Cardiac Arrest Management

If an individual has a return of spontaneous circulation (ROSC), start post-cardiac arrest care immediately. The initial BLS/ACLS processes are meant to save an individual’s life, while post-cardiac arrest care is meant to optimize ventilation and circulation, preserve the heart and brain tissue/function, and to maintain recommended blood glucose levels. Pay close attention to oxygenation, blood pressure control, the need for percutaneous coronary intervention, and ideal temperature management. The 2020 ILCOR Guidelines recommend formal assessment and support for an individual’s continued physical, cognitive, and psychosocial needs because recovery from a cardiac arrest event continues long after the initial hospitalization. Be sure to remember to address the mental health needs of the First Responders also, and schedule a debriefing for lay rescuers, EMS providers, and hospital-based healthcare workers after a resuscitation event.

VOMIT – AN ACRONYM TO DESCRIBE POST-CARDIAC ARREST CARE

• Vital signs- Especially checking blood pressure.
• Oxygen- Do they need to be intubated at all, or do they need a type of oxygen apparatus?
• Myocardial infarction- Do they need to get to a chest pain center?
• Iv- Do they need IV fluids? Do they need a drip?
• Targeted Temperature Management (TTM)- Only if they are still unresponsive.

AIRWAY MANAGEMENT

• Early placement of advanced airway as needed
• Manage respiratory parameters:
  – Keep 10 breaths per minute
  – Pulse Ox goal 92-98%
  – Titrate to PaCO₂ 35-45 mm Hg
  – Waveform capnography (capnometry) to confirm ETT placement

BLOOD PRESSURE SUPPORT AND VASOPRESSORS

• Obtain early ECG.
• Consider blood pressure support in any individual with systolic blood pressure less than 90 mmHg or mean arterial pressure (MAP) less than 65.
• Unless contraindicated, 1 to 2 liters of IV saline or Lactated Ringer’s is the first intervention.
• When blood pressure is very low, consider vasopressors (commonly referred to as “pressors”). Vasopressors and inotropes are medications used to create vasoconstriction or increase cardiac contractility, respectively. Consider using the following:
  – Dopamine and norepinephrine are the pressors of choice for individuals who are not in cardiac arrest.
  – Vasopressin and phenylephrine are the second agents to be added.
  – Epinephrine is generally reserved for severe hypotension or as a last-line agent
• Titrate the infusion rate to maintain the desired blood pressure.

The Post–Cardiac Arrest Care Algorithm (Figure 30) was updated to emphasize the need to prevent hyperoxia, hypoxemia, and hypotension.

TARGETED TEMPERATURE MANAGEMENT (TTM)

Targeted temperature management is the only documented intervention that improves/enhances brain recovery after cardiac arrest. Induced targeted temperature management can be performed in unresponsive individuals and should be continued for at least 24 hours. The goal of induced targeted temperature management is to maintain a core body temperature between 89.6 to 96.8 degrees F (32 to 36 degrees C) for at least 24 hours by using a cooling device with a feedback loop. Device manufacturers have developed several innovative technologies that improve the ability to affect and manage targeted temperature management in the post-arrest individual. Targeted temperature management should be induced and monitored by trained professionals. Induced targeted temperature management should not affect the decision to perform percutaneous coronary intervention (PCI), because concurrent PCI and targeted temperature management are reported to be feasible and safe.