Post resus therapy in ALS (ANZCOR)

Question 1

Discuss goals for blood pressure post resus

Answer 1

HD goals (MAP, systolic blood pressure) should be set post resus

there is in insufficient evidence for specific HD goals

General recomendations include
-BP >100mg hg

Different goals should be set for different pathologies especially intracranial injury or potential ICP

Question 2

Discuss goals for oxygenation and ventialtion in post resus patients

Answer 2

Avoid Hypoxia and hyperoxia
Goal of spo2 of 94-98% is a reasonable target

Normocarbia 35-40mmhg –
Routine hyperventilation may be detrimental (result of vasoconstriction) and should be avoided

Question 3

Discuss glucose control post resus

Answer 3

Strong evidence for high BSL and poor neurological outcome post ROSC
To tight BSL control has also been assoicated with poorer outcome due to iatrogenic episdoes of hypoglycaemia

ANZCOR recommend treatment only if BSL >10

Question 4

Discuss the use of antiarrythmogenics post resus

Answer 4

It is reasonable to continue an infusion of an antiarrhythmic drug that successfully restored a stable rhythm during resus (lignoacine 2-4mg/min or amiodarone 0.6 mg/kg/hr for 24 hours)

If no antiarrhytmic drug was used during resus from a shockable rhythm an antiarrhytmic drug may be consdered to prevent recurrent VF

Question 5

Discuss temperature control post resus

Answer 5

ANZCOR suggest TTM as opposed to no TTM for adults with OHCA with an initial non shockable or shockable rhtyhm who remain unresponsive after ROSC

Selecting and maintaining a constant target tepreature between 32-36 degree for those patient in whom TTM is used. -Whether certain subpopulations of cardiac arrest patients may beneift from lower 32-34 degrees or higher 36 degrees remains unknown

Question 6

Discuss rationale for TTM and indications/contraindications

Answer 6

Rationale

• Avoidance of hyperthermia
• reduction in metabolic demand
• improved overal care
• Reduction in ischaemic reperfusion injury

Indications

• post cardiac arrest (any cause)
• ROSC <30 minutes from team arrival
• Time <6 hours from ROSC
• patient remains comatose
• MAP >65

Contraindications

• ARP directive stating nor resus
• Traumatic arrest
• Active bleeding
• pregnancy, recent major surgery, severe sepsis

ANZCOR recommends against routine use of prehosptial cooling with rapid infusion of alrge volumes of cold IV fluids

Question 7

Discuss how to cool and re-warm

Answer 7

Imitation

• Aim for temperature between 32-34
• infusion of ice cold IV fluids up to 30ml/kg or use of ice packs

Maintenance
-maintain core body temperature for 24 hours

Re-warming

• either controlled or passive
• 0.25 degrees per hour over 8-12 hours
• avoid hyperthermia

Question 8

Discuss evidence of TTM

Answer 8

Bernard et al 2002 - found an absolute risk reduction for death and severe disability of 23%

• small pseudo randomised trial without allocation conealment
• cooled to T33 for 12 hours vs standard care

HACA (hypothermia after cardiac arrest) found an ARR for unfavouarble neurological outcome of 24% and NNT of 4

Nielsen et al (2013) found no difference between TTM at 33 or 36C following ROSC

• MCRCT
• Not just VF/VT unlike HACA or bernard
• Standard protocol for neruolgoical prognostication
• signifiacnt power to study

Likley means target of TTM will be 36 rather than 33

Question 9

Discuss PCI post ROSC

Answer 9

Safe and feasible and may be associated with improved outcomes
Should be considered in all patient in whom primary cardiac event is considered as cause or contributor to arrest