Post-Cardiac Arrest Care 2010년 AHA 심폐소생술 가이드라인 설명회 Post-Cardiac Arrest Care 건양대학교병원 응급의학과, ACLS 위원회 이미진

경축 !!! Chain of Survival 진입 성공

Table of Contents 1. 이전가이드라인, 개론 2. 체온 조절 3. 기관 평가와 치료 4. 예후평가 5. 장기이식

Recommendation / LOE LOE A Class I LOE B Class IIa LOE C Class IIb Class III

Postresuscitation Support (2000 Guideline) Optimize cardiopulmonary function and vital organ perfusion. After out-of-hospital cardiac arrest, transport patient to an appropriate hospital and continue care in an critical care Try to identify and treat the precipitating causes of the arrest and prevent recurrent arrest Antiarrhythmics

Postresuscitation Support (2000 Guideline) 자발적인 경도 저체온 유지(Class IIb) Induced hypothermia (Class Indeterminate) 고체온 시 fever control (Class IIa)

Postresuscitation Support (2000 Guideline) 환기 지표 - 혼수환자에게 정상 탄산 상태유지 (Class IIa) - 통상적인 과다호흡 (Class III) - 뇌이탈증후군이나 폐동맥고혈압 시 과다호흡 치료 (Class IIa) 광범위항생제 치료에도 불구하고 혈관수축제 저항성쇼크인 경우 고용량 스테로이드 사용 (Class IIb)

Postresuscitation Support (2005 Guideline) Optimize cardiopulmonary function and vital organ perfusion. After out-of-hospital cardiac arrest, transport patient to an appropriate hospital and continue care in an critical care Try to identify and treat the precipitating causes of the arrest and prevent recurrent arrest. Prevent recurrence, improve survival

Postresuscitation Support (2005 Guideline) Induced Hypothermia (치료적 저체온요법) 무의식 성인, 병원외심정지 환자, 초기 리듬이 VF인 경우 ROSC 획득 후 첫 12-24시간에 32℃에서 34℃ 사이 저체온요법 시행 (Class IIa) 병원외심정지 + non-VF (Class IIb) 원내심정지 (Class IIb)

Postresuscitation Support (2005 Guideline) Glucose control : strict control, using insulin, target ? 호흡기계: PaCO2 ?, 일상적인 과환기 (Class III) 심혈관계: target BP ? CNS: 확인된 간질발작 치료, 항경련제 사용 (Class IIa), 예방적인 간질 치료 (Class Indeterminate)

Postresuscitation Support (2005 Guideline) 예후인자 (LOE 1) - 24시간에 corneal reflex 소실 - 24시간에 pupillary response 소실 - 24시간에 pain 저항 없음 - No motor response at 24 hours - No motor response at 72 hours 24-48시간 이상 지속적인 EEG 관찰

Post–cardiac arrest care (2010 Guideline) Optimize cardiopulmonary function and vital organ perfusion. After out-of-hospital cardiac arrest, transport patient to an appropriate hospital with a comprehensive post–cardiac arrest treatment system of care that includes acute coronary interventions, neurological care, goal-directed critical care, and hypothermia. Transport the in-hospital post–cardiac arrest patient to an appropriate critical-care unit capable of providing comprehensive post–cardiac arrest care. Try to identify and treat the precipitating causes of the arrest and prevent recurrent arrest. Control body temperature, ACS, MV, Assess prognosis

Post-cardiac arrest care algorithm

Systemic care for improving outcomes Structured Program interventions therapeutic hypothermia optimization of hemodynamics and gas exchange immediate coronary reperfusion/PCI glycemic control neurological diagnosis, management, and prognostication

Multiple System Approach-Ventilation Capnography - Endotracheal tube when possible for comatose patients - PETCO2 35–40 mm Hg - Paco2 40–45 mm Hg Pulse Oximetry/ABG - Maintain adequate oxygenation and minimize FIO2 - SpO2 ≥ 94% (between 94% and 96%) (Class I) - Reduce FIO2 as tolerated - Pao2/FIO2 ratio to follow acute lung injury (200 to 300) Mechanical Ventilation - Minimize acute lung injury, potential oxygen toxicity - Tidal Volume 6–8 mL/kg, RR 10-12 breaths/min - Reduce Fio2 as tolerated to keep Spo2 or Sao2 ≥ 94%

Pulmonary Treatment of Pulmonary Embolism after CPR In post–cardiac arrest patients with arrest due to presumed or known pulmonary embolism, fibrinolytics may be considered (Class IIb, LOE C) Ventilation - Routine hyperventilation with hypocapnia (Class III) - Ventilation rate and volume may be titrated to maintain high-normal PaCO2 (40 to 45 mm Hg) or PETCO2 (35 to 40 mm Hg) (Class IIb)

