emergency medicine and cardiac arrest. In 2010, he joined the University of Pittsburgh Medical Center’s Post Cardiac Arrest team. Since 2019, he has been the clinical director of this unique service line across the UPMC network of hospitals. 

Dr. Doshi has authored or co-authored more than 30 peer-reviewed publications in the field of cardiac arrest care. He has lectured nationally and internationally on this subject. Additionally, he is an accomplished educator and mentor for undergraduate students, medical students, and graduate medical trainees. He has been awarded multiple teaching awards and has been recognized as a member of the selective UPSOM Academy of Master Educators.

Mohamed:

Welcome back to eMERGE and EM, the podcast where we explore core aspects of emergency medicine. I'm your host, Dr. Mohammed Hagahmed. And today's topic is one that impacts the outcome of so many critically ill patients, that's post cardiac arrest care. There's a lot of nuance to caring for patients who've achieved return of spontaneous circulation known as ROSC, but remain critically ill. Today, we're breaking down the latest evidence and practical strategies for managing these patients. And I'm so honored to have my esteemed colleague and friend, Dr. Ankur Doshi to join me to discuss this topic. Ankur, can you please just tell us what you do and why you chose the field of cardiac arrest care?

Ankur:

Yeah. So Mo first, thank you. It's an honor to be on this podcast to be with a friend and colleague, as you said, and someone who's taught me a lot. And I think we've taught each other a lot over the years. So thanks for having me. So as you said, I'm Ankur Joshi. I'm an emergency physician by trade and got into the. Interested in cardiac arrest like many of us did in emergency medicine, you know Probably the most morbid of the conditions that you can have if you're interested in either EMS or emergency medicine I was blessed to work and train again with some of the giants in emergency Medicine people like Peter Saffer and Cliff Calloway and I got the bug in med school and in residency to take care of cardiac arrest patients. But what I really do is not only work in the ER as I run an inpatient cardiac arrest service. And what that means is that we see patients here and provide structured in hospital care after patients get ROSC. And as you mentioned this is really important. The entire chain of survival matters. If we don't. do inpatient care with the up to date evidence that all of our really great EMS colleagues do out of the hospital, we can actually just, get rid of all the good work they did and patients don't have the outcome we want. So for the past 20 years or so of my career, I've been working on inpatient care of cardiac arrest as opposed to the outpatient care.

Mohamed:

And I feel like before we dive into the clinical content, which I'm sure is going to be rich, it's crucial to frame the problem in a global context. Cardiac arrest is a significant public health issue that with survival rate after out of hospital arrest being less than, what, 15%? While in hospital cardiac arrest fares maybe slightly better at 22%. These numbers come from studies like the one by the Lazarin and colleagues. which emphasize that many deaths occur not during resuscitation, but after ROSC, due to the post cardiac arrest syndrome. Unfortunately, the burden of cardiac arrest is not evenly distributed. Studies have shown that racial, social, economic, and geographic disparities play a huge role in determining who survives and who doesn't. In fact, patients from underserved communities often have limited access to advanced post cardiac arrest care, which significantly impact outcomes. Dr. Doshi, how do these disparities manifest in practice and what steps can we take to address them?

Ankur:

Yeah, great question. And, maybe actually the million dollar question, right? All of medicine, unfortunately, we know is affected by disparities. Let's take the rest of the world out of it for a second and just focus on the United States. It's because. I think disparities are involved in your milieu and your context. We know that patients of color, specifically those who are African American and Latino, are the best studied, have poorer outcomes after cardiac arrest. And interestingly, when you break it down, they probably have different interventions all the way through the chain of survival. That starts at different calling 911. different rates of layperson CPR. Not sure, but concerned for different care by EMS, although not as well studied, although some studies, we know they get differential care in the hospital. We know that whether you have a cardiac arrest, you have different care in the hospital based on what you look like, whether it would be cardiac catheterization or withdrawal of life sustaining treatment. And you're exactly correct. We need to look at all these individually. And one of the really interesting things is in order to do that, you need to know what the right thing is to do and you need to monitor in your own system what you do. So one of the things that many hospitals still are struggled to do in hospital is to collect their cardiac arrest data. Now, if a hospital is part of the cares database or the get with the guidelines database, they likely will collect these data. But remember that's not all of our hospitals in the country. And so one of the charges actually to all of us who are interested in this is to make sure we're collecting our data to make sure we're not. Perpetuating what we know happens when we don't collect data, which is it disparities based on patients, age, gender, sex race or socioeconomic status.

