Note: Your progress in watching these videos WILL NOT be tracked. These training videos are the same videos you will experience when you take the full ProACLS program. You may begin the training for free at any time to start officially tracking your progress toward your certificate of completion.
There has been substantial research and success in post-resuscitation care and recovery. Because of this, it has become an extremely important part of an aggressive ACLS resuscitation program.
In this section of your ProACLS course, we'll be discussing the most current guidelines for achieving the most effective and successful recovery post-resuscitation and return of spontaneous circulation available today.
This section will follow the latest recommendations provided by the American Heart Association and has been taken from the latest ECC published protocols. Now let's look at the return of spontaneous circulation (ROSC) and post-cardiac arrest care.
Post Cardiac Arrest Programs
Every healthcare system should implement a comprehensive and multidisciplinary system of care in a universal and consistent manner for the treatment of post-cardiac arrest patients to assure the very best of outcomes.
All post-cardiac arrest programs should address the following:
- Targeted temperature management (TTM)
- Hemodynamic and ventilation optimization
- Immediate coronary reperfusion
- Percutaneous coronary intervention (PCI) for eligible patients
- Neurological care and prognostication
- Cognitive impairments
- Other structured interventions
Post Cardiac Arrest Syndrome
Pro Tip #1: It's important to understand that patients who have experienced a return of spontaneous circulation after cardiac arrest, regardless of the setting, have a complex combination of pathophysiological processes that are described as post-cardiac arrest syndrome.
Post cardiac arrest syndrome includes the following:
- Post arrest brain injury
- Post arrest myocardial dysfunction
- Systemic ischemia
- Reperfusion response
- Persistent, acute, and chronic pathologies that may have participated in the cardiac arrest itself
Post-cardiac arrest syndromes play a significant role in patient mortality and should be taken very seriously.
Support for Caregivers Post Cardiac Arrest
In addition to patient support, caregivers are also vulnerable. They should receive comprehensive discharge planning that includes:
- Medical and rehabilitative recommendations
- Return to normal activity expectations
- Return to work expectations
This caregiver support should begin immediately during the patient's initial hospitalization and continue for as long as it's needed.
Return to Normal Life Post Cardiac Arrest
Returning to normal life after a traumatic event is never an easy thing. And it can be a challenge for both the patient and their primary caregiver.
For this reason, a structured assessment should be part of any post-cardiac arrest care plan to assess for:
- Anxiety
- Depression
- Post-traumatic stress
- Fatigue
And again, this assessment should be done for both the cardiac arrest survivor and any of their caregivers.
Post Cardiac Arrest Care for Healthcare Providers
It's not just the cardiac arrest survivors and their caregivers who need support after a traumatic cardiac arrest event. Both in-hospital and out-of-hospital healthcare providers may also experience emotional or psychological effects after providing care for patients in cardiac arrest.
Pro Tip #2: The work of healthcare providers is never easy, and good outcomes are never guaranteed. When a patient dies following a cardiac arrest event, healthcare providers are at their most vulnerable. This is when emotional support is most needed.
Following a cardiac arrest event, debriefing and referrals should be offered for follow-up care for emotional support. This should be provided for everyone involved, including lay rescuers, EMS providers, and hospital-based healthcare workers.
A team debriefing can also be beneficial to allow for a review of the team's performance and quality improvement.
A Word About Post Cardiac Arrest Treatment
Providers should ensure an adequate airway and support breathing immediately after ROSC. Unconscious patients usually require an advanced airway for mechanical support of breathing. Providers should also elevate the head of the bed 30 degrees if tolerated by the patient to reduce the incidence of cerebral edema, aspiration, and ventilatory-associated pneumonia.
Proper placement of an advanced airway, particularly during patient transport, should be monitored by waveform capnography. The oxygenation of the patient should be monitored continuously with pulse oximetry.
While 100 percent oxygen may have been used during initial resuscitation, providers should titrate inspired oxygen to the lowest level required to achieve an arterial oxygen saturation of 92 to 98 percent to avoid potential oxygen toxicity.
Hyperventilation is common after cardiac arrest and should be avoided because of the potential for adverse hemodynamic effects. Hyperventilation increases intrathoracic pressure, which decreases preload and lowers cardiac output.
The decrease in PaCO2 seen with hyperventilation can also decrease cerebral blood flow directly. Ventilation should be started at 10 per minute and titrated to achieve a PetCO2 of 35 to 40 mmHg or a PaCO2 of 40 to 45 mmHg.
Healthcare providers should frequently reassess vital signs and monitor for recurrent cardiac arrhythmias by using continuous ECG monitoring. If the patient is hypotensive, fluid boluses can be administered.
If TTM is indicated, cold fluids may be helpful for the initial induction of hypothermia. If the patient's volume status is adequate, infusions of vasoactive agents may be initiated and titrated to achieve a minimum SBP of 90 mmHg or greater or a mean arterial pressure of 65 mmHg or more. Some advocate higher mean arterial pressures to promote cerebral blood flow.
Brain injury and cardiovascular instability are the major factors that determine survival after cardiac arrest. Because TTM is currently the only intervention demonstrated to improve neurologic recovery, it should be considered for any patient who is comatose and unresponsive to verbal commands after ROSC. The patient should be transported to a location that reliably provides this therapy in addition to coronary reperfusion and other goal-directed post-arrest care therapies.
Clinicians should treat the precipitating cause of cardiac arrest after ROSC and initiate or request studies that will further aid in evaluating the patient. It is essential to identify and treat any cardiac, electrolyte, toxicologic, pulmonary, and neurologic precipitants of the arrest.
Overall, the most common cause of cardiac arrest is cardiovascular disease and associated coronary ischemia. Therefore, a 12-lead ECG should be obtained as quickly as possible to detect ST elevation or LBBB. Coronary angiography should be performed emergently for OHCA patients with suspected cardiac etiology of arrest and ST elevation on ECG.
When there is a high suspicion of AMI, local protocols for the treatment of AMI and coronary reperfusion should be activated.
Coronary angiography, if indicated, can be beneficial in post-cardiac arrest patients regardless of whether they are awake or comatose. Even in the absence of ST elevation, emergent coronary angiography is reasonable for patients who are comatose after OHCA of suspected cardiac origin.
Concurrent PCI and TTM are safe, with good outcomes reported for some comatose patients who have undergone PCI.
Critical care facilities that treat patients after cardiac arrest should use a comprehensive care plan that includes acute cardiovascular interventions, use of TTM, standardized medical goal-directed therapies, and advanced neurologic monitoring and care.
Neurologic prognosis may be difficult to determine during the first 72 hours after resuscitation. This should be the earliest time to prognosticate a poor neurologic outcome in patients not treated with TTM.
For those treated with TTM, providers should wait 72 hours after the patient returns to normothermia before prognosticating by using clinical examination where sedation or paralysis can be a confounder.
Many initially comatose survivors of cardiac arrest have the potential for a full recovery. For this reason, it's important to place patients in a hospital critical care unit where expert care and neurologic evaluation can be performed and where appropriate testing to aid prognosis can also be performed promptly.
