1. Post-resuscitation care
Version: Jan 2016

2. 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

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
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

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

8. 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

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 - SpO2 90% on high flow oxygen

10. 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

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

12. 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

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 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)

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

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 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

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. 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

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