Post cardiac arrest care

I46.0

• Description
• General Measures
• Medical Treatment
• Referral

DESCRIPTION

Post cardiac arrest care starts following successful CPR. During this time the patient is vulnerable to several processes, including:

• the underlying disease condition or injury causing the cardiac arrest
• post cardiac arrest haemodynamic instability
• post cardiac arrest brain injury
• the sequelae of global ischaemia and reperfusion.

Care should be aimed at reversing or minimising the above processes to optimise the likelihood of neurologically intact survival.

GENERAL MEASURES

The priorities of management post cardiac arrest include:

Determining the cause of cardiac arrest

• careful history and physical examination
• bedside tests such as 12-lead ECG, blood glucose, Hb, pulse oximetry, blood gases
• special investigations such as chest x-ray, eFAST, CT of the brain

Treating reversible conditions

This will be specific to the presentation and clinical findings.

Evidence of ST elevation myocardial infarction (STEMI) on ECG should prompt urgent treatment. See section 3.2.1: ST elevation myocardial infarction (STEMI).

Note: Prolonged CPR may be a contraindication to administration of thrombolytic or fibrinolytic agents. Consult a specialist to determine whether referral for percutaneous intervention is possible.

Supportive care and prevention of complications

Airway

• Ensure that the airway is patent and protected.
• Endotracheal intubation may be required in patients that do not rapidly regain consciousness following return of spontaneous circulation.

Breathing

• Maintain oxygen saturation above 94%.
• Avoid hyperoxia by weaning the inspired oxygen concentration to the lowest percentage required to maintain the above saturation.
• Maintain PaCO2 within normal range in ventilated patients where feasible.

Circulation

• Correct hypovolaemia if present, with judicious IV fluids.
• Monitor response to fluids: pulse rate, BP, urine output, skin perfusion, development of basal crepitations.
• If hypotension persists despite fluid resuscitation, in the absence of ongoing blood loss, commence inotropes (e.g. adrenaline (epinephrine)).
• Aim to maintain mean arterial blood pressure (MAP) above 65 mmHg.
• If brain or spinal cord injury is suspected, it is reasonable to increase the target MAP to 80 mmHg.

Neurological care

• Position head up 30 degrees.
• Monitor for seizures. Treat promptly and load with an anti-epileptic agent if seizures occur.

Blood glucose control

• Maintain blood glucose between 8 and 10 mmol/L and avoid hypoglycaemic episodes.

LoEIII [5]

Temperature control

• Strictly avoid fever. Aim to control temperature below 36ºC in unconscious patients in the first 24 hours, using physical cooling methods e.g.: ice packs and fans, and antipyretics.

Deep vein prophylaxis

• Consider prophylaxis for venous thrombo-embolism, as required. See Venous thrombo-embolism.

LoEI [6]

MEDICAL TREATMENT

Hypoglycaemia

• Dextrose 50%, rapid IV injection, up to 50 mL. LoEIII [7]

Assess clinical status and finger prick glucose level over the next 5–10 minutes.

Hypovolaemia

• Sodium chloride 0.9%, IV. LoEI [8]

Hypotension (after volume correction)

• Adrenaline (epinephrine), IV infusion, start at 0.1 mcg/kg/minute titrated according to the response.
  • Dilute 10 mg i.e. 10 ampoules of adrenaline 1:1 000 in 1 L sodium chloride 0.9%.
  • Infuse according to weight and clinical response.
  • Infusion rate: mL/hour:

LoEIII [9]

Seizures

Treat seizures in post cardiac arrest, similar to management of status epilepticus. See Status epilepticus.

LoEIII [10]

Fever

• Paracetamol, oral, 1 g 4–6 hourly when required.
  • Maximum dose: 15 mg/kg/dose.
  • Maximum daily dose: 4 g in 24 hours.

LoEIII [11]

REFERRAL

• Following successful resuscitation cases should be discussed with a hospital with intensive care facilities for transfer.
• If evidence of myocardial infarction is present or if strongly suspected cases should be discussed with a cardiology service.