Download - Post resuscitation care
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Post Resuscitation Care
By Kane Guthrie
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Objectives
• Case study• Understand post-resuscitation care• Look at therapeutic hypothermia
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Cardiac Arrest the Stat’s
• Generally 6-7% survival rate (worldwide)• 0nly 3-4% leave hospital with RONF• Early Defib/compressions make the difference• Post resuscitation care is the answer to
improving mortality and morbidity with ROSC.
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The New Guidelines!!
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Case Study
• 68 male walking home from pub• Collapse > Cardiac Arrest >Bystander CPR• SJA arrive 13mins post arrest• In VF, Successful ROSC post x3 defibs• Arrives in T2 20 mins later with no RONF• What should we do now?
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Post Resuscitation Care
• What is it?• Where does it start?• Why is it done poorly?• What is Post Cardiac Arrest Syndrome?• What is Therapeutic Hypothermia?
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Post Cardiac Arrest Syndrome!!
• Thought to be RT production of free radicals• Pathophysiology is very complex = BORING• Hypoperfusion & Ischaemia cause cascade of
events1. Disruption of homeostasis
2. Free radical formation
3. Protease activation
• Hypothermia helps slow down this cascade
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The Big 4 in Postcardiac Arrest Syndrome
1. Postcardiac arrest brain injury •Disruption of cerebral perfusion may result in Ischaemia/hyperaemia
2. Postcardiac arrest myocardial dysfunction
•Initially heart becomes hyperkinetic from catecholamine's, then global hypokinesis follows
3. Systemic Ischaemia/reperfusion Response
•Similar to septic shock, activation of immune and compliment systems, release inflammatory cytokines, wide range of cellular responses
4. Persistent precipitating pathology • Cause of arrest may continue to impact physiological parameters
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Therapeutic Hypothermia
• ‘Induced hypothermia” is were pt is deliberately cooled between 32-33.9°C
• It aims to reduce hypoperfusion (& reperfusion) injury post arrest.
• Focuses mainly on brain (neuroprotection), but offers protection to heart, liver, kidneys.
• Current research shows benefit of inducing TH before or during event.
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Therapeutic Hypothermia
• Therapeutic hypothermia is the first treatment that has proven effective for post-resuscitation
reperfusion injury.
• NNT 1:6 vs 1:42 for aspirin in STEMI
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Who’s up for it?
• Cardiac arrest with ROSC • Persistent significant altered level of
consciousness• <12 hours from time of ROSC• Patients >18 years
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Who’s on the Fence?
Relative:• Persistent hypotension (MAP <60, SBP<90)
despite use of inotropes and vasoconstrictors Note:Hypothermia will cause vasoconstrictionAnd help ∧BP
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Who’s not?
• Advanced directive stipulating DNR (absolute)• Traumatic arrest• Active bleeding (including intracranial)• Pregnancy, recent major surgery, severe sepsis
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What are the 3 Phase’s of TH?
Induction• Aim reduce core temp 32-34°C (within 6 hours,
preferably 2 hours)Maintenance• Maintain core body temp for 12-24Rewarming • Either controlled or passive rewarming to
normothermia 37°C• 0.2-0.5°C per hour –over 8-12 hours
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ED Management
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Cooling Methods
• Cold saline (during arrest & post arrest)• ICE Packs (axilla, groin) Keep pt dryMonitor skin integrity• Machine (Vest, Artic Ice)
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What you need
• Patient airway secured (sedated & paralyzed)• ICE and bags• Cold saline• 12 lead ECG• Artline• NGT• IDC• Rectal probe• ?CVC
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ED ManagementAirway • secure ETT, continuous EtCO2
Breathing •Prevent VILI
Circulation •ECG (risk arrhythmias)•Monitor U/O (cold diuresis)
Disability •Paralyze, sedate
Exposure •Core temp monitoring•Monitoring skin integrity•Once at 34°C remove ICE packs & maintain•Monitor and prevent shivering
•Prepare patient for T/F to ICU, Cath Lab
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Monitoring the bloods
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Remember the basics
• Pressure area care• VTE prophylaxis• Stress ulcer prophylaxis• Lung protective ventilation• Nutrition• Social support (family)
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Complications
• Tachycardia > bradycardia• Hypertension• Diuresis (hypovolaemia)• Shivering (increases temp)• Arrhythmia's• Increase bleeding• Spiking temp’s look for signs of infection
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Questions
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Thank-You