9 post resuscitation care 2010v1
TRANSCRIPT
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Lecture
Post Resuscitation Care
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Learning outcomes
To understand:
The need for continued resuscitation after return of spontaneous circulation
How to treat the post cardiac arrest syndrome
How to transfer the patient safely
The role and limitations of assessing prognosis after cardiac arrest
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Chain of Survival
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Post resuscitation care
The goal is to restore:
Normal cerebral function
Stable cardiac rhythm
Adequate organ perfusion
Quality of life
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Post cardiac arrest syndrome
Post cardiac arrest brain injury:– Coma, seizures, myoclonus
Post cardiac arrest myocardial dysfunction
Systemic ischaemia-reperfusion response– ‘Sepsis-like’ syndrome
Persistence of precipitating pathology
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Airway and breathing
Ensure a clear airway, adequate oxygenation and ventilation
Consider tracheal intubation, sedation and controlled ventilation
Pulse oximetry: – Aim for SpO2 94 – 98%
Capnography:– Aim for normocapnia– Avoid hyperventilation
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Airway and breathing
Look, listen and feel
Consider:– Simple/tension pneumothorax– Collapse/consolidation– Bronchial intubation– Pulmonary oedema– Aspiration– Fractured ribs/flail segment
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Airway and breathing
Insert gastric tube to decompress stomach and improve lung compliance
Secure airway for transfer
Consider immediate extubation if patient breathing and conscious level improves quickly after ROSC
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Circulation
Pulse and blood pressure
Peripheral perfusion e.g. capillary refill time
Right ventricular failure– Distended neck veins
Left ventricular failure– Pulmonary oedema
ECG monitor and 12-lead ECG
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Disability
Neurological assessment:
Glasgow Coma Scale score
Pupils
Limb tone and movement
Posture
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Glasgow Coma Scale score
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Further assessment
HistoryHealth before the cardiac arrest
Time delay before resuscitation
Duration of resuscitation
Cause of the cardiac arrest
Family history
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Further assessment
MonitoringVital signsECGPulse oximetryBlood pressure e.g. arterial lineCapnographyUrine outputTemperature
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Further assessment
InvestigationsArterial blood gases Full blood countBiochemistry including blood glucoseTroponinRepeat 12-lead ECG Chest X-rayEchocardiography
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Chest X-ray
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Transfer of the patient
Discuss with admitting teamCannulae, drains, tubes securedSuctionOxygen supplyMonitoringDocumentationReassess before leavingTalk to family
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Out-of-hospital VF arrest associated with AMI
Pacing
Cooling
IABP
Defibrillator
Inotropes
Ventilation
Enteral nutrition
Insulin
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Optimising organ functionHeart
Post cardiac arrest syndrome
Ischaemia-reperfusion injury:– Reversible myocardial dysfunction for 2-3 days– Arrhythmias
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Optimising organ functionHeart
Poor myocardial function despite optimal filling:– Echocardiography– Cardiac output monitoring– Inotropes and/or balloon pump
Mean blood pressure to achieve: – Urine output of 1 ml kg-1 hour-1 – Normalising lactate concentration
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Optimising organ functionBrain
Impaired cerebral autoregulation – maintain ‘normal’ blood pressureSedationControl seizuresGlucose (4-10 mmol l-1)NormocapniaAvoid/treat hyperthermiaConsider therapeutic hypothermia
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Therapeutic hypothermiaWho to cool?
Unconscious adults with ROSC after VF arrest should be cooled to 32-34oC
May benefit patients after non-shockable/in-hospital cardiac arrest
Exclusions: severe sepsis, pre-existing medical coagulopathy
Start as soon as possible and continue for 24 h
Rewarm slowly 0.25oC h-1
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Therapeutic hypothermiaHow to cool?
Induction - 30 ml kg-1 4oC IV fluid and/or external cooling
Maintenance - external cooling:– Ice packs, wet towels– Cooling blankets or pads– Water circulating gel-coated pads
Maintenance - internal cooling– Intravascular heat exchanger– Cardiopulmonary bypass
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Therapeutic hypothermiaPhysiological effects and complications
Shivering: sedate +/- neuromuscular blocking drug Bradycardia and cardiovascular instabilityInfectionHyperglycaemiaElectrolyte abnormalitiesIncreased amylase valuesReduced clearance of drugs
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Assessment of prognosis
No clinical neurological signs can predict outcome < 24 h after ROSC
Poor outcome predicted at 3 days by:– Absent pupil light and corneal reflexes– Absent or extensor motor response to pain
But limited data on reliability of these criteria after therapeutic hypothermia
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Organ donation
Non-surviving post cardiac arrest patient may be a suitable donor:
– Heart-beating donor (brainstem death)
– Non-heart-beating donor
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Any questions?
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Summary
Post cardiac arrest syndrome is complex
Quality of post resuscitation care influences final outcome
Appropriate monitoring, safe transfer and continued organ support
Assessment of prognosis is difficult