Post-Cardiac Arrest Syndrome

Question 1

When does reperfusion injury occur?

Answer 1

Complete loss of blood flow followed by abrupt ROSC

Question 2

Ischemia and reperfusion bring about these 3 mechanisms that result to blood vessel instability, cell death, and brain swelling

Answer 2

1. ROS
2. Inflammatory casades
3. Mitochondrial dysfunction

Cytochrome C, Oxygen free radicals, IL-6, TNF a

Question 3

Common and dangerous effect of post resuscitation syndrome

Answer 3

Cerebral edema

Other ogran system effects: Myocardial stunning, Adrenal insufficiency

Question 4

Most common cause of sudden cardiac arrest

Answer 4

Myocardial ischemia

Question 5

Remarks on neuro examination post resuscitation

Answer 5

Bedside neurologic examination should not influence decisions for continued care in the first 72 hours following resuscitation

Question 6

Targeted Temperature Management Goal Temperature

Answer 6

32-36C (89.6-96.8F)
33-36C

Range from diff sources: 33-36C; 32-34C

Application for 24 hours improves survival and neurological outcomes

Question 7

Inclusion criteria for Postarrest TTM (4)

Answer 7

1. Postresuscitation ROSC and GCS <6
2. No other reason for coma
3. No DNR or DNI
4. Adult >17

Question 8

Exclusion criteria (6)

Answer 8

1. Awake/alert after cardiac arrest
2. Arrest of traumatic etiology
3. Arrest associated with significant bleeding
4. Coma or vegetative state prior to arrest
5. Pregnancy
6. DNR/DNI

Not an exclusion crieteria: Warfarin/heparin use, initial arrest rhythm was nonshockable, Long Qt syndrome

Question 9

3 Phases of TTM

Answer 9

1. Cooling
2. Maintenance
3. Rewarming

Question 10

These are done during the cooling phase of TTM

Answer 10

1. Placement of central lines/arterial lines
2. Sedation/paralytic treatment
3. EEG/Neurologic monitoring
4. Concern for shivering

Question 11

Concern for hypotension is present in this phase of TTM

Answer 11

Rewarming

Question 12

Methods of cooling in TTM (4)

Answer 12

1. Surface wrap
2. Catheter based cooling
3. Chilled saline/Ice packs to axilla or groin
4. Intravascular cooling (IV 30ml/kg NS at 4C over 30 mins)

Continuous monitoring including ECG and esp core temp monitoring

Do not let core temp drop to <32C; avoid fever

Question 13

Duration of Hypotermia and rewarming in TTM

Answer 13

12 to 24 hours

Monitor MAP >60 mmHg

Too rapid rewarming = hypotenstion from vasodilation

Initiate cooling within 4-6 hrs post ROSC

Question 14

Electrolyte imbalance to watch out for in TTM

Answer 14

HYPOKALEMIA

can result from cold-mediated diuresis
check q4

Question 15

More Common Complications of TTM (6)

Answer 15

1. Bradycarida (<50)
2. Qt prolongation
3. Coagulopathy (Inc PTT)
4. HYPOkalemia during cooling
5. HYPERkalemia during rewarming
6. Shivering

Question 16

Less Common Complications of TTM (3)

Answer 16

1. Nonsustained Vtach
2. Significant bleeding
3. Skin injury/ulceration from cooling

Question 17

Special considerations of TTM in Children

Answer 17

Careful avoidance of post arrest fever

Question 18

T or F
Prehospital induction of TTM is approved

Answer 18

False

Question 19

the most definitive treatment approach to shivering

Answer 19

neuromuscular blockade
(shivering can impede the lowering of body temperature)

Question 20

Cerebral edema and increased ICP can cause cerebral herniation and serve as the cause of death, often in the initial _____ hours following resuscitation

Answer 20

72

Question 21

Myocardial stunning is clinically evident on echocardiography as

Answer 21

global hypokinesis and markedly reduced EF

Myocardial depression is usually transient and typically resolves over the first few days

Question 22

post-ROSC glycemic goal

Answer 22

100-180 mg/dL

Question 23

Many postarrest patients should be considered for prompt coronary catheterization given the likelihood of coronary occlusion, especially in the setting of

Answer 23

ventricular fibrillation arrest in patients with coronary risk factors

(TTM started in the ED can be continued safely in the catheterization laboratory without untoward effects)