Post-Cardiac Arrest Care
Post Cardiac Arrest Care
Integrated post-cardiac arrest care is now the 5th link in the AHA adult chain of survival. Topics of focus for post-cardiac arrest care include therapeutic hypothermia, hemodynamic and ventilation optimization, immediate coronary reperfusion with PCI (percutaneous coronary intervention), glycemic control, neurologic care and other technical interventions. To be successful, post-cardiac arrest care requires an integrated multidisciplinary approach.
For the purposes of this site, the review of post-cardiac arrest care interventions will focus primarily on immediate post arrest interventions and aspects that you will most likely be tested on.
For a complete review of the subject refer to your AHA provider manual. (pages: 28-29, 72-77, and 164)
Therapeutic Hypothermia
Therapeutic hypothermia is the only intervention that has been shown to improve neurological outcomes after cardiac arrest. Induced hypothermia should occur soon after ROSC (return of spontaneous circulation). The decision point for the use of therapeutic hypothermia is whether or not the patient can follow commands.
One of the most common methods used for inducing therapeutic hypothermia is rapid infusion of ice-cold (4° C), isotonic, non-glucose-containing fluid to a volume of 30 ml/kg. The optimum temperature for therapeutic hypothermia is 32-34 ° C (89.6 to 93.2 ° F). This temperature should be maintained for 12 to 24 hours.
During induced therapeutic hypothermia, the patients core temperature should be monitored with any one of the following: esophageal thermometer, a bladder catheter in the nonanuric patients, or a pulmonary artery catheter if one is already in place.
Axillary and oral temperatures are inadequate for monitoring core temperatures.
Ventilation Optimization
During the post-cardiac arrest phase inspired oxygen should be titrated to maintain an arterial oxygen saturation of ≥ 94%. This reduces the risk of oxygen toxicity. Excessive ventilation should also be avoided because of the potential for reduced cerebral blood flow related to a decrease in PaCO2 levels. Also, excessive ventilation should be avoided because of the risk of high intrathoracic pressures which can lead to adverse hemodynamic effects during the post arrest phase. Quantitative waveform capnography can be used to regulate and titrate ventilation rates during the post-arrest phase. Visit the link for more details about waveform capnography and the 2010 guidelines.
Hemodynamic Optimization
Hypotension, a systolic blood pressure < 90 mmHg should be treated and the administration of fluids and vasoactive medications can be used to optimize the patients hemodynamic status. While the optimal blood pressure during the post-cardiac arrest phase is not known, the primary objective is adequate systemic perfusion, and a mean arterial pressure of ≥ 65 mmHg should accomplish this.
The goal of post-cardiac arrest care should be to return the patient to a level of functioning equivalent to the their prearrest condition.
Other considerations
Moderate glycemic control measures should be implemented to maintain glucose levels from 144-180 mg/dL, and since there is an increased risk for hypoglycemia in the post-arrest phase these more moderate levels should be maintained rather than normal levels of 80-110 mg/dL
Every effort should be made to provide coronary reperfusion (PCI), and interventions should be directed with this goal in mind. PCI has been shown to be safe and effective in both the alert and comatose patient, and hypothermia does not contraindicate PCI.
Is there a specific drug and dosage that should be used to reduce shivering during hypothermia therapy? I have not found an acls protocol. But I was quizzed on it and didn’t have an answer. I nailed the whole megacode, but felt like an idiot when asked about the shivering.
Honestly, I would have probably felt the same way. This information is not addressed in the ACLS provider manual and you should not have been formally asked this during testing. Hopefully, they did not count this against your score. I had to look this up after reading your comment, and I did not find anything from AHA that addressed the issue. Here is an article that I found on the topic. Below is a quote from the article
Kind regards,
Jeff
Hi,
in the manual on the pages 154, 155 (the megacode checklists) in the post cardiac arrest portion one of the criteria we are to verbalize is:need for ET intubation, etc, and orders lab tests. My question is what lab tests do they want us to verbalize? I searched for a list, I could guess, but want to be sure since it is on the megacode checklist. Thanks
The comprehensive metabolic panel (CMP), complete blood count, and arterial blood gas (ABG) would all be important because several of the H’s and T’s will become identifiable.
The CMP will show you the levels for potassium, sodium, calcium, magnesium, and glucose. This would tell you if you are dealing with hypo/hyperkalemia, hypo/hypernatremia, hypomagnesaemia, hypocalcaemia, hypo/hyperglycemia.
The Complete Blood Count (CBC) will give you the hemoglobin and hematocrit which can indicate be an indicator of (H)ypovolemia
The Arterial Blood Gas (ABG) can give you information about the patients respiratory status and pH.
I would say that these three would be the most important (CBC, CMP, and ABG).
Kind regards,
Jeff
For hospitals without facilities to achieve the ideal hypothermic goals, would lesser levels of lowering temp be useful, or is there a threshold pt must reach for benefit?
Warmer temps are not helpful.
Kind regards,
Jeff
what is PCI?
PCI means Percutaneous Coronary Intervention. This is the technical name for a heart catheterization to open a blocked coronary artery.
Kind regards,
Jeff
Does your facility temperature correct arterial blood gases during therapeutic hypothermia?
We currently do not but now we are considering temperature correcting.
Thoughts?
Is temp correcting ABG’s part of ACLS guidelines?
The facility that I work for does not use therapeutic hypothermia at this time and I am not very familiar with temperature correction of arterial blood gases. AHA ACLS guidelines to given recommendation or guidelines for ABG’s. Kind regards, Jeff
Just out of curiosity Jeff, how come your hospital does not have therapeutic hypothermia protocol after a cardiac arrest when it help improve patients neurologial state? Wondering the rationale as to why not use it?
Thanks,
Phil
Therapeutic hypothermia is becoming more widely accepted. Unfortunately, the hospital that I work for is fairly small and moves quite slow when it comes to implementing new and cutting edge therapies.
Kind regards,
Jeff
wondering if the core temperature for therapeutic hypothermia can be monitored by an in situ rectal probe? We have the soft sided rectal probes that attach to the monitor…..
Yes, this would be one way to accurately monitor core temp. Body temperature of patients in critical care units can be monitored with a variety of devices and at a variety of body sites. In recent years, monitoring of urinary bladder temperature has become common.
There are a number of other devices that monitor core temp by tympanic membrane, pulmonary artery, distal esophagus, and nasopharynx as well.
Kind regards,
Jeff
Thanks Jeff, I assumed so but was wondering if the formal answer for exam. It is very odd, I think, that the AHA would not make mention to this basic way of monitoring.
Another question. How do you achieve the 4 degree temperature of IV fluid? I suspect that this would need to be cooled and ready to be of service. The only fridge we have with a temp monitor would be the immunization fridge but I think it ranges from 3 to 5. Kind regards, Susan
If a hospital has a policy in place for the use of therapeutic hypothermia, they would need to have implemented some means of having cooled IV fluids available on a stat basis. Probably, the pharmacy would have a refrigerator to maintain cooled IV fluids.
The hospital that I work in does not have a therapeutic hypothermia policy in place and we do not do therapeutic hypothermia, but we do have a refrigerator in our ICU where we keep medications that need to be refrigerated.
I am sure that if we implement a policy for therapeutic hypothermia, we will utilize this refrigerator to keep cooled IV fluids readily available.
Kind regards,
Jeff