Mohamed:

I know you and I look at these issues like very carefully. And I agree exactly. One of the key challenges we face is ensuring equitable access to the full spectrum of post cardiac arrest care in many underserved areas or communities. Temperature management, 24 7 access to P. C. I. And advanced neural monitoring are simply not available, which means patients are inherently already a disadvantage, right? So this ties back to the importance of robust emergency systems, as you already mentioned, and post resuscitation care guidelines.

Ankur:

Yeah, exactly. And, I think many of the things we're not really sure what matters, right? We know that a bundle of care helps. We're not really sure what part of that bundle and we're going to get to that later. But I think the key is if you don't collect the data on what you do and do what you do systematically, In the hospital, out of the hospital, it doesn't really matter. You can't figure out if there's a disparity. And so what that means is if there's a hospital, for instance, that doesn't document how they do temperature management or nerve resuscitation on each one of their patients, you don't know if you're really doing it the same way every time. And it doesn't have to be super complex. We'll talk about that here in a little bit. It can be done with actually resources that can be done anywhere maybe even in other parts of the world, not in the United States, a high resource area. And in the exact same way, if you're an EMS service and you're not collecting the data on what you do, and you're not QAing every cardiac arrest. You're liable to actually provide different care, whether you know it or not, on somebody unintentionally, right? Because we all have our own biases that we know. We know our own unconscious biases, but we don't always know what those are, and we can't correct those unless we have the data in front of us.

Mohamed:

I agree. I feel like the key point here is that cardiac arrest is universal, but survival isn't, right? To tackle this, we need to have more targeted interventions at the community level, like public CPR training initiatives improving pre hospital care, like I already said, and also addressing these gaps in post resuscitation care. All of this is essential to leveling the playing field. So let's kick off with a typical scenario, and I just gonna share with you a case that I had recently. So imagine you have a 65 year old man who. Collapsed at home, had bystander CPR, so they were lucky enough to get bystander CPR immediately. EMS arrives, and after 25 minutes of resuscitation, ROSC is achieved. The patient is intubated. They did a great job. Is still hypotensive with initial blood pressure of 80 over 60, and unresponsive upon arrival at the ED. With no ST segment elevation in the EKG. That was the initial EKG that was obtained by EMS. Now the real work begins, right? How do we manage this patient to give him the best possible outcome?

Ankur:

Great question. And a big question. How many hours do you got?

Mohamed:

Only 30 minutes left.

Ankur:

This is hard and complex and the exact right question you're asking, right? What does it, what can we do that actually changes the outcome and move the needle? And I would first start. By taking a step back, if you're an EMS provider, or an ED provider, or an ICU provider, and saying, that sounds like a completely survivable event, what you just described. A person who got immediately person CPR, got a relatively short resuscitation, although not zero, and makes it to us with good signs of life in the emergency department. The first thing I think we can do to increase survival, is to say, We're going to have this person survive and we're not going to think of them what we used to think of when I trained in cardiac arrest. Another cardiac arrest patient, they're going to end up in the ICU. They're going to end up brain injured. They're never going to go home. We're going to do a bunch of stuff and the family is going to be unreasonable because none of that is true. So I think the first priorities are the same priorities. Always we do an emergency medicine, and I know it sounds simple, but it's your A, B's and C's. We know that the brain is exquisitely sensitive to hypoperfusion and hypoxia in the peri arrest state. An anoxic brain that for any time is exquisitely sensitive to that, and that's why we do A, B's and C's. Simple thing, make sure they got an airway, get their oxygen up, and perfuse their brain. A couple studies now have shown norepinephrine's probably better than epinephrine if you get a choice. You may not have a choice in the field, right? Epinephrine premix is way easier. Pick a presser, get their map up to 65 and we can talk about their final map goals later, but in the emergency department, let's get it there. You said they already had an EKG, so they probably don't have ST elevations. They probably don't need to go to the cath lab. Then we need to figure out two things with them. First is why they arrest. If it wasn't a STEMI, what was it? And if we don't address that, then it really doesn't matter because they'll have another event. So go through some type of protocol to do that. What we do here is real simple. We pan scan everybody looking for things like PEs and injuries. We look for head bleeds and we do a whole bunch of emergency medicine labs. And we know those labs will give us the answer most of the time. It'll at least give me the stuff I got to do right away. This guy had a respiratory run because he choked. He's intubated. He's gonna, you've already taken care of that, but don't let him be hypoxic and try to figure out what happened and then start resuscitating the brain.

