What is the recommended management for post cardiac arrest syndrome?

Management of Post-Cardiac Arrest Syndrome

The recommended management for post-cardiac arrest syndrome requires a comprehensive, structured, integrated, multidisciplinary system of care implemented consistently to optimize survival and neurological recovery. 1, 2

Initial Objectives

• Transport patients to an appropriate hospital with a comprehensive post-cardiac arrest treatment system of care that includes acute coronary interventions, neurological care, goal-directed critical care, and temperature management 1
• Optimize cardiopulmonary function and vital organ perfusion after return of spontaneous circulation (ROSC) 1
• Identify and treat the precipitating causes of the arrest to prevent recurrent arrest 1
• Transport in-hospital post-cardiac arrest patients to an appropriate critical care unit capable of providing comprehensive post-cardiac arrest care 1

Respiratory Management

• Avoid both hypoxia and hyperoxia by targeting arterial oxygen saturation of 94% but less than 100% 1, 3
• Suggest using 100% inspired oxygen initially until arterial oxygen saturation can be measured reliably 1
• Maintain PaCO₂ within normal physiologic range (35-40 mmHg) as part of post-ROSC bundle of care 1, 2
• Optimize mechanical ventilation to minimize lung injury 1
• Elevate head of bed 30° if tolerated to reduce cerebral edema, aspiration, and ventilator-associated pneumonia 2

Hemodynamic Management

• Consider hemodynamic goals (e.g., mean arterial pressure, systolic blood pressure) as part of any bundle of post-resuscitation interventions 1
• Use vasopressors such as norepinephrine and dobutamine as first-line treatment for post-cardiac arrest shock 3
• Implement protocolized hemodynamic optimization and multidisciplinary early goal-directed therapy protocols 1
• Provide intravascular volume expansion, vasoactive and inotropic drugs as needed to support blood flow and ventilation 1

Temperature Management

• Control body temperature to optimize survival and neurological recovery 1
• Select and maintain a constant target temperature between 32°C and 36°C for those patients in whom temperature control is used 1
• Recommend targeted temperature management (TTM) for patients with initial shockable rhythm who remain unresponsive after out-of-hospital cardiac arrest 1
• Suggest TTM for patients with initial non-shockable rhythm who remain unresponsive after out-of-hospital cardiac arrest 1
• Suggest TTM for adults with in-hospital cardiac arrest with any initial rhythm who remain unresponsive after ROSC 1
• If TTM is used, suggest a duration of at least 24 hours 1
• Recommend against routine use of prehospital cooling with rapid infusion of large volumes of cold intravenous fluid immediately after ROSC 1
• Suggest prevention and treatment of fever in persistently comatose adults after completion of TTM 1

Coronary Management

• Identify and treat acute coronary syndromes (ACS) 1
• Triage patients with suspected ACS to a facility with reperfusion capabilities 1
• Consider early invasive coronary angiography to identify and treat coronary artery obstructive disease 3, 4
• Implement systems of care for patients with ST-elevation myocardial infarction (STEMI) 1
• Utilize prehospital 12-lead ECGs with transmission or interpretation by EMS providers and advance notification of the receiving facility 1

Neurological Management

• Monitor for seizures using continuous electroencephalography (EEG) 3, 5
• Recommend treatment of seizures but suggest against routine seizure prophylaxis 1
• Suggest no modification of standard glucose management protocols 1
• In comatose post-cardiac arrest patients treated with TTM, suggest that clinical criteria alone not be used to estimate prognosis after ROSC 1
• Suggest prolonging observation of clinical signs when interference from residual sedation or paralysis is suspected 1
• Recommend that the earliest time to prognosticate a poor neurologic outcome is 72 hours after ROSC 1
• Suggest using multiple modalities of testing (clinical examination, neurophysiologic measures, imaging, or blood markers) to estimate prognosis 1

Multiorgan Support

• Reduce the risk of multiorgan injury and support organ function if required 1
• Anticipate, treat, and prevent multiple organ dysfunction 1, 6
• Implement glycemic control and metabolic management for favorable neurological outcomes 3, 5
• Monitor for and manage acute kidney injury, which is essential for survival and good neurological outcome 3

Prognostication and Long-term Care

• Objectively assess prognosis for recovery 1
• Ensure prognostic assessment in the setting of hypothermia involves experts qualified in neurologic assessment 1
• Assist survivors with rehabilitation services when required 1
• Recommend that all patients who have restoration of circulation after CPR and who subsequently progress to death be evaluated as potential organ donors 1

Common Pitfalls and Caveats

• Avoid excessive ventilation as it can impede venous return and decrease cardiac output 2
• Do not rely solely on clinical criteria for prognostication, especially during or shortly after TTM 1
• Avoid using end-tidal carbon dioxide threshold or cutoff values alone to predict mortality or to decide to stop a resuscitation attempt 1
• Do not make early prognostic decisions that may lead to premature withdrawal of life-sustaining therapy 1
• Recognize that withdrawal of life-sustaining therapy is the most frequent cause of death (approximately 50%) in patients with a prognosticated bad outcome 1