13. Post-resuscitation care Flashcards
what does the post-cardiac arrest syndrome comprise?
post arrest brain injury
post arrest myocardial dysfunction
systemic ischaemia/ reperfusion response
persistent precipitating pathology
significant myocardial dysfunction is common after cardiac arrest but typically starts to recover how long after?
by 2-3 days (full recovery may take much longer)
approach to the patient following ROSC?
ABCDE
aim sats of what following ROSC?
94-98%
(some studies suggest an association between hyperoxaemia and poor outcome)
why is achieving normocapnia important to post-arrest neurological function?
hypercapnia increases cerebral blood flow/ blood volume and intracerebral pressure
hypocapnia causes vasoconstriction that may decrease blood flow and cause cerebral ischaemia
a tracheal tube that has been inserted too far will tend to go down the ____ main bronchus
right
therefore failing to ventilate the left lung
what can be done following ROSC to decompress the stomach, prevent splinting of the diaphragm and enable drainage of gastric contents
insert a gastric tube
following ROSC, what does grossly dilated neck veins when the pt is semi-upright indicate about the heart?
may indicate right ventricular failure
in rare cases could be pericardial tampondade
T/F: prolonged CPR is a contraindication to fibrinolytic therapy
false
GCS score
Eyes
1- nil
2- to pain
3- to voice
4- spontaneously
Verbal
1- nil
2- sounds
3- words
4- confused
5- normal
Motor
1- nil
2- extension (decerebrate)
3- abnormal flexion (decorticate)
4- normal flexion
5- localises
6- obey commands
T/F: bicarbonate is recommended in the treatment of acidaemia post arrest
false - it may, paradoxically, increase the intracellular acidosis, as it’s converted to CO2 with the release of hydrogen ions within the cell
only indicated post arrest ass with hyperkalaemia or TCA overdose
investigations to order following ROSC?
FBC - exclude anaemia
Biochem - renal function, electrolytes, glucose, trops
ECG- cardiac rhythm, evidence ACS, evidence of primary arrhythmogenic causes e.g. Brugada, long QT
CXR- position of tracheal tube/ gastric tube/ central venous catheter, evidence pulmonary oedema/ aspiration/ pneumothorax/ cardiac contour
ABG- adequacy of ventilation and oxygenation, correction of acid/ base imbalance
ECHO- identify contributing causes, assess LV and RV structure and function
CT- exclude IC bleed or stroke as cause, exclude PE or other resp causes
post resuscitation myocardial dysfunction often requires ____ support, at least transiently
what meds are used for this most often?
inotropic
noradrenaline with or without dobutamine and fluid is usually most effective
post arrest, if treatment with fluid resuscitation, inotropes and vasoactive drugs is insufficient to support the circulation, consider insertion of what device?
an intra-aortic balloon pump (IABP)
immediately after cardiac arrest there is typically a period of ___kalaemia
hyperkalaemia
subsequent endogenous catecholamine release and correction of met resp acidosis promotes intracellular transportation of potassium»_space; hypokalaemia
give K to maintain conc 4 - 4.5
what pts should be considered for ICD post arrest?
any pt who had a shockable rhythm outside the context of proven acute ST-segment elevation MI
all need cardio review before discharge
T/F: immediately after ROSC there is a period of cerebral hyperaemia
true
in many post arrest pts cerebral autoregulation is impaired and very dependent on MAP - ie can get hypoperfusion if MAP low or hyperaemia and cerebral hypertension if MAP high
what is the most common type of clinical seizure in post arrest pts
myoclonus (sudden brief shock like involuntary muscle contraction)
T/F: post arrest seizures usually develop in the first 1-2 days and are ass with poor prognosis
true
how to treat post arrest seizures?
levetiracetam and/ or sodium valproate
after the first event start maintenance therapy
T/F: prophylactic antiepileptic drugs should be used in post arrest pts
false - currently no evidence for this
maintain blood glucose in what range following ROSC?
</= 10
whilst avoiding hypoglycaemia (<4)
continuously monitor core temperature in comatose pts post ROSC
HYPOTHERMIA/ PYREXIA is common in the first 2-3 days following arrest and is associated with a poor outcome
treatment of any pyrexia post arrest?
pyrexia
antipyretics, active cooling (blankets, pads, water, air circulating blankets, IV heat exchanger)
actively prevent fever for at least 72hrs post arrest in those who remain comatose (temp >37.7)
T/F: comatose pts with mild hypothermia following ROSC should be actively rewarmed
false - not recommended (aiming to avoid pyrexia for first 72hrs)
T/F: rapid pre-hospital cooling using large volumes of cold IV fluids is recommended in any pyrexia pt following ROSC
false - not recommended
prognostication of the comatose pt post arrest should be multimodal and involve the following tests
1) clinical examination including…
2) neurophysiological studies including…
3) biochemical marks - the most commonly used is…
4) imaging studies- including…
1) GCS, pupil response to light/ corneal reflex, presence of seizures
2) SSEPs, EEG
3) neuron specific enolase
4) CTB and MRI
T/F: neurological outcome is considered to be good for the majority of cardiac arrest survivors
true
T/F: long term cog impairments are present in 1/2 of survivors of cardiac arrest
true - memory if most frequently affected, followed by problems in attention and executive functioning (mostly mild impairments)
