Admission to ICU following cardiac arrest is a common presentation.
Below is a brief overview of some of the management strategies used in these patients.
This is