Post ROSC Care Flashcards
What is the post cardiac arrest syndrome?
The physiological state a patient presents immediately after ROSC
What is the post cardiac arrest brain injury?
Pathophysiology;
- Post ischaemic neurodegenerative (Micro thrombi forming in brain - worsens ischaemia)
- Impaired cerebrovascular auto-regulation
- Cerebral oedema
Clinical manifestations;
- Coma
- Seizures
- Myoclonus
- Cognitive dysfunction
- Persistent vegetative state
- Secondary Parkinsonism
- Cortical stroke
- Spinal stroke
- Brian death
Potential treatments;
- Therapeutic hypothermia
- Early haemodynamic optimisation
- Airway protection & mechanical ventilation
- Seizure control
- Controlled reoxygenation (SaO2 between 94-96%)
- Supportive care
What is the post cardiac arrest myocardial dysfunction?
Pathophysiology;
- Global hypokinesis
- Reduced cardiac output
- ACS
Clinical manifestations;
- Early revascularisation of AMI (acute myocardial infarction)
- Hypotension
- Dysrhythmias
- Cardiovascular collapse
- Tachycardia
- Rejection fraction decreases
Potential treatments;
- Early haemodynamic optimisation
- IV fluid
- Inotropes
- Intra-aortic balloon pump (IABP)
- Left ventricular assist device (LVAD)
- Extracorporeal membrane oxygenation (EMCO)
What is the systemic ischaemic / repercussion response?
Pathophysiology;
- Systemic inflammatory response syndrome
- Impaired vasoregulation
- Increased coagulation
- Adrenal suppression
- Impaired tissue oxygen delivery & utilisation
- Impaired resistance to infection
- Increase in free radicals = cell death
- Circulation of infarcted cells & components
Clinical manifestations;
- Ongoing tissue hypoxia/ischaemia
- Hypotension
- Cardiovascular collapse
- Pyrexia
- Hyperglycaemia
- Multiorgan failure
- Infection
Potential treatments;
- Early haemodynamic optimisation
- IV fluid
- Vasopressors
- High-volume haemofiltration
- Temperature control
- Glucose control
- Antibiotics for infection
What is the persistent precipitating pathology?
Pathophysiology;
- Cardiovascular disease
- Pulmonary disease (COPD, asthma)
- Central nervous system (CNS) disease
- PE
- Toxicologic (overdose, poisoning’
- Infection (sepsis, pneumonia)
- Hypovolaemia (haemorrhage, dehydration)
POST ROSC CARE
AIRWAY
- IGel or ETI
- ETI used….
- drowning, burns, asthma/COPD, pulmonary oedema
- Guided by GCS
- Use of sedation/paralytics e.g. midazolam reduces metabolic demand = less strain on hear + brain
POST ROSC CARE
BREATHING
- Use ETCO2 as a marker - target 4.6-6 kPa
- hypercapnia = vasodilation in brain = cerebral oedema = ICP
- Hypocapnia = vasoconstriction
- central perfusion pressure = mean arterial BP + inter cranial pressure
- control mean arterial BP with fluids (intravascular volume), sedation (not to lower BP) and CO2
- When using mechanical ventilation - lengthen expiratory phase for COPD its = allows them more time to exhale oxygen
Mechanical Ventilation facilitates treatment of/migrates secondary brain injury - by facilitating MAP/BP control.
POST ROSC CARE
CIRCULATION
- Ensure adequate perfusion & minimise subsequent injury
- MAP >60/70 mmHg
- Good for renal & brain function as well as cardiac function + renal perfusion
- ETCO2 >4.6
- ETCO2 is reflective of perfusion status - can guide to identify pathology causing malperfusion - V/Q mismatch, poor CO
- BP = CO = SV/HR
- Circulatory support
- Volume (positive leg rise)
- Inotropes - Increase contractility of heart
- Chronotropes - increase HR
POST ROSC CARE
CIRCULATION
What inotropes are used for circulatory support?
Alpha 1
- Noradrenaline
- Adrenaline
- Smooth muscle constriction = facilitates influx of intracellular Ca ++
- Give noradrenaline in septic shock -= causes vasoconstriction, to overcome volume issue
Alpha 2 NOT USED
- has mixed effects on smooth muscle + inhibition of intrinsic noradrenaline secretion
Beta 1
- Adrenaline
- Dopamine
- Increased chronotrophy = Ca++ channels open more rapidly. calcium binding to troponin in increased = faster diastole
- Give dopamine for ROSC with PE
Beta 2
- Adrenaline
- Dobutamine
- Salbutamol
- Smooth muscle dilation, increased chronotrophy, inotrophy
Atropine when indicated..
- Initial catecholamine storm post-ROSC may present with myocardial dysfunction
- Undue vagal stimulation from airway management may cause bradycardia
- Systemic reperfusion injury may cause bradycardia
- May also help to dry secretions - but NOT prime use
POST ROSC CARE
DISABILITY
- Seizures -manage as normal - may indicate cerebral insult / injury
- Analgesia
- Targeted temperature management
POST ROSC CARE
ENVIRONMENT
- Fever - increases mortality = fever presents as a result of systemic illness/injury
- Pt position - 30 o angle of head = helps venous return = improves ICP
- Minimise stimulation - noise, light, movement = further agitation
When should adrenaline be given post ROSC?
Should the patient remain hypotensive (systolic <90mmHg AND NO palpable RADIAL pulse, and pulse below 100bpm) then a dose of adrenaline 1ml (0.1mg) of 1 in 10,000 may be given IV/EZIO up to a total of 0.5mg.
