1. Post-resuscitation care Version: Jan 2016

2. 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 Learning outcomes

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

4. 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

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

7. Airway Assessment – patient not responsive – clear airway with LMA in situ

8. Airway Assessment – 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

9. 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 - SpO 2 90% on high flow oxygen

10. Breathing Treatment – waveform capnography: aim for normocapnia avoid hyperventilation – pulse oximetry: aim for SpO 2 94 – 98% – chest xray +/- other imaging Consider – simple/tension pneumothorax – collapse/consolidation – bronchial intubation – pulmonary oedema – aspiration – fractured rib 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 - SpO 2 90% on high flow oxygen

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

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

13. 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

14. Disability 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) Assessment – AVPU – pupils equal and reacting – blood glucose 5.9 mmol L -1 – no limb movement – no seizures

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

16. 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

17. 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

18. How to control temperature? Induction – 30 ml kg -1 4 o C 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

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

20. 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

22. 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)

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

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

25. Any questions?

26. 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 Summary

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