Hemodynamics Frequent BP Monitoring/Arterial-line - Maintain perfusion and prevent recurrent hypotension - Mean arterial pressure 65 mmHg or SBP ≥ 90 mm Hg - ScvO2 ≥ 70% Treat Hypotension - Fluid bolus if tolerated - Dopamine 5–10 mcg/kg/min - Norepinephrine 0.1–0.5 mcg/kg/min (SBP < 70mmHg) - Epinephrine 0.1–0.5 mcg/kg/min (SBP < 70mmHg)

Cardiovascular Continuous cardiac monitoring 12-lead ECG as soon as possible (Class I) / Troponin Treat Acute Coronary Syndrome - Aspirin/heparin - Transfer to acute coronary treatment center - Consider emergent PCI or fibrinolysis (STEMI/non-STEMI) Echocardiogram (first 24 hours after arrest) Treat Myocardial Stunning - Fluids to optimize volume status (requires clinical judgment) - Dobutamine 5–10 mcg/kg per min - Mechanical augmentation (IABP)

Neurological Serial Neurological Exam, EEG (Class I) Core Temperature Measurement If Comatose - Rationale: Minimize brain injury and improve outcome - Prevent hyperpyrexia >37.7°C (Class I) - Induce therapeutic hypothermia if no contraindications - Cold IV fluid bolus 500mL to 30 mL/kg if no contraindication - Surface or endovascular cooling for 32°C–34°C x 24 hours - After 24 hours, slow rewarming 0.25°C/hr - OHCA+VF (Class I), IHCA or OHCA+non-VF (Class IIb) Consider Non-enhanced CT Scan, others (?) Sedation/Muscle Relaxation

Neurological Sedation after cardiac arrest - Consider the titrated use of sedation and analgesia in critically ill patients who require mechanical ventilation or shivering suppression during induced hypothermia after cardiac arrest (Class IIb, LOE C) - Duration of neuromuscular blocking agents should be kept to a minimum or avoided altogether

Neurological Neuroprotective drugs (Class IIb) Prognostification of neurologic outcomes - Tools used to prognosticate poor outcome must be accurate and reliable with a false-positive rate (FPR) approaching 0%. - Poor outcome: death, persistent unresponsiveness, or the inability to undertake independent activities after 6 months

Neurological Prognostification of neurologic outcomes - Absence of both pupillary light and corneal reflexes at 72 hours - Absence of vestibulo-ocular reflexes at 24 hours (FPR 0%) - Glasgow Coma Scale (GCS) score <5 at 72 hours (FPR 0%) - But, other clinical signs, including myoclonus,are not recommended for predicting poor outcome (Class III) - Unprocessed EEG interpretation observed 24 hours (Class IIb) - Bilateral absence of the N20 cortical response to median nerve stimulation after 24 hours predicts poor outcome in comatose arrest survivors not treated with therapeutic hypothermia (Class IIa)

Neurological Prognostification of neurologic outcomes - Most promising and extensively studied biomarker is serum NSE, which has been reported to have a 0% FPR (95% CI 0% to 3%) for predicting poor outcome when measured between 24 and 72 hours after cardiac arrest - The routine use of any serum or CSF biomarker as a sole predictor of poor outcome in comatose patients after cardiac arrest is not recommended (Class III, LOE B) - Durations of observation greater than 72 hours after ROSC should be considered before predicting poor outcome in patients treated with hypothermia (Class I)

Metabolic Serial Lactate, Potassium (maintain K >3.5 mEq/L) Urine Output, Serum Creatinine Serum Glucose - Rationale: Detect hyperglycemia and hypoglycemia - Treat hypoglycemia (<80 mg/dL) with dextrose - Target glucose 144–180 mg/dL (Class IIb) - Lower range (80 to 110 mg/dL) (Class III) - Local insulin protocols, not strict Avoid Hypotonic Fluids

Patient monitoring & parameters 사 진 Multiple trauma 로 CPR 후 ROSC 되어 Ventilator (etco2 모니터) care 중인 환자 사진 (사진은 환자정보 비밀유지를 위하여 삭제함)

Patient monitoring & parameters

Patient monitoring & parameters * MAP > 65 mmHg, SBP > 90 mmHg * ECG, Esophageal core temperature * ETCo2: 35-40 mmHg * SVOsat>70% , CVP, Pulse oximeter * ABGA: PCO2 40-45 mmHg BST, electrolytes, lactate * Cardiac enzyme * Urine output

Organ Donation After Cardiac Arrest Adult patients who progress to brain death after resuscitation from cardiac arrest should be considered for organ donation (Class I)

Summary Post-cardiac arrest care - 원내 goal-directed therapy + Post arrest care 시스템 구축 - 각 기관별 parameters의 확립 - Therapeutic hypothermia Class 상향조정 향후 추가 - Induced hypothermia 의 방법, 프로토콜 정립 - Induced hypothermia groups에 대한 parameter 확립 - 예후인자에 대한 cut-off value, timing 확립