POST RESUSCITATION

CARE
15 SEPTEMBER 2014

Dr Faridah Jaafar
Emergency Physician
Hospital Queen
Elizabeth
Kota Kinabalu

Lecture outline

Definition & Introduction

AHA Guidelines 2010

Component of Post Resuscitation Care

Therapeutic Hypothermia

Summary / Conclusion

Definition
Return Of Spontaneous Circulation
(ROSC)
defined as resumption of sustained
perfusing cardiac activity associated
with significant respiratory effort
aftercardiac arrest.

Signs of ROSC include breathing (more than

an occasional gasp), coughing, or
movement. For healthcare personnel,
signs of ROSC also may include evidence

Definition & introduction

Post Cardiac Arrest Syndrome
The complex pathophysiological processes
that occur following whole body ischaemia
during cardiac arrest and the subsequent
reperfusion response following successful
resuscitation/ return of spontaneous
circulation (ROSC)

Post resuscitation care starts at the location

where ROSC is achieved.

Definition & introduction

because multiple organ systems are

affected after cardiac arrest, successful
post cardiac arrest care will benefit
from system-wide plans for proactive
treatment of the patient.

AHA guidelines

2010 American Heart Association Guidelines for

Cardiopulmonary Resuscitation and Emergency
Cardiovascular Care

Part 9: PostCardiac Arrest Care

AHA Guidelines

Most deaths occur during the first 24 hours after

cardiac arrest

Multiple organ systems are affected after cardiac

arrest

Reduce early mortality caused by hemodynamic

instability and later morbidity and mortality from
multiorgan failure and brain injury

Components in post resuscitation

care

Ventilations
Hemodynamic
Cardiovascular
Neurological
Metabolic

Component of Post
resuscitation care- General

Elevate the head of the bed 30

Avoid using ties that pass circumferentially around the
patient's neck
Insert Gastric Tube .....FOR WHAT????????
Adequate sedation : can reduce O2 consumption
Adequate dosage of neuromuscular blocking agent ( give
bolus, not infusion.......) will reduce oxygen consumption.
CXR : WHAT TO SEE???????????

AIRWAY & VENTILATIONS

Oxygenation should be maintained in the range 94%98%. Monitor oxygen concentration by arterial blood
gases (ABGs) and/ or pulse oximetry.

Avoid hyperventilations / overbagging the patient.

WHY????

Ventilation is adjusted to achieve normocarbia and to

monitor using end-tidal PCO 2 (PETCO2) and ABGs.

Ventilation_ 10 to 12 breaths per minute

Titrated to achieve a PETCO2 of 35 to 40 mm Hg or a PaCO2 of 40 to 45 mm

CIRCULATIONS

Intravenous/Intraosseous access

Assess vital signs and monitor for recurrent cardiac

arrythmias Aim MAP (>65mmHg) SBP>90mmHg
If hypotension, can give fluid boluses, then treat with
inotropes/vasopressors

Insert CBD monitor urine output , aim

Most common cause of cardiac arrest- cardiovascular disease and coronary

ischemia - 12-lead ECG to detect ST elevation or new left bundle-branch
block

Best treatment for AMI........Percutaneous Coronary Intervention (PCI)

DISABILITY

Seizures increase the cerebral metabolism

by 3 fold it will cause cerebral injury.
Can treat with benzodiazepines, phenytoin
or sodium valproate.
If myoclonus : clonazepam is the first
choice,but sodium valproate and propofol
maybe used.

Electrolyte : Glucose
control
Post

cardiac arrest patient is likely to develop

hyperglycemia
There are strong association between high blood
glucose after ROSC and poor neurological outcomes
and increase mortality
Treat hypoglycemia / hyperglycemia
Ideal Glucose control level is :
4.0 6.0 mmol/l
6.0 8.0 mmol/l
8.0 10.0 mmol/l
<10mmol/l

Electrolyte : Potassium

Immediately post arrest, there is a period of

hyperkalemia
This will give signal to endogenous
catecholamines to promotes intracellular
transport of potassium.
Hypokalemia will predisposing to ventricular
arrythmias.
Maintain serum Potassium 4.0
4.5mmol/l

Temperature Control

Hyperpyrexia is common in the first 48H

post arrest.
After resuscitation, temperature elevation
above normal can impair brain recovery and
poor outcomes.
After cardiac arrest, body will release
inflammatory cytokines FEVER
Treat any hyperthermia with antipyeretic or
active cooling

Therapeutic Hypothermia

Animal & human data indicate that mild

hypothermia is neuroprotective and improve
outcomes after a period of global cerebral
hypoxia.
Hypothermia reduces inflammatory response
associated with post cardiac arrest.
Indication: Post cardiac arrest patient in coma
Target Temperature : 32-34 celcious
Timing : at least 12H, maybe 24H, up to 72H
(newborn)

Therapeutic hypothermia :
how??
It contains 3 phases:
Phase 1 : Induction
Phase 2 : Maintenance
Phase 3 : Rewarming / Reversal

ANY CONTRAINDICATIONS????
1..
2.
3.

Induction Phase

External or internal cooling

Infusion 30mls/kg of 4 celcious saline/HM
solution
Simple ice packs/wet towels
Cooling blankets or pad
Transnasal evaporating cooling
Water @ Air circulating blanket
Water circulating gel-coated pads
Cardiopulmonary bypass
SHIVERING???????

Maintenance Phase

Monitor core temperature

(esophageal/bladder)
Target 3234 Celcious
Can using external or internal cooling
method
Avoid temperature fluctuations

Rewarming Phase

Must be done slowly (0.25-0.5

celcious/hour) to avoid electrolyte
imbalance

Can be done after 24H treatment

POTENTIAL COMPLICATIONS

Coagulopathy
Arrhythmias
Hyperglycemia
Pneumoniae
Sepsis
Reduce immune function

THANK YOU
ANY QUESTION?