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In this lesson, we're going to cover post cardiac arrest interventions, such as targeted temperature management, hemodynamic and ventilation optimization, immediate coronary reperfusion with PCI, glycemic control, and neurologic care and prognostication.
Targeted Temperature Management
According to the latest national guidelines update for CPR and ECC, it is recommended that targeted temperature management interventions, also known as TTM, be administered to comatose adult patients with ROSC after cardiac arrest by selecting and maintaining a constant temperature somewhere between 32 and 36 degrees Celsius, or 89.6 to 95.2 degrees Fahrenheit, for at least 24 hours.
Comatose is technically defined as lacking meaningful response to verbal commands.
Hemodynamic and Ventilation Optimization
Hemodynamic and ventilation optimization is the next intervention in post arrest care.
Pro Tip #1: Although ACLS providers often use 100 percent oxygen while performing their initial resuscitation, you should titrate inspired oxygen during post cardiac arrest care to the lowest level required to achieve arterial oxygen saturation of 92 to 98 percent whenever possible.
Doing so may help prevent any potential complications associated with oxygen therapy.
Warning: Remember, excessive ventilations with high oxygen levels can have adverse hemodynamic effects, especially when intrathoracic pressures increase and because of a potential decrease in cerebral blood flow when partial pressure of carbon dioxide (PaCO2) in arterial blood decreases.
It's important that healthcare providers start ventilation rates at 10 per minute. The goal is to achieve normocarbia – a partial pressure of end-tidal carbon dioxide (PetCO2) of 30 to 40 mmHg or a PaCO2 of 35 to 45 mmHg. This is a reasonable goal unless patient factors prompt more individualized treatments.
Other PaCO2 targets may be tolerated for specific patients. An example of this would be when a higher PaCO2 may be more appropriate in a patient with an acute lung injury or high airway pressures.
Likewise, mild hypercapnia might be a beneficial treatment as a temporary measure when treating cerebral edema. But hyperventilation could cause cerebra vasoconstriction.
Pro Tip #2: Health care providers should note that when a patient's temperature is below normal, laboratory values reported for PaCO2 might be higher than actual values.
In addition, healthcare professionals should titrate fluid administration in vasoactive or inotropic agents as needed to optimize blood pressure, cardiac output, and systemic perfusion.
While optimal post cardiac arrest blood pressure remains unknown, a mean arterial pressure of 65 mmHg or greater is a reasonable goal per scientific studies and current guidelines.
Immediate Coronary Reperfusion with PCI
When treating for a return of spontaneous circulation in patients where coronary artery occlusion is suspected, rescuers should transport patients to a capable and reliable facility known for providing coronary reperfusion and other goal-directed post cardiac arrest care therapies.
The decision to perform percutaneous coronary intervention (PCI) can be made irrespective of coma or a decision to induce hypothermia, because concurrent PCI and hypothermia are feasible and safe and have reported good outcomes.
Glycemic Control
Altering glucose concentration within a lower range of 80 to 110 mg/dL should not be attempted because of the increased risk of hypoglycemia.
The latest guidelines update for CPR and ECC does not have a recommended specific target range of glucose management in adult patients with a return of spontaneous circulation after cardiac arrest.
Neurologic Care and Prognostication
The American Heart Association guidelines have established the following: the goal of post cardiac arrest management is to return the patient to their prearrest function levels.
Reliable early prognostication on neurological outcome is an essential component of post cardiac arrest care. However, optimal timing is important to consider. In patients treated with TTM, prognostication using clinical examinations should be delayed for at least 72 hours after the return of normothermia.
For those patients not treated with TTM, the earliest time is 72 hours after cardiac arrest and potentially longer if the residual effects of sedation or paralysis confounds the clinical examination.
