20201021 PCAS care

1. Post-Cardiac
Arrest Syndrome
F 곽형규

3. PostCardiac Arrest syndrome
• 1970s: Negovsky
• Pathology caused by complete whole body ischemia and
reperfusion
• (1) post-cardiac arrest brain injury
• (2) post-cardiac arrest myocardial dysfunction
• (3) systemic ischaemia/reperfusion response.
• (4) persistent precipitating pathology

4. Epidemiology
• Variable mortality
• Almost 60%

5. Stage of PCAS
• Immediate
• Early
• Intermediate
• Recovery

7. Post-cardiac arrest brain injury
• Excitotoxicity
• Disrupted calcium homeostasis
• Free radical formation
• Pathological protease cascades
• Activation of cell death signaling pathways
• Weak: hippocampus, cortex, cerebellum, corpus striatum, and
thalamus

8. Post-cardiac arrest brain injury
• Prolonged cardiac arrest
• Poor neurologic outcome d/t impaired microcirculation
• Reperfusion injury
• Brain edema
• 2ndary injury

9. Post-cardiac arrest brain injury
• Fever
• Hyperglycemia
• Seizure
• Coma

10. Post-cardiac arrest myocardial
dysfunction
• Sometimes… Poor survival outcome
• Sometimes… Can Reversible

11. Systemic ischaemia/reperfusion
response
• Decrease: O2 supply , metabolic substrates
• Increase: O2 demand, metabolite
• Cytokine, soluble receptors, endotoxin
• DO2 < VO2

14. Acute Cardiovascular Interventions
• Coronary angiography
• 12-lead ECG after ROSC (Class I)
• STE – Emergecy CAG after OHCA (Class I)
• No STE – Emergency CAG after OHCA and suspected cardiac origin
in comatose (Class IIa)
• Reasonable: CAG is indicated (Class IIa)

15. Hemodynamic Goals
• Avoid hypotension
• Keep SBP >90mmHg, MAP >65mmHg (Class IIb).

16. Targeted Temperature Management

18. Targeted Temperature Management
• TTM: Recommend that comatose adult patients with ROSC
after cardiac arrest (Class I)
• OHCA, IHCA, shockable, non-shockable
• 32°C ~ 36°C (Class I).
• Maintain at least 24 hours after achieving target temperature
(Class IIa).

19. Hypothermia in the Prehospital Setting
• Prehospital cooling: no benefit (Class III).

20. Avoidance of Hyperthermia
• Prevent fever in comatose patients after TTM (Class IIb).

21. Seizure Management
• EEG for seizure should be performed and should be
monitored frequently or continuously in comatose patients
after ROSC (Class I).
• Status epilepticus: same anticonvulsant regimens(Class IIb).

22. Respiratory Care
• Maintaining the Paco2 within a normal physiological range
(Class IIb)
• Avoid hypoxia (Class IIa)
• Titrate the FIO2 to maintain oxyhemoglobin greater than 94%
and lesser than 100% (Class IIa)

23. Glucose Control
• Uncertain(Class IIb)

24. Prognostication of Outcome

25. Timing of Outcome Prediction
• 72 hours after return to normothermia with TTM patients
(Class IIb)
• 72 hours after cardiac arrest without TTM patients (Class I)
• Over 72 hours - Sedation or paralysis confounds exam (Class IIa)

26. Clinical Examination Findings That
Predict Outcome
• Absence of pupillary reflex to light at 72 hours without TTM -
poor neurologic outcome (Class IIa)
• Absence of pupillary reflex to light at 72 hours with TTM - poor
neurologic outcome (Class I)
• Absent motor movements or extensor posturing should not be
used alone for predicting a poor neurologic outcome (Class III)
• The motor examination – need further prognostic testing to predict poor
outcome (Class IIb)
• Myoclonus(not status myoclonus) should not be used to predict
poor neurologic outcomes (Class III)
• Status myoclonus during the first 72 to 120 hours - help predict
poor neurologic outcomes (Class IIa)

27. EEG Findings to Predict Outcome
• Comatose TTM patients, persistent absence of EEG - predict a
poor outcome (Class IIb)
• Intractable and persistent (more than 72 hours) status
epilepticus in the absence of EEG reactivity - predict poor
outcome (Class Iib)
• Comatose without TTM patients, presence of burst
suppression on EEG at 72 hours in combination with other
predictors, to predict a poor neurologic outcome (Class IIb)

28. Evoked Potentials to Predict Outcome
• Comatose TTM patients, bilateral
absence of the N20 SSEP wave 24
to 72 hours - predictor of poor
outcome (Class IIa)

29. Imaging Tests to Predict Outcome
• Comatose TTM patients, marked reduction of the GWR on
brain CT obtained within 2 hours - predict poor outcome
(Class IIb)
• Extensive restriction of diffusion on brain MRI at 2 to 6 days
after cardiac arrest in combination with other predictors -
poor neurologic outcome (Class IIb)

30. Blood Markers to Predict Outcome
• Blood levels of NSE and S-100B should not be used alone to
predict a poor neurologic outcome (Class III)
• High serum values of NSE at 48 to 72 hours after cardiac
arrest to support the prognosis of a poor neurologic
outcome (Class IIb), especially if repeated sampling reveals
persistently high values (Class IIb)

31. Organ Donation
• Subsequently progress to death or brain death be evaluated
for organ donation (Class I)
• Patients who do not have ROSC after resuscitation efforts and
who would otherwise have termination of efforts may be
considered candidates for kidney or liver donation in settings
where programs exist (Class IIb)