Mohamed:

So let's break it down. We're talking about more than just keeping the patient alive, right? We're aiming for survival with good neurologic functioning. In this episode we'll focus on some key areas, as you mentioned, of post arrest care, let's start with a temperature management first. Break it down a little bit because you mentioned a lot of good stuff there, and I want to make sure that we don't miss any important points. So TTM for years, man, I feel like when I was a medic, I remember admiring what you do as a post cardiac arrest expert. And I'm like, Oh my God, this cooling thing. It's like a suspended animation. You can just freeze people and send them to different planets and Mars, right? So for years like this, therapeutic hypothermia concept or cooling up to around 33, 33 Celsius was seen as the gold standard for improving neural outcome in postcardiac arrest patients. But recent studies, and I looked at the TTM2 trial have led to a shift in our approach. Can you explain what we've learned so far, and what is the latest evidence when it comes to controlled temperature management?

Ankur:

Yeah and what you're basically asking, in a different way, is how can we protect the brain from secondary brain injury and reperfusion injury? Which are a little bit separate and I think we conflate them, so let's take it step by step. We know that anoxic cells get reperfusion injury when they get blood back. We know this, it happens everywhere. If you really want funsies, go to the cath lab and see someone whose LAD lesion gets opened up and they VF, and they have reperfusion injury. We know this happens in the brain. We've had a whole slew of failed neuro protectants over the years. Dozens. to scores of neuro protectants have been tried to see if we can minimize reperfusion entry. One of those is TTM. And we probably know temperature actually matters in the sense that we all know if you're cold and you rest, you do okay, right? You're not dead until you're cold and dead. And we've anyone who's been doing this long enough in the north knows that has a story of that. They saw someone else saw that was cold somewhere in a snowbank, had a long cardiac arrest and did really well. Problem is most of our patients aren't cold before they arrest, right? And so the question is, can we cool them down and make them better? And we know in animal models, this works. We have literally decades of animal data to show that rapid initiation of TTM improves outcomes to the point where we know cells are better. We can see cellular lines that we know are better if you do TTM. So now the question is, does it work in humans? And the answer is probably, but it's hard to know the nuance. So back to the TTM2 trial, great trial you talked about. And I actually love this trial because I always tell folks, if you want to read a trial and know how to do a good trial. read this one. We nitpick trials all the time but this one's a hard one to nitpick. And for those who don't know, the TTM2 trial said a randomized control trial which was an international trial with just under 2000 patients, 1850 patients in it. And they randomized patients to two arms after ROSC after out of possible cardiac arrest mostly out of possible. They randomized to 33 degrees. Or fever suppression. And in the fever suppression group, they actually did nothing unless the patient's temperature made it above 37, or up to 37. 8 and then they kept them at 37. 5. Really well done trial. Outcomes are the same. Now what's really cool about this trial is a couple things. And this one I think blows people's mind when they don't think about it for a second is their good outcomes in both arms, 55%. More than half of their patients went home with a good outcome as defined. So now the question I ask myself is, do I have 55 percent good outcomes in my institution or not? And if not, why? Is it because I'm not as good? One definite possibility, are we doing something wrong? Or, do they have different patients who start differently? And the devil's in the details as always, right? So in the TTM 2 trial, the vast majority of those patients were bystander CPR, VTVF. And that's not what we see in the United States. Our center sees about a third of patients or less would be TDM. And we see about 15 to 30 percent, depending on the time we do it, who've actually had an ACS as their primary etiology. We know that the majority of our patients are actually respiratory events. And we know in the United States, the majority of people don't get late person CPR, while in TTM2 trials, 80 percent. So the question that I ask myself is, are they the same patients I see? And if so, I agree that the patient who gets enrolled in TTM2, there's no difference in outcomes. Is that all cardiac arrest patients? And if it's not all cardiac arrest patients, does it matter? Just because they didn't enroll people or their people look different, maybe this still doesn't matter. I just don't know. Back to your easy, simple question. Does temperature management matter? And the answer is absolutely yes. The question is what temperature? Because remember in TTM2, no one got no look at a temperature. They monitored and documented everyone's temperatures. That's different than what happened before we started doing this 20 years ago where people were parked in the corner of the ICU and no one even knew their temperature. Now at least we know people's temperature.

