see also: [[ALS algorithm|ALS]], [[ECMO]], [[Anti-arrhythmic drugs]] [[APLS]] [[Peri-intubation collapse]] [[Cessation of resus]] see: [ANZCOR - resuscitation in special circumstances](x-devonthink-item://581DA354-94FE-42BE-B9ED-C0B244208243), [ANZCOR - medications in adult cardiac arrest](x-devonthink-item://5D599D1A-5274-4D3E-BE0F-1A4785279DF7) > [!references]- > See: [Dunn Cardiac arrest](x-devonthink-item://817B84F1-838E-4771-A21A-EF2416E69EB4), [Dunn - Cardiac arrest in special circumstances](x-devonthink-item://85591596-269C-4D41-B1FA-C98F11F15277), [Cardiac arrest in pregnancy](x-devonthink-item://10EB7561-AF2A-46E4-83F8-94F356BF6897) > [Dunn - post arrest care](x-devonthink-item://77519B89-0BE4-4AAD-AA2B-54ABBEC190D9) > [Rosen - post cardiac arrest care](x-devonthink-item://87C25449-FCD3-46C4-95D2-108ACE4D40F5?page=7) > [Cameron - cerebral resuscitation after cardiac arrest](x-devonthink-item://B016B4C4-CA01-466D-95E3-B2C99FB338B0?page=46) > > ANZCOR guidelines: [web link](https://www.anzcor.org/home/adult-advanced-life-support/) > - [resuscitation in special circumstances](x-devonthink-item://581DA354-94FE-42BE-B9ED-C0B244208243) > - [post-resuscitation therapy](x-devonthink-item://89EBD800-B1F9-4395-8FF7-26A8472BFD07) > - [targeted temperature management](x-devonthink-item://8547B71C-9268-4A14-B4D9-3D0A900945AA) ![[ALS algorithm#Hs and Ts]] # predictors of good neurological outcomes - witnessed collapse - CPR commenced immediately - rhythm is VF or VT - early defibrillation within 2-3 minutes of collapse - short duration of ALS / ROSC <20 min - no hypotension following ROSC - signs of neurological activity post ROSC (reactive pupils, motor score >3) see: [Tintinalli - ethical issues of resuscitation](x-devonthink-item://A00C55A2-ADEC-4659-A7F6-16B070F19B63?page=29), [Standards for Studies of Neurological Prognostication in Comatose Survivors of Cardiac Arrest: A Scientific Statement From the American Heart Association.](bookends://sonnysoftware.com/ref/DL/202364) # special circumstances | circumstance | variation | | ---------------------------------------------- | ---------------------------------------------- | | [[drowning]] | focus on oxygenation / ventilation | | [[Sodium channel blocker\|Na-channel blocker]] | [[HCO3 therapy]] | | [[Pulmonary Embolism]] | 50mg [[tPA]] or 40mg tenectoplase if PE likely | | [[Torsades de Pointes]] | [[Magnesium]] | | [[hyperkalemia]] | [[Calcium Gluconate]] | ## witnessed VF / pulseless VT - 3 stacked shocks (i.e. as soon as defibrillator recharged) A sequence of up to 3 stacked shocks can be considered in patients with a perfusing rhythm who develop a shockable rhythm where the setting is: - a witnessed and monitored setting and - the defibrillator is immediately available (eg. first shock able to be delivered within 20 seconds and - the time required for rhythm recognition and for recharging the defibrillator is short ie: <10 seconds). ## trauma see [[Traumatic arrest]] ## ventricular assist device (VAD) - have continuous blood flow and no pulse - may remain conscious despite malignant arrhythmias - elective defibrillation in controlled enviornment - don't do chest compressions → can cause retrograde flow and damage outflow graft on aorta - consider [[ECMO]] ## HOCM - consider in males early 20s with arrest during exertion - hypovolaema and adrenaline may worsen outflow obstruction - consider: - withholding vasoconstrictiors - large fluid bolus (improve pre-load) - give beta blocker or calcium channel blocker ## pregnancy see: [Tintinalli -resuscitation in pregnancy](x-devonthink-item://A00C55A2-ADEC-4659-A7F6-16B070F19B63?page=21), [AHA - cardiac arrest in