OUR CASE
The paramedics transfer Drew straight into Resus in ED. He has an LMA in situ, and these are his obs:
HR 52
BP 92/50
Sats 96%
Normal ETCO2 trace, value 38
What is the most likely cause of Drew’s arrest?
Resus Priorities
Although these are listed here, you will obviously be doing much of this concurrently.
Overall concepts:
> Consider ECMO
> Continue respiratory support
> Maintain cerebral perfusion
> Treat and prevent cardiac arrhythmias
> Determine and treat the cause of the arrest, specifically getting to coronary angiography and intervention if appropriate
> Consider TTM
ECMO CPR (ECPR)
Obviously only in places and at times that this is an offered.
For patients who still have no ROSC but are getting CPR (usually mechanical), or who keep arresting or are about to arrest again.
Covered first here because this is a time critical intervention – ECMO team needs to be notified as soon as this is being considered.
Different services vary, this is one example:
INCLUSION CRITERIA Out of Hospital Arrests
ALL of:
Age 16-70
Suspected cardiac or respiratory cause
The cardiac arrest was witnessed
Chest compressions within 10 minutes
Initial cardiac rhythm VF/ VT
The cardiac arrest duration (collapse to arrival in ED) has been <45 minutes
INCLUSION CRITERIA In Hospital Arrests
ONE of:
Suspected ACS who arrests in ED AND does not respond to standard ACLS
Patient arrests in cardiac cath lab AND does not immediately respond to standard ACLS
Other potentially reversible cause, if artificial circulation was provided (e.g. PE)
Exclusion Criteria
Inclusion criteria not met
Active bleeding
Vascular condition making peripheral cannulation not feasible (e.g. Aortic dissection)
No realistic prospect of reversal of the underlying cardiac condition
Major co-morbidities (e.g. Active malignancy, severe brain injury, immunosuppressed, additional severe symptomatic chronic organ failure)
Limitation of medical treatment precludes further resuscitation
Not sure what ECPR is all about?
Lots of resources on this, one is here
Approximately 20% of patients rearrest within minutes of initial restoration of pulses.
Even without actual re-arrest, haemodynamic instability is very common
Patients resuscitated from cardiac arrest typically require intubation, mechanical ventilation, close cardiac and invasive hemodynamic monitoring, and intensive care management
PRACTICAL TIPS:
Keep pads in correct position and connected to defibrillator
Insert arterial line and central line
Have bolus dose vasopressors available to maintain blood pressure
Have antiarrhythmics available
Use ETCO2 monitoring
Consider eligibility for, and practicalities of, VA ECMO prior to re-arrest
If an antiarrhythmic restored a stable rhythm, continue an infusion of the same medication e.g. amiodarone
In context of recurrent VF, load and infuse amiodarone
> Definitely Keep MAP > 65
> Some advocate to keep MAP >80 mmHg Why?
> This may require IV fluids and vasopressors
Consider:
> Volume resuscitation and blood pressure goals with cerebral perfusion and prevention of secondary brain injury in mind
> Rapid PCI when patient is identified as a candidate for intervention
> Do the basics to optimise intracranial pressure (more here)
- Head of bed 30-45 degrees. In patients with spinal precautions, tilt the bed head up.
- Avoid constrictive ETT ties. Instead opt for brown ‘neuro’ tube tapes or EDATs
- Keep the head in a neutral position
- Avoid straining as this may raise intrathoracic pressure e.g. coughing, pain, constipation, ventilator asynchrony
- Replace cervical collars with sandbags
Urgent Percutaneous Coronary Intervention If:
- STEMI or new LBBB on ECG
- Not the above but still high probability of acute coronary occlusion (e.g. patients with haemodynamic and/or electrical instability, no other obvious cause).
ECG
CXR
- ETT / lines / NGT placement
- ?Pneumothorax
- Heart size
ABG
- For blood glucose and lactate
Bloods
- Troponin (essential)
- Blood cultures, CRP, PCT if sepsis considered (rarely needed)
Urine
- For tox screen if appropriate (rarely needed)
Ultrasound
- Exclude cardiac tamponade
- Look for signs of PE
- Cardiac function / regional wall motion abnormality
- Abdomen – blood or ascites
- Legs – ?DVT if PE possible
CT
- Non-contrast CT head to exclude aSAH or other intracranial pathology (essential)
- CTPA if PE suspected (rarely needed)
- CT abdo / pelvis if that’s a potential source of sepsis / bleeding (rarely needed)
Next steps
Refer
If potentially for ECPR, call ECMO team as soon as you hear of patient, even if all details not yet known
If no good evidence of non-cardiac cause, discuss with cardiology about potential PCI early
Communicate:
Age, known medical history
Details of arrest
Duration of arrest
Time to CPR
Duration of CPR
Initial rhythm
PCI eligibility
TTM / temperature
Current temp
Medications