Mohamed:

And by the way, this is a great summary of the TTM2 trial, but just to be clear, the recommendation now is not cooling, but just maintaining normal thermia. Is that correct?

Ankur:

Yeah, so the most recent ECC recommendations from the AHA from 2023 in their update says, pick a temperature between 32 and 37. 5 degrees and do it. It doesn't say what temperature to do. It also says that doesn't have, we don't have enough data to know, do some people need 32 and some people need 37 and some people need 35 and some people need 36. Although I think that's the next place we're working on. The real, the next place is to say that maybe we shouldn't take all the patients the same. The guy you described, who got layperson CPR, who was VTVF and a fairly rapid resuscitation and is fairly young, sounds a lot like the TTM2 patients. Now the next thing I want to do is take that same patient cohort, but someone who got an hour of CPR, or someone who's 30 years old, or someone who's 80 years old, and I want to see if that's different or not. And we're going to find out.

Mohamed:

Good questions. So this is something that can be done in most hospital settings, managing fever, Without necessarily needing specialized cooling equipment. Let's move to the next big aspect. I feel like my experience in a pre hospital setting, which is hemodynamic stabilization or optimization. So hemodynamic instability is a common issue after ROSC with many patients experiencing myocardial dysfunction or distributive shock. Guidelines recommend maintaining a mean arterial pressure or a MAP of at least 65, as you mentioned. But is this always sufficient? Is this like, everybody needs to be able to 65 MAP goal?

Ankur:

Yeah, it's a great question. And I would ask, is everyone outside on the street outside my office got the same MAP? We don't know. This is one of the limitations in cardiac arrest work. And I think this is important to think about when we think of this. We have lumped cardiac arrest patients in as a monolith. Think of oncology, for instance, we would never lump all patients with breast cancer and say that the same treatment mattered. We actually know that doesn't work, right? The thing is with some types of cancer, you can do genetic assessments and you can find their genome and find what they need. That's what we don't have in cardiac arrest with all comers. Yes, there's multiple studies now where the 65 seems adequate. If you just take all people as comers. But for some people, they probably need a higher map. Maybe they lived with a map of 105. Maybe that long standing hypertension. Maybe we're under perfusing their brain at 65 or maybe they're now in cardiogenic shock because they're having a big MI and increasing their map to 65 is the wrong thing because you're, really making the heart struggle. And they haven't had a map that high in a long time because they have a history of heart failure. So I don't know the answer to that. Other than if you don't have any data to tell you, are you perfusing the brain well or not, then I would pick a map of 65. But what I would actually do if I could is try to get data to see if I was perfusing the brain.

Mohamed:

So how would you manage this issue at bedside? What is your current practice?

Ankur:

Yeah, and this is hard because not every place has the same resources, and so I think it depends on your resources. In our setting, what I will do is do two tests early. I'll get an EEG on the patient, and if I can increase and decrease their map and change their EEG, And it looks suppressed at 65, but at 70 it looks good. Maybe they needed more blood pressure. That's something you can do actually at the bedside in titrate, but you have to have an EEG to do that. Another thing we'll do is we'll check the jugular oxygen the jugular venous oxygen. And if the brain is starving for oxygen, it's going to draw out more oxygen. We'll know that jugular venous sat will go down. Then we can sometimes increase the map to see it. and see if we can do it. But simple stuff is if the patient's awake or doing well not awake and following, but has pupils. And now you drop their map to 65 and it was a hundred gosh, maybe they, and now they lost their pupils. Maybe they need it. One of the things I never do is I never artificially bring someone's map down unless there's something else I'm doing to help. So if I'm, if I think their heart's struggling and I'm going to bring their map down for that, or they're bleeding in their brain, otherwise I'm going to let them auto regulate. Like we do a stroke.

Mohamed:

So you tend to lean towards a higher map and not like anything below 65 that's not acceptable in your book.

