Post Resuscitation CarePost Resuscitation Care

““Restart the Heart and Keep it RestartedRestart the Heart and Keep it Restarted””

Dr. Rashidi AhmadDr. Rashidi AhmadMalaysian Association of Emergency Medicine Malaysian Association of Emergency Medicine

(MAEM)(MAEM)

AimAim

To create an awareness that post To create an awareness that post resuscitation intervention is as important resuscitation intervention is as important as resuscitation itself as resuscitation itself To highlight the proper resuscitation careTo highlight the proper resuscitation careTo save human livesTo save human lives

OutlineOutline

Understanding post resuscitation phase & Understanding post resuscitation phase & carecareCauses of failure post resuscitationCauses of failure post resuscitationPrinciples post resuscitation care Principles post resuscitation care MxMxDiscuss by an examplesDiscuss by an examples

IntroductionIntroduction

Phases of Resuscitation: resuscitation & post Phases of Resuscitation: resuscitation & post resuscitationresuscitationOutcome: death or ROSCOutcome: death or ROSCUpon ROSC patient may:Upon ROSC patient may:

Awake with stable hemodynamic Awake with stable hemodynamic Remain comatose with unstable circulationRemain comatose with unstable circulationHalf of death occurs first 24 hrsHalf of death occurs first 24 hrsOver 1 to 3 days: sepsis syndrome and MOFOver 1 to 3 days: sepsis syndrome and MOFDays later; rapid deterioration Days later; rapid deterioration →→ DeathDeathPost resuscitation syndromePost resuscitation syndrome

Post resuscitation syndromePost resuscitation syndrome

Reperfusion failureReperfusion failureReperfusion injuryReperfusion injuryCerebral intoxication from ischemic Cerebral intoxication from ischemic metabolitesmetabolitesCoagulopathyCoagulopathy

CPR related injuriesCPR related injuries

In a study of CPR related autopsy findings:In a study of CPR related autopsy findings:40% of patients had injuries related to 40% of patients had injuries related to closed chest CPR, i.e. fractured ribs, closed chest CPR, i.e. fractured ribs, sternum, bone marrow emboli to lung, sternum, bone marrow emboli to lung, mediastinalmediastinal bleeding, etc.bleeding, etc.

What is post resuscitation What is post resuscitation care?care?

Post resuscitation care is referred to a period Post resuscitation care is referred to a period between restoration of a spontaneous circulation between restoration of a spontaneous circulation and transfer of patient care to another healthcare and transfer of patient care to another healthcare provider who assumes responsibility.provider who assumes responsibility.In general, this period will be less than 30 In general, this period will be less than 30 minutes (CRUCIAL TIME)minutes (CRUCIAL TIME)The immediate goal is to provide cardioThe immediate goal is to provide cardio--respiratory support to optimize tissue perfusion, respiratory support to optimize tissue perfusion, especially to the brain. especially to the brain.

Principles of Post Principles of Post resusresus MxMx

Avoid CPA recurrenceAvoid CPA recurrenceRestore perfusion & oxygenation of regional Restore perfusion & oxygenation of regional organ & cell tissuesorgan & cell tissuesContinuous Continuous ABCDsABCDs of Primary and Secondary of Primary and Secondary surveyssurveysEvaluate and monitor neurologic functions Evaluate and monitor neurologic functions (restoration of cerebral circulation) (restoration of cerebral circulation) Support other dysfunction organsSupport other dysfunction organsResolve the situation that promoted CPA Resolve the situation that promoted CPA

Scenario 1Scenario 1

46 years old man, had severe ischemic chest 46 years old man, had severe ischemic chest pain since an hour ago.pain since an hour ago.Suddenly he had Suddenly he had pulselesspulseless ventricular ventricular tachycardia.tachycardia.Immediate Immediate asynchronizedasynchronized cardioversioncardioversionreverted the rhythm.reverted the rhythm.What is your next step?What is your next step?

Scenario 2Scenario 2

6 years old boy, near drowning6 years old boy, near drowningCardiopulmonary resuscitation was Cardiopulmonary resuscitation was commencedcommencedROSC after 45 minutes ROSC after 45 minutes What is your next step?What is your next step?

Scenario 3Scenario 3

37 years old man had MVA (high velocity 37 years old man had MVA (high velocity injury)injury)He sustained head injury & He sustained head injury & intraabdominalintraabdominalinjuryinjuryHemodynamic unstable Hemodynamic unstable While on fluid resuscitation he developed VTWhile on fluid resuscitation he developed VTWhat is your next step?What is your next step?

Airway & respiratory systemAirway & respiratory system

1. Is the patient intubated?YES: rapidly assess patency, position, security, and oxygenationNO: rapidly assess the need for intubation, i.e. oxygenation, mental status, other considerations.

INTUBATE if any indication for it exists.

Airway & respiratory systemAirway & respiratory system

2. All patients will receive supplemental oxygen.Assessment of adequate ventilation and oxygenation:Pulse oximetryABG's (if already available)Physical exam (i.e. breath sounds, symmetrical chest expansionRespiratory character, skin color, midline trachea)

Airway & respiratory systemAirway & respiratory system

3. Consider mechanical impediments to adequate respiration, and pursue treatment of these when feasible:Tension pneumothorax, pneumothorax, and hemothoraxFlail chestMucous pluggingInterstitial edemaImproperly places endotracheal tube

Mechanical VentilationMechanical Ventilation

Volume ventilatorVolume ventilator--assistassist--control or control or intermittent mandatory ventilation (IMV)intermittent mandatory ventilation (IMV)Tidal volume = ideal weight in kg x 10Tidal volume = ideal weight in kg x 10I:E ratio 1:2 or 1:1.5I:E ratio 1:2 or 1:1.5Respiratory rate: 10Respiratory rate: 10--12 times/min12 times/minOxygen FiO2 Oxygen FiO2 -- 1.0 (100%) 1.0 (100%) Sensitivity: 2 cmH2O for assistSensitivity: 2 cmH2O for assist--controlcontrolHumidifier: 36Humidifier: 36°° CCPEEP: 5 cmH2O, increased as requiredPEEP: 5 cmH2O, increased as required

Circulatory systemCirculatory system

1. Assess the status of the circulatory system:Clinical indicators: skin temperature, capillary refill, quality of pulses, level of consciousness Monitor parameters: heart rate and rhythm, BP, urine output (use of Foley catheter when available)PMH and current medications

Circulatory systemCirculatory system

2. Support inadequate circulatory system:Hypotension - if there is evidence of bleeding, treat with IV crystalloids and blood productsFor evidence of cardiogenic shock, septic shock or spinal shock – treat appropriatelyProphylactic drugs for reverted VF/VTWell function cardiac pace makerMaintain the drug infusion preferably via central line

General surveyGeneral surveyAfter stabilization of the respiratory and circulatory systems, a general survey of the entire patient should be performed.Look for a cause and precipitating causes of CASerial exams of areas of particular concern should be performed.Serial review of vital signsReview ECG and Chest x rayReview ABG, and pH, serum electrolytes, Review ABG, and pH, serum electrolytes, magnesium and calciummagnesium and calcium

Chest XChest X--RayRay

Position of Position of endotrachealendotracheal tubetubePosition of central venous catheterPosition of central venous catheterPneumothorax, Pneumothorax, hemothoraxhemothorax, hydrothorax, hydrothoraxPulmonary edema, CHFPulmonary edema, CHFCardiac Cardiac silhouttesilhoutteDiaphragmsDiaphragmsRib fractureRib fracture

Other considerationsOther considerations

Optimally, there should be two well-secured, functioning intravenous lines.A nasogastric tube (or orogastric) is useful to keep the stomach decompressed, especially in patients receiving positive-pressure ventilation.Preserve body temperature.Stop the seizure

Communication & documentationCommunication & documentation

It is important to maintain a collaborative approach to patient care utilizing the referring physicians/nurses' report and suggestions prior to liftoff. Resus notes should include the history, assessmentfindings, and any treatments done by the referring EMS or hospital personnel. It is acceptable to state "see transfer notes," for particular details, and write out only the most prominent interventions.

TransferTransfer

Transfer to special care unit as soon as possible Transfer to special care unit as soon as possible by senior most experience personalby senior most experience personalSupport ventilation and provide oxygenationSupport ventilation and provide oxygenationMonitor ECG, oxygen saturation and BPMonitor ECG, oxygen saturation and BPPrior to transport, make sure IV is securedPrior to transport, make sure IV is securedTransport with portable monitor, defibrillatorTransport with portable monitor, defibrillatorOxygen with connections to bagOxygen with connections to bag--valvevalve--systemsystemResusResus drugs must accompany the patientdrugs must accompany the patient

Take Home Message Take Home Message

Resuscitated the heart, restore the brainResuscitated the heart, restore the brainTreat the patient, not the arrhythmiaTreat the patient, not the arrhythmiaThe value of unbroken Chain of Survival:The value of unbroken Chain of Survival:Time is criticalTime is criticalSeek and treat the cause, not just the Seek and treat the cause, not just the conditioncondition