Post–Cardiac Arrest Care

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Post–Cardiac Arrest Care 2010 AHA Guidelines for CPR and ECC http://decode-medicine.blogspot.com/ summarized & animated by sun yaicheng Circulation 2010;122:S768-S786

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The Initial Objectives of Post–Cardiac Arrest Care 1 2 3 Optimize cardiopulmonary function and vital organ perfusion. After OHCA, transport patient to an appropriate hospital with a comprehensive PCAC that includes acute coronary interventions, neurological care, goal-directed critical care, and hypothermia. Transport the IHCA patient to an appropriate ICU capable of providing comprehensive PCAC. 4 Try to identify and treat the precipitating causes of the arrest and prevent recurrent arrest.

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Subsequent Objectives of PCAC 1 2 3 Control body temperature to optimize survival and neurological recovery Identify and treat acute coronary syndromes (ACS) Optimize mechanical ventilation to minimize lung injury 4 Reduce the risk of multiorgan injury and support organ function if required 5 6 Objectively assess prognosis for recovery Assist survivors with rehabilitation services when required

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Multiple System Approach to Post–Cardiac Arrest Care

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Ventilation

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Capnography Rationale: Confirm secure airway and titrate ventilation Endotracheal tube when possible for comatose patients PETCO2 ~35–40 mmHg PaCO2 ~40–45 mmHg

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Chest X-ray Rationale: Confirm secure airway and detect causes or complications of arrest pneumonitis pneumonia pulmonary edema

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Pulse Oximetry/ABG Rationale: Maintain adequate oxygenation and minimize FiO2 SpO2 ~94% PaO2 ~100 mmHg Reduce FiO2 as tolerated PaO2/FiO2 ratio to separate acute lung injury/ARDS (<300 or <200)

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Mechanical Ventilation Rationale: Minimize acute lung injury, potential oxygen toxicity Tidal Volume 6–8 mL/kg Titrate minute ventilation to PETCO2 ~35–40 mm Hg PaCO2 ~40–45 mm Hg Reduce FiO2 as tolerated to keep SpO2 or SaO2 ≧94%

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Hemodynamics

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Frequent BP Monitoring/Arterial-line Rationale: Maintain perfusion and prevent recurrent hypotension MAP≧65 mmHg or SBP≧90 mmHg

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Treat Hypotension Rationale: Maintain perfusion Fluid bolus if tolerated Dopamine 5–10 mcg/kg per min Norepinephrine 0.1–0.5 mcg/kg per min Epinephrine 0.1–0.5 mcg/kg per min

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Cardiovascular

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Continuous Cardiac Monitoring Rationale: Detect recurrent arrhythmia No prophylactic antiarrhythmics Treat arrhythmias as required Remove reversible causes

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12-lead ECG/Troponin Rationale: Detect ACS/STMI; Assess QT interval.

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Treat Acute Coronary Syndrome Aspirin/heparin Transfer to acute coronary treatment center Consider emergent PCI or fibrinolysis

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Echocardiogram Rationale: Detect global stunning, wall-motion abnormalities, structural problems or cardiomyopathy

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Treat Myocardial Stunning Fluids to optimize volume status Dobutamine 5–10 mcg/kg per min Mechanical augmentation (IABP)

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Neurological

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Serial Neurological Exam Rationale: Serial examinations define coma, brain injury, and prognosis Response to verbal commands or physical stimulation Pupillary light and corneal reflex, spontaneous eye movement Gag, cough, spontaneous breaths

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Organ Donation After Cardiac Arrest There is no difference in functional outcomes of organs transplanted from patients who are brain-dead as a consequence of cardiac. Adult patients who progress to brain death after resuscitation from cardiac arrest should be considered for organ donation (Class I, LOE B).

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EEG Monitoring If Comatose Rationale: Exclude seizures Anti-convulsants if seizing

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Core Temperature Measurement If Comatose Rationale: Minimize brain injury and improve outcome Prevent hyperpyrexia >37.7°C Induce therapeutic hypothermia Cold IV fluid bolus 30 mL/kg Surface or endovascular cooling for 32–34°C x24 hours After 24 hours, slow rewarming 0.25°C/hr

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Induced Hypothermia Comatose (ie, lack of meaningful response to verbal commands) adult patients with ROSC after out-of-hospital VF cardiac arrest should be cooled to 32°C to 34°C for 12 to 24 hours (Class I, LOE B). Induced hypothermia may be considered for comatose adult patients with ROSC after IHCA of any initial rhythm or after OHCA with an initial rhythm of PEA or asystole (Class IIb, LOE B). Active rewarming should be avoided in comatose patients who spontaneously develop a mild degree of hypothermia (>32°C ) after resuscitation from cardiac arrest during the first 48 hours after ROSC. (Class III, LOE C).

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Consider Non-enhanced CT Rationale: Exclude primary intracranial process

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Sedation/Muscle Relaxation Rationale: To control shivering, agitation, or ventilator desynchrony as needed

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Metabolic

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Serial Lactate Rationale: Confirm adequate perfusion

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Serum Potassium Rationale: Avoid hypokalemia which promotes arrhythmias Replace to maintain K >3.5 mEq/L

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Urine Output, Serum Creatinine Rationale: Detect acute kidney injury Maintain euvolemia Renal replacement therapy if indicated

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Serum Glucose Rationale: Detect hyperglycemia and hypoglycemia Treat hypoglycemia (<80 mg/dL) with dextrose Treat hyperglycemia to target glucose 144–180 mg/dL Local insulin protocols

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Avoid Hypotonic Fluids Rationale: May increase edema, including cerebral edema

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http://decode-medicine.blogspot.com/ summarized & animated by sun yaicheng

Summary: Post–Cardiac Arrest Care 2010 AHA Guidelines for CPR and ECC Circulation 2010;122:S768-S786

Tags: acls cpr

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