What's the next step for a comatose adult patient on a ventilator with hypotension, awaiting transfer to a cath lab for percutaneous coronary intervention (PCI), after receiving 2L of normal saline (NS) boluses?

Immediate Vasopressor Support for Post-ROSC Hypotension

Start an epinephrine infusion immediately at 0.05 mcg/kg/min and titrate upward every 10-15 minutes to achieve a MAP ≥65 mmHg while proceeding urgently to the cath lab. 1

Critical Hemodynamic Management

This patient has persistent hypotension (MAP 53 mmHg) despite 2L NS boluses, indicating vasopressor-dependent shock that requires immediate pharmacologic intervention before PCI.

Vasopressor Initiation

• Start epinephrine infusion at 0.05 mcg/kg/min, titrating up to 2 mcg/kg/min as needed to achieve MAP ≥65 mmHg 1
• Titrate in increments of 0.05-0.2 mcg/kg/min every 10-15 minutes until blood pressure targets are met 1
• Administer through a large vein; avoid leg veins in this clinical context 1
• After hemodynamic stabilization, wean incrementally over 12-24 hours 1

Avoid Additional Fluid Boluses

• Do not administer additional cold IV fluid boluses, as rapid infusion of large volumes of cold fluids increases risk of cardiac re-arrest (RR 1.22) and pulmonary edema (RR 1.34) without mortality benefit 2
• The 2L NS already given is adequate volume resuscitation; further hypotension reflects vasodilatory shock requiring vasopressors, not hypovolemia 3, 1

Proceed Urgently to Cath Lab

Emergency Coronary Angiography Indication

• This patient requires emergency cardiac catheterization despite the absence of ST elevation on ECG 3
• Emergency angiography is reasonable (Class IIa) for select comatose adult patients after OHCA of suspected cardiac origin without ST elevation, particularly when electrically or hemodynamically unstable 3
• Very-low-quality evidence from 513 patients shows emergency catheterization improves hospital mortality (OR 0.51,95% CI 0.35-0.73) and neurologically favorable survival (OR 1.96,95% CI 1.35-2.85) in this population 3

Timing Considerations

• Do not delay catheterization for hemodynamic optimization—proceed to cath lab while simultaneously managing hypotension with vasopressors 3
• Emergency catheterization should be incorporated into a standardized post-cardiac arrest protocol 3
• The combination of emergency PCI and targeted temperature management is feasible and safe 3

Ventilator Management During Transport

Current Settings Assessment

• PETCO2 of 43 mmHg and RR 10/min are appropriate targets 3
• Maintain ventilation at 10-12 breaths/min targeting PETCO2 35-40 mmHg or PaCO2 40-45 mmHg 3
• Avoid hyperventilation, which decreases cardiac output through increased intrathoracic pressure and reduces cerebral blood flow 3

Oxygenation Management

• Titrate FiO2 to maintain SpO2 94-98% once able—avoid both hypoxemia and hyperoxemia 3
• 100% oxygen used during initial resuscitation should be weaned to the lowest level achieving adequate saturation to avoid oxygen toxicity 3

Airway Security

• Elevate head of bed to 30° if tolerated to reduce cerebral edema risk and aspiration 3
• Confirm endotracheal tube placement with continuous waveform capnography during transport 3
• Avoid circumferential neck ties that could obstruct venous return from the brain 3

Concurrent Post-Cardiac Arrest Care

Targeted Temperature Management

• Initiate targeted temperature management (32-34°C for 12-24 hours) immediately for this comatose post-arrest patient 3
• TTM can be safely combined with emergency cardiac catheterization and should not delay PCI 3
• Prevent hyperthermia, which worsens outcomes 3

Additional Monitoring

• Maintain continuous cardiac monitoring for arrhythmias 3
• Monitor for seizures, which should be treated aggressively if they occur 3
• Avoid hypoglycemia and treat hyperglycemia >180 mg/dL 3

Common Pitfalls to Avoid

• Do not give additional fluid boluses in an attempt to correct hypotension—this patient needs vasopressors, not more volume 2, 1
• Do not delay catheterization to "stabilize" the patient—proceed urgently while managing hypotension with vasopressors 3
• Do not hyperventilate the patient, as this worsens hemodynamics and cerebral perfusion 3
• Do not use cold IV fluids for routine resuscitation—this increases complications without benefit 2
• Do not delay TTM until after catheterization—both interventions should proceed simultaneously 3