If there is ECG evidence of STEMI, undertake coronary angiography first
This is followed by CT brain and/or CTPA if coronary angio. fails to ID the arrest cause
If there are signs or symptoms pre-arrest suggesting a neurological or respiratory cause (e.g. headache, seizures or neuro. deficits, SoB or documented hypoxaemia), perform a CT brain ± CTPA
Airway & Breathing post ROSC
Airway
If alert, maintain sats >94% with supplementary O2
If comatose, intubate with neuroprotective RSI
After ROSC, use 100% inspired O2 ABGs available
Then titrate to sats 94-98% (PaO210-13 kPa)
Avoid hypoxia (PaO2 <8 kPa) or hyperoxaemia
Breathing
Obtain an ABG & use end tidal CO2 in ventilated patients
If ventilated, target normal PaCO2 (4.5–6.0 kPa)
Beware hypocapnia in TTM patients
Use lung protective vent. (TV 6-8 mL/Kg ideal body wt.)
Circulation
Emergent coronary angiography (±PCI) in those with STEMI
Consider cath. lab in those (ROSC in OHCA) without STEMI but with signs of ACS (e.g. haemodynamic/electrical instability
Art line in all
Low threshold for Resusc. room ECHO
Avoid hypotension (<65 mmHg)
Target MAP to achieve urine >0.5 mL/kg/hr and ↓ing/normal lactate
During TTM at 33°C, ↓HR may be left untreated if BP, lactate, SvO2 is adequate
If not, consider ↑ the target temp., but to no higher than 36°C
Maintain perfusion with crystalloids, noradrenaline and/or dobutamine as indicated
Do not give steroids routinely after cardiac arrest
Avoid hypokalaemia (assoc. with ventricular arrhythmias)
Consider mechanical circulatory support (e.g. intra-aortic balloon pump, ECMO) if above fail
Disability
Consider EEG monitoring if concern re seizures
Routine seizure prophylaxis is not indicated but use levetiracetam if seizing
In comatose patients (OHCA or IHCA), maintain TTM at 34-36°C
Avoid fever (>37.7°C) for at least 72h
Use short-acting sedatives and opioids
Avoid using a neuromuscular blocking drug routinely in patients undergoing TTM (unless shivering)
Provide stress ulcer and DVT prophylaxis routinely
Avoid hypoglycaemiain (<4.0 mmol/L) but maintain normoglycaemia
Start enteral feeding during TTM
No routine prophylactic antibiotics
Recommendations (UK Resusc Council 2021)
Post ROSC, maintain MAP > 65mmHg
Levetiracetam is preferred instead of phenytoin for seizures
Targeted temperature management (TTM) is recommended (post OHCA or IHCA)
Maintain temperature at a constant value betw. 32° - 36°C for for at least 24 h
Avoid fever (>37.7°C) for at least 72 h after ROSC in patients who remain in coma
In a comatose patient with a Glasgow Motor Score ≤ 3 at ≥ 72 h from ROSC, in the absence of confounders, poor outcome is likely when two or more of the following are present:
No pupillary and corneal reflexes at ≥ 72 h
Bilaterally absent N20 SSEP wave at ≥24 h
Highly malignant EEG (suppressed background or burst suppression) at ≥ 24 h
NSE >60 mcg L-1 at 48 h and/or 72 h
Status myoclonus ≤ 72 h or a diffuse and extensive anoxic injury on brain CT/MRI
Greater emphasis is placed on screening cardiac arrest survivors for physical, cognitive and emotional problems and, where indicated, referring for rehabilitation