Post-Cardiac Arrest Syndrome:  Epidemiology, Pathophysiology, Treatment, and Prognostication A Consensus Statement From the International Liaison Committee on Resuscitation Circulation. 2008;118:2452-2483

1. ILCOR Consensus StatementPost-Cardiac Arrest Syndrome: Epidemiology, Pathophysiology, Treatment, and PrognosticationA Consensus Statement From the International Liaison Committee on Resuscitation Circulation. 2008;118:2452-2483

2. Background Cardiopulmonary Resuscitation (CPR) Resumption of Spontaneous Circulation (ROSC) Resuscitation Post-CardiacArrest Syndrome (PCAS)

3. Epidemiology The largest published in-hospital cardiac arrest database (theNRCPR) includes data from >36000 cardiac arrests. In-hospital mortalityrate was 67% for the 19819 adults with any documented ROSC, 62% for the 17183 adults with ROSC >20 minutes.

4. Phases of post-cardiac arrest syndrome.

5. Pathophysiology of Post–Cardiac Arrest Syndrome

6. Post-Cardiac Arrest Brain Injury Triage Systems in the United States

7. Post–Cardiac Arrest Myocardial Dysfunction Triage Systems in the United States

8. Systemic Ischemia/Reperfusion Response Triage Systems in the United States

9. Persistent Precipitating Pathology Triage Systems in the United States

10. Therapeutic Strategies Monitoring Early Hemodynamic Optimization Ventilation Circulatory Support Management of ACS Therapeutic Hypothermia Sedation and Neuromuscular Blockade Seizure Control and Prevention Glucose Control Placement of Implantable Cardioverter-Defibrillators

11. Monitoring Options General intensive care monitoring Arterial catheter Oxygen saturation by pulse oximetry Continuous ECG CVP ScvO2 Temperature (bladder, esophagus) Urine output Arterial blood gases Serum lactate Blood glucose, electrolytes, CBC, and general blood sampling Chest radiograph More advanced hemodynamic monitoring Echocardiography Cardiac output monitoring (either noninvasive or PA catheter) Cerebral monitoring EEG (on indication/continuously): early seizure detection and treatment CT/MRI

12. Early Hemodynamic Optimization Early Goal-Directed Therapy CVP: 8 to 12 mm Hg, MAP: 65 to 90 mm Hg, ScvO2 >70%, Hematocrit >30% or hemoglobin >8 g/dL, lactate <2mmol/L, urine output >0.5 mL · kg–1 · h–1, oxygen deliveryindex >600 mL · min–1 · m–2

14. VentilationSurviving Sepsis CampaignRecommends:

15. Circulatory Support Dysrhythmias can be treated by maintenance of normal electrolyteconcentrations, use of standard drug and electrical therapies. The first-line intervention for hypotension is to optimize right-heart filling pressures by use of IV fluids. In 1 study,3.5 to 6.5 L of IV crystalloid was required in thefirst 24 hours after ROSC after OHCAto maintain CVP in the range of 8 to 13 mmHg.

16. Circulatory Support Inotropes and vasopressors should be considered if hemodynamicgoals are not achieved despite optimized preload. Early echocardiography willenable the extent of myocardial dysfunction to be quantifiedand may guide therapy. Additionalcardiac support: intra-aorticballoon pump (IABP), percutaneous cardiopulmonary bypass, extracorporeal membraneoxygenation (ECMO), transthoracic ventricular assist devices.

17. Management of ACS Patients resuscitated from cardiac arrest who have ST-elevation myocardial infarctionshould undergo immediate coronary angiography, with subsequentPCI if indicated. It is appropriate toconsider immediate coronary angiography in all post–cardiacarrest patients in whom ACS is suspected.

18. Therapeutic Hypothermia Unconscious adult patientswith ROSC after out-of-hospital VF cardiacarrest should be cooled to 32°C to 34°C for at least12 to 24 hours. Rapid IV infusion of ice-cold 0.9% salineor Ringer’s lactate (30 mL/kg) is a simple, effectivemethod for initiating cooling. Slow rewarming: 0.25°C to 0.5°C per hour. If therapeutic hypothermia is not undertaken, pyrexia duringthe first 72 hours after cardiac arrest should be treated aggressivelywith antipyretics or active cooling.

19. Sedation and Neuromuscular Blockade Critically ill post–cardiac arrest patientswill require sedation for mechanical ventilation and therapeutichypothermia. Adequate sedation is particularly important for prevention ofshivering during induction of therapeutic hypothermia, maintenance,and rewarming.

20. Seizure Control and Prevention Prolonged seizures may cause cerebral injury andshould be treated promptly and effectively with benzodiazepines,phenytoin, sodium valproate, propofol, or a barbiturate. Clonazepam is the drug of choice for the treatmentof myoclonus.

21. Glucose Control Tight control blood glucose (80 to 110mg/dL) with insulin reduced hospital mortality rates in criticallyill adults.

22. Placement of Implantable Cardioverter-Defibrillators In survivors with good neurological recovery, insertion of anICD is indicated if subsequentcardiac arrests cannot be reliably prevented by other treatments(such as pacemaker for AV block, transcatheterablation of a single ectopic pathway, or valve replacement forcritical aortic stenosis).