Ankur:

I think that any, I think the most important thing for the brain is to get oxygen up there. And we know it's the map that actually perfuses the brain. It's not the systolic. And so one of the things actually, we've been taking a step back. We keep talking about map, but for folks who don't know, the map is what perfuses your brain, right? It's simple. Your cerebral perfusion pressure is your map minus your intracranial pressure. And You need to one check their map, which is something we don't always do. But gosh, most places can place an arterial line and do that. And then you need to follow it in some fashion. So yeah, I keep their map at 65 or higher. I don't really think it's almost ever appropriate to be lower. That's never saying never, but for the most part, most people need a map to make sure you're perfusing the brain because even small amounts of hypoxia and hypoxia can be due to your oxygen or it could be due to the oxygen that you're not sending because you're not sending blood are really bad.

Mohamed:

And just a quick brief note on the agent of choice. I know in the state of Pennsylvania now by the way, EMS clinicians paramedics could actually use norepinephrine. This has been approved, but does it matter whether epi or norepi for you. Is there any difference between the two?

Ankur:

Yeah, there's been a couple studies that norepi is probably better than epi if you get a choice. Most people actually don't have a choice, right? If you're an EMS provider, you may only get one. Even if norepi is allowed, you may only have one. I would give them a presser early. Also like in the hyperacute state, like in the perirosc state, like even before you make it to the hospital. Remember, you've given them a bunch of epi. And that epi is going to wear off, so you just have to assume at some point they're going to get hypotensive again. And so whatever you have ready, I would have ready to go. In the hospital, if you started epi, I may keep it if it's working, or I may switch it to norepi. In the emergency department, almost always I use norepi first. But, I think that's a little bit of a stylistic thing.

Mohamed:

So the goal is to individualize care based on the patient's history, obviously. So let's move to another important topic, which is coronary intervention. And also you spoke about that briefly. So for years Ankur, the practice was to rush patients who achieve ROSC to the cath lab. I think I kept cardiology awake 24 seven and they're probably hating me for that. Yeah. Even without evidence of any ST segment elevation on the EKG, but the COACT trial has questioned that approach. So what did the COACT show and how does it change our practice?

Ankur:

Yeah, actually three trials were done in the last 10 years on cardiac arrest. catheterization. And if you look at all three trials together, it's the COAC, the AXIS, and the Tomahawk trials. And we don't need to go into the details of each three, but if you sum them up together, what they tell us with pretty good certainty is that cardiac arrest patients without ST elevation generally don't benefit from an emergent cardiac catheterization unless they have other signs that they need a catheterization. Significant cardiogenic shock, arrhythmias you can't treat any other way. Those patients still probably benefit from going to the cath lab, right away. But everybody else doesn't, and it's a great question why. And again, backing it to individualizing care. Not everyone needs a cardiac catheterization. And we don't always think of the, we don't always think of the sequela of what we do. In the sense that, if we send someone to the cath lab, there's an opportunity cost. In the United States, most cardiac catheterization labs don't have an anesthesiologist or intensivist there. So now you have the intensive the interventionalist trying to manage the patient and open up an artery if they need it, and manage the patient's vent. and manage the patient's blood pressure and do all the other things that we can do at the bedside in the ICU, but you can't do easily in the cath lab. And so there's an opportunity cost by going to the cath lab in the sense that your neural resuscitation can sometimes be more challenging. Doesn't mean it can't be done, just challenging. And so I always ask myself, will this cath, I think, help this person or not? And if they have an ST elevation, generally the answer is yes. If they're in cardiogenic shock that I can't treat easily with pressors, etc, and I need a mechanical device, the answer is yes. If they have unstable continued arrhythmias, the answer is yes. And then they should go to the cath lab because that's what they need right now. And if they don't, they can actually go to the ICU and get a cath before they leave the hospital, protect their brain, get their brain better, then cath them. And I think that's a very logical approach.

Mohamed:

And that's like a significant change for many of us. I'll tell you I've never seen a normal EKG after a cardiac arrest, right? This is always abnormal. I'm saying something caused

Ankur:

them to

Mohamed:

die, right? So what EKG do you base it on? Do you base it like immediately after the ROSC situation, or you wait a little bit and get more diagnostics before you determine?

Ankur:

The answer is yes. And I use all of them. And very often our pre hospital providers will bring us an EKG. And that, as you said, is very often aberrant, whether it's ST elevation or a wide complex or whatever. I tend to repeat an EKG right away, and I like to compare it. Because if it's, whatever they showed aberrantly in the field is continuing, then it very likely will continue. Often that'll change, and maybe it's still aberrant but different. That helps me understand, how is this going to progress? So I would do one right away when they hit the ED door, once you stabilize. And then we can follow that serially. But if that one right away still shows ST elevation, I would call cardiology. Now they may say, Hey, let's get a little bit more data, check in another hour. That's not an unreasonable plan, but I would first get that thing activated because you don't want to waste time if they really do need it.

