1. Post Cardiac Arrest Care American Heart Association Guidelines 2015
Dr. Ankit Jain

2. Primary Assessment – The ABCs
Airway secured during CPR?
Advanced Airway for Comatose patients
Ensure patency and adequacy of airway.
Avoid neck ties
30° Head High if acceptable
Aspiration Risk
Cerebral Oedema
VAP

3. Primary Assessment – The ABCs
Most patients mechanically ventilated
Strategy for ventilator management
Assess
PCO2 using ABG
ETCO2 using Quantitative waveform capnography
Maintain Normocapnia
PCO mm Hg
ETCO mm Hg.

4. Primary Assessment – The ABCs
Avoid hyperventilation.
Hyperventilation→↓PCO2→Cerebral Vasoconstriction→ Cerebral Oedema→Poor Neurological Outcome
Hyperventilation→↑PEEP→Hyperinflation→ ↑Intrathoracic Pressure→↓Preload→Hypotension
Unless……
↑PCO2 eg ALI, High airway pressure
↓PCO2 (Mild) eg. Raised ICP

5. Primary Assessment – The ABCs
Oxygenation
The issue of hyperoxia. (PaO2 >300 mmHg)
Absorptive atelectasis, accentuation of preexisting hypercapnia, airway injury, parenchymal lung injury, and extrapulmonary toxicity.
Hyperoxia may cause coronary vasoconstiction.
Mediated by reactive oxygen species, which can promote inflammation and induce cell death.

6. Primary Assessment – The ABCs
A Reasonable guideline…
Preventing hypoxic (PaO2 <60 mm Hg) episodes with their ESTABLISHED side effects is more important than avoiding any POSSIBLE risks of hyperoxia.
Use highest possible FiO2 until PaO2/SpO2 available; then titrate asap to an SpO2 of 94% or PaO2 60 mmHg.
(Peripheral vasoconstriction post cardiac arrest may make SpO2 measurements unreliable. )

7. Primary Assessment – The ABCs
Secure IV access if not secured during CPR
Patients often hemodynamically unstable.
How?
Fluids vs Vasopressors??
No consensus.
Use your clinical acumen.

8. Primary Assessment – The ABCs
BP Goals
Maintain End Organ perfusion
MAP>65 mm Hg to reverse shock.
MAP mm Hg for cerebral perfusion.
↑MAP
↓MAP
Reverse Acute Shock State
Optimize Cerebral Perfusion
Maintain CVP
Adequate Urine Output
Overstressing a Decompensated Heart

9. Primary Assessment – The ABCs
Fluids
Isotonic Saline or RL
RL avoids Hyperchloremic Acidosis.
Avoid Hypotonic fluids → Exacerbate Cerebral oedema.
Target central venous pressure (CVP) of 8 to 12 mmHg.
Adjuvant for TTM.  

10. Primary Assessment – The ABCs
Vasopressors
Once an adequate CVP has been established patients whose MAP remains below 80 mmHg generally need treatment with an inotropic agent or vasopressor.
Prior to CVP monitoring, it is reasonable to start vasoactive drugs in patients with hypotension that does not resolve after a rapid infusion of 2 liters of isotonic crystalloid.
Choice of Vasopressor agent??
No superiority of any one agent in post arrest patients.
IABP
Role of Advanced cardiac monitoring.
Targets for other hemodynamic or perfusion measures (such as cardiac output, mixed/central venous oxygen saturation) remain undefined in post–cardiac arrest patients.

11. CORONARY REVASCULARISATION
POST CARDIAC ARREST

12. CORONARY REVASCULARISATION
ACS common cause of out of hospital cardiac arrest.
Obtain 12 lead ECG as soon as possible after ROSC after cardiac arrest.
Emergent (same day) coronary catheterization if ST segment elevation myocardial infarction (STEMI) or new left bundle branch block (LBBB).

13. CORONARY REVASCULARISATION
Non ST elevation on initial ECG
High Incidence of CAD in OHCA due to VF or PVT. (435 patients; 70% CAD)
Raising Troponin levels, RWMA on 2DEcho, hemodynamic instability due to cardiogenic shock.

14. CORONARY REVASCULARISATION
CAG and COMA
TTM not a contraindication to CAG.
CAG
NEURO PROGNOSTICATION
Of ROSC
<24 HOURS
Benefit
>72 HOURS

15. Targeted temperature management
NEUROLOGIC CARE

16. TARGETED TEMPERATURE MANAGEMENT
Why?
Only intervention that has proven to improve neurological recovery after ROSC.
High neurologic morbidity and mortality without any specific interventions.
Temperature is an important variable for neurologic recovery.
Who?
Comatosed patients (No meaningful response to VC) with ROSC post cardiac arrest.

