1. Post Resuscitation Care

2. To understand: The need for continued resuscitation after return of spontaneous circulation How to treat the post cardiac arrest syndrome How to transfer the patient safely The role and limitations of assessing prognosis after cardiac arrest Learning outcomes

3. Chain of Survival

4. Post resuscitation care The goal is to restore: Normal cerebral function Stable cardiac rhythm Adequate organ perfusion Quality of life

5. Post cardiac arrest syndrome Post cardiac arrest brain injury: Coma, seizures, myoclonus Post cardiac arrest myocardial dysfunction Systemic ischaemia-reperfusion response ‘Sepsis-like’ syndrome Persistence of precipitating pathology

6. Airway and breathing Ensure a clear airway, adequate oxygenation and ventilation Consider tracheal intubation, sedation and controlled ventilation Pulse oximetry: Aim for SpO 2 94 – 98% Capnography: Aim for normocapnia Avoid hyperventilation

7. Airway and breathing Look, listen and feel Consider: Simple/tension pneumothorax Collapse/consolidation Bronchial intubation Pulmonary oedema Aspiration Fractured ribs/flail segment

8. Airway and breathing Insert gastric tube to decompress stomach and improve lung compliance Secure airway for transfer Consider immediate extubation if patient breathing and conscious level improves quickly after ROSC

9. Circulation Pulse and blood pressure Peripheral perfusion e.g. capillary refill time Right ventricular failure Distended neck veins Left ventricular failure Pulmonary oedema ECG monitor and 12-lead ECG

10. Disability Neurological assessment: Glasgow Coma Scale score Pupils Limb tone and movement Posture

11. Glasgow Coma Scale score Glasgow Coma Scale score (GCS 3 – 15) Eyes (4)Verbal (5)Motor (6) 6Obeys commands 5OrientatedLocalises 4SpontaneouslyConfusedNormal flexion 3To speechInappropriate wordsAbnormal flexion 2To painIncomprehensible soundsExtension 1Nil

12. Further assessment History Health before the cardiac arrest Time delay before resuscitation Duration of resuscitation Cause of the cardiac arrest Family history

13. Further assessment Monitoring Vital signs ECG Pulse oximetry Blood pressure e.g. arterial line Capnography Urine output Temperature

14. Further assessment Investigations Arterial blood gases Full blood count Biochemistry including blood glucose Troponin Repeat 12-lead ECG Chest X-ray Echocardiography

15. Chest X-ray

16. Transfer of the patient Discuss with admitting team Cannulae, drains, tubes secured Suction Oxygen supply Monitoring Documentation Reassess before leaving Talk to family

17. Out-of-hospital VF arrest associated with AMI Pacing Cooling IABP Defibrillator Inotropes Ventilation Enteral nutrition Insulin

18. Optimising organ function Heart Post cardiac arrest syndrome Ischaemia-reperfusion injury: Reversible myocardial dysfunction for 2-3 days Arrhythmias

19. Optimising organ function Heart Poor myocardial function despite optimal filling: Echocardiography Cardiac output monitoring Inotropes and/or balloon pump Mean blood pressure to achieve: Urine output of 1 ml kg -1 hr -1 Normalising lactate concentration

20. Optimising organ function Brain Impaired cerebral autoregulation – maintain ‘normal’ blood pressure Sedation Control seizures Glucose (4-10 mmol l -1 ) Normocapnia Avoid/treat hyperthermia Consider therapeutic hypothermia

21. Therapeutic hypothermia Who to cool? Unconscious adults with ROSC after VF arrest should be cooled to 32-34 o C May benefit patients after non-shockable/in-hospital cardiac arrest Exclusions: severe sepsis, pre-existing medical coagulopathy Start as soon as possible and continue for 24 h Rewarm slowly 0.25 o C h -1

22. Therapeutic hypothermia How to cool? Induction - 30 ml kg -1 4 o C IV fluid and/or external cooling Maintenance - external cooling: Ice packs, wet towels Cooling blankets or pads Water circulating gel-coated pads Maintenance - internal cooling Intravascular heat exchanger Cardiopulmonary bypass

23. Therapeutic hypothermia Physiological effects and complications Shivering: sedate +/- neuromuscular blocking drug Bradycardia and cardiovascular instability Infection Hyperglycaemia Electrolyte abnormalities Increased amylase values Reduced clearance of drugs

24. Assessment of prognosis No clinical neurological signs can predict outcome < 24 h after ROSC Poor outcome predicted at 3 days by: Absent pupil light and corneal reflexes Absent or extensor motor response to pain But limited data on reliability of these criteria after therapeutic hypothermia

25. Organ donation Non-surviving post cardiac arrest patient may be a suitable donor: Heart-beating donor (brainstem death) Non-heart-beating donor

26. Any questions?

27. Post cardiac arrest syndrome is complex Quality of post resuscitation care influences final outcome Appropriate monitoring, safe transfer and continued organ support Assessment of prognosis is difficult Summary

28. Advanced Life Support Course Slide set All rights reserved ©Australian Resuscitation Council and Resuscitation Council (UK) 2010