Mohamed:

So this is all great stuff. I feel like that we need to talk more about but for the sake of time, I feel like I need to save the most important topic and the most challenging aspect, neurologic prognostication. I know this is one of your favorite topics. And of course you're very passionate about that. But I feel like neuro recovery post cardiac arrest is notoriously hard to predict. Often we tend to prematurely withdraw care based sometimes on not, enough data. So what's the current thinking and how we approach this?

Ankur:

Yeah, that's a great question. And I think you actually hit the nail on the head that this. Once you get to the ICU, once a patient gets to the ICU after cardiac arrest, the number one reason a patient dies is withdrawal of life sustaining therapy for a perceived or neurologic prognosis. I. E. Someone in the hot care team, hopefully everyone together tells the loved ones of this patient. This is gonna be bad and your loved one may or may not make it through, but they're gonna have neurologic deficits. And the family says, thanks so much, doctor. Thanks so much, nurse. But they wouldn't want to live like this and we withdraw care. And that can be righteous if we're right, and if we're wrong, that's tragic, right? Because we can all count, those of us who do this a lot, on one hand or less, the amount of people who we told the family to withdraw care on, they withdrew care on, who still live, right? That's a self fulfilling prophecy where we can bring most of it down. And the data shows it's probably about 60 percent of people who die after out of hospital cardiac arrest in the ICU die from this reason. And so I think we have to get as close to right as we can, and we'll never be perfectly accurate, but we also need to be efficient. It's probably just It's not quite as tragic, but still tragic for the family who spends a month in the ICU and also has a bad outcome. I think we really try to get closer, close to the truth. And the number one thing I would recommend people to do if you have to have one kind of high point from this is wait 72 hours. Because that's the recommendation from all of the guidelines is we don't rush to this. We know that actually in many patients, we withdraw care before. And in fact, in some of the studies, the majority of patients get withdrawn on before 72 hours.

Mohamed:

That's awesome. So managing family expectations during this period can be very challenging, as you said. Do you have a certain way or strategy to approach these conversations?

Ankur:

Yeah. I tell folks that this is indeterminate and indeterminate is really hard. They want an answer. They want to know, is my loved one going to do well or not? And I say, just don't know. And the only way to know is to give them time because we know the patient in shock or the patient whose brain was just injured for a little bit because they got CPR, their exam is not reliable. We actually have a number of studies show that our physical exam in the first 72 hours isn't amazing either. That, people who didn't have pupils before now will get pupils at 72 hours. And so waiting those couple days is really important. And so I tell them it's a marathon, not a sprint. And we're not going to overreact to good or bad news. And we're just going to try to keep an even keel. And we're going to protect their brain through all that. With our kind of neurosuscitation bundle, and then we're going to see what happens in a couple days and get some tests to help us know, and then put that all together as a package. Sometimes with that package we're still indeterminate 72 hours, or sometimes our package gives us pretty good likelihood they're going to get better and we need some time, or they've already gotten better. And sometimes that package tells us things aren't going to go well. And then we can have a really nuanced conversation with families, show them that we did this, and this, and how we did it sequentially, which I think helps their trust in healthcare as well.

Mohamed:

Oh, so many pearls. I learned so much. Thank you so much, Dr. Doshi. Thank you for sharing your insights, your expertise. I'm going to do the hardest work here by trying to summarize some of the key takeaways and key points from this conversation. So temperature management should focus on fever prevention. With a target, you said about 36-37.5 Celsius hemodynamic support requires maintaining a map of at least 65 with higher targets for selected patients and coronary intervention should be preserved. For patients with clear signs of ischemia and, STEMI on EKG, others cannot, or if they're not be able to be stabilized first. And neuromonitoring is a complex and should involve a multimodal approach with decisions on withdrawal of care delayed for at least 72 hours. And of course, emphasizing on these important family discussions. Thank you so much. This is great. Do you have any last words you want to share with us? Thank you so much.

Ankur:

No, thanks for having me. I, as this is my passion as well, and happy to help anybody with this and very excited to be able to try to help people.

Mohamed:

Thanks to you, Dr. Doshi, and thank you to our listeners until the next one.