Adult Immediate Post-Cardiac Arrest Care Algorithm
Algorithm at a Glance
- The team recognizes ROSC.
- Team members optimize oxygenation and ventilation.
- The team treats hypotension immediately.
- The team obtains a 12-lead ECG.
- If the patient has a decreased level of consciousness, the team leader considers targeted temperature management.
- The team prevents hyperoxia, hypoxemia, and hypotension.
- The team admits the patient for advanced critical care.
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Goals for Adult Post-Cardiac Arrest Care
The team must succeed in the following goals to successfully manage the patient’s condition in the immediate post-cardiac arrest period:
- Understand the treatment modalities after cardiac arrest.
- Prevent further damage to the patient’s health.
Adult Post-Cardiac Arrest Care Algorithm Explained
This algorithm was created to present the steps for assessing and managing patients needing care post ROSC following cardiac arrest.
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Highlights of the Post-Cardiac Arrest Care Algorithm
The AHA guidelines were revised in 2020 to include the following recommendations based on the post-cardiac arrest algorithm. The algorithm is divided into an Initial Assessment and Stabilization Phase (Boxes 1–3) and an Ongoing Assessment and Treatment phase (Boxes 4–8).
Box 1: ROSC
Post-cardiac arrest care begins when the patient achieves a return of spontaneous circulation (ROSC).
These recommendations include the following steps after ROSC has occurred:
Box 2: Optimizing Oxygenation and Ventilation
This step includes maintaining a patent airway and providing supplemental oxygen to keep the oxygen saturation between 92% and 98%. If available, waveform capnography should be implemented to verify the patient’s ventilation status. The team should insert an advanced airway if not yet done.
For intubated patients, it is essential to avoid hyperventilation. The team should start at 10 bpm and target an ETCO2 between 35 mm Hg and 45 mm Hg.
The goal should be to maintain a systolic pressure > 90 mm Hg and a mean arterial pressure (MAP)> 65 mm Hg. Diagnosing and treating hypotension is necessary for the immediate post-cardiac arrest period. A systolic blood pressure < 90 mm Hg or a MAP < 65 mm Hg warrants intervention to correct hypotension. Vasopressors should be used to improve cardiac output and blood perfusion to the heart and brain.
Patients with hypotension are at risk for higher mortality rates and diminished functional recovery. In contrast, if the team maintains the systolic blood pressure at levels > 100 mm Hg, the patient will exhibit better recovery.
Vasopressors are used to improve cardiac output and perfusion to the heart and brain. Different vasoactive drugs provide various effects on the cardiovascular system, such as alterations in:
- heart rate (chronotropic effects)
- myocardial contractility (inotropic effects)
- electrical conduction (dromotropic effect)
- arterial pressure (vasoconstrictive effects)
- afterload (vasodilator effects)
The clinician must balance the type of vasopressors used and the patient’s clinical condition because most vasopressors are not selective to the receptors upon which they exert their effect. If not properly utilized and monitored, vasopressors may induce cardiac arrhythmias or worsen myocardial ischemia due to a mismatch between perfusion and increased oxygen demand. Inappropriate use of vasopressors can cause myocardial function to deteriorate further.
Fluid boluses should be used to help maintain blood pressure, particularly when hypovolemia is suspected as being a cause of cardiac arrest. The clinician should administer 1–2 liters of normal saline or lactated Ringer solution. Frequent respiratory assessments should be performed when volume loading a patient to monitor for signs of fluid overload or congestive failure.
Box 3: Obtaining a 12-Lead ECG
The team obtains a 12-lead ECG as soon as possible after ROSC to determine if an AMI was the underlying cause of cardiac arrest and to evaluate the need for reperfusion therapy.
Box 4: Considering Coronary Reperfusion
For patients with STEMI, unstable cardiogenic shock, or need for circulatory support, the team leader considers emergency cardiac intervention.
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Box 5: Does the Patient Follow Commands?
The ability to follow commands determines whether the patient requires targeted temperature management and EEG monitoring. If the patient does not follow commands, the team proceeds to Box 6. If the patient is awake and alert, they proceed to Box 7.
Box 6: Comatose
The team begins targeted temperature management (TTM) in all patients with a decreased level of consciousness who achieve ROSC after cardiac arrest. The goal is to maintain a constant core temperature between 32°C and 36°C for a minimum of 24 hours.
Other interventions to consider include EEG monitoring, obtaining a CT scan of the brain, and other ongoing monitoring and interventions. Studies show that there is a better neurologic outcome when hypothermia is induced.
- Preventing fever after TTM ends is essential to prevent neurologic injury. Prehospital responders should not infuse cold IV fluids. (Follow institutional protocols.)
- Prognostication of outcomes for the post-cardiac arrest patient can be done 72 hours after the completion of TTM. (Note: For the patient post-cardiac arrest who has not undergone TTM, prognostication of outcomes must be done 72 hours after ROSC.)
- Patients with brain circulatory death should be evaluated for organ donation. Organs transplanted from cardiac arrest donors have comparable success rates as those organs transplanted from donors with other conditions. Likewise, donated organs from resuscitated patients after cardiac arrest that have progressed to brain death perform like those from patients with brain death from other causes.
Key Takeaway
Clinical Findings Associated with Poor Neurologic Outcome
- Absent pupillary reflex to light.
- Presence of status myoclonus.
- Absence of N20 somatosensory cortical wave.
- Marked reduction of the gray-white matter ratio on CT scan 2 hours from the arrest.
- Restriction of diffusion evidenced by MRI at 2-6 days after cardiac arrest.
- Absence of EEG reactivity to external stimuli at 72 hours after cardiac arrest.
- Burst suppression or intractable status epilepticus on EEG after rewarming.
Targeted temperature management is critical following ROSC.
Patient undergoing an electroencephalogram (EEG).
Box 7: Awake and Alert
When emergency treatment is complete, and the patient is stable, they are admitted to the critical care service for ongoing management.
Box 8: Reversible Causes
In all cases, the team assesses for and treats reversible causes of cardiac arrest. The team leader should also obtain expert consultation.
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