Post-resusciation care

1. ROSCAND POST RESUSCITATION CARE
LAKMAL NANDADEWA

3. ROSC OPENS THE DOORS TO CONTINUUM OF RESUSCITATION
MAIN GOALS
 TO INSTITUTE MEASSURES THAT ENSURE A HIGHER LIKELYHOOD OF NEUROLOGICALLY INTACT SURVIVAL
 PROMPT IDENTIFICATION AND TREATMENT OF THE CAUSE OF CARDIAC ARREST -4Ts AND 4Hs
 ESTABLISH DEFINITIVE AIRWAY MAMAGEMENT TO MAINTAIN NORMOCAPNIC VENTILATION,PREVENT HYPEROXIA
 TO ESTABLISH AND MAINTAIN A STABLE CARDIAC RHYUTHM
 TO ACHIEVE A NORMAL HAEMODYNAMIC FUNCTION-JUDICIOUS IV FLUIDS/VASOPRESSORS/INOTROPES
 TTM,GLYCAEMIC CONTROL,SEIZURE MANAGEMENT,NEUROPROGNOSTICATION
 TRANSFER THE PATIENT TO THE MOST APPROPRIATE HIGH-CARE AREA –ICU,CCU FOR CONTINUED MONITORING AND
TREATMENT

4. POST CARDIAC ARREST SYNDROME
PATHOPHYSIOLOGY
1.Persistant precipitating pathology
coronary thrombus,hypoxia,PE,sepsis
2.Anoxic brain injury
Reperfusion after a period of cerebral hypoxia------formation of free radicals--------activation of cell death signalling pathways --------disturbance of cerebral microvascular haemostasis despite of adequate CPP and CBF is established
Aggravated by hyperthermia, hyper/hypoglycaemia, hyperoxia/hypoxia
Symptoms-coma, seizure, myoclonus, neurocognitive dysfunction and brain death
3.Post cardiac arrest myocardial dysfunction
Hypokinesia of the cardiac myocytes leads to significant drop in LVEF----first 24-48hrs post ROSC despite preserved coronary blood flow
Manifests as tachycardia, hypotension, poor cardiac output and elevated LVEDP
4.Systemic ischaemia/reperfusion response
Whole body hypoxia and ischaemia-------post ROSC reperfusion-----systemic inflammation, endothelial activation immunologic and coagulation cascade activation, ------increased risk of multiorgan system
dysfunction
Manifests as fever , altered oxygen consumption, increased susceptibility to infection

5. POST CARDIAC ARREST BRAIN INJURY

6. POST CARDIAC ARREST BRAIN INJURY

7. POST CARDIAC ARREST MYOCARDIAL DYSFUNCTION

8. SYSTEMIC ISCHAEMIA/REPERFUSION SYNDROME

10. AIRWAY , VENTILATION AND OXYGENATION(ANZCOR)
 Ensure clear airway, adequate ventilation and oxygenation
 All comatose patients –definitive airway, ventilation and sedation
 Blood oxygen saturation of 94%98%-ABG/pulse oximetry
 Aim for normocapnia and avoid hyperventilation-End tidal CO2and waveform capnography
 Avoid prolonged periods of hyperoxia-excessive oxidative stress may harm various organs, neuronal damage
and irreversible changes within alveolar spaces ,associates with decreased survival to hospital discharge
 Avoid hypocapnia .Aim arterial PaCO2 35-45mmHg and end tidal CO2 at 30-40mmHg
 Initial vent settings should begin with 6-8ml/kg for TV and RR at 10-12 breaths/min
 Look listen and feel
 Consider collapse/consolidation, tension pneumothorax, Bronchial intubation, pulmonary oedema, aspiration
and fractured ribs

11. THE EXACT STUDY
Reduction of oxygen after cardiac arrest (EXACT)
Compelling evidence that 100% oxygen (“hyperoxia”) during
reperfusion(i.e. post arrest) may be harmful to the brain and the
heart:
•Animal studies
•Observational human studies
•The AVOID trial

13.  Multicenter retrospective cohort study
 120 US hospitals 2001-2005
 Non-traumatic cardiac arrest within 24 hours of ICU admission
 Association between PaO2 of 1st ABG in ICU and in-hospital mortality
 • Hyperoxia mortality rate 63%
 • Hypoxia mortality rate 57%
 • Normoxia mortality rate 45%

14. THE EXACT STUDY
 Proposed Phase 3 study started in 2016 conducts in Victoria, Adelaide and Perth
 Post OHCA with pulse oximeter>94%
 Paramedics randomise to •2L/min O2(=50%) or •10L/min 02(=100%)
 ED/Cath lab continue target of 100% or 94% oxygen saturation
 ICU adjust to “normal”

15. HAEMODYNAMIC MANAGEMENT
 Aim for a blood pressure equal to patients usual BP or at least a SBP >100mmHgor a MAP of
>65mmHg
 Targets for other haemodynamic parameters can vary among patients based on their specific
comorbidities
 Hypotensive patients –Vasopressors/inotropes(small IV increments of Adrenaline 50-
100mcg)/infusion
 Insufficient evidence to support or refute the routine use of IV fluids-cold 0.9%NACL/lactated
ringers appears to be well tolerated in TTM
 ECHO should be performed at 24-48Hrs following ROSC to monitor EF and rule out regional
wall motion abnormalities
 Mechanical circulatory support may be beneficial-IABP,ECMO

16. TARGETED TEMPERATURE MANAGEMENT
 Maintain a constant, target temperature of 32–36oC for 24 h and rewarm slowly 0.25oC h-1
 TTM is recommended for adults after out-of-hospital cardiac arrest with an initial shockable rhythm who
remain unresponsive after ROSC
 TTM is suggested for those unresponsive after non-shockable/in-hospital cardiac arrest
 Exclusions: severe sepsis, pre-existing coagulopathy

