Transcript Post-cardiac arrest syndrome - the Australian Resuscitation Council

Post-resuscitation care
Version: Jan 2016
Learning outcomes
This lecture should enable you to:
• understand the need for continued resuscitation
after return of spontaneous circulation
• understand the post-cardiac arrest syndrome
• facilitate safe transfer of the patient
• consider the role and limitations of assessing
prognosis after cardiac arrest
Post-resuscitation care
The goal is to restore:
• normal cerebral function
• stable cardiac rhythm
• adequate organ perfusion
• quality of life
Post-cardiac arrest syndrome
• post-cardiac arrest brain injury:
– coma, seizures, myoclonus
• post-cardiac arrest myocardial dysfunction
• systemic ischaemia-reperfusion response
– ‘sepsis-like’ syndrome
• persistence of precipitating pathology
Post Arrest Case
Clinical setting and history
I You are part of a medical emergency response
S A 32-year-old previously healthy man has
been resuscitated following a VF arrest
B He was given bystander CPR for 5 minutes and
then received 2 shocks
A He is not breathing adequately by himself
R Please assess immediately
Airway
• Assessment
– patient not responsive
– clear airway with LMA in
situ
Airway
• Assessment
– patient not responsive
– clear airway with LMA in
situ
• Treatment
– ensure a clear airway, adequate
oxygenation and ventilation
– secure the airway for transfer
– insert gastric tube to
decompress stomach and
improve lung compliance
• Consider
– tracheal intubation, sedation and
controlled ventilation
Or
– immediate extubation if patient
breathing and conscious level
improves quickly after ROSC
Breathing
• Assessment
• Look, Listen and Feel
– R - RR 4 min-1
– A - normal, symmetrical chest
expansion, breath sounds
and percussion note
– T - trachea normal
– E - no effort
– S - SpO2 90% on high flow
oxygen
Breathing
• Assessment
– Look, Listen and Feel
– R - RR 4 min-1
– A - normal, symmetrical chest
expansion, breath sounds
and percussion note
– T - trachea normal
– E - no effort
– S - SpO2 90% on high flow
oxygen
• Treatment
– waveform capnography:
• aim for normocapnia
• avoid hyperventilation
– pulse oximetry: aim for SpO2
94 – 98%
– chest xray +/- other imaging
• Consider
–
–
–
–
–
–
simple/tension pneumothorax
collapse/consolidation
bronchial intubation
pulmonary oedema
aspiration
fractured rib
Circulation
• Assessment
– regular central pulse (rate
90 min-1)
– BP 88/55 mmHg
– CRT <4 s
– normal heart sounds
– ECG rhythm – sinusbradycardia
Circulation
• Assessment
– regular central pulse (rate
90 min-1)
– BP 88/55 mmHg
– CRT <4 s
– normal heart sounds
– ECG rhythm – sinusbradycardia
• Treatment
–
–
–
–
–
request 12-lead ECG
ABG and other bloods
IV fluids
urinary catheter
blood pressure, via direct
measurement
– aim SBP > 100 mmHg-1
• Consider
– right and /or left ventricular failure
– pulmonary oedema
– circulatory support
• vasopressors/fluids/other – mechanical
Optimising organ function
Heart
• Ischaemia-reperfusion injury:
– reversible myocardial dysfunction for 2-3 days
– Arrhythmias
• Poor myocardial function despite optimal filling:
– echocardiography
– cardiac output monitoring
– inotropes and/or balloon pump
• Mean blood pressure to achieve:
– urine output of 1 ml kg-1 h-1
– normalising lactate concentration
Disability
• Assessment
–
–
–
–
–
AVPU
pupils equal and reacting
blood glucose 5.9 mmol L-1
no limb movement
no seizures
• Treatment
– monitor blood glucose and
maintain normal
– document arrest accurately
Consider
• Neurological assessment:
– Glasgow Coma Scale score
– posture / seizure / limb
movement
• Targeted Temperature
Management (TTM)
Exposure
• Assessment
– temperature 36.6 ˚C
– no bleeding or rashes
– IV obtained right arm
functioning
• Treatment
– monitor temperature
Optimising organ function
Brain
• impaired cerebral autoregulation – maintain
‘normal’ blood pressure
• sedation
• control seizures
• glucose (4-10 mmol L-1)
• normocapnia
• avoid/treat hyperthermia
• targeted temperature management
Targeted temperature management (TTM)
• maintain a constant, target temperature of 32–36˚C for 24 h
and rewarm slowly 0.25˚C h-1
• TTM is recommended for adults after out-of-hospital cardiac
arrest with an initial shockable rhythm who remain
unresponsive after ROSC
• TTM is suggested for those unresponsive after nonshockable/in-hospital cardiac arrest
• exclusions: severe sepsis, pre-existing coagulopathy
How to control temperature?
• Induction
– 30 ml kg-1 4oC IV fluid with monitoring (in-hospital)
– +/- external cooling
• Maintenance - external cooling
– ice packs, wet towels
– cooling blankets or pads
– water circulating gel-coated pads
• Maintenance - internal cooling
– intravascular heat exchanger
– cardiopulmonary bypass
Targeted temperature management
Physiological effects and complications
•
•
•
•
•
•
shivering
bradycardia and cardiovascular instability
infection
hyperglycaemia
electrolyte abnormalities
reduced clearance of drugs
Transfer of the patient
•
•
•
•
•
•
•
•
discuss with admitting team
cannulae, drains, tubes secured
suction
oxygen supply
monitoring
documentation
reassess before leaving
talk to the patient’s family
Assessment of prognosis
• Generally deferred until at least 72 h after cardiac arrest
• Multimodal tests interpreted by experienced clinicians:
– clinical examination – GCS score, pupillary response to light, corneal
reflex, seizures
– neurophysiological studies – somatosensory evoked potentials (SSEPs) and
electroencephalography (EEG)
– biochemical markers – neuron-specific enolase (NSE)
– imaging studies – brain CT and magnetic resonance imaging (MRI)
Rehabilitation
• Majority of survivors are considered to have
‘good’ neurological outcome
• Emotional problems and cognitive problems are
common
• May benefit from rehabilitation program
Organ donation
• Non-surviving post-cardiac arrest patient
may be a suitable donor:
– heart-beating donor (brainstem death)
– non-heart-beating donor
Any questions?
Summary
• post-cardiac arrest syndrome is complex
• quality of post-resuscitation care influences final
outcome
• appropriate monitoring, safe transfer and continued
organ support
• delay assessment of prognosis and to be undertaken
by experienced clinicians
Advanced Life Support Level 2 Course
Slide set
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© Australian Resuscitation Council (June 2016)