pregnancy](x-devonthink-item://10EB7561-AF2A-46E4-83F8-94F356BF6897) - early intubation - [[Resuscitative Hysterotomy]] consider obstetric complications: - haemorrhage (uterine rupture, placental abruption, liver rupture) - DIC - [[amniotic fluid embolism]] - peripartum cardiomyopathy - [[Pulmonary Embolism|PE]] - [[Seizures]] from hypoxia → cardiac arrest - hypertensive disorder of pregnancy / [[Pre-eclampsia|Eclampsia]] - [[Aortic dissection]] - [[antepartum haemorrhage|Placenta praevia or placental abruption]] ## hypothermia see [[Hypothermia]] ![[Hypothermia#arrest]] ## OOHCA see also: [[Cessation of resus]], [[ECMO|ECPR]] > - Generally better outcomes from primary cardiac arrhythmias and poisoning than from other causes > - [[FELS|POCUS (FELS)]]: absence of cardiac kinetic activity has ==< 5% probability of ROSC== ; presence of kinetic activity has an 80% chance of ROSC ### Bystander CPR critical to survival - bystander CPR significantly improves survival rates - 10% decrease in survival/min in without CPR - 4% decrease in survival/min with CPR - CPR < 3 minutes and ALS < 6 minutes → 70% survivors from VF - CPR > 3 minutes and ALS < 6 minutes → 40% - ​likely no survivors if CPR not commenced within 8 minutes ### ?pan-scan - Branch KRH, Gatewood MO, Kudenchuk PJ, et al. Diagnostic yield, safety, and outcomes of Head-to-pelvis sudden death CT imaging in post arrest care: The CT FIRST cohort study. Resuscitation. 2023; 188:109785. - “The addition of a whole-body CT to standard care in the management of post-arrest patients improved the identification of the etiology of arrest and shortened the time to diagnosis but did not affect patient mortality.” [ CT FIRST cohort study](bookends://sonnysoftware.com/ref/DL/224877) , [summary](bookends://sonnysoftware.com/annotation/DL/257353/1727007138/3/-32/-260) , [review article by CT FIRST authors](bookends://sonnysoftware.com/ref/DL/262418) ### ?cath lab ASAP See ANZCOR [11-7 post arrest care: treat underlying cause](x-devonthink-item://89EBD800-B1F9-4395-8FF7-26A8472BFD07?page=9): - comatose post-arrest patients *without* ST-segment elevation: either an early (within 2 to 6 hours) or a delayed (within 24 hours) approach for coronary angiography is reasonable \[CoSTR 2022, weak recommendation, low certainty evidence]. - *STEMI*: ANZCOR suggests early coronary angiography in comatose post–cardiac arrest patients with ST-segment elevation \[Good Practice Statement] - [NEJM 2021 - TOMAHAWK](https://www.nejm.org/doi/full/10.1056/NEJMoa2101909) — [The Bottom Line summary](https://www.thebottomline.org.uk/summaries/icm/tomahawk/) — [2023 meta analysis](https://pmc.ncbi.nlm.nih.gov/articles/PMC9970266/) - Among patients with resuscitated out-of-hospital cardiac arrest without ST-segment elevation, a strategy of performing immediate angiography provided no benefit over a delayed or selective strategy with respect to the 30-day risk of death from any cause. - Likely reasonable for ICU if stable ; appropriate to discuss with cardiology regardless given equipoise - Current [2025 ACS guideline](https://www.heartfoundation.org.au/for-professionals/acs-guideline?tab=3#Acute%20management%20of%20ACS%20with%20cardiac%20arrest%20and/or%20cardiogenic%20shock) states that in "haemodynamically stable people with resuscitated cardiac arrest and no STE on ECG, do not perform routine emergency coronary angiography." ### Survival to hospital discharge - ~ 5 - 15% in total - ​up to 20% in systems with good AICD access - 10 - 35% for VT/VF - ​5 - 10% for PEA - 1 - 10% for asystole - 15% for patients with VT/VF and witnessed arrest # post-arrest care See: [ANZCOR guideline-11-7 post-resuscitation