Management of Cardiac Arrest Secondary to Brain Hemorrhage
The management of cardiac arrest secondary to brain hemorrhage requires immediate implementation of standard CPR protocols with special attention to neurological protection and addressing the underlying intracranial pathology.
Initial Resuscitation Approach
- Begin high-quality CPR immediately with chest compressions at a rate of 100-120 compressions per minute and a depth of at least 2 inches (5 cm), allowing complete chest recoil between compressions 1, 2
- Minimize interruptions in chest compressions to maintain cerebral and coronary perfusion 1, 2
- Apply defibrillator/AED as soon as possible to identify and treat shockable rhythms if present 1
- For patients with brain hemorrhage as the suspected cause, the traditional A-B-C approach may be more appropriate than C-A-B due to the likely hypoxic nature of the arrest 1
- Rotate compressors every 2 minutes to maintain effective compressions 1, 2
Airway Management
- Establish an advanced airway (endotracheal tube or supraglottic airway) 1
- Confirm proper placement using waveform capnography 1
- After advanced airway placement, provide 8-10 breaths per minute with continuous chest compressions 1
- Avoid hyperventilation as it can decrease cerebral blood flow and worsen neurological outcomes 1
Ventilation and Oxygenation
- Titrate inspired oxygen to achieve arterial oxygen saturation of 94% to avoid potential oxygen toxicity 1
- Maintain normocarbia (PETCO2 35-40 mmHg or PaCO2 35-45 mmHg) to prevent cerebral vasoconstriction from hypocapnia 1, 2
- Monitor oxygenation continuously with pulse oximetry 1
Addressing Reversible Causes
- Specifically consider and address the "H's and T's" with particular attention to 1:
- Hypovolemia (possible from hemorrhage)
- Hydrogen ion (acidosis)
- Tension pneumothorax (if trauma involved)
- Tamponade (cardiac)
- Thrombosis (pulmonary or coronary)
- Identify and treat the precipitating cause of the brain hemorrhage if possible 1
Post-ROSC Care
- If ROSC is achieved, implement targeted temperature management (TTM) for comatose survivors 1
- Consider therapeutic hypothermia (32-34°C) for 24 hours in comatose patients after ROSC 1, 3
- Elevate the head of the bed 30° if tolerated to reduce cerebral edema, aspiration, and ventilator-associated pneumonia 1, 2
- Avoid hypotension (maintain systolic BP >100 mmHg) to ensure adequate cerebral perfusion 1
- Control seizures with appropriate anticonvulsants if they occur 1
- Obtain urgent neuroimaging (CT scan) to evaluate the extent of brain hemorrhage 1
Specialized Neurological Management
- Consider neurosurgical consultation for potential intervention (e.g., evacuation of hematoma, external ventricular drain placement) 1
- Monitor for signs of increased intracranial pressure and treat accordingly 1, 3
- Consider nimodipine for patients with subarachnoid hemorrhage to improve neurological outcomes (60 mg every 4 hours for 21 days) 4
- Maintain blood glucose within normal range (avoid hyperglycemia >180 mg/dL and hypoglycemia) 1
Prognostication and Further Care
- Avoid early prognostication as many accepted predictors of poor outcome are unreliable, especially if the patient has been treated with therapeutic hypothermia 1
- Implement a comprehensive, structured treatment protocol which may improve survival after cardiac arrest 1, 3
- Consider transfer to a specialized center with expertise in post-cardiac arrest care and neurocritical care capabilities 1, 3
Special Considerations for Brain Hemorrhage
- Brain injury and cardiovascular instability are major determinants of survival after cardiac arrest 1, 3
- Patients with cardiac arrest due to brain hemorrhage may require more aggressive neurological management compared to other causes of cardiac arrest 3, 5
- Avoid hyperoxia and hyperventilation which can worsen cerebral injury 1
- Consider hemodynamic monitoring to guide management in unstable patients 1