Post Resuscitation Care

By Kane Guthrie

Objectives

• Case study• Understand post-resuscitation care• Look at 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.

The New Guidelines!!

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?

Post Resuscitation Care

• What is it?• Where does it start?• Why is it done poorly?• What is Post Cardiac Arrest Syndrome?• What is Therapeutic Hypothermia?

Post Cardiac Arrest Syndrome!!

• Thought to be RT production of free radicals• Pathophysiology is very complex = BORING• Hypoperfusion & Ischaemia cause cascade of

events1. Disruption of homeostasis

2. Free radical formation

3. Protease activation

• Hypothermia helps slow down this cascade

The Big 4 in Postcardiac Arrest Syndrome

1. Postcardiac arrest brain injury •Disruption of cerebral perfusion may result in Ischaemia/hyperaemia

2. Postcardiac arrest myocardial dysfunction

•Initially heart becomes hyperkinetic from catecholamine's, then global hypokinesis follows

3. Systemic Ischaemia/reperfusion Response

•Similar to septic shock, activation of immune and compliment systems, release inflammatory cytokines, wide range of cellular responses

4. Persistent precipitating pathology • Cause of arrest may continue to impact physiological parameters

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 benefit of inducing TH before or during event.

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 up for it?

• Cardiac arrest with ROSC • Persistent significant altered level of

consciousness• <12 hours from time of ROSC• Patients >18 years

Who’s on the Fence?

Relative:• Persistent hypotension (MAP <60, SBP<90)

despite use of inotropes and vasoconstrictors Note:Hypothermia will cause vasoconstrictionAnd help ∧BP

Who’s not?

• Advanced directive stipulating DNR (absolute)• Traumatic arrest• Active bleeding (including intracranial)• Pregnancy, recent major surgery, severe sepsis

What are the 3 Phase’s of TH?

Induction• Aim reduce core temp 32-34°C (within 6 hours,

preferably 2 hours)Maintenance• Maintain core body temp for 12-24Rewarming • Either controlled or passive rewarming to

normothermia 37°C• 0.2-0.5°C per hour –over 8-12 hours

ED Management

Cooling Methods

• Cold saline (during arrest & post arrest)• ICE Packs (axilla, groin) Keep pt dryMonitor skin integrity• Machine (Vest, Artic Ice)

What you need

• Patient airway secured (sedated & paralyzed)• ICE and bags• Cold saline• 12 lead ECG• Artline• NGT• IDC• Rectal probe• ?CVC

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 care• VTE prophylaxis• Stress ulcer prophylaxis• Lung protective ventilation• Nutrition• Social support (family)

Complications

• Tachycardia > bradycardia• Hypertension• Diuresis (hypovolaemia)• Shivering (increases temp)• Arrhythmia's• Increase bleeding• Spiking temp’s look for signs of infection

Questions

Thank-You