17. TARGETED TEMPERATURE MANAGEMENT
 Induction
 30 ml kg-1 4oC IV fluid with monitoring (in-hospital)
 +/- 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
Complications---sepsis, bradyarrhythmia, coagulopathy, shivering, decreased clearance of drugs ,electrolyte imbalances, Hyperglycaemia

18. GLYCAEMIC CONTROL, SEIZURE MANAGEMENT
 BSL-6-10mmol/l
 Seizure incidence -3-44%,no routine seizure prophylaxis recommended by
NAZCOR but to treat if occurs and maintain therapy

20. CORONARY ARTERY DISEASE –MAJORITY
 ASAP following ROSC-12 –lead ECG
 Recommendation –ANZCOR guideline 11.7
 STEMI/new LBBB –immediate angiography and PCI
 Typical history without STE-Urgent angio+/- PCI
 Fibrinolytic if primary PCI is not feasible in an appropriate time frame(within 90 mins of first
medical contact –Resus council UK)
 TTM is recommended in combination with primary PCI-should be started preferably prior to
PCI

21. ACUTE PULMONARY EMBOLISM
 Accounts for about 2-10% of cases
 Fibrinolysis following cardiac arrest in suspected /diagnosed PE might be beneficial-Several
studies showed no significant increase in survival to hospital discharge . Increased bleeding
risk specially who had CPR
 Surgical embolectomy for suspected /diagnosed after ROSC following cardiac arrest-Mortality
is high and should be avoided in patients who have received CPR
 Percutaneous mechanical thromboembolectomy may be beneficial and may be considered in
patients sustaining cardiac arrest from PE who are not candidates for fibrinolysis

22. CARDIOTOXIC AGENTS, METABOLIC DISTURBANCES, SEPSIS
 TCA, cardiac glycosides etc
 Intralipids to enhance elimination may be considered and in massive overdoses HD to be
considered
 Hyper / hypokalaemia, hypercalcaemia should be promptly addressed
 Sepsis-one of the common causes of circulatory collapse –Cultures, antibiotics
Resuscitation related injuries always to be assessed and appropriately manage post ROSC

23. TRANSFER OF THE PATIENT
 discuss with admitting team
 cannulae, drains, tubes secured
 suction
 oxygen supply
 monitoring
 documentation
 reassess before leaving
 talk to the patient’s family

24. PROGNOSTICATION , ORGAN DONATION
 Brain injury is a result of initial ischaemic injury followed by reperfusion injury
 Features- coma, seizures, myoclonus ,neurocognitive dysfunction ,memory deficits, persistent vegetative
state and finally brain death
Absence of both pupillary light and corneal reflex at or after 72 hrs predicts poor outcome in who are comatose and no TTM,myoclonus ,low
GCS,absence of vestibule ocular reflex are less reliable
 Patients who had TTM prognostication should be performed 72 hrs post cardiac arrest and DNR
orders/withdrawal of care should be avoided for 72 hrs following ROSC
 Clinical examination, blood markers ,neurophysiological studies (Somatosensory evoked potentials
/SEEPs,EEG,TCDs)imaging are used
 ANZCOR recommends all patients who had ROSC post CPR and subsequently progress to death should
be evaluated for organ donation

25. Pacing
Targeted
Temperature
Management
IABP
Defibrillator
Inotropes
Ventilation
Enteral nutrition
Insulin

26. REHABILITATION

27. REFERENCES
 Deakin CD, Morrison LJ, Morley PT, Callaway CW, Kerber RE, Kronick SL, et al. Part 8: Advanced life support: 2010 International Consensus on Cardiopulmonary
Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation. [doi: DOI: 10.1016/j.resuscitation.2010.08.027]. 2010;81(1,
Supplement 1):e93-e174.
 Nolan JP, Neumar RW, Adrie C, Aibiki M, Berg RA, Bottiger BW, et al. Post-cardiac arrest syndrome: epidemiology, pathophysiology, treatment, and prognostication. A
Scientific Statement from the International Liaison Committee on Resuscitation; the American Heart Association Emergency Cardiovascular Care Committee; the Council on
Cardiovascular Surgery and Anesthesia; the Council on Cardiopulmonary, Perioperative, and Critical Care; the Council on Clinical Cardiology; the Council on Stroke.
Resuscitation. 2008 Dec;79(3):350-79.
 Soar J, Callaway C, Aibiki M, Böttiger BW, Brooks SC, Deakin CD, Donnino MW, Drajer S, Kloeck W, Morley PT, Morrison LJ, Neumar RW, Nicholson TC, Nolan JP, Okada K,
O’Neil BJ, Paiva EF, Parr MJ, Wang TL, Witt J, on behalf of the Advanced Life Support Chapter Collaborators. Part 4: Advanced life support. 2015 International Consensus on
Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation 2015;95:e71–e1203
 Consensus on Science and Treatment Recommendations Part 4: Advanced life support. Resuscitation 2005;67(2-3):213-47.
 Randomized clinical study of thiopental loading in comatose survivors of car-diac arrest. Brain Resuscitation Clinical Trial I Study Group. N Engl J Med1986;314:397–
403.234.
 Longstreth Jr WT, Fahrenbruch CE, Olsufka M, Walsh TR, Copass MK, CobbLA. Randomized clinical trial of magnesium, diazepam, or both after out-of-hospital cardiac
arrest. Neurology 2002;59:506–14.235.
 SMJ-post resuscitation care
 ANZCOR guideline 11.7 and 12.7
 BMJ-therapeutic hypothermia for comatose survivors in OHCA