9 post resuscitation care 2010v1

Lecture

Post Resuscitation Care

Learning outcomes

To understand:

The need for continued resuscitation after return of spontaneous circulation

How to treat the post cardiac arrest syndrome

How to transfer the patient safely

The role and limitations of assessing prognosis after cardiac arrest

Chain of Survival

Post resuscitation care

The goal is to restore:

Normal cerebral function

Stable cardiac rhythm

Adequate organ perfusion

Quality of life

Post cardiac arrest syndrome

Post cardiac arrest brain injury:– Coma, seizures, myoclonus

Post cardiac arrest myocardial dysfunction

Systemic ischaemia-reperfusion response– ‘Sepsis-like’ syndrome

Persistence of precipitating pathology

Airway and breathing

Ensure a clear airway, adequate oxygenation and ventilation

Consider tracheal intubation, sedation and controlled ventilation

Pulse oximetry: – Aim for SpO2 94 – 98%

Capnography:– Aim for normocapnia– Avoid hyperventilation

Airway and breathing

Look, listen and feel

Consider:– Simple/tension pneumothorax– Collapse/consolidation– Bronchial intubation– Pulmonary oedema– Aspiration– Fractured ribs/flail segment

Airway and breathing

Insert gastric tube to decompress stomach and improve lung compliance

Secure airway for transfer

Consider immediate extubation if patient breathing and conscious level improves quickly after ROSC

Circulation

Pulse and blood pressure

Peripheral perfusion e.g. capillary refill time

Right ventricular failure– Distended neck veins

Left ventricular failure– Pulmonary oedema

ECG monitor and 12-lead ECG

Disability

Neurological assessment:

Glasgow Coma Scale score

Pupils

Limb tone and movement

Posture

Glasgow Coma Scale score

Further assessment

HistoryHealth before the cardiac arrest

Time delay before resuscitation

Duration of resuscitation

Cause of the cardiac arrest

Family history

Further assessment

MonitoringVital signsECGPulse oximetryBlood pressure e.g. arterial lineCapnographyUrine outputTemperature

Further assessment

InvestigationsArterial blood gases Full blood countBiochemistry including blood glucoseTroponinRepeat 12-lead ECG Chest X-rayEchocardiography

Chest X-ray

Transfer of the patient

Discuss with admitting teamCannulae, drains, tubes securedSuctionOxygen supplyMonitoringDocumentationReassess before leavingTalk to family

Out-of-hospital VF arrest associated with AMI

Pacing

Cooling

IABP

Defibrillator

Inotropes

Ventilation

Enteral nutrition

Insulin

Optimising organ functionHeart

Post cardiac arrest syndrome

Ischaemia-reperfusion injury:– Reversible myocardial dysfunction for 2-3 days– Arrhythmias

Optimising organ functionHeart

Poor myocardial function despite optimal filling:– Echocardiography– Cardiac output monitoring– Inotropes and/or balloon pump

Mean blood pressure to achieve: – Urine output of 1 ml kg-1 hour-1 – Normalising lactate concentration

Optimising organ functionBrain

Impaired cerebral autoregulation – maintain ‘normal’ blood pressureSedationControl seizuresGlucose (4-10 mmol l-1)NormocapniaAvoid/treat hyperthermiaConsider therapeutic hypothermia

Therapeutic hypothermiaWho to cool?

Unconscious adults with ROSC after VF arrest should be cooled to 32-34oC

May benefit patients after non-shockable/in-hospital cardiac arrest

Exclusions: severe sepsis, pre-existing medical coagulopathy

Start as soon as possible and continue for 24 h

Rewarm slowly 0.25oC h-1

Therapeutic hypothermiaHow to cool?

Induction - 30 ml kg-1 4oC IV fluid and/or external cooling

Maintenance - external cooling:– Ice packs, wet towels– Cooling blankets or pads– Water circulating gel-coated pads

Maintenance - internal cooling– Intravascular heat exchanger– Cardiopulmonary bypass

Therapeutic hypothermiaPhysiological effects and complications

Shivering: sedate +/- neuromuscular blocking drug Bradycardia and cardiovascular instabilityInfectionHyperglycaemiaElectrolyte abnormalitiesIncreased amylase valuesReduced clearance of drugs

Assessment of prognosis

No clinical neurological signs can predict outcome < 24 h after ROSC

Poor outcome predicted at 3 days by:– Absent pupil light and corneal reflexes– Absent or extensor motor response to pain

But limited data on reliability of these criteria after therapeutic hypothermia

Organ donation

Non-surviving post cardiac arrest patient may be a suitable donor:

– Heart-beating donor (brainstem death)

– Non-heart-beating donor

Any questions?

Summary

Post cardiac arrest syndrome is complex

Quality of post resuscitation care influences final outcome

Appropriate monitoring, safe transfer and continued organ support

Assessment of prognosis is difficult