1 PostResusCare

Post resuscitation care 26 February 2014

POST RESUSCITATION CARE

15 SEPTEMBER 2014Dr Faridah JaafarEmergency PhysicianHospital Queen ElizabethKota KinabaluLecture outlineDefinition & Introduction

AHA Guidelines 2010

Component of Post Resuscitation Care

Therapeutic Hypothermia

Summary / Conclusion

DefinitionReturn Of Spontaneous Circulation (ROSC)defined as resumption of sustained perfusing cardiac activity associated with significant respiratory effort aftercardiac arrest.

Signs of ROSC include breathing (more than an occasional gasp), coughing, or movement. For healthcare personnel, signs of ROSC also may include evidence of a palpable pulse or a measurable blood pressure (approximately >30 seconds)Definition & introductionPost Cardiac Arrest SyndromeThe complex pathophysiological processes that occur following whole body ischaemia during cardiac arrest and the subsequent reperfusion response following successful resuscitation/ return of spontaneous circulation (ROSC)

Post resuscitation care starts at the location where ROSC is achieved.

Definition & introductionbecause multiple organ systems are affected after cardiac arrest, successful post cardiac arrest care will benefit from system-wide plans for proactive treatment of the patient.AHA guidelines 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

Part 9: PostCardiac Arrest Care

AHA GuidelinesMost deaths occur during the first 24 hours after cardiac arrest

Multiple organ systems are affected after cardiac arrest

Reduce early mortality caused by hemodynamic instability and later morbidity and mortality from multiorgan failure and brain injury

Components in post resuscitation careVentilationsHemodynamicCardiovascularNeurologicalMetabolicComponent of Post resuscitation care- GeneralElevate the head of the bed 30Avoid using ties that pass circumferentially around the patient's neckInsert Gastric Tube .....FOR WHAT????????Adequate sedation : can reduce O2 consumptionAdequate dosage of neuromuscular blocking agent ( give bolus, not infusion.......) will reduce oxygen consumption.CXR : WHAT TO SEE???????????

AIRWAY & VENTILATIONS Oxygenation should be maintained in the range 94%-98%. Monitor oxygen concentration by arterial blood gases (ABGs) and/ or pulse oximetry.

Avoid hyperventilations / overbagging the patient. WHY????

Ventilation is adjusted to achieve normocarbia and to monitor using end-tidal PCO2 (PETCO2) and ABGs.

Ventilation_ 10 to 12 breaths per minute Titrated to achieve a PETCO2 of 35 to 40 mm Hg or a PaCO2 of 40 to 45 mm

CIRCULATIONSIntravenous/Intraosseous access

Assess vital signs and monitor for recurrent cardiac arrythmias Aim MAP (>65mmHg) SBP>90mmHgIf hypotension, can give fluid boluses, then treat with inotropes/vasopressors

Insert CBD monitor urine output , aim

Most common cause of cardiac arrest- cardiovascular disease and coronary ischemia - 12-lead ECG to detect ST elevation or new left bundle-branch block

Best treatment for AMI........Percutaneous Coronary Intervention (PCI)

DISABILITYSeizures increase the cerebral metabolism by 3 fold it will cause cerebral injury.Can treat with benzodiazepines, phenytoin or sodium valproate.If myoclonus : clonazepam is the first choice,but sodium valproate and propofol maybe used.

Electrolyte : Glucose controlPost cardiac arrest patient is likely to develop hyperglycemiaThere are strong association between high blood glucose after ROSC and poor neurological outcomes and increase mortalityTreat hypoglycemia / hyperglycemiaIdeal Glucose control level is :

4.0 6.0 mmol/l6.0 8.0 mmol/l8.0 10.0 mmol/l