Post Resuscitation Care

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

Learning outcomes

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 scoreGlasgow Coma Scale score (GCS 3 – 15)

Eyes (4) Verbal (5) Motor (6)

6 Obeys commands

5 Orientated Localises

4 Spontaneously Confused Normal flexion

3 To speech Inappropriate words Abnormal flexion

2 To pain Incomprehensible sounds Extension

1 Nil Nil Nil

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

Pacing

Cooling

IABP

Defibrillator

Inotropes

Ventilation

Enteral nutrition

Insulin

Optimising organ functionHeart

• Post cardiac arrest syndrome

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

Optimising organ functionHeart

• 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 hr-1 • Normalising lactate concentration

Optimising organ functionBrain

• Impaired cerebral autoregulation – maintain ‘normal’ blood pressure

• Sedation• Control seizures• Glucose (4-10 mmol l-1)• Normocapnia• Avoid/treat hyperthermia• Consider therapeutic hypothermia

Therapeutic hypothermiaWho to cool?

• Unconscious adults with ROSC after VF arrest should be cooled to 32-34oC

• May benefit patients after non-shockable/in-hospital 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 hypothermiaHow 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 hypothermiaPhysiological 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?

• 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

Summary

Advanced Life Support Course Slide set

All rights reserved©Australian Resuscitation Council and Resuscitation Council (UK) 2010