Lecture

Post Resuscitation Care

Learning outcomes
To understand: The need for continued resuscitation after return of spontaneous circulation How to treat the post cardiac arrest syndrome

How to transfer the patient safely

The role and limitations of assessing prognosis after cardiac arrest

Chain of Survival

Post resuscitation care

The goal is to restore: Normal cerebral function Stable cardiac rhythm Adequate organ perfusion Quality of life

Post cardiac arrest syndrome

Post cardiac arrest brain injury:
Coma, seizures, myoclonus

Post cardiac arrest myocardial dysfunction

Systemic ischaemia-reperfusion response
Sepsis-like syndrome

Persistence of precipitating pathology

Airway and breathing

Ensure a clear airway, adequate oxygenation and ventilation

Consider tracheal intubation, sedation and controlled ventilation

Pulse oximetry:
Aim for SpO2 94 98%

Capnography:
Aim for normocapnia Avoid hyperventilation

Airway and breathing

Look, listen and feel Consider:
Simple/tension pneumothorax Collapse/consolidation Bronchial intubation Pulmonary oedema Aspiration Fractured ribs/flail segment

Airway and breathing

Insert gastric tube to decompress stomach and improve lung compliance Secure airway for transfer Consider immediate extubation if patient breathing and conscious level improves quickly after ROSC

Circulation
Pulse and blood pressure Peripheral perfusion e.g. capillary refill time Right ventricular failure
Distended neck veins

Left ventricular failure

Pulmonary oedema

ECG monitor and 12-lead ECG

Disability
Neurological assessment: Glasgow Coma Scale score Pupils Limb tone and movement Posture

Glasgow Coma Scale score

Further assessment
History Health before the cardiac arrest Time delay before resuscitation Duration of resuscitation Cause of the cardiac arrest Family history

Further assessment
Monitoring Vital signs ECG Pulse oximetry Blood pressure e.g. arterial line Capnography Urine output Temperature

Further assessment
Investigations Arterial blood gases Full blood count Biochemistry including blood glucose Troponin Repeat 12-lead ECG Chest X-ray Echocardiography

Chest X-ray

Transfer of the patient

Discuss with admitting team Cannulae, drains, tubes secured Suction Oxygen supply Monitoring Documentation Reassess before leaving Talk to family

Out-of-hospital VF arrest associated with AMI

Enteral nutrition Insulin Inotropes Defibrillator Ventilation Pacing Cooling

IABP

Optimising organ function

Heart
Post cardiac arrest syndrome

Ischaemia-reperfusion injury:
Reversible myocardial dysfunction for 2-3 days Arrhythmias

Optimising organ function

Heart
Poor myocardial function despite optimal filling:
Echocardiography Cardiac output monitoring Inotropes and/or balloon pump

Mean blood pressure to achieve:

Urine output of 1 ml kg-1 hour-1 Normalising lactate concentration

Optimising organ function

Brain
Impaired cerebral autoregulation maintain normal blood pressure Sedation Control seizures Glucose (4-10 mmol l-1) Normocapnia Avoid/treat hyperthermia Consider therapeutic hypothermia

Therapeutic hypothermia

Who to cool?
Unconscious adults with ROSC after VF arrest should be cooled to 32-34oC

May benefit patients after non-shockable/inhospital cardiac arrest

Exclusions: severe sepsis, pre-existing medical coagulopathy Start as soon as possible and continue for 24 h Rewarm slowly 0.25oC h-1

Therapeutic hypothermia

How to cool?

Induction - 30 ml kg-1 4oC IV fluid and/or external cooling

Maintenance - external cooling:

Ice packs, wet towels Cooling blankets or pads Water circulating gel-coated pads

Maintenance - internal cooling

Intravascular heat exchanger Cardiopulmonary bypass

Therapeutic hypothermia

Physiological effects and complications

Shivering: sedate +/- neuromuscular blocking drug Bradycardia and cardiovascular instability Infection Hyperglycaemia Electrolyte abnormalities Increased amylase values Reduced clearance of drugs

Assessment of prognosis
No clinical neurological signs can predict outcome < 24 h after ROSC Poor outcome predicted at 3 days by:
Absent pupil light and corneal reflexes Absent or extensor motor response to pain

But limited data on reliability of these criteria after therapeutic hypothermia

Organ donation
Non-surviving post cardiac arrest patient may be a suitable donor:
Heart-beating donor (brainstem death) Non-heart-beating donor

Any questions?

Summary
Post cardiac arrest syndrome is complex Quality of post resuscitation care influences final outcome Appropriate monitoring, safe transfer and continued organ support Assessment of prognosis is difficult