POST-CARDIAC ARREST CARE (ROSC MANAGEMENT)
Post-cardiac arrest care begins immediately after return of spontaneous circulation (ROSC) and is critical for improving survival and neurological recovery. Without proper management, patients remain at high risk for hemodynamic instability, brain injury, and recurrence of cardiac arrest.
Why It’s Important:
Prevents secondary organ damage (especially the brain & heart). Optimizes oxygenation, circulation, and neurological recovery. Reduces the risk of recurrent cardiac arrest and multi-organ failure.
IMMEDIATE POST-ROSC CARE (FIRST 10 MINUTES)
Step 1: Airway & Breathing – Secure & Optimize Oxygenation
- Confirm & secure the airway (Endotracheal intubation is often needed).
- Provide mechanical ventilation – Titrate oxygen to maintain SpO₂ 92-98% (Avoid hyperoxia!)
- Monitor capnography (EtCO₂ goal: 35-45 mmHg) – Prevent hypoventilation or hyperventilation.
Step 2: Circulation – Optimize Hemodynamics
- Treat hypotension (SBP < 90 mmHg) with IV fluids & vasopressors (e.g., norepinephrine, epinephrine, dopamine).)
- Maintain Mean Arterial Pressure (MAP) ≥ 65 mmHg to ensure brain perfusion.
- Obtain a 12-Lead ECG – Identify STEMI or other cardiac abnormalities.
Step 3: Identify & Treat the Underlying Cause (Hs & Ts)
- Consider immediate PCI if STEMI is detected – Urgent coronary angiography is often needed.
- Check for reversible causes (Hs & Ts) → Hypoxia, Hypovolemia, Hydrogen ion (Acidosis), Hyper/Hypokalemia, Hypothermia, Tension Pneumothorax, Tamponade, Toxins, Thrombosis (PE or MI).
Key Takeaway: Post-ROSC care should immediately focus on oxygenation, circulation, and identifying reversible causes!
TARGETED TEMPERATURE MANAGEMENT (TTM)
What is TTM?
Targeted Temperature Management (TTM) (formerly called therapeutic hypothermia) is used for comatose patients after ROSC to reduce brain injury and improve neurological outcomes.
Who Needs TTM?
Patients who remain comatose (unresponsive) after ROSC. Especially for out-of-hospital cardiac arrest (OHCA) due to VF/pVT.
TTM Protocol
Lower body temperature to 32-36°C for 24 hours (Cool using ice packs, cooling blankets, or IV cold fluids). Avoid rapid rewarming—gradually warm at 0.25-0.5°C per hour. Prevent shivering with sedation & paralytics (e.g., Midazolam, Propofol, Vecuronium).
Key Takeaway: TTM significantly improves neurological outcomes—cool comatose ROSC patients!
CORONARY ANGIOGRAPHY (IF STEMI IS PRESENT)
Perform an immediate PCI if STEMI or acute coronary syndrome (ACS) is suspected. If STEMI is absent, assess for other causes (Hs & Ts) before deciding on PCI. Obtain cardiology consultation for further evaluation.
Key Takeaway: If ECG shows STEMI, the patient must go to the cath lab immediately!
GLUCOSE CONTROL & NEUROLOGICAL MONITORING
Avoid hyperglycemia (Target Blood Glucose: 80-180 mg/dL). Frequent neurological exams (Pupillary response, motor function). Monitor for seizures (EEG may be needed if unexplained unresponsiveness persists).
Key Takeaway: Neurological damage is a major concern after cardiac arrest—monitor closely!
SEIZURE MANAGEMENT
Post-cardiac arrest seizures are common and can worsen brain injury. If seizures occur, treat with benzodiazepines (e.g., Lorazepam, Midazolam). Consider continuous EEG monitoring in comatose patients.
Key Takeaway: Uncontrolled seizures worsen outcomes—treat aggressively!
HEMODYNAMIC MANAGEMENT & PREVENTING RE-ARREST
Maintain SBP ≥ 90 mmHg and MAP ≥ 65 mmHg Use fluids (NS or LR) if hypovolemic. Vasopressors (Norepinephrine, Epinephrine, Dopamine) if BP remains low. Avoid excessive fluids in heart failure patients (consider diuretics).
Key Takeaway: Preventing hypotension prevents secondary brain injury!
MULTIDISCIPLINARY CARE & TRANSPORT
Transfer to an ICU with post-cardiac arrest expertise. Involve neurology, cardiology, and critical care teams. Ensure continuous cardiac monitoring and advanced critical care support.
Key Takeaway: Post-ROSC patients require ICU-level care for best survival outcomes!
COMMON MISTAKES & HOW TO AVOID THEM
| Mistake | Impact | Prevention |
|---|---|---|
| Over-oxygenation (FiO₂ 100% for prolonged periods) | Causes oxygen toxicity, worsens neurological outcomes | Titrate O₂ to SpO₂ 92-98% |
| Not recognizing STEMI in post-ROSC ECG | Misses opportunity for urgent PCI | Always obtain 12-lead ECG post-ROSC |
| Not initiating TTM in comatose patients | Increases risk of severe brain injury | Start cooling for comatose ROSC patients! |
| Delaying BP stabilization | Leads to poor brain perfusion | Maintain MAP ≥ 65 mmHg with fluids & pressors |
| Not treating post-cardiac arrest seizures | Worsens neurological recovery | Use benzodiazepines & continuous EEG if needed |
Key Takeaway: Avoid these common post-cardiac arrest pitfalls to improve survival and neurological function!
SUMMARY: MASTERING POST-CARDIAC ARREST CARE
Secure the airway, provide oxygen (SpO₂ 92-98%), and optimize ventilation (EtCO₂ 35-45 mmHg). Maintain SBP ≥ 90 mmHg, MAP ≥ 65 mmHg (fluids & vasopressors as needed). Get a 12-lead ECG—perform urgent PCI if STEMI is detected. Use Targeted Temperature Management (TTM) for comatose ROSC patients. Monitor glucose, seizures, and neurological function closely. Transport to an ICU for multidisciplinary post-arrest care.
Takeaway: Post-cardiac arrest care is crucial for survival—optimizing oxygenation, circulation, and brain recovery is key!