Post Cardiac Arrest Care

OVERVIEW

Priorities

1. prevent further cardiac arrest
2. define the underlying pathology
3. limit organ damage
4. predict non-survivors

Ideally patients should be taken to a cardiac intervention center with 24/7 capabilities

PREVENT FURTHER CARDIAC ARREST

• Optimise FiO2
  — target SaO2 94-98% to avoid hyperoxia
  — decrease FiO2 as soon as possible
• protective lung ventilation via ETT (confirm placement)
• commence sedation
• ventilate to normocapnia
• correct electrolyte abnormalities
• control glucose (e.g. <10 mmol/L)
• administer appropriate anti-arrhythmic (amiodarone 300mg or 5mg/kg)

DEFINE UNDERLYING PATHOLOGY

• diagnose and treat cause (may need PCI or thrombolysis)
• treat complications (e.g. heart failure, hypotension, rib fractures, pneumothorax)
• cath lab on ECMO or using LUCAS2 device if refractory arrest
• assess neurology (see Prognosis After Cardiac Arrest)

LIMIT ORGAN DAMAGE

• if unconscious despite ROSC commence targeted temperature management
  — Until 2013 the approach was to cool to T33C (T32-34C ) for ~24 hours
  — after the TTM trial (Nielsen et al, 2013) T36C is expected to be widely adopted as the appropriate target
  — depending on the target used and the patient’s actual temperature: use cold IV saline, ice, cooling blanket
  — control shivering
  — control temperature with a cooling device
  — controlled slow rewarming (0.25C per hour; ILCOR guidelines support 0.25 to 0.5C per hour)
• invasive monitoring
• inotropes/vasopressors
  — target MAP>70; some experts target >80 to ensure adequate CPP and other experts (such as Steve Bernard) advocate SBP >120 mmHg

PREDICTION OF NON-SURVIVORS

• Prognosticate on day 5
• see Prognosis After Cardiac Arrest (includes neurological prognostication protocol from TTM trial)

References and Links

LITFL

• CCC — Prognosis After Cardiac Arrest
• CCC — Post-cardiac arrest syndrome
• CCC — Targeted temperature management (TTM) after cardiac arrest

Journal articles

• Neumar RW, et al. Post-cardiac arrest syndrome: epidemiology, pathophysiology, treatment, and prognostication. A consensus statement from the International Liaison Committee on Resuscitation. Circulation. 2008 Dec 2;118(23):2452-83. doi: 10.1161/CIRCULATIONAHA.108.190652. Epub 2008 Oct 23. PubMed PMID: 18948368. [Free Full Text]
• Stub D, Bernard S, Duffy SJ, Kaye DM. Post cardiac arrest syndrome: a review of therapeutic strategies. Circulation. 2011 Apr 5;123(13):1428-35. doi: 10.1161/CIRCULATIONAHA.110.988725. Review. PubMed PMID: 21464058. [Free Full Text]

FOAM and web resources

• EMCrit — Post-Arrest Hypothermia Protocols and Resources
• FET — Post Arrest Care – It’s More than Hypothermia by Michael Winters (2013)
• FET — Post Cardiac Arrest Management by Michael Kuiper (2009)