Part 8: Post–Cardiac Arrest Care

Post–cardiac arrest care research has advanced significantly over the past decade. Multiple studies and trials detail the heterogeneity of patients and the spectrum of pathophysiology after cardiac arrest. Post–cardiac arrest care should be titrated based on arrest etiology, comorbid disease, and illness severity. Thus, the 2015 Guidelines Update integrates available data to help experienced clinicians make the complex set of therapeutic decisions required for these patients. The central principles of postarrest care are (1) to identify and treat the underlying etiology of the cardiac arrest, (2) to mitigate ischemia-reperfusion injury and prevent secondary organ injury, and (3) to make accurate estimates of prognosis to guide the clinical team and to inform the family when selecting goals of continued care.

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New Developments

Early coronary angiography and coronary intervention are recommended for patients with ST elevation as well as for patients without ST elevation, when an acute coronary event is suspected. The decision to perform coronary angiography should not include consideration of neurologic status, because of the unreliability of early prognostic signs. Targeted temperature management is still recommended for at least 24 hours in comatose patients after cardiac arrest, but clinicians may choose a target temperature from the wider range of 32°C to 36°C. Estimating the prognosis of patients after cardiac arrest is best accomplished by using multiple modalities of testing: clinical examination, neurophysiological testing, and imaging.

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Significant New and Updated Recommendations

One of the most common causes of cardiac arrest outside of the hospital is acute coronary occlusion. Quickly identifying and treating this cause is associated with better survival and better functional recovery. Therefore, coronary angiography should be performed emergently (rather than later in the hospital stay or not at all) for OHCA patients with suspected cardiac etiology of arrest and ST elevation on ECG. Emergency coronary angiography is reasonable for select (eg, electrically or hemodynamically unstable) adults who are without ST elevation on ECG but are comatose after OHCA of suspected cardiac origin. Emergency coronary angiography is also reasonable for post–cardiac arrest patients for whom coronary angiography is indicated, regardless of whether the patient is comatose or awake.

A high-quality randomized controlled trial did not identify any superiority of targeted temperature management at 36°C compared with management at 33°C. Excellent outcomes are possible when patients are actively managed at either temperature. All comatose (ie, lack of meaningful response to verbal commands) adult patients with ROSC after cardiac arrest should have targeted temperature management, with providers selecting and maintaining a constant temperature between 32°C and 36°C for at least 24 hours after achieving target temperature. It is also reasonable to actively prevent fever in comatose patients after targeted temperature management.

  • Multiple randomized controlled trials tested prehospital infusion of cold intravenous fluids to initiate hypothermia after OHCA. The absence of any benefit and the presence of some complications in these trials led to a recommendation against the routine prehospital cooling of patients after ROSC by using rapid infusion of cold saline. However, this recommendation does not preclude the use of cold intravenous fluids in more controlled or more selected settings and did not address other methods of inducing hypothermia.
  • Specific management of patients during postresuscitation intensive care includes avoiding and immediately correcting hypotension and hypoxemia. It is reasonable to use the highest available oxygen concentration until the arterial oxyhemoglobin saturation or the partial pressure of arterial oxygen can be measured. However, the benefits of any specific target ranges for blood pressure, ventilator management, or glucose management are uncertain.
  • Multiple studies examined methods to determine prognosis in patients after cardiac arrest, and the use of multiple modalities of testing is recommended. The earliest time to prognosticate a poor neurologic outcome by using clinical examination in patients not treated with targeted temperature management is 72 hours after ROSC, but this time can be even longer after cardiac arrest if the residual effect of sedation or paralysis is suspected to confound the clinical examination. In patients treated with targeted temperature management, where sedation or paralysis could confound clinical examination, it is reasonable to wait until 72 hours after return to normothermia.
  • Useful clinical findings that are associated with poor neurologic outcome include
    • The absence of pupillary reflex to light at ≥72 hours after cardiac arrest
    • The presence of status myoclonus during the first 72 hours after cardiac arrest
    • The absence of the N20 somatosensory evoked potential cortical wave 24 to 72 hours after cardiac arrest or after rewarming
    • The presence of a marked reduction of the gray-white ratio on brain computed tomography obtained within 2 hours after cardiac arrest
    • Extensive restriction of diffusion on brain magnetic resonance imaging at 2 to 6 days after cardiac arrest
    • Persistent absence of electroencephalographic reactivity to external stimuli at 72 hours after cardiac arrest
    • Persistent burst suppression or intractable status epilepticus on electroencephalogram after rewarming
    • Note: Absent motor movements, extensor posturing or myoclonus should not be used alone for predicting outcome.
  • All patients who are resuscitated from cardiac arrest but who subsequently progress to death or brain death should be evaluated as potential organ donors. Patients who do not have ROSC after resuscitation efforts also may be considered candidates as kidney or liver donors in settings where programs exist.

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Knowledge Gaps

  • Which post-cardiac arrest patients without ST elevation are most likely to benefit from early coronary angiography?
  • What are the optimal goals for blood pressure, ventilation, and oxygenation in specific groups of post-cardiac arrest patients?
  • What are the optimal duration, timing, and methods for targeted temperature management?
  • Will particular subgroups of patients benefit from management at specific temperatures?
  • What strategies can be used to prevent or treat post–cardiac arrest cerebral edema and malignant electroencephalographic patterns (seizures, status myoclonus)?
  • What is the most reliable strategy for prognostication of futility in comatose post–cardiac arrest survivors?

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References

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Part 8: Post–Cardiac Arrest Care

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