Adult ROSC / Post-Cardiac Arrest Care Algorithm Flashcards
(15 cards)
2020 AHA Adult Post-ROSC Algorithm
Here’s my summary of Post-cardiac arrest care, which I bet will pretty fully answer any question about Post-ROSC care:
“After ROSC is achieved because of successful ACLS for cardiac arrest, I would first ensure the patient was intubated if his airway or breathing (ABC’s) wasn’t optimized, and would target a normal PaO2 (SpO2 92-98%), normal EtCO2 (35-45 mmHg), and support BP as necessary for a normal BP (SBP > 90 mmHg, MAP > 65 mmhg)…
…my next point of focus is saving the heart (ABC’s), so I’ll order a 12-lead EKG and investigate this patient’s need for any emergent cardiac interventions, such as coronary revascularization for STEMI, or ECMO for circulatory support…
…Then I’ll focus on the saving the brain, so I’ll do a neurologic exam and if the patient is comatose, I’ll immediately employ targeted temperature management (TTM) at 32-36 deg C for 24 hours with active cooling, as well as consultation with neurology for proper neuro-imaging for workup and EEG for neuro monitoring during this time…
…Finally, I’ll continue working up and treating the 5 H’s and 5 T’s that I would have started a working up during the code by obtaining other relevant H&P info, labwork, and imaging as indicated”
What are the TWO Phases of the ACLS Healthcare Provider Post-Cardiac Arrest Care Algorithm has TWO Phases
- Initial Stabilization Phase / Post-ROSC Phase
- Continued Management and Additional Emergent Activities
The first phase of the post-Cardiac Arrest Care Algorithm is the “Initial Stabilization Phase” or the “post-ROSC phase.” What are the steps/goals of this phase?
These steps can absolutely occur concurrently, but if prioritization is necessary, follow the order of the ABC’s:
1. AIRWAY - Early ETT placement and monitor/confirm with capnography or capnometry
2. BREATHING: Manage RESPIRATORY Parameters - SAME respiratory rate as when coding, and essentially just normal SpO2 and PaCO2 parameters:
- 10 breaths/min
- SpO2 92%-98%
- PaCO2 35-45
3. CIRCULATION: Manage HEMODYNAMIC Parameters - administer crystalloid and/or vasopressor/inotrope for the following HD goals:
- SBP > 95
- MAP > 65
Additionally and very importantly, get an EKG
The second phase of the post-Cardiac Arrest Care Algorithm is the “Continued Management and Additional Emergent Activities phase.” What’s the overall theme of this phase?
HEART and BRAIN evaluation and treatment: “These evaluations should be done concurrently so that decisions on targeted temperature management (TTM) receive high priority as cardiac interventions”
In the “Continued Management and Additional Emergent Activities” phase, what two organs are you basically thinking about?
Heart and Brain
What are you thinking about with respect to the HEART in the “Continued Management and Additional Emergent Activities” phase?
Consideration for emergent cardiac INTERVENTION if there is:
- a STEMI
- Unstable Cardiogenic shock
- Mechanical circulatory support (eg, ECMO) is required
In order to evaluate the need for any cardiac interventions, you’ll IMMEDIATELY evaluate the EKG, and the patient’s current Hemodynamics will guide decision on cardiac intervention
What are you thinking about with respect to the BRAIN in the “Continued Management and Additional Emergent Activities” phase? Specifically, which one specific thing do you need to see if the patient is doing or not?
You need to see if the patient is FOLLOWING COMMANDS or not (ie, is patient COMATOSE or not)?
Patient is YES following commands. What do you do?
Relevant Critical Care Managment:
1. Continuously monitor CORE TEMPURATURE - esophageal, rectal, bladder
2. maintain NORMAL LABS - normoxia, normocapnia, euglycemia
3. provide continuous or intermittent EEG (ELECTROENCEPHALOGRAM) monitoring
4. LUNG-PROTECTIVE VENTILATION if intubated
patient is NOT following commands. What do you do?
- TTM (Targeted Temperature Management) - different card to go over this in depth
- stat CT Brain
- EEG Monitoring
- Other Critical Care management, as applicable, as would also do if pt was YES following commands
TTM (Targeted Temperature Management). Talk about it.
TTM is started after ROSC if patient is NOT following commands. Start as soon as possible. You begin at 32-36 deg for 24 hours by using a cooling device with a feedback loop
- Note that the upper end of that goal temp (36) is actually just a normal temp
Therapeutic hypothermia is indicated with the following recommendations:
Class I rec: any patient who is comatose following ROSC after being resuscitated for an OUT-of-hospital V-FIB cardiac arrest (key: OUT of hospital and specifically V-FIB)
Class IIb: ROSC after IN-hospital cardiac arrest with ANY initial rhythm (key: IN hospital and ANY rhythm)
Class IIb: ROSC after OUT-of-hospital cardiac arrest where the initial rhythm was PEA arrest (key; OUT of hospital and specifically PEA)
Methods to achieve cooling for TTM:
- Cooling blankets, ice packs, or rapid infusion of 30 mL/kg of ice-cold (4 deg C) LR or NS to reduce tempurature.
UBP had a postpartum woman get ROSC after a PEA arrest. The question then asks if you should Induce Hypothermia? Answer:
I would agree to inducing therapeutic hypothermia if she were unable to meaningfully respond to verbal commands after treating everything, including:
- any precipitating causes
- optimizing ventilation and oxygenation (e.g. providing the lowest FiO2 that will maintain an arterial oxygen saturation ≥ 94%, avoiding hyperventilation, and
- utilizing waveform capnography), and
- optimizing cardiopulmonary function (e.g. utilizing fluids, inotropes, and vasopressors to treat any systolic blood pressure < 90 mmHg and maintain a mean arterial pressure ≥ 65 mmHg).
Therapeutic hypothermia is believed to provide protection for the brain and other organs in patients who remain comatose post-cardiac arrest.
UBP question: when is Therapeutic hypothermia indicated post-cardiac arrest?
Therapeutic hypothermia is indicated for any patient who is comatose following the return of spontaneous circulation after being resuscitated for an out-of-hospital ventricular fibrillation cardiac arrest (Class I), an in-hospital cardiac arrest with any initial rhythm (Class IIb), or an out-of-hospital cardiac arrest where the initial rhythm was PEA (Class IIb).
UBP: How would you institute therapeutic hypothermia?
I would utilize cooling blankets, ice packs, or the rapid infusion of 30 mL/kg ice-cold (4ºC) LR or normal saline to reduce her temperature to 32-34 ºC (89.6-93.2 ºF). I would then utilize an esophageal thermometer, a bladder catheter (in non-anuric patients), or a pulmonary artery catheter (if one were already being utilized for other indications) to monitor her core temperature and maintain her hypothermia for 12-24 hours.
Notes:
- No single method of inducing hypothermia has proven to be optimal.
- Axillary and oral temperatures are inadequate for monitoring core temperatures; tympanic temperature probes are often unreliable.
- Bladder temperatures in anuric patients and rectal temperatures may differ significantly from brain or core temperatures, making these methods of temperature monitoring unreliable.
- Consider using two sources for temperature measurement during induced hypothermia.
What are you at least always thinking about, in terms of diagnosis and treatment, in any ACLS situation, INCLUDING ROSC?
5 Ht’s and 5 T’s, and how you might treat each
Post-Cardiac Arrest Algorithm - printout
