Immediate Post-Cardiac Arrest Care

Immediate Post-Cardiac Arrest Care Algorithm

Immediate Post-Cardiac Arrest Care Algorithm

Post-cardiac arrest care begins immediately after the patient experiencing cardiac arrest achieves return of spontaneous circulation (ROSC).¹ It involves two phases: 1) initial assessment and management, and 2) ongoing assessment and management.

Initial Stabilization Post-Cardiac Arrest

In the initial stabilization phase, the emphasis is on optimizing ventilation and oxygenation and the treatment of hypotension. 

During this phase, the team must manage the airway, obtain an electrocardiogram (ECG), initiate waveform capnography, and titrate oxygen to achieve an oxygen saturation from 92% to 98% and a partial pressure of carbon dioxide of 35–45 mm Hg. The respiratory rate can be started at 10 breaths per minute but should be increased or decreased based on the patient’s response. 

The patient’s blood pressure (BP) should be maintained with a systolic BP > 90 mm Hg or a mean arterial pressure (MAP) > 65 mm Hg. The team can administer crystalloid fluids or vasopressors or inotropes to increase the BP.

Ongoing Assessment and Management Post-Cardiac Arrest

Once the patient is stabilized, the team must continue to provide ongoing assessment and manage the patient’s care. The elements of this phase are detailed below.

Coronary Angiography

If a patient is suspected of having ST elevation myocardial infarction (STEMI), unstable cardiogenic shock, or if mechanical support is required in the prehospital setting, then emergency coronary angiography should be considered. It can be performed even if the patient is comatose.

Studies show that increased rates of survival are achieved in patients who undergo emergency coronary revascularization procedures.

Does the Patient Follow Commands?

If the patient is awake, the team should provide other critical care management.

If the patient is comatose, the team should implement targeted temperature management (TTM), obtain a computed tomography (CT) of the brain, provide ongoing electroencephalogram (EEG) monitoring, along with providing other critical care management.

Targeted Temperature Management

Post-cardiac arrest patients who are comatose must undergo TTM. That involves using various measures, such as a cooling blanket, to maintain a core temperature of 32–36°C for 24 hours.²

Continuing Temperature Management Beyond 24 Hours

Fever must be prevented or controlled in post-cardiac arrest patients because a high core temperature is closely related to neurologic injury in patients who are comatose. Providing antipyretics will not hinder any treatments provided to patients receiving advanced critical care.

Out-of-Hospital Cooling

Emergency services must refrain from providing rapid infusion therapy with cold intravenous fluids if the patient has achieved ROSC in the field. There are possible complications that can develop from doing so, and these complications are better addressed in a critical care setting.

Hemodynamic Goals after Resuscitation

Corrective treatment of hypotension is indicated in post-cardiac arrest patients with a systolic blood pressure of less than 90 mm Hg and a diastolic blood pressure of less than 65 mm Hg. Hypotension is linked to higher mortality rates and diminished functional recovery.

Prognostication after Cardiac Arrest

Prognostication and assessing the neurologic outcome for the comatose patient is best performed 72 hours after cardiac arrest. When a patient has undergone TTM or has been sedated, prognostication can start 72 hours after the patient has returned to normal body temperature or after the effects of sedation have waned.

Organ Donation

It is recommended that all patients who have been diagnosed with brain death undergo evaluation for possible organ donation. There is no documented difference in outcomes if an organ transplanted to a patient came from a post-cardiac arrest patient or a healthy patient.

Immediate Post-Cardiac Arrest Algorithm

Immediate Post-Cardiac Arrest Care Algorithm

The goal of post-cardiac arrest care is to improve the outcomes of patients achieving ROSC.³ The algorithm guides the clinician in performing post-cardiac arrest care. It involves a multidisciplinary approach and requires several specialists to work together for the survival of the patient with an optimal neurologic outcome. 

If there is cardiovascular dysfunction from an acute cardiac etiology, for example, then these patients must have ventilatory support and close monitoring of circulation using vasopressors and other interventions to address cardiac dysfunction. If there is severe neurological dysfunction (such as coma), the patient must undergo TTM.

Optimizing Ventilation and Oxygenation

Excessive ventilation and hyperoxygenation should be avoided in the post-cardiac arrest patient on a mechanical ventilator. Hyperventilation and excessive oxygenation are associated with increased morbidities and mortality. 

Hyperventilation constricts cerebral blood vessels as a compensatory mechanism from a decrease in arterial carbon dioxide concentration. It can also increase intrathoracic pressure that may inhibit the circulation in the mediastinum. It can also cause volutrauma or tension pneumothorax. 

The rate of ventilation can be titrated to achieve end-tidal carbon dioxide pressures between 35 mm Hg and 45 mm Hg.

Hyperoxygenation can cause oxygen toxicity-induced reperfusion injuries in the post-cardiac arrest period, as too much oxygen precipitates free radicals that can potentially harm cells. Oxygen supplementation must be titrated to achieve an oxygen saturation between 92% and 98%.

Post-cardiac arrest care includes optimizing ventilation and oxygenation for patients on a mechanical ventilator.

Cardiovascular Care

If a patient is suspected of having acute coronary syndrome, then it is necessary to perform ancillary testing to make the diagnosis and perform prompt interventions. A 12-lead electrocardiogram (ECG) must be obtained to determine if the patient has experienced STEMI.⁴

If the patient has experienced STEMI, they immediately undergo angiography with possible recanalization therapy of the diseased coronary artery.

Acute coronary syndromes are common in the prehospital setting. Studies have shown that 96% of patients with STEMI will have a coronary artery lesion, while only 58% of patients without STEMI will have a coronary artery lesion.⁵

Selected patients with non-ST segment elevation myocardial infarction (NSTEMI) should also undergo invasive treatments. These interventions can be performed in patients who are comatose after ROSC.

There are no blood pressure goals in these patients, except for immediate treatment of hypotension (systolic blood pressure < 90 mm Hg or diastolic blood pressure < 65 mm Hg). 

Vasopressors are used to improve cardiac output and, subsequently, perfusion to the heart and brain. Vasopressors have positive chronotropic effects to improve heart rate, inotropic effects to improve myocardial contractility, and vasoconstrictive and vasodilatory effects to improve arterial pressure or reduce afterload, respectively. 

Clinicians must carefully balance these medications. Therefore, close monitoring of the patient’s hemodynamic status is necessary. These drugs are titrated to achieve the desired effect.

Common Vasoactive Drugs

The following medications are the common vasoactive drugs used to treat patients post-cardiac arrest:

• Epinephrine
• Norepinephrine
• Phenylephrine
• Dobutamine
• Dopamine
• Milrinone

Targeted Temperature Management

The goals of targeted temperature management (TTM) are to induce hypothermia between 32°C and 36°C for at least 24 hours to improve the neurologic function of the patient who is comatose. TTM can be deferred in certain situations, such as acute bleeding.⁶ However, it is a priority if a post-cardiac arrest patient is prone to seizures or has cerebral edema. 

After completing TTM, fever must be strictly controlled. Fever is associated with worsening of neurologic dysfunction and patient outcome. 

Post-cardiac arrest care begins as soon as the patient achieves ROSC and includes initial assessment and management and ongoing assessment and management.