What is the management for perioral twitching after Cardiopulmonary Resuscitation (CPR) and Direct Current (DC) cardioversion revival?

Management of Perioral Twitching After CPR and DC Cardioversion

Perioral twitching following CPR and DC cardioversion should be treated with magnesium sulfate as first-line therapy, especially if associated with QT prolongation or suspected electrolyte disturbances.

Causes and Assessment

• Perioral twitching after cardiac arrest and resuscitation is often related to electrolyte disturbances, particularly magnesium deficiency, calcium abnormalities, or metabolic acidosis that commonly occur during the post-cardiac arrest period 1
• Cardiac arrest causes a cascade of metabolic and electrolyte disturbances throughout the body triggered by loss of cardiac output, which can manifest as muscle twitching and other neurological symptoms 1
• Post-resuscitation arrhythmias and their treatments (particularly antiarrhythmic medications) may contribute to perioral twitching 2
• Assess for QT interval prolongation, as perioral twitching may be an early manifestation of torsades de pointes, especially if the patient received medications that prolong QT interval during resuscitation 2

Management Algorithm

First-line Treatment:

1. Administer IV magnesium sulfate:

   • Indicated especially if twitching is associated with QT prolongation or suspected torsades de pointes 2
   • Magnesium is the treatment of choice for polymorphic VT associated with acquired long QT syndrome 2
   • Dosage: 1-2g IV over 5-15 minutes 2

2. Correct other electrolyte abnormalities:

   • Check and correct serum potassium, calcium, and sodium levels 1
   • Severe hypokalaemia and hyperkalaemia should be avoided as they can worsen neuromuscular symptoms and cardiac instability 1

Second-line Treatments:

1. For persistent twitching with hemodynamic stability:

   • Consider benzodiazepines for symptomatic relief if twitching is severe or distressing 2
   • Monitor for and treat agitation and seizures which may accompany or be confused with perioral twitching 2

2. For twitching associated with arrhythmias:

   • If twitching is related to ongoing arrhythmias, selection of optimal drug therapy depends on underlying cardiac pathology 2
   • Amiodarone or lidocaine may be considered if ventricular arrhythmias are present 2
   • Avoid drugs that prolong QT interval if long QT syndrome is suspected 2

Special Considerations

• Post-resuscitation monitoring: Target hemodynamic goals to optimize tissue perfusion as indicated by adequate urine output (1 ml/kg/h) and normal or decreasing plasma lactate values 2
• Blood glucose management: Monitor for and treat hypoglycemia, as it can exacerbate neurological symptoms including muscle twitching 2
• Avoid triggers: Minimize use of medications that can worsen electrolyte disturbances or prolong QT interval 2
• Cardiac consultation: Consider cardiology or cardiac electrophysiology consultation for patients with persistent symptoms, especially if associated with arrhythmias 2

Important Caveats

• Perioral twitching may be an early warning sign of more serious neurological or cardiac complications and should not be dismissed 1
• Bradycardia is common during targeted temperature management but usually does not require treatment; however, if associated with perioral twitching, it may indicate more serious electrolyte disturbances 2
• Avoid antiarrhythmic drugs that can worsen QT prolongation if that is the suspected mechanism of twitching 2
• In patients with known or suspected long-QT syndrome, avoid any drugs that prolong the QT interval 2