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

Last updated 2010.