Please click on the arrow on the lower left corner of the video to play video.
Once the patient has had a return of spontaneous circulation (ROSC) the team switches to stabilization mode. Management of the airway through early placement of an ET Tube and ensuring ventilation at a rate of at least 10 breaths per minute while maintaining an SPO2 of 92%-98% and and PaCO2 of 35-45 mm Hg is essential. Volume and vasopressors should be administered to maintain a systolic BP greater than 90 mm Hg with a mean arterial pressure greater than 656 mm Hg. As soon as possible a 12-lead ECG should be obtained and the patient should be considered for emergent cardiac intervention if there is a STEMI present, the patient is in unstable cardiogenic shock, or if mechanical circulatory support is still required. Targeted Temperature management is indicated if the patient shows any evidence of neurological impairment. This may be determined by seeing if the patient is able to follow commands correctly. If the patient is comatose and unresponsive a brain CT should be obtained as soon as possible and EEG monitoring should be started. Whether the patient is comatose or awake other critical care management should be begun as needed by the patient.
H’s and T’s
Determining the underlying cause of the cardiac arrest and treating it is essential to prevent the patient from going back into cardiac arrest. The H’s and T’s are some of the most common treatable underlying causes of cardiac arrest. Hypovolemia, Hypoxia, Hypothermia, Hypokalemia/Hyperkalemia (and other electrolyte imbalances), Hydrogen Ion (metabolic acidosis), Tension Pneumothorax, Tamponade (cardiac), Toxins, Thrombosis–Pulmonary and Cardiac, and Trauma.
Beta Blockers
After ROSC routine use of beta-blockers is not currently recommended. However, for patients who had cardiac arrest due to VF/pVT either initiation or continuation of either an oral or IV beta-blocker may be considered.
Lidocaine
It is reasonable use Lidocaine as an antiarrhythmic when ROSC occurs to prevent VF/pVT. Lidocaine
Targeted Temerpature Management
Hypothermia therapy is now called Targeted Temperature Mangement TTM. Patients who show signs of neurological impairment such as a change in LOC, are comatose, or even just unable to follow commands correctly should receive TTM. A single target temperature between 32°C and 36°C should be chosen and maintained for 24-72 hours. Variations in temperature up or down have been shown to be associated with poorer outcomes. The patient’s core temperature should not deviate more than a 1/2 a degree Celsius up or down during this time as some studies have shown that temperature variation greatly decrease positive outcomes for the patient. Even after 24-72 hours when the patient is returned to normal temperature efforts should be made to avoid a fever for at least 7 days, as fever during this time has been shown to be associated with poorer outcomes.
Goals for Hemodynamic status after ROSC
After ROSC hypotension should be avoided by immediate administration via IV or IO of appropriate volume expanders. Systolic blood pressure should be maintained at 90 mm Hg or greater and the mean arterial pressure should be maintained at 65 mm Hg. Studies have shown that less than these pressure have been associated with negative outcomes after ROSC. Studies have also shown that systolic pressure greater than 90 mm Hg were associated with positive outcomes after ROSC.
Copyright 2023, MasterACLS
