Immediate Post-ROSC Management

OVERVIEW

• A team-based approach to the management of the post-ROSC (return of spontaneous circulation) patient focuses on initiation of therapeutic hypothermia, treatment of the underlying cause with transfer to the cath lab where appropriate, and management of the post-cardiac arrest syndrome.
• The approach below is based on the protocol developed by Stephen Bernard

INITIAL ASSESSMENT AND MONITORING

Handover from paramedics, noting the following if known:

• Age
• Relevant past medical history
• Previous functional status
• Initial cardiac rhythm (VF/VT versus PEA/asystole)
• Presence and duration of bystander CPR
• EXACT total duration of arrest (ambulance first call time to ROSC time)
• Number of DC shocks
• Dose of adrenaline given

Initial actions:

• ETT secured, waveform ETCO2 connected
• Pulse oximeter connected
• NIBP set for q2min
• 12 lead ECG
• Temperature probe inserted into naso-pharynx/ oesophagus/ bladder (NOT SKIN TEMPERATURE)
• IV x2 patent
• C-spine collar if head strike or attempted hanging
• Portable CXR
• Arterial line inserted and routine bloods sent (check glucose and blood gas)

AIRWAY AND BREATHING

• Target SaO2 94-98%
• ABG (not corrected for temperature) of a pO2 of 70-100 mmHg and a pCO2 of 40mmHg.

CIRCULATION

Blood pressure management

• Target SBP 100 mmHg ( “normal” blood pressure is associated with improved outcomes)
• higher blood pressure may be targeted in patients with known hypertension.
• Hypertension (SBP>160mmHg) should be treated with additional sedation (or a propofol infusion) followed by a GTN infusion if needed.

Heart rate

• Bradycardia (35-50/minute) is a physiological effect of hypothermia and does not require treatment.
• If bradycardia is not present, suspect something else is wrong!

Inopressors

• Commence adrenaline infusion as first line
• If the dose of adrenaline exceeds 20 mcg/min or the lactate level is increasing, then an infusion of noradrenaline should be considered.
• If a further fluid challenge is required for CVP<12mmHg, infuse a bolus (i.e. 500mL) of ice-cold 0.9% saline.

Transfer appropriate patients to the cath lab

• VF arrest
  — ideally all patients (may not be feasible after hours)
  — especially: STEMI, shock requiring IABP, recurrent dysrhythmias
  — if not performed immediately after hours should be first on next elective list
• non-VF arrest
  — suspected cardiac cause with STEMI, shock requiring IABP, recurrent dysrhythmias

NEUROLOGICAL

• On-going sedation is required during mechanical ventilation and cooling.
• Hypothermia is also sedating so only modest doses of sedation should be administered.
• Start an infusion of midazolam (max 5mg/hour) or propofol 50mg/hr if blood pressure is stable. Use adrenaline or noradrenaline to support blood pressure as needed.
• If shivering or movement occurs despite sedation at the above dosage administer a long acting non-depolarizing neuromuscular blocking drug (e.g. rocuronium 100mg IV)
• Avoid calcium infusions for asymptomatic hypocalcemia as calcium us potentially toxic to injured neurons

TEMPERATURE CONTROL

A core temperature of 32-34 C should be achieved as quickly as possible using the following strategies.

• Administer midazolam 1-5mg IV, and commence an infusion @ 2-5mg/hr
• Administer a large dose of a non-depolarizing muscle relaxant (eg rocuronium 100mg IV)
• Infuse 30ml/kg of ice cold crystalloid fluid (0.9% saline at 4°C) as soon as possible, at 100mls/min using a standard giving set and pressure bag inflated to 300mmHg
• Apply surface cooling using a cooling vest with a cooling machine (e.g. Gaymar Meditherm III) temperature set to 33°C and the rate of cooling set to the “hare” setting. Note: the vest is radiolucent and does not need to be removed for cardiac catherisation.

References and Links

• Kern KB. Optimal treatment of patients surviving out-of-hospital cardiac arrest. JACC Cardiovasc Interv. 2012 Jun;5(6):597-605. doi: 10.1016/j.jcin.2012.01.017. PMID: 22721654.
• Kilgannon JH, Jones AE, Shapiro NI, Angelos MG, Milcarek B, Hunter K, Parrillo JE, Trzeciak S; Emergency Medicine Shock Research Network (EMShockNet) Investigators. Association between arterial hyperoxia following resuscitation from cardiac arrest and in-hospital mortality. JAMA. 2010 Jun 2;303(21):2165-71.PMID: 20516417.
• Peberdy MA, Callaway CW, Neumar RW, Geocadin RG, Zimmerman JL, Donnino M, Gabrielli A, Silvers SM, Zaritsky AL, Merchant R, Vanden Hoek TL, Kronick SL. Part 9: post-cardiac arrest care: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010 Nov 2;122(18 Suppl 3):S768-86. doi: 10.1161/CIRCULATIONAHA.110.971002. Review. Erratum in: Circulation. 2011 Feb 15;123(6):e237. Circulation. 2011 Oct 11;124(15):e403. PMID: 20956225.
• Trzeciak S, Jones AE, Kilgannon JH, Milcarek B, Hunter K, Shapiro NI, Hollenberg SM, Dellinger P, Parrillo JE. Significance of arterial hypotension after resuscitation from cardiac arrest. Crit Care Med. 2009 Nov;37(11):2895-903; quiz 2904. PMID: 19866506.