Multiple System Approach to Post–Cardiac Arrest Care

Ventilation Hemodynamics Cardiovascular Neurological Metabolic
  • Capnography
    • Rationale: Confirm secure airway and titrate ventilation

    • Endotracheal tube when possible for comatose patients

    • Petco2∼35–40 mm Hg

    • Paco2∼40–45 mm Hg

  • Frequent Blood Pressure Monitoring/Arterial-line
    • Rationale: Maintain perfusion and prevent recurrent hypotension

    • Mean arterial pressure ≥65 mm Hg or systolic blood pressure ≥90 mm Hg

  • Continuous Cardiac Monitoring
    • Rationale: Detect recurrent arrhythmia

    • No prophylactic antiarrhythmics

    • Treat arrhythmias as required

    • Remove reversible causes

  • Serial Neurological Exam
    • Rationale: Serial examinations define coma, brain injury, and prognosis

    • Response to verbal commands or physical stimulation

    • Pupillary light and corneal reflex, spontaneous eye movement

    • Gag, cough, spontaneous breaths

  • Serial Lactate
    • Rationale: Confirm adequate perfusion

  • Chest X-ray
    • Rationale: Confirm secure airway and detect causes or complications of arrest: pneumonitis, pneumonia, pulmonary edema

  • Treat Hypotension
    • Rationale: Maintain perfusion

    • 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

  • 12-lead ECG/Troponin
    • Rationale: Detect Acute Coronary Syndrome/ST-Elevation Myocardial Infarction; Assess QT interval

  • EEG Monitoring If Comatose
    • Rationale: Exclude seizures

    • Anticonvulsants if seizing

  • Serum Potassium
    • Rationale: Avoid hypokalemia which promotes arrhythmias

    • Replace to maintain K >3.5 mEq/L

  • Pulse Oximetry/ABG
    • Rationale: Maintain adequate oxygenation and minimize Fio2

    • Spo2 ≥94%

    • Pao2∼100 mm Hg

    • Reduce Fio2 as tolerated

    • Pao2/Fio2 ratio to follow acute lung injury

  • Treat Acute Coronary Syndrome
    • Aspirin/heparin

    • Transfer to acute coronary treatment center

    • Consider emergent PCI or fibrinolysis

  • Core Temperature Measurement If Comatose
    • Rationale: Minimize brain injury and improve outcome

    • Prevent hyperpyrexia >37.7°C

    • Induce therapeutic hypothermia if no contraindications

    • Cold IV fluid bolus 30 mL/kg if no contraindication

    • Surface or endovascular cooling for 32°C–34°C×24 hours

    • After 24 hours, slow rewarming 0.25°C/hr

  • Urine Output, Serum Creatinine
    • Rationale: Detect acute kidney injury

    • Maintain euvolemia

    • Renal replacement therapy if indicated

  • Mechanical Ventilation
    • Rationale: Minimize acute lung injury, potential oxygen toxicity

    • Tidal Volume 6–8 mL/kg

    • Titrate minute ventilation to Petco2∼35–40 mm Hg Paco2∼40–45 mm Hg

    • Reduce Fio2 as tolerated to keep Spo2 or Sao2 ≥94%

  • Echocardiogram
    • Rationale: Detect global stunning, wall-motion abnormalities, structural problems or cardiomyopathy

  • Consider Non-enhanced CT Scan
    • Rationale: Exclude primary intracranial process

  • Serum Glucose
    • Rationale: Detect hyperglycemia and hypoglycemia

    • Treat hypoglycemia (<80 mg/dL) with dextrose

    • Treat hyperglycemia to target glucose 144–180 mg/dL

    • Local insulin protocols

  • Treat Myocardial Stunning
    • Fluids to optimize volume status (requires clinical judgment)

    • Dobutamine 5–10 mcg/kg per min

    • Mechanical augmentation (IABP)

  • Sedation/Muscle Relaxation
    • Rationale: To control shivering, agitation, or ventilator desynchrony as needed

  • Avoid Hypotonic Fluids
    • Rationale: May increase edema, including cerebral edema