Cardiac Arrest And Post Arrest Care

Question 1

Identify the general approach to Post-cardiac arrest care (go through your thought process and big picture items that you need to do/identify)

Answer 1

ABCs —> Intubate if needed and not already done

Is invasive hemodynamics monitoring needed?

• Adequate peripheral IVs? Yes —> likely no need for central line yet
• Hemodynamically stable? No —> place an arterial line

Treat SHOCK

Minimize secondary brain injury (therapeutic hypothermia, avoid hyperoxia, goal PaCO2, EEG and treat seizures, etc)

Search for underlying etiology!

Question 2

In Post-cardiac arrest care what is the first thing to identify with regards to cardiovascular status?

Answer 2

Do they need PCI?

• EKG shows STEMI —> yes!
• No STEMI? —> any potential STEMI equivalents? These could be: a)Initial rhythm is shockable; b) There is ongoing hemodynamics instability
• Determine the number of “unfavorable” case features that would suggest you do should NOT pursue PCI

Question 3

What are the “unfavorable” features that you should assess for after ROSC to help determine if a patient should have PCI or not?

Answer 3

UNFAVORABLE features:
- Unwitnessed arrest

• Initial rhythm is NON-VF
• No bystander CPR performed
• > 30 min to achieve ROSC
• Ongoing CPR
• pH <7.2
• Lactate >7
• Age >85
• ESRD
• Non-cardiac causes identified

NOTE: If there are multiple features above identified then the patient is less likely to benefit from PCI

Question 4

These are the first line agents to use to give hemodynamics support and treat cardiogenic shock in Post-cardiac arrest care

What are the next things to be added as needed after first line?

Answer 4

FIRST line:

• IV fluids with isotonic fluid
• NOR-epi 0.05-0.1 ug/kg/min, titrate to effect

As needed:

• Dobutamine 2-20 ug/kg/min, titrate to effect
• Epinephrine 0.05-2 ug/kg/min, titrate to effect

Additional things: Blood products as needed, Coronary revascularization, Mechanical circulatory support (ECMO, ventricular assist device)

Question 5

What is the target MAP in post-cardiac arrest care? Why?

Answer 5

MAP of 80 mmHg

To support neurological status (perfume the brain!)

Question 6

Goal SaO2 in post-cardiac arrest care? How is this achieved?

Answer 6

Goal: 94-98% - you want to avoid 100% (hyperoxia)

Do this with titration of FiO2.

Why? —> To help aid in preserving neurological function

Question 7

Goal PaCO2 in post-cardiac arrest care?

Answer 7

35-40 mmHg

Question 8

Temperature management in post-cardiac arrest patients. Goals.

Answer 8

Following commands?
- NO —> initiate targeted temperature management with goal body temperature of 32-36ºC. Meticulously avoid hyperthermia (≥ 38ºC)

• YES —> Meticulously avoid hyperthermia (≥38ºC)