Post-cardiac arrest syndrome
Reviewed and revised 15 November 2016
OVERVIEW
aka post-resuscitation syndrome
- occurs after return of spontaneous circulation (ROSC) following cardiorespiratory arrest and involves multiple systems
- Reflects a state of whole-body ischaemia and subsequent reperfusion
- Often super-imposed on the underlying condition, which caused the cardiac arrest and pre-existing comorbidities, and other complications of resuscitation
- Severity depends on the duration and cause of cardiac arrest
Mortality and morbidity following cardiac arrest
- Early mortality due to cardiovascular instability
- Late mortality and morbidity occurs from brain injury (the most common cause of death after ROSC), multi-organ failure and sepsis
MECHANISM
Postcardiac arrest syndrome was once thought to be largely due to production of free radicals, although the pathophysiology is more complex
- Hypoperfusion and ischaemia cause a cascade of events
- disruption of homeostasis
- free radical formation
- protease activation
- a SIRS response resembling severe sepsis
- The disruption may continue for hours or days
- Hypothermia may slow down this cascade
MAJOR MANIFESTATIONS
- Postcardiac arrest brain injury
- Disruption on both a micro- and macro- circulatory levels may result in either ischaemia or hyperaemia
- Postcardiac arrest myocardial dysfunction
- Although the heart initially becomes hyperkinetic, likely due to circulating catecholamines, global hypokinesis often follows
- Usually resolves within 72 hours
- Systemic ischaemia/reperfusion response
- The response of the body is similar to the septic shock with activation of the immune and complement systems, and release of inflammatory cytokines and a wide range of cellular responses
- Persistent precipitating pathology
- The cause of the arrest may continue to impact physiological parameters
CONTRIBUTING FACTORS
Post cardiac arrest brain injury
- Impaired cerebrovascular autoregulation
- Cerebral oedema
- Neurodegeneration
Post cardiac arrest myocardial dysfunction
- Myocardial stunning – global hypokinesis
- Poor cardiac output
- Acute coronary syndromes
Systemic ischaemia / reperfusion response
- Systemic inflammatory response syndrome (SIRS)
- Poor vasoregulation
- Microcirculatory failure
- Activation of coagulation cascade
- Adrenal suppression
- Poor tissue oxygen deliver and utilization
- Susceptibility to infection
Persistent precipitating pathology
- Cardiovascular disease (e.g. myocardial ischemia, cardiomyopathy)
- Pulmonary disease (e.g. pulmonary embolus, asthma)
- CNS disease (e.g. stroke, subarachnoid hemorrhage)
- Poisoning
- Infection / Sepsis
- Hypovolaemia
Other complications of resuscitation such as injuries (e.g. rib fractures, sternal fractures), medication adverse effects and complications of invasive lines and monitoring.
References and Links
LITFL
- CCC — Prognosis After Cardiac Arrest
- CCC — Post-cardiac arrest care
- CCC — Targeted temperature management (TTM) after cardiac arrest
Journal articles
- Mongardon N, Dumas F, Ricome S, Grimaldi D, Hissem T, Pène F, Cariou A. Postcardiac arrest syndrome: from immediate resuscitation to long-term outcome. Ann Intensive Care. 2011 Nov 3;1(1):45. PMC3223497.
- 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. 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. PMID: 21464058. [Free Full Text]
- Zia A, Kern KB. Management of postcardiac arrest myocardial dysfunction. Curr Opin Crit Care. 2011 Jun;17(3):241-6. PMID: 21378558.
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
Specialist Intensive Care Physician working at the Austin Hospital, Melbourne. Interests: Shoulder Dislocations, Pain Management, End-of-life care, Organ Donation and ECGs | Linkedin |