17. TARGETED TEMPERATURE MANAGEMENT
Contraindications??
Essentially no patients in whom temperature control between 32 C and 36 C is contraindicated.
Change from earlier guidelines
Target temperature 32 to 34
Lead to various Contraindications
Eg. Pregnancy, hemodynamic instability, active bleeding

18. TARGETED TEMPERATURE MANAGEMENT
What temperature exactly?
32 C-36 C
Higher temperatures in patients for whom lower temperatures pose some risk and vice versa.
Temperature at onset.

19. TARGETED TEMPERATURE MANAGEMENT
How long?
No direct comparisons of different durations of TTM in post–cardiac arrest patients. The largest trials and studies of TTM maintained temperatures for 24 hours or 28 hours followed by a gradual (approximately 0.25ºC/hour) return to normothermia

20. TARGETED TEMPERATURE MANAGEMENT
Methodology
Measure Core body temperature
Oesophageal
Bladder PA
No surface temperature.
Cooling Techniques
Intravascular Cooling
Cold C
Endovascular Catheters
Surface Cooling
Ice packs, cooling blankets, cooling vests, and cold water immersion.

21. TARGETED TEMPERATURE MANAGEMENT
PRECAUTIONS:
Shivering
Natural response to hypothermia.
Sedation and Analgesia via IV Boluses and Infusions to prevent pain and discomfort. Choose agent with short half life as elimination delayed in hypothermia
Increases metabolism and delays achievement of target temperature.
Usually between 35 and 37 C. Reduces once target temperature reached.
Increase dose of sedatives/anesthetic agents.
Neuromuscular Blocking agents Infusion or boluses.
NMB may mask seizure activity, common cause of coma. Use EEG.

22. TARGETED TEMPERATURE MANAGEMENT
PRECAUTIONS:
Hemodynamics
Initial Tachycardia and Hypertension during initiation of hypothermia due to shivering and cutaneous vasoconstriction.
Then Bradycardia (prolonged PR, QTc, Sinus, junctional or ventricular rhythm).
Treat bradycardia only if with hypotension.
Target MAP>90 mm Hg.
Target CVP 10-12
Rewarming may cause hypotension.
Treat arrythmias as per medical protocol.
Increase target temperature if arrhythmia or hypotension persists.

23. TARGETED TEMPERATURE MANAGEMENT
PRECAUTIONS:
Oxygenation and Ventilation.
Mechanical Ventilation mandatory.
PaO
Avoid prolonged FiO2of 100 as it may ppt reactive oxygen radicals and neuronal damage.
Ventilation to target normocarbia.
Glucose
Hyperglycemia secondary to reduced insulin secretion and resistance in hypothermia.
Hypoglycemia during rewarming.
Monitor sugars hourly.
Stop Insulin if glucose <200 mg/dL.
Potassium
Hypothermia causes intracellular shift of potassium and hypokalemia.
Monitor 4 hourly.
Potassium replacement to target S.K of 3.5 mEq/L.
Stop replacement 4 hours prior to initiating rewarming.
Hyperkalemia during rewarming as efflux of potassium from cells.

24. TARGETED TEMPERATURE MANAGEMENT
Rewarming After Therapeutic Hypothermia
Begin 24 hours after initiation of cooling/ achieving target temperature.
Rewarming at a rate of 0.25C per hour until normothermia 37 C.
Watch for Hypotension, Hypoglycemia, Hyperkalemia.
Avoid Hyperthermia which can be detrimental.
Neurological evaluation 72 hours after normothermia as delayed neurological recovery after TH.

25. GLYCEMIC CONTROL
No data suggest that the approach to glucose management chosen for other critically ill patients should be modified for cardiac arrest patients.

26. Other Investigations Chest Xray
Respiratory dysfunction common after Cardiac arrest
Pulmonary oedema secondary to LV failure.
Aspiration during arrest or resuscitation.
Complications of Chest Compressions
Rib fractures.
Pnueumothorax
Lines and Tubes.

27. Identify and Treat Cause of Cardiac Arrest
Remember 5 H and 5 T
Fibrinolysis during or after CPR does not pose an unacceptable risk!
5 H
5 T
Hypoxia
Toxins
Hypovolemia
Tamponade
H+ Ions
Tension pneumothorax
Hyper/Hypo Kalemia
Thrombosis (Pulmonary)
Hypothermia
Thrombosis(Coronary)

28. Thank You.
ANY QUESTIONS??