Megacode Pulseless VF/VT Part 5 (Post Arrest Goals)

Post Arrest Goals

Optimize the patient’s ventilation status

·         Avoid excessive ventilations

·         Oxygenate 10-12 breaths per minute

·         Target PETCO2 35-40 mm Hg

·         Titrate FIO2 to keep spo2 >94%

·         Avoid using ties that pass circumferentially around the patient’s neck

·         Elevate the head of the bed 30 to reduce cerebral edema and aspiration

·         Correct placement of airway monitored using waveform

·         Oxygenation monitored continuously with pulse oximetry.

·         Pao2/FIO2 ratio to follow acute lung injury

·         Institute lung-protective strategy for mechanical ventilation

·         Opioids, anxiolytics, and sedative-hypnotic agents to improve patient-ventilator interaction

Optimize the patient’s hemodynamic status

·         Frequent Blood Pressure Monitoring/Arterial-line

·         Treat Hypotension

·         1-2L NS or LR bolus (cool fluid 4 C if inducing hypothermia)

·         Epinephrine 0.1-0.5mcg/kg/min titrate to SPB > 90 mmHg or MAP > 65 mm Hg

·         Dopamine 5-1mcg/kg/min titrate to SPB > 90 mmHg or MAP > 65 mm Hg

·         Norepinephrine 0.1-0.5mcg/kg/min titrate to SPB > 90 mmHg or MAP > 65 mm Hg

·         Dobutamine 5–10 mcg/kg/min

·         Milrinone Load 50 mcg/kg over 10 minutes then infuse at 0.375 mcg/kg/min

·         Phenylephrine 0.5–2.0 mcg/kg/min

·         Mechanical augmentation (IABP)

Initiate therapeutic hypothermia

·         Only intervention demonstrated to improve neurologic recovery after cardiac arrest

·         Protects brain and other vital Cool patient to a target temperature of 32-34 C for 12-24 hours

·         In patients who spontaneous develop a mild degree of hypothermia  after cardiac arrest, avoid active rewarming

·         Concurrent PCI and hypothermia is feasible and safe

·         Cold IV fluid bolus 30 mL/kg if no contraindication

·         Surface or endovascular cooling for 32°C–34°C 24 hours

·         After 24 hours, slow rewarming 0.25°C/hr

·         Sedation/Muscle Relaxation

Provide immediate coronary reperfusion with PCI

·         Obtain 12 lead EKC after ROSC to identify STEMI

·         Attempt coronary reperfusion and PCI in patient s with STEMI or high suspicion for AMI

·         Continuous Cardiac and treat arrhythmias as required

·         12-lead ECG/ serial troponins

·         Treat reversible causes

Avoid Hyperthermia

·         Elevated temperature can impair brain recovery

·         Studies note an association between poor survival outcomes and pyrexia ≥37.6°C

·         The cause of hyperthermia after rewarming should also be identified and treated

Institute glycemic control

·         Treat hypoglycemia (80 mg/dL) with dextrose

·         Treat hyperglycemia to target glucose 144–180 mg/dL

Provide neurologic care 

·         EEG Monitoring If Comatose

·         Anticonvulsants if seizing

·         Consider Non-enhanced CT Scan

·         Prevent hyperpyrexia  37.7°C

·         Core Temperature Measurement If Comatose

·         Induce therapeutic hypothermia if no contraindications

Minimize complications of therapeutic hypothermia

·         Coagulopathy

·         Arrhythmias

·         Hyperglycemia

·         Pneumonia

·         Sepsis 

Prognostication of Neurological Outcome in Comatose

·         No pre-arrest or intra-arrest parameters accurately predict outcome of patients that achieve ROSC.

·         Decision to limit care should never be made on the basis of a single prognostic parameter

·         Seek expert consultation

·         Neurological examination should be undertaken only in the absence of confounding factors (hypotension, seizures, sedatives, or neuromuscular blockers).

·         Neuroimaging is not an accurate predictor of outcome in a comatose individual

·         Poor neurologic functions should be observed for greater than 72 hours after ROSC before predicting poor outcome in patients treated with hypothermia (Class I, Level C).

Sources

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;122(suppl 3):S768 –S786.