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In emergency medicine, we are so heavily trained in resuscitation that any senior resident could recite the ACLS algorithm to you after being woken up at 3 am. However, the real work begins after the pulse return. Up to two-thirds of patients with return of spontaneous circulation (ROSC) will not survive to discharge.This approach, modeled after the 2015 American Heart Association Guidelinesand an excellent review article by Dr. Jacob Jentzer et al,can help guide you through the chaos to stabilize your next post-ROSC patient.

AIRWAY

If you have not already during active resuscitation period, now is the time to intubate the patient. Make sure the hemodynamics are stable first. If you can adequately ventilate the patient there is no rush to intubate until you are completely prepared. While you are at the head, place an orogastric (OG) or nasogastric (NG) tube to decompress the stomach, which will potentially improve ventilation and reduce aspiration risk.

BREATHING

Once the patient is intubated, set your ventilator to standard lung-protective settings (tidal volume 6-8 mL/kg). Although maximum oxygenation should be used during the arrest, the goal post-arrest is just to keep the SpO2 over 94%. Do this by adjusting the PEEP and FiO2. Avoid over-oxygenation. Bedside ultrasound can confirm endotracheal tube placement, but a chest x-ray should be performed as well. End-tidal CO2 monitoring should target normocarbia (ETCO2 30-40 mmHg or PaCO2 35-45 mmHg) unless there is a specific reason to do otherwise.

CIRCULATION

Electrocardiogram

A 12-lead ECG should be done as soon as possible after ROSC. Up to 30% of ROSC patients will have a ST-elevation myocardial infarction (STEMI) and they should go immediately to the cardiac catheterization lab.5,6 Since prognostication of post-ROSC patients is very difficult early on, this recommendation applies to comatose patients as well. Even patients without ST elevation on their ECG may benefit from angiography as up to 25% have an acute occlusion.7 Finally, an initial non-shockable rhythm is not an exclusion for emergent percutaneous coronary intervention (PCI) either as 25% of these patients also required coronary intervention after ROSC.8,9

Blood Pressure

The goal blood pressure is an SBP >90 mmHg and a MAP of >65 mmHg. Begin with standard crystalloid fluid resuscitation (30 mL/kg) while using ultrasound or a straight leg raise to determine fluid responsiveness. A central line and arterial line should be placed, and if the patient has persistent hypotension then norepinephrine should be started. Epinephrine is a reasonable second vasopressor, and dobutamine should be considered for poor contractility.

Diagnostic Tests

A bedside ultrasound should be performed to exclude some causes of the arrest, such as pericardial tamponade, tension pneumothorax, and possibly a massive pulmonary embolus. A CT chest angiogram should be considered to exclude a pulmonary embolism as this has a 3% prevalence in cardiac arrest survivors.10 Labs should be sent, including an arterial blood gas (for ventilator adjustment) and lactate (for trending). Place a Foley catheter to track urine output.

DISABILITY

Targeted Temperature Management (TTM) is currently recommended for all patients regardless of rhythm. The patient should be cooled to 32–36°C as soon as possible after ROSC using whatever technique is available in your institution, and kept cool for 24 hours.11 Control shivering as needed with sedation or paralysis and consider a non-contrast head CT to exclude intracranial hemorrhage.

Post-ROSC Checklist

System Action Airway Intubate → Ventilation tidal volume @ 6-8 mL/kg Place OG or NG tube Confirm endotracheal and OG/NG tube placement with chest x-ray Breathing SpO2 goal >94% → adjust PEEP & FiO2 to achieve goal EtCO2 goal 30-40 mmHg → adjust respiratory rate to achieve Circulation 12-lead ECG → Activate cardiac catheterization lab for STEMI; consult cardiology for all other patients SBP goal >90 mmHg (MAP > 65 mmHg) → Use fluids, norepinephrine infusion, then epinephrine infusion to achieve goal Place central line Place arterial line Perform point of care ultrasound with the cardiac, lung, and IVC views Send labs, which includes an arterial blood gas and serum lactate Place Foley catheter → Goal urine output 0.5-1 mL/kg/hr Consider CT chest angiography to rule-out a pulmonary embolism Disability Begin cooling → Goal temperature 32–36°C Consider head CT

For more information, Dr. Sean Kivlehan will be giving this talk at the 2017 UCSF High Risk Emergency Medicine Hawaii conference.

1. MMWR Surveill Summ. 2011;60(8):1-19. PubMed] McNally B, Robb R, Mehta M, et al. Out-of-hospital cardiac arrest surveillance — Cardiac Arrest Registry to Enhance Survival (CARES), United States, October 1, 2005–December 31, 2010.. 2011;60(8):1-19. 2. N Engl J Med. 2012;367(20):1912-1920. PubMed] Girotra S, Nallamothu B, Spertus J, et al. Trends in survival after in-hospital cardiac arrest.. 2012;367(20):1912-1920. 3. Circulation. 2015;132(18 Suppl 2):S465-82. PubMed] Callaway C, Donnino M, Fink E, et al. Part 8: Post-Cardiac Arrest Care: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.. 2015;132(18 Suppl 2):S465-82. 4. Ann Emerg Med. 2016;68(6):678-689. PubMed] Jentzer J, Clements C, Wright R, White R, Jaffe A. Improving Survival From Cardiac Arrest: A Review of Contemporary Practice and Challenges.. 2016;68(6):678-689. 5. J Am Coll Cardiol. 2013;61(4):485-510. PubMed] American C, Society for, O’Gara P, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.. 2013;61(4):485-510. 6. Circulation. 2013;128(7):762-773. PubMed] Peberdy M, Donnino M, Callaway C, et al. Impact of percutaneous coronary intervention performance reporting on cardiac resuscitation centers: a scientific statement from the American Heart Association.. 2013;128(7):762-773. 7. J Am Coll Cardiol. 2015;66(1):62-73. PubMed] Rab T, Kern K, Tamis-Holland J, et al. Cardiac Arrest: A Treatment Algorithm for Emergent Invasive Cardiac Procedures in the Resuscitated Comatose Patient.. 2015;66(1):62-73. 8. Circ Cardiovasc Interv. 2015;8(10). PubMed] Stær-Jensen H, Nakstad E, Fossum E, et al. Post-Resuscitation ECG for Selection of Patients for Immediate Coronary Angiography in Out-of-Hospital Cardiac Arrest.. 2015;8(10). 9. Resuscitation. 2017;113:83-86. PubMed] Wilson M, Grossestreuer A, Gaieski D, Abella B, Frohna W, Goyal M. Incidence of coronary intervention in cardiac arrest survivors with non-shockable initial rhythms and no evidence of ST-elevation MI (STEMI).. 2017;113:83-86. 10. Circulation. 2016;134(25):2125-2127. PubMed] Bougouin W, Marijon E, Planquette B, et al. Factors Associated With Pulmonary Embolism-Related Sudden Cardiac Arrest.. 2016;134(25):2125-2127. 11. Resuscitation. 2016;98:97-104. PubMed] Donnino M, Andersen L, Berg K, et al. Temperature Management After Cardiac Arrest: An Advisory Statement by the Advanced Life Support Task Force of the International Liaison Committee on Resuscitation and the American Heart Association Emergency Cardiovascular Care Committee and the Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation.. 2016;98:97-104.