post cardiac arrest syndrome
DESCRIPTION
My talk for emergency nurses on managing post cardiac arrest syndrome.TRANSCRIPT
S
When you get one Back.
Post Cardiac Arrest Syndrome!By Kane Guthrie
Learning Points
Cardiac arrest were are we at?
A case!
Post resuscitation care is it the answer?
A chilling look at the benefits of therapeutic hypothermia!
Cardiac Arrest the Stat’s
Generally 6-7% survival rate (worldwide)
0nly 3-4% leave hospital with RONF
Early Defib/compressions make the difference
Post resuscitation care is the answer to improving mortality and morbidity with ROSC.
Cardiac Arrest
We loose so many!
We need to focus on the ones we get back.
The REAL resuscitation starts once we get ROSC!
RONF or organ donation is the only good outcome’s!
The Approach
The things that help get em back!
The 3 things that have the evidence:
1. Early high quality chest compressions
2. Early defibrillation
3. Therapeutic hypothermia
Case Study
68 male walking home from pub
Collapse > Cardiac Arrest >Bystander CPR
SJA arrive 13mins post arrest
In VF, Successful ROSC post x3 defibs
Arrives in T2 20 mins later with no RONF
What should we do now?
Remember!
The Goals Post Arrest
1. Induce Therapeutic Hypothermia
2. Maximise Haemodynamic’s
3. Optimise Oxygenation
4. Advocate for Cardiac Catheterisation
Post Cardiac Arrest Syndrome!!
Thought to be RT production of free radicals
Pathophysiology is very complex = BORING
Hypoperfusion & Ischaemia cause cascade of events
1. Disruption of homeostasis
2. Free radical formation
3. Protease activation
• Hypothermia helps slow down this cascade
The Patho
1. Brain Injury Cerebral oedema and ischaemia
2. Myocardial dysfunction Haemodynamically labile R/T global hypokinesis.
3. Systemic ischemia/reperfusion response SIRS response – looks like sepsis.
4. Persistent precipitating pathology. The underlying cause.
Oxygen and Ventilation
Avoid hyperoxia:
O2 toxicity detrimental to heart and brain.
Adjust 02 to keep spo2 >90.
Avoid hyperventilation:
Hypocarbia causes cerebral vasoconstriction.
Circulatory Support
Haemodynamic instability is the norm!
Each episode of hypotension worsens mortality & neuro function.
Aggressive IVF- replace volume depletion
Keep MAP- 65-100mmHg (adrenaline, noradrenaline or dopamine)
ICU via Cath Lab?
PCI improves survival and neurological function.
STEMI should go straight to CATH Lab.
Consider for all other survivors within 12-24 hours post ROSC – up to 40% have unstable plaques.
Can be difficult convincing cardiology!!!
Therapeutic Hypothermia
‘Induced hypothermia” is were pt is deliberately cooled between 32-33.9°C
It aims to reduce hypoperfusion (& reperfusion) injury post arrest.
Focuses mainly on brain (neuroprotection), but offers protection to heart, liver, kidneys.
Current research shows no benefit of inducing TH before or during event. (RINSE trial ongoing)
Therapeutic Hypothermia
Therapeutic hypothermia is the first treatment that has proven effective for post-resuscitation
reperfusion injury.
NNT 1:6 vs 1:42 for aspirin in STEMI
Who’s in? Who's Out?
In.
Cardiac arrest with ROSC.
Persistent significant altered GCS.
<12 since ROSC.
Out.
Advanced directive or DNR.
Traumatic arrest.
Active bleeding.
Pregnant, recent major surgery or severe sepsis.
3 phases of TH.
1. Induction: •Aim reduce core temp to 32-34°C •Preferably within 2 hours
2: Maintenance: •Maintain core temp 12-24 hours
3:Rewarming: •controlled or passive rewarming to normothermia 37°C•0.2-0.5°C per hour –over 8-12 hours
How to Cool!
Cold fluids
ICE Packs
Machine’s
ED ManagementAirway • secure ETT, continuous
EtCO2
Breathing •Prevent VILI
Circulation •ECG (risk arrhythmias)•Monitor U/O (cold diuresis)
Disability •Paralyze, sedate
Exposure •Core temp monitoring•Monitoring skin integrity•Once at 34°C remove ICE packs & maintain•Monitor and prevent shivering•Prepare patient for T/F to ICU, Cath Lab
Monitoring the bloods
Remember the basics
Pressure area & skin care
Adequate sedation/analgesia
Lung protective ventilation
Seizure control
Social support (family)
Complications
Tachycardia > bradycardia
Hypertension
Diuresis (hypovolaemia)
Shivering (increases temp)
Arrhythmia's
Increase bleeding
Spiking temp’s look for signs of infection
Case Continued
Pt intubated and ventilated in ED
Cooling began.
Taken to CATH lab 90% occlusion to LAD.
Warmed and extubated 24 hours later in ICU.
GCS 15
Back at the pub 4/7 later.
The Future
Take Home Points
Good post resus care improves outcomes.
Therapeutic hypothermia should be done on all ROSC with-out RONF.
Maximise haemodynamic’s and oxygenation in ED.
Advocate for the early CATH Lab.
Thank-you