The document outlines the importance of post resuscitation care to stabilize patients after return of spontaneous circulation, including supporting oxygenation and circulation, treating injuries from CPR, monitoring for recurrent cardiac arrest, and promptly transferring patients to intensive care units for specialized monitoring and treatment. Proper post resuscitation care is critical to optimize outcomes in the hours after resuscitation.

1. Post Resuscitation Care
“Restart the Heart and Keep it Restarted”
Dr. Rashidi Ahmad
Malaysian Association of Emergency Medicine
(MAEM)

2. Aim
To create an awareness that post
resuscitation intervention is as important
as resuscitation itself
To highlight the proper resuscitation care
To save human lives

3. Outline
Understanding post resuscitation phase &
care
Causes of failure post resuscitation
Principles post resuscitation care Mx
Discuss by an examples

4. Introduction
Phases of Resuscitation: resuscitation & post
resuscitation
Outcome: death or ROSC
Upon ROSC patient may:
Awake with stable hemodynamic
Remain comatose with unstable circulation
Half of death occurs first 24 hrs
Over 1 to 3 days: sepsis syndrome and MOF
Days later; rapid deterioration → Death
Post resuscitation syndrome

5. Post resuscitation syndrome
Reperfusion failure
Reperfusion injury
Cerebral intoxication from ischemic
metabolites
Coagulopathy

6. CPR related injuries
In a study of CPR related autopsy findings:
40% of patients had injuries related to
closed chest CPR, i.e. fractured ribs,
sternum, bone marrow emboli to lung,
mediastinal bleeding, etc.

7. What is post resuscitation
care?
Post resuscitation care is referred to a period
between restoration of a spontaneous circulation
and transfer of patient care to another healthcare
provider who assumes responsibility.
In general, this period will be less than 30
minutes (CRUCIAL TIME)
The immediate goal is to provide cardio-
respiratory support to optimize tissue perfusion,
especially to the brain.

8. Principles of Post resus Mx
Avoid CPA recurrence
Restore perfusion & oxygenation of regional
organ & cell tissues
Continuous ABCDs of Primary and Secondary
surveys
Evaluate and monitor neurologic functions
(restoration of cerebral circulation)
Support other dysfunction organs
Resolve the situation that promoted CPA

9. Scenario 1
46 years old man, had severe ischemic chest
pain since an hour ago.
Suddenly he had pulseless ventricular
tachycardia.
Immediate asynchronized cardioversion
reverted the rhythm.
What is your next step?

10. Scenario 2
6 years old boy, near drowning
Cardiopulmonary resuscitation was
commenced
ROSC after 45 minutes
What is your next step?

11. Scenario 3
37 years old man had MVA (high velocity
injury)
He sustained head injury & intraabdominal
injury
Hemodynamic unstable
While on fluid resuscitation he developed VT
What is your next step?

12. Airway & respiratory system
1. Is the patient intubated?
YES: rapidly assess patency, position, security,
and oxygenation
NO: rapidly assess the need for intubation, i.e.
oxygenation, mental status, other considerations.
INTUBATE if any indication for it exists.

13. Airway & respiratory system
2. All patients will receive supplemental oxygen.
Assessment of adequate ventilation and
oxygenation:
Pulse oximetry
ABG's (if already available)
Physical exam (i.e. breath sounds, symmetrical
chest expansion
Respiratory character, skin color, midline trachea)

14. Airway & respiratory system
3. Consider mechanical impediments to adequate
respiration, and pursue treatment of these when
feasible:
Tension pneumothorax, pneumothorax, and
hemothorax
Flail chest
Mucous plugging
Interstitial edema
Improperly places endotracheal tube

15. Mechanical Ventilation
Volume ventilator-assist-control or
intermittent mandatory ventilation (IMV)
Tidal volume = ideal weight in kg x 10
I:E ratio 1:2 or 1:1.5
Respiratory rate: 10-12 times/min
Oxygen FiO2 - 1.0 (100%)
Sensitivity: 2 cmH2O for assist-control
Humidifier: 36° C
PEEP: 5 cmH2O, increased as required

16. Circulatory system
1. Assess the status of the circulatory system:
Clinical indicators: skin temperature, capillary
refill, quality of pulses, level of consciousness
Monitor parameters: heart rate and rhythm, BP,
urine output (use of Foley catheter when
available)
PMH and current medications

17. Circulatory system
2. Support inadequate circulatory system:
Hypotension - if there is evidence of bleeding,
treat with IV crystalloids and blood products
For evidence of cardiogenic shock, septic shock
or spinal shock – treat appropriately
Prophylactic drugs for reverted VF/VT
Well function cardiac pace maker
Maintain the drug infusion preferably via central
line

18. General survey
After stabilization of the respiratory and
circulatory systems, a general survey of the
entire patient should be performed.
Look for a cause and precipitating causes of
CA
Serial exams of areas of particular concern
should be performed.
Serial review of vital signs
Review ECG and Chest x ray
Review ABG, and pH, serum electrolytes,
magnesium and calcium

19. Chest X-Ray
Position of endotracheal tube
Position of central venous catheter
Pneumothorax, hemothorax, hydrothorax
Pulmonary edema, CHF
Cardiac silhoutte
Diaphragms
Rib fracture

21. Other considerations
Optimally, there should be two well-secured,
functioning intravenous lines.
A nasogastric tube (or orogastric) is useful to
keep the stomach decompressed, especially in
patients receiving positive-pressure ventilation.
Preserve body temperature.
Stop the seizure

22. Communication & documentation
It is important to maintain a collaborative
approach to patient care utilizing the referring
physicians/nurses' report and suggestions prior
to liftoff.
Resus notes should include the history,
assessment
findings, and any treatments done by the
referring EMS or hospital personnel.
It is acceptable to state "see transfer notes,"
for particular details, and write out only the
most prominent interventions.

23. Transfer
Transfer to special care unit as soon as possible
by senior most experience personal
Support ventilation and provide oxygenation
Monitor ECG, oxygen saturation and BP
Prior to transport, make sure IV is secured
Transport with portable monitor, defibrillator
Oxygen with connections to bag-valve-system
Resus drugs must accompany the patient

24. Take Home Message
Resuscitated the heart, restore the brain
Treat the patient, not the arrhythmia
The value of unbroken Chain of Survival:
Time is critical
Seek and treat the cause, not just the
condition