EM@3AM: Post Cardiac Arrest Care

Author: Brit Long, MD (@long_brit, EM Attending Physician, San Antonio, TX) // Edited by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UTSW / Parkland Memorial Hospital)

Welcome to EM@3AM, an emDocs series designed to foster your working knowledge by providing an expedited review of clinical basics. We’ll keep it short, while you keep that EM brain sharp.

A 42-year-old male is brought in by EMS with ventricular fibrillation. He has been defibrillated once. Your team continues compressions and provides another defibrillation. You finally obtain ROSC, though the patient remains comatose.

What’s the next step in your evaluation and treatment?

Answer: Post Cardiac Arrest Care

Once you achieve ROSC, your real work starts. Over 60% of patients with ROSC do not survive to hospital discharge. Our job is to optimize treatment and survival.

Assess etiology for patient arrest: ACS, arrhythmias; Electrolyte disorders; Tamponade; Airway obstruction, asthma, COPD, pneumonia, PE, tension pneumothorax; Trauma, GI bleed, AAA rupture, ICH; Overdose, either intentional or accidental. US can provide valuable information.

Evaluation: Cardiac arrest patients with ROSC should have an ECG, blood gas (ABG/VBG), CBC, CMP, troponin, lactate, coags, a chest x-ray, and point of care ultrasound (POCUS) to assess cardiac function. Place a Foley catheter for the ICU as well if you have time.

Airway: If the patient was not intubated during arrest, the patient should be intubated after ROSC. If the patient is easy to ventilate with BVM or LMA, optimize cardiovascular status first (see C) before intubation, as this should not be a “crash intubation”. Place orogastric or nasogastric tube with intubation to decrease aspiration risk.

Breathing: Ventilator settings should be set to maintain an end-tidal CO2 from 35-45 mmHg and SpO2 of at least 94%. Hypoxia must be avoided, but hyperoxia may be harmful as well.  Aim for a tidal volume of 6-8 mL/kg. Don’t forget about analgesia/sedation (fentanyl drip).

Circulation: For optimal cerebral perfusion post-ROSC, the MAP goal is controversial; some advocate for > 80 mm Hg. If patient is in shock after ROSC, add norepi or epi +/- dobutamine (if cardiogenic shock component present). An A-line (some place this during code) and central line can assist.

An emergent cardiac revascularization should be considered for any patient with findings of ST segment elevation on ECG or with a presenting rhythm of VF or VT. Note: Immediate post-ROSC ECG has limited predictive value in diagnosing acute coronary lesions. However, ST elevation and initial VF and pulseless VT are predictive of cardiac etiology for arrest.

There is no evidence to support the prophylactic use of antiarrhythmic drugs even if the presenting rhythm was VT or VF and antiarrhythmic drugs were administered during the initial resuscitation.

Therapeutic Hypothermia: Cool to 32-36℃; pendulum on therapeutic hypothermia keeps swinging. Can start with IV fluid bolus of cold crystalloids. Place a surface cooling device if available. Patients cooled to 36℃ may demonstrate more shivering, which can be controlled with paralytics.

References:

– Jentzer J, Clements C, Wright R, White R, Jaffe A. Improving Survival From Cardiac Arrest: A Review of Contemporary Practice and Challenges. Ann Emerg Med. 2016;68(6):678-689.

– American C, Society for, O’Gara P, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013;61(4):485-510.

– Peberdy M, Donnino M, Callaway C, et al. Impact of percutaneous coronary intervention performance reporting on cardiac resuscitation centers: a scientific statement from the American Heart Association. Circulation. 2013;128(7):762-773.

– Rab T, Kern K, Tamis-Holland J, et al. Cardiac Arrest: A Treatment Algorithm for Emergent Invasive Cardiac Procedures in the Resuscitated Comatose Patient. J Am Coll Cardiol. 2015;66(1):62-73.

– Kern KB. Optimal treatment of patients surviving out-of-hospital cardiac arrest. JACC Cardiovasc Interv. 2012 Jun;5(6):597-605.

– Kilgannon JH, Jones AE, Shapiro NI, Angelos MG, Milcarek B, Hunter K, et al; Emergency Medicine Shock Research Network (EMShockNet) Investigators. Association between arterial hyperoxia following resuscitation from cardiac arrest and in-hospital mortality. JAMA. 2010 Jun 2;303(21):2165-71.

– Peberdy MA, Callaway CW, Neumar RW, et al. Part 9: post-cardiac arrest care: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010 Nov 2;122(18 Suppl 3):S768-86. doi: 10.1161/CIRCULATIONAHA.110.971002. Review. Erratum in: Circulation. 2011 Feb 15;123(6):e237. Circulation. 2011 Oct 11;124(15):e403. \

– Trzeciak S, Jones AE, Kilgannon JH, et al. Significance of arterial hypotension after resuscitation from cardiac arrest. Crit Care Med. 2009 Nov;37(11):2895-903; quiz 2904.