Post-resuscitation care Version: Jan 2016

Learning outcomes This lecture should enable you to: understand the need for continued resuscitation after return of spontaneous circulation understand the post-cardiac arrest syndrome facilitate safe transfer of the patient consider the role and limitations of assessing prognosis after cardiac arrest

Post-resuscitation care The goal is to restore: normal cerebral function stable cardiac rhythm adequate organ perfusion quality of life

Post-cardiac arrest syndrome post-cardiac arrest brain injury: coma, seizures, myoclonus post-cardiac arrest myocardial dysfunction systemic ischaemia-reperfusion response ‘sepsis-like’ syndrome persistence of precipitating pathology

Post Arrest Case Clinical setting and history I You are part of a medical emergency response S A 32-year-old previously healthy man has been resuscitated following a VF arrest B He was given bystander CPR for 5 minutes and then received 2 shocks A He is not breathing adequately by himself R Please assess immediately

Airway Assessment patient not responsive clear airway with LMA in situ

Airway Assessment Treatment patient not responsive clear airway with LMA in situ Treatment ensure a clear airway, adequate oxygenation and ventilation secure the airway for transfer insert gastric tube to decompress stomach and improve lung compliance Consider tracheal intubation, sedation and controlled ventilation Or immediate extubation if patient breathing and conscious level improves quickly after ROSC

Breathing Assessment Look, Listen and Feel R - RR 4 min-1 A - normal, symmetrical chest expansion, breath sounds and percussion note T - trachea normal E - no effort S - SpO2 90% on high flow oxygen

Breathing Assessment Treatment Look, Listen and Feel R - RR 4 min-1 A - normal, symmetrical chest expansion, breath sounds and percussion note T - trachea normal E - no effort S - SpO2 90% on high flow oxygen Treatment waveform capnography: aim for normocapnia avoid hyperventilation pulse oximetry: aim for SpO2 94 – 98% chest xray +/- other imaging Consider simple/tension pneumothorax collapse/consolidation bronchial intubation pulmonary oedema aspiration fractured rib

Circulation Assessment regular central pulse (rate 90 min-1) BP 88/55 mmHg CRT <4 s normal heart sounds ECG rhythm – sinus rhythm

Circulation Assessment Treatment regular central pulse (rate 90 min-1) BP 88/55 mmHg CRT <4 s normal heart sounds ECG rhythm – sinus rhythm Treatment request 12-lead ECG ABG and other bloods IV fluids urinary catheter blood pressure, via direct measurement aim SBP > 100 mmHg-1 Consider right and /or left ventricular failure pulmonary oedema circulatory support vasopressors/fluids/other – mechanical

Optimising organ function Heart Ischaemia-reperfusion injury: reversible myocardial dysfunction for 2-3 days Arrhythmias Poor myocardial function despite optimal filling: echocardiography cardiac output monitoring inotropes and/or balloon pump Mean blood pressure to achieve: urine output of 1 ml kg-1 h-1 normalising lactate concentration

Disability Assessment Treatment AVPU pupils equal and reacting blood glucose 5.9 mmol L-1 no limb movement no seizures Treatment monitor blood glucose and maintain normal document arrest accurately Consider Neurological assessment: Glasgow Coma Scale score posture / seizure / limb movement Targeted Temperature Management (TTM)

Exposure Assessment Treatment temperature 36.6 ˚C no bleeding or rashes IV obtained right arm functioning Treatment monitor temperature

Optimising organ function Brain impaired cerebral autoregulation – maintain ‘normal’ blood pressure sedation control seizures glucose (4-10 mmol L-1) normocapnia avoid/treat hyperthermia targeted temperature management

Targeted temperature management (TTM) maintain a constant, target temperature of 32–36˚C for 24 h and rewarm slowly 0.25˚C 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

How to control temperature? 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

Targeted temperature management Physiological effects and complications shivering bradycardia and cardiovascular instability infection hyperglycaemia electrolyte abnormalities reduced clearance of drugs

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

Assessment of prognosis Generally deferred until at least 72 h after cardiac arrest Multimodal tests interpreted by experienced clinicians: clinical examination – GCS score, pupillary response to light, corneal reflex, seizures neurophysiological studies – somatosensory evoked potentials (SSEPs) and electroencephalography (EEG) biochemical markers – neuron-specific enolase (NSE) imaging studies – brain CT and magnetic resonance imaging (MRI)

Rehabilitation Majority of survivors are considered to have ‘good’ neurological outcome Emotional problems and cognitive problems are common May benefit from rehabilitation program

Organ donation Non-surviving post-cardiac arrest patient may be a suitable donor: heart-beating donor (brainstem death) non-heart-beating donor

Any questions?

Summary post-cardiac arrest syndrome is complex quality of post-resuscitation care influences final outcome appropriate monitoring, safe transfer and continued organ support delay assessment of prognosis and to be undertaken by experienced clinicians

Advanced Life Support Level 2 Course Slide set All rights reserved © Australian Resuscitation Council (June 2016)