Management of the Resuscitated Post-Cardiac Arrest Patient
Raghu R. Seethala
Benjamin M. Scirica
I. GENERAL PRINCIPLES
A. Despite recent advances in resuscitation care, cardiac arrest remains a leading cause of death worldwide. Even in patients who achieve return of spontaneous circulation (ROSC), mortality rates range between 50% and 75%.
B. Integrated post-cardiac arrest care has become an essential link in the American Heart Association’s (AHA’s) Chain of Survival.
C. Prolonged whole body ischemia results in the post-cardiac arrest syndrome (PCAS), which is defined as a complex multiorgan system process characterized by neurologic injury, myocardial dysfunction, systemic ischemia/reperfusion response, and the precipitating pathology that caused the arrest.
D. The major objectives of post-cardiac arrest care are to institute therapeutic hypothermia (TH) in a timely fashion, identify and treat acute coronary ischemia, ensure adequate end-organ perfusion, maintain appropriate oxygenation and ventilation, and provide general critical care.
II. PATHOPHYSIOLOGY
A. Post-cardiac arrest brain injury.
1. Accounts for a large portion of morbidity and mortality in resuscitated cardiac arrest patients. The brain has limited tolerance to ischemia and has a unique response to reperfusion.
2. Much of the neurologic dysfunction that occurs after ROSC can be attributed to cerebral edema, postischemic neurodegeneration, and impaired cerebrovascular autoregulation.
B. Post-cardiac arrest myocardial dysfunction.
1. Patients can be hemodynamically unstable after ROSC because of a period of global hypokinesis (myocardial stunning) that occurs or directly from the precipitating pathology (e.g. myocardial infarction).
2. Myocardial stunning is usually reversible but can last up to 72 hours.
C. Systemic ischemia/reperfusion response.
1. After ROSC, a sepsis-like state has been described, in which there is a significant systemic inflammatory response syndrome (SIRS) response, impaired vasoregulation, increased coagulation, and adrenal suppression.
D. Persistent precipitating pathology.
1. The underlying cause of the arrest commonly contributes to and complicates the pathophysiologic state of the patient, such as acute coronary syndrome, pulmonary embolism, respiratory failure, electrolyte abnormalities, metabolic abnormalities, environmental insults, toxic exposures, trauma, sepsis, and others.
III. DIAGNOSIS
A. ECG should be performed as soon as possible post-ROSC to determine if an ST-elevation myocardial infarction (STEMI) was the cause of the arrest.
B. Chest x-ray should be performed to detect reversible causes of cardiac arrest (i.e., pneumothorax) and to confirm position of supporting tubes and lines.
C. A head CT should be performed when there is a suspicion that an intracranial event precipitated the cardiac arrest. Otherwise head CT is not mandatory and should not delay further care.
D. CT angiography of the chest if pulmonary embolism or aortic dissection is suspected.
E. Laboratory studies appropriate for critically ill patients should be obtained including complete blood cell count, comprehensive metabolic panel, liver function tests, cardiac enzymes, lactic acid, arterial blood gas, and toxin screen.
IV. TREATMENT (Table 24-1)
A. General measures.
1. Ventilation—A definitive airway (i.e., a cuffed endotracheal tube in the trachea) is required in most cases in patients who are comatose and are hemodynamically unstable. Ensure any temporary airways obtained during arrest are replaced with an advanced airway.
TABLE 24-1 Post-ROSC Treatment | |||||||||||
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