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. Chain of Survival

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

5. 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

7. Airway and breathing ensure a clear airway, adequate oxygenation and ventilation consider tracheal intubation, sedation and controlled ventilation pulse oximetry: – aim for SpO 2 94 – 98% waveform capnography: – aim for normocapnia – avoid hyperventilation

8. Airway and breathing Look, Listen and Feel Consider: – simple/tension pneumothorax – collapse/consolidation – bronchial intubation – pulmonary oedema – aspiration – fractured ribs

9. Airway and breathing Insert gastric tube to decompress stomach and improve lung compliance Secure the airway for transfer Consider immediate extubation if patient breathing and conscious level improves quickly after ROSC

10. Circulation pulse and blood pressure peripheral perfusion e.g. CRT right ventricular failure left ventricular failure – pulmonary oedema ECG monitor and 12-lead ECG circulatory support – vasopressors/fluids/other – mechanical ABG and other bloods

11. Disability Neurological assessment: Glasgow Coma Scale score Pupils Glucose limb tone and movement posture

12. Glasgow Coma Scale score

13. Further assessment History health before the cardiac arrest time delay before resuscitation duration of resuscitation cause of the cardiac arrest family history

14. Further assessment Monitoring vital signs ECG pulse oximetry blood pressure, preferably direct measurement waveform capnography urine output temperature

15. Further assessment Investigations Arterial blood gases Bloods – full blood count – biochemistry, including blood glucose – troponin Chest X-ray – Deeper radiology - consider early CT scan ECG - repeat 12-lead – Echocardiography

16. 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

18. Out-of-hospital VF arrest associated with AMI Pacing Targeted Temperature Management IABP Defibrillator Inotropes Ventilation Enteral nutrition Insulin

19. 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

20. 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

21. Targeted temperature management (TTM) Maintain a constant, target temperature of 32–36 o C for 24 h and rewarm slowly 0.25 o 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

22. 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

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

24. 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)

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

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

27. Cardiac arrest centres Regionalisation of post-cardiac care may be associated with better outcome 24/7 access to cardiac catheterisation laboratory Experienced intensive care clinicians Neurological monitoring (including EEG and SSEPs)

28. Any questions?

29. 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

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