Case of the Month #12 - cardiac arrest

Published 02/02/2022

Optimising recovery/ critical care management

  • Temperature control
    • Targeted Temperature Management (TTM)2, previously known as therapeutic hypothermia, of 32-36oC degrees for ≥ 24h with prevention of fever (temperature >37.5oC) is suggested to be neuroprotective.1
    • TTM should be considered in OHCA survivors who remain unresponsive after ROSC
    • Shivering should be treated with adequate sedation +/- neuromuscular blockade.
    • Rewarm by 0.25-0.5 degrees oC/hour after 24 hours of TTM to normothermia1
    • Contraindications to TTM: severe systemic infection, pre-existing medical coagulopathy, cardiac dysrhythmias.1
  • Optimise haemodynamics
    • Target MAP/ SBP to achieve adequate urine output (0.5-1ml/kg/hr), with a normal/ decreasing plasma lactate1,3
    • Bradycardias associated with induced hypothermia ≤40 bpm may be left untreated (as long as BP and lactate are adequate)
    • Some centres use intra-aortic balloon pumps (IABP) in patients with cardiogenic shock – however, IABP-SHOCK II trial failed to show improvements in 30-day mortality
    • Consider implantable cardioverter defibrillator (ICD) placement in patients with significant left ventricular dysfunction or persistent ventricular arrhythmias >24h after primary coronary event (in most circumstances, this will be once the patient has been discharged from the critical care unit).1
  • Normoglycaemia
    • Aim blood ≤10 mmol/L and avoid hypoglycaemia.1
    • Do not implement strict glucose control as this increases risk of hypoglycaemia and associated complications
  • Diagnose/ treat seizures
    • Routine seizure prophylaxis is not recommended1
  • Echo
    • To optimise cardiac output and estimate myocardial recovery.
  • Delay prognostication for ≥72hrs after rewarming
    • Neurological prognostication remains a challenge and should involve combining results of the following: physical examination (particularly pupillary response, corneal reflex and best motor response), electroencephalogram (EEG), neuroimaging of CT or MRI, somatosensory evoked potentials (SSEPs) and neurone-specific enolase (NSE) levels (if available).