Wait, we got em back?! Post-Cardiac Arrest Care.

Sometimes the unexpected happens and you get a patient back after they’ve arrested. What’s next?

#1: Treat the underlying disease (if known)

Things die for a reason. Focus on fixing those issues. If it’s still a mystery, the 5 H’s and 5 T’s are a good place to start:

#2: Manage RESPIRATORY parameters

Target a SpO₂ of ~92%-98% or PaO₂ of 80-100 mm Hg. Avoid hyperoxygenation!
Target a normal EtCO₂ or PaCO₂ of roughly 35-45 mm Hg.

Titrate oxygen as needed. Room air may be appropriate.
Manually bag and change rate as needed.

#3: Manage HEMODYNAMIC parameters

Target a Systolic BP >90 mm Hg or MAP >65 mm Hg. RECOVER recommends SBP of 100-200 & MAP 80-120 mm Hg.
Can also consider lactate < 2.5 mmol/L, ScvO₂ >/= 70%

If hypovolemic, give IV fluids.
Consider vasopressor therapy (norepinephrine)
Consider positive inotrope (dobutamine)
If hypertensive, decrease vasopressors, treat pain, and/or give antihypertensive. Benign neglect is also reasonable if immediately post-CPR.

#4: Protect the BRAIN

Consider hypertonic saline/mannitol if signs of cerebral edema
Consider seizure prophylaxis (e.g. levetiracetam)
Rewarm slowly (<1^oF per hour)
If comatose, consider permissive hypothermia (24-48 h) and passive rewarming.
AVOID: steroids unless hemodynamically unstable despite fluids and pressors. Steroids may cause hyperglycemia and worse outcomes.

#5: Manage COMPLICATIONS

Ischemia and reperfusion injury: The brain and heart are particularly sensitive. Monitor and treat complications.
Systemic inflammatory response syndrome (SIRS): can leads to vasodilation, hypoperfusion, and more tissue/organ damage.
Disseminated intravascular coagulopathy (DIC): being dead promotes blood clotting, endothelial damage, and consumption of clotting factors and platelets. Monitor for bleeding.
Critical illness-related corticosteroid insufficiency (CIRCI): being dead is stressful. The adrenal glands and the rest of the HPA axis could be dysfunctional and unable to respond appropriately to stress. This may lead to hypotension unresponsive to fluids and pressors. If suspected, steroids may be considered.
Multiorgan dysfunction syndrome (MODS): All of the above can lead to organ damage and failure. Monitor for acute kidney injury (increased creatinine, decreased urine output, urinary casts, etc.), liver injury (hyperbilirubinemia, hypoglycemia, etc.), coagulopathy (prolonged pt/ptt, thrombocytopenia, abnormal TEG), lung injury (decreased PF ratio), etc. Complications may arise soon after, but may also take days to develop.

Unproven therapies to consider include B vitamins, thiamine, taurine, SAMe, hyperbaric oxygen therapy, N-acetylcysteine, melatonin.

#6: Set realistic expectations

Return of spontaneous circulation (ROSC) can happen in over 50% of patients, but most will re-arrest. Only 5-10% of CPR patients will live to discharge. If they survive many complications are reversible, but long-term morbidities may be possible.

Hope for the best, but prepare for the worst…

Peer reviewed by Katie Nash and Kathy Gerken.