Post Cardiac Arrest Care
OVERVIEW
Priorities
- prevent further cardiac arrest
- define the underlying pathology
- limit organ damage
- 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)
Critical Care
Compendium
Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.
After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.
He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.
His one great achievement is being the father of three amazing children.
On Twitter, he is @precordialthump.
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