therapy](x-devonthink-item://89EBD800-B1F9-4395-8FF7-26A8472BFD07), [targeted temperature management](x-devonthink-item://8547B71C-9268-4A14-B4D9-3D0A900945AA) #tables > [!key points] > - avoid over-oxygenation > - avoid hyperthermia > - post-ROSC hypotension associated with significantly worse outcome; 85% mortality | Issue | Target | Discussion | | ----------------------- | -------------------------------------- | ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | | Treat reversible causes | [[ALS algorithm#Hs and Ts\|"Hs & Ts"]] | See [[#?cath lab ASAP]] and [[#?pan-scan]] section above | | Oxygenation | 96 - 98%<br>paO2 100 | - Avoid hyperoxia → may worsen reperfusion injury (a/w ↓ survival and ↓ neuro outcome) | | Ventilation | normal CO2 | Assess for aspiration with CXR | | Repeat ECG | ?STEMI | - PCI if STEMI<br>- Best 8 min post ROSC<br>- STE ∝ *better* prognosis<br>- Post-arrhythmia features: ↑ QTc, [[hypokalemia\|hypo-k]], [[Sodium channel blocker\|Na-channel blocker]] tox, [[Syncope ECG patterns#Brugada\|Brugada]]<br>- 25% have bundle branch block | | Haemoglobin | > 8 | - In most cases<br>- See [[Blood transfusion#PRBC transfusion threshold table\|transfusion targets]] for some special cases | | Glucose | 5 - 10 | | | ABG | | Assess ventilation, K, oxygenation, glucose | | Treat injuries from CPR | | May need CT chest / [[#?pan-scan\|pan scan]] | | Targeted temperature | 34 - 37.5º | - TTM may improve neurologically intact survival <br>- Cool if ≥ 37.5º<br>- Don't warm if > 34º<br>- If needing to cool, can use paralysis, arctic sun, IVTm device<br>- Maintain 24 hours<br>- Therapeutic hypothermia out of vogue as of TTM2 trial 2021 showing hypothermia does not improve morbidity or mortality | > [!key points]- Above table as a list > *treat reversible causes* > - With respect to whether or not to PCI (which is often one of the important disposition decision points in ED post-arrest), current [2025 ACS guideline](https://www.heartfoundation.org.au/for-professionals/acs-guideline?tab=3#Acute%20management%20of%20ACS%20with%20cardiac%20arrest%20and/or%20cardiogenic%20shock) states that in "haemodynamically stable people with resuscitated cardiac arrest and no STE on ECG, do not perform routine emergency coronary angiography." > > *oxygenation* > - ANZCOR suggests the use of 100% inspired oxygen until the arterial oxygen saturation, or the partial pressure of arterial oxygen can be measured reliably in adults with ROSC after cardiac arrest in any setting. > - Only O2 if O2 <94% > - aim 96-98% paO2 100 > - avoid hyperoxia → may worsen reperfusion injury (a/w worse survival and neurological outcome) > > *ventilation* > - normocarbia > - assess for aspiration with CXR > > *repeat ECG* > - ECG to help determine cause → PCI if STEMI > - best ~8 min post ROSC > - STE associated with *better* prognosis > - postarrhythmic features: > - ↑ QTc > - [[hypokalemia]] > - [[Sodium channel blocker|Na-channel blocker]] toxicity > - brugada > - 25% have bundle branch block > > *ABG* > - ventilation, K, oxygenation, glucose > > *Treat injuries from CPR* > > *glucose control* > - aim 5-10 > > *haemoglobin* > - \> 8 > > *targeted temperature management* > - TTM following CA may improve neurologically intact survival with a number of proposed mechanisms > - Prior to TTM, the term ‘therapeutic hypothermia’ was used, however recent evidence (TTM2 trial June 2021) demonstrated that hypothermia does not lead to improved mortality or morbidity > - 24 hours > - cool to below 37.5 deg C > - don't warm if T > 34 deg C > - paralysis helpful > - methods: > - IVTm device > - arctic sun ![[Pasted image 20240820214304.png]] ![[Pasted image 20240820214351.png]]