2010 American Heart Association

S770 Circulation November 2, 2010
Table 1. Multiple System Approach to Post–Cardiac Arrest Care
Ventilation Hemodynamics Cardiovascular Neurological Metabolic
● Capnography ● Frequent Blood Pressure
Monitoring/Arterial-line
● Continuous Cardiac Monitoring ● Serial Neurological Exam ● Serial Lactate
● Rationale: Confirm secure airway ● Rationale: Maintain perfusion and ● Rationale: Detect recurrent ● Rationale: Serial examinations define ● Rationale: Confirm adequate
and titrate ventilation
prevent recurrent hypotension
arrhythmia
coma, brain injury, and prognosis perfusion
● Endotracheal tube when possible ● Mean arterial pressure
● No prophylactic antiarrhythmics ● Response to verbal commands or
for comatose patients
�65 mm Hg or systolic blood
pressure �90 mm Hg
physical stimulation
● PETCO2�35–40 mm Hg ● Treat arrhythmias as required ● Pupillary light and corneal reflex,
spontaneous eye movement
● Paco2�40–45 mm Hg ● Remove reversible causes ● Gag, cough, spontaneous breaths
● Chest X-ray ● Treat Hypotension ● 12-lead ECG/Troponin ● EEG Monitoring If Comatose ● Serum Potassium
● Rationale: Confirm secure airway ● Rationale: Maintain perfusion ● Rationale: Detect Acute Coronary ● Rationale: Exclude seizures ● Rationale: Avoid hypokalemia which
and detect causes or
Syndrome/ST-Elevation
promotes arrhythmias
complications of arrest:
Myocardial Infarction; Assess QT
pneumonitis, pneumonia,
pulmonary edema
interval
● Fluid bolus if tolerated
● Dopamine 5–10 mcg/kg per min
● Norepinephrine 0.1–0.5 mcg/kg
per min
● Epinephrine 0.1–0.5 mcg/kg per
min
● Anticonvulsants if seizing ● Replace to maintain K �3.5 mEq/L
● Pulse Oximetry/ABG . . . ● Treat Acute Coronary Syndrome ● Core Temperature Measurement If
Comatose
● Urine Output, Serum Creatinine
● Rationale: Maintain adequate
... ● Aspirin/heparin ● Rationale: Minimize brain injury and ● Rationale: Detect acute kidney
oxygenation and minimize FIO2 improve outcome
injury
● SpO2 �94% ... ● Transfer to acute coronary
treatment center
● Prevent hyperpyrexia �37.7°C ● Maintain euvolemia
● PaO2�100 mm Hg ... ● Consider emergent PCI or
● Induce therapeutic hypothermia if no ● Renal replacement therapy if
fibrinolysis
contraindications
indicated
● Reduce FIO2 as tolerated ... ● Cold IV fluid bolus 30 mL/kg if no
contraindication
● Pao2/FIO2 ratio to follow acute
... ● Surface or endovascular cooling for
lung injury
32°C–34°C�24 hours
... ● After 24 hours, slow rewarming
0.25°C/hr
● Mechanical Ventilation . . . ● Echocardiogram ● Consider Non-enhanced CT Scan ● Serum Glucose
● Rationale: Minimize acute lung
... ● Rationale: Detect global
● Rationale: Exclude primary
● Rationale: Detect hyperglycemia
injury, potential oxygen toxicity
stunning, wall-motion
abnormalities, structural
problems or cardiomyopathy
intracranial process
and hypoglycemia
● Tidal Volume 6–8 mL/kg . . . ● Treat hypoglycemia (�80 mg/dL)
with dextrose
● Titrate minute ventilation to
... ● Treat hyperglycemia to target
PETCO2�35–40 mm Hg
Paco2�40–45 mm Hg
glucose 144–180 mg/dL
● Reduce Fio2 as tolerated to keep
Spo2 or Sao2 �94%
... ● Local insulin protocols
... ● Treat Myocardial Stunning ● Sedation/Muscle Relaxation ● Avoid Hypotonic Fluids
... ● Fluids to optimize volume status ● Rationale: To control shivering, ● Rationale: May increase edema,
(requires clinical judgment)
agitation, or ventilator desynchrony
as needed
including cerebral edema
... ● Dobutamine 5–10 mcg/kg per
min
... ● Mechanical augmentation (IABP)
hypothermia. Concurrent PCI and hypothermia are safe, with
good outcomes reported for some comatose patients who
undergo PCI.
Patients who are unconscious or unresponsive after cardiac
arrest should be directed to an inpatient critical-care facility
with a comprehensive care plan that includes acute cardiovascular
interventions, use of therapeutic hypothermia, standardized
medical goal-directed therapies, and advanced neu-
rological monitoring and care. Neurological prognosis may
be difficult to determine during the first 72 hours, even for
patients who are not undergoing therapeutic hypothermia.
This time frame for prognostication is likely to be extended in
patients being cooled. 18 Many initially comatose survivors of
cardiac arrest have the potential for full recovery such that
they are able to lead normal lives. 1,2,19 Between 20% and 50%
or more of survivors of out-of-hospital cardiac arrest who are
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