❤️ Chapter 69: Post-Cardiac Arrest Care

ROSC · Therapeutic hypothermia (32-34°C) · Post-arrest myocardial stunning · CPP optimisation · Avoid hyperoxia/hypocapnia · Seizure control · ECMO (ECPR) · Prognosis: GCS ≤5 at 72h poor outcome

🔍 Core Concepts: Post-Cardiac Arrest Care

📌 ROSC Goals
Stabilise ABCs, maintain CPP, prevent secondary injury. Therapeutic hypothermia (32-34°C for 24h) improves neurological outcome in adults and neonates (extrapolated to children).
❄️ Therapeutic Hypothermia
Initiate soon after ROSC if patient cannot follow commands. Cooling methods: cold IV fluids (4°C NS 10-30 mL/kg), cooling blankets, intravascular catheters. Rewarm slowly (0.3-0.5°C/h). Avoid hyperthermia.
🫀 Myocardial Support
Post-arrest myocardial stunning (global hypokinesis) common. Echocardiogram within 12h. Support with inotropes (dobutamine, milrinone) or vasopressors (dopamine, norepinephrine). Avoid hypotension, maintain age-appropriate BP.
🧠 Neurological Management
Target normocapnia (PaCO2 35-45), normoxia (SpO2 94-98%, avoid hyperoxia), normoglycaemia (80-180 mg/dL), treat seizures (EEG if comatose). CPP optimisation (MAP - ICP >40-50).
📊 Prognosis
GCS ≤5 with myoclonic jerks at 72h predicts poor outcome. Absent pupillary/corneal reflexes at 72h poor. SSEP (absent N20) poor. Therapeutic hypothermia may delay prognostication.
🔄 ECPR (ECMO-CPR)
Consider for refractory cardiac arrest with reversible cause. VA-ECMO provides circulatory and respiratory support. Requires experienced centre.

🩺 Stepwise Approach: Post-Cardiac Arrest Care

1
Immediate post-ROSC stabilisation
Secure airway (if not already), confirm ETT position, set ventilator to normocapnia (PaCO2 35-45), FiO2 to SpO2 94-98% (avoid hyperoxia). Obtain 12-lead ECG, bedside echo (assess myocardial function).
2
Targeted temperature management (TTM)
If patient not following commands, initiate hypothermia to 32-34°C within 6h. Methods: cold IV fluids (10-30 mL/kg 4°C NS), cooling blankets. Maintain 24h, then rewarm slowly (0.25-0.5°C/h).
3
Haemodynamic optimisation
Treat hypotension (maintain age-appropriate MAP). Use inotropes (dobutamine) for low cardiac output, vasopressors (norepinephrine) for low SVR. Goal CPP >40-50 mmHg if ICP elevated.
4
Ventilation & oxygenation
Avoid hyperoxia (FiO2 1.0) once SpO2 >94% — wean to lowest FiO2. Avoid hypocapnia (PaCO2 <30) — causes cerebral vasoconstriction. Normocapnia target.
5
Neurological monitoring & seizure control
Continuous EEG if comatose or on neuromuscular blockers. Treat seizures (benzodiazepines, levetiracetam). Prognostication at 72h (GCS, SSEP, MRI).
6
Glycaemic & metabolic control
Maintain normoglycaemia (80-180 mg/dL). Avoid hypoglycaemia. Monitor electrolytes (K, Mg, PO4). Treat fever aggressively.