ERC - post ROSC care

Question 1

You’ve achieved ROSC - talk through ABC and what you’d do

Answer 1

A - insert advanced airway if significant cerebral dysfunction
B - aim for 94-98% sats, normocapnia, CXR, NG tube to decompress stomach
C - ECG, access + adrenaline + dobutamine + fluids if necessary to keep sBP >100

Question 2

You have a post ROSC HR of 35, is this ok?

Answer 2

As long as…
BP >100
urine output >1ml/kg/hr
sats 94-95%

Question 3

You’ve got ROSC and have gone through ABC - now for a diagnosis… what investigatios do you do

Answer 3

likely cardiac: coronary angiopgraphy and PCI

not likely cardiac: CT brain or CTPA

Question 4

What things happen in ICU post ROSC

Answer 4

Temp controlled 32-26 for 24 hours at least
normoxia
normocapnia
normoglycaemia 
normokalaemia

Question 5

when is the post ROSC neurological assessment carried out

Answer 5

72 hours - after TTM and rewarming

Question 6

what are some confounders to the post ROSC neurological assessment

Answer 6

sedation and neuromuscular blocking agents 
hypoglycaemia 
hypothermia 
severe hypotension
electrolyte derangements

Question 7

State some findings of post ROSC neurological assessment that indicate a poor prognosis

Answer 7

CT head - loss of sulci, reduction of the GM/WM ration, diffuse anoxic brain injury
MRI - diffuse ischaemic changes
status myoclonus
Bilateral absent corneal and pupillary reflex
bilaterally absent N20 SSEP wave
high NSE and S-100B markers
EEG: no activity, status epilepticus, unreactive burst suppression

Question 8

What is SSEP

Answer 8

somatosensory evoked potentials - EEG activity in response to tactile stimulation

Question 9

What is NSE

Answer 9

neuron specific enolase - a biomarker released from dead neurones

Question 10

Name 2 biomarkers used in post ROSC prognostication

Answer 10

NSE - released from neurones

S-100B - released from glial cells

Question 11

what things on an EEG indicate poor post ROSC prognosis

Answer 11

no activity
status epilepticus
unreactive burst-suppression

Question 12

What is unreactive burst-suppression on an EEC

Answer 12

> 50% of the EEC consists of voltage <10uV with alternating bursts

Question 13

What does N20 SSEP mean

Answer 13

corresponds to arrival of the nerve impulse at the primary somatosensory region

Question 14

What benefits does sedation offer post ROSC

Answer 14

stops shivering so TTM easier to maintain

reduces metabolic rate and oxygen demand

Question 15

benefits of TTM on a cellular level

Answer 15

reduced apoptosis
reduced cerebral metabolism therefore reduced free radical production
reduced inflammation
blocks intracellular consequence of excitotoxin exposure

Question 16

what temperature and for how long are patients cooled in TTM

Answer 16

32-36 degrees C

>24 hours

Question 17

who is TTM considered in

Answer 17

unresponsive post ROSC
initial shockable rhythm
adults

Question 18

what drug can be given to reduce the threshold for shivering

Answer 18

MgSO4

Question 19

how is the temperature monitored in TTM

Answer 19

thermister in bladder or oesophagus

Question 20

how many degrees/hour is a patient rewarmed after TTM

Answer 20

0.25 - 0.5 degrees c/hour

Question 21

which patients should be considered for post ROSC ICD insertion

Answer 21

those with significant LV dysfunction suffering from a ventricular arrhythmia >24 hours after the primary occlusive event

Question 22

which drugs are effective in treating post anoxic myoclonus

Answer 22

propofol
sodium valproate
levetiracetam

Question 23

what is self-fulfilling prophecy

Answer 23

a bias occuring when physicians are not blind to the result of the outcome predictor and use it to make decisions on withdrawal of life sustaining treatment

Question 24

what imaging can aid in prognostication

Answer 24

CT - reduction in GM/WM ratio, loss of sulci

MRI - diffuse ischaemic changes