Post resuscitation care

Question 1

What comprises the post-cardiac arrest syndrome?

Answer 1

• post cardiac arrest brain injury
• post cardiac arrest myocardial dysfunction
• systemic ischaemia/reperfusion response
• persistent precipitating pathology

Question 2

Describe post ROSC care

Answer 2

• re-evaluate ABCDE
• obtain 12 lead ECG
• Control temp to 32-36 and sedate to control shivering

if likely cardac cause consider angio +/- PCI (if no cause found do CTs below)
if not likely cardiac consider CTB+/-CTPA and treat any cause found

Admit to ICU
TTM
normoxia, normocapnea, normoglycaemia 
ECHO, EEG
no prognostication for 72hr

Question 3

How is it decided whether to do coronary angiography or CTB/CTPA first post resus?

Answer 3

in the absence of signs or symptoms suggesting a neurological or respiratory cause for arrest (HA, seizures, neuro deficits, SOB, documented hypoxia) or if clinical/ecg evidence of MI then angio is done first followed by CT

Question 4

Treatment of post cardiac arrest myocardial dysfunction

Answer 4

• TTE to assess the severity

- usually will require inotropy - dobutamine and may require it with NA to support BP

Question 5

Post ROSC management of potassium

Answer 5

• usually there is hyperkalaemia which resolves with ROSC and release of endogenous catecholamines (and correction of metabolic/resp acidosis)
• can turn in to hypokalaemia - aim K 4-4.5

Question 6

Who should be considered for an ICD post ROSC

Answer 6

• resus from a shockable rhythm outside of a STEMI or known noncardiac arrhythmogenic cause

Question 7

what is the most common type of seizure post cardiac arrest?

Answer 7

myoclonic seizures

Question 8

Describe targeted temperature management

Answer 8

• neuroprotection from decreasing CMRO, blocks intracellular consequences of excitotoxin exposure (glutamate/Ca) and reduces inflammation
• no difference between 33 and 36. 36 may be better as there is less need for vasopressor, rewarming can happen quicker, reduced risk of rebound hyperthermia, lactate levels are lower
• for people who remain unresponsive post ROSC
• requires sedation to stop shivering, Mg helps this by its action on the NMDA receptor
• 3 phases induction, maintenance , rewarming
• methods include arctic sun cooling blanket, ice or wet blankets, transnasal evaporative cooling, intravascular heat exchanger, ECMO
• duration of at least 24 hours should be used
• rewarm at 0.25-0.5C per hour

Question 9

Physiological effects of hypothermia

Answer 9

1. CVS - increases SVR, causes bradycardia
2. causes diuresis, electrolyte abnormalities
3. decreases insulin sensitivity
4. impairs coagulation
5. impairs immune system
6. drug clearance is impaired

Question 10

Describe prognostication post ROSC

Answer 10

• wait at least 72hr
• clinical exam
• neurophysiology - somatosensory evoked potentials (SSEPs), EEG
• neuron-specific enolase
• CT/MRI