Post-Cardiac Arrest Care

Research indicates that increased survival rates and positive victim outcomes of ACLS are directly influenced by the quality of post-cardiac care that a victim receives. Vital post-resuscitation efforts include:

• Early placement of the endotracheal tube (ETT).
• The use of quantitative waveform capnography to keep the partial pressure of end-tidal carbon dioxide (PETCO2) between 35 to 45 mm Hg. This form of monitoring is the most effective means of optimizing hemodynamics and ventilation.
• Set initial RR 10 breaths/min, goal SPO2 92-98%.
• Administer inotropes, crystalloid, or vasopressors to maintain BPs > 90/65 mmHg
• The application of therapeutic hypothermia if the victim achieves ROSC but does not respond to verbal stimulation. This entails lowering the victim’s core temperature to 32°C- 36°C for at least 24 hours post-resuscitation.
• Obtain EKG and evaluate for STEMI / cardiogenic shock.
• Transport the victim to a facility capable of performing coronary reperfusion using percutaneous coronary intervention (PCI).
• Maintaining glucose levels between 144 mg/dL and 180 mg/dL without attempting to achieve a lower blood glucose level as the risk of causing hypoglycemia outweighs the benefits.
• Post resuscitative neuroprognostication should be obtained within 72 hours of normothermia (CT, MRI, EEG, N20 SSEP, serum NSE).

The Post-Cardiac Arrest Care Algorithm (see Figure 8) includes the following steps:

1. Verify ROSC.

2. Manage the airway and provide a breath every 5-6 seconds. If an advanced airway is in place, provide a breath every 6 seconds. Using quantitative waveform capnography, titrate the oxygen to maintain a PETCO2of 35-40 mm Hg. If you do not have access to a waveform capnography machine, titrate oxygen to keep the victim's oxygen saturation between 94% and 99%.

3. Insert and maintain an IV for medication administration. Maintain the blood pressure above 90 mm Hg and/or a mean arterial pressure of 65 mmHg. Avoid hypotension. For a low blood pressure, consider one or more of these treatments:

4. Give 1-2 liters of saline or Ringer's lactate IV fluid.

5. Start an epinephrine IV infusion to keep the systolic pressure >90 mm Hg.

6. Start a dopamine IV infusion.

7. Consider norepinephrine for extremely low systolic blood pressure.

8. Evaluate the H's and T's for treatable causes (see Figure 4: H's and T's).