FRCA Notes

Post-Resuscitation Care

As with cardiac arrest itself, post-resuscitation care is largely under the auspices of the guidelines from the Resus Council.

Once again, Deranged Physiology has a plethora of pages on the topic for those seeking more detail.

There is a separate page on prognostication post-cardiac arrest.

My notes here represent a relatively brief A-E aide memoire for those short on time.

Resources

Airway

  • Intubate the patient, if not already
  • The exception is the patient with a very brief arrest who is subsequently awake and oxygenation/ventilating appropriately

Breathing

  • Mechanically ventilate the patient according to local preference for mandatory mode
  • Aim for:
    • Normoxia i.e. saturations 94 - 98% (avoid both hypoxia and hyperoxia)
    • Normocapnoea i.e. PaCO2 4.5 - 6.0kPa
      • The recently published TAME trial (2023) found no benefit to mild hypercapnoea (6.5 - 7.3kPa), though reassuringly no harm either
    • Lung-protective ventilatory strategy i.e. 6-8ml/kg IBW tidal volume

  • Perform early PCI if STEMI
  • Perform TTE as soon as possible

  • Aim for a MAP of 65mmHg (- 70mmHg)
    • Higher MAPs may not add benefit

  • Target MAP should acheive 0.5ml/kg/hr urine output
  • One can use IV fluid, vasopressors (commonly noradrenaline) or positive inotroptes (commonly dobutamine) to achieve target MAP based on individual requirements
  • Do not routinely give steroids

  • Sedate using short-acting sedatives and opioids; generally better to avoid benzodiazepines
  • Avoid routine use of NMBA, except for shivering in the patient undergoing TTM which fails to respond to other methods

  • Do not routinely give anti-epileptic drug prophylaxis
  • If suffering seizures, keppra or valproate are preferred to phenytoin (see separate notes on post-hypoxic myoclonus)

  • This is an area of intense, ongoing research and debate
  • It's a bit of a headache, though LITFL has an excellent summary
  • Relevant trials include TTM (2013), Hyperion (2019), TTM2 (2021), the ongoing TAME trial
  • In brief:
    • Do not actively re-warm patients unless their temperature is <33°C
    • Regular paracetamol
    • Avoid hyperthermia (>37.7°C) for 72hrs in those comatose post-ROSC

  • Start enteral feeding
  • Provide stress ulcer prophylaxis
  • Standard glycaemic control measures apply

  • Provide VTE prophylaxis

  • No place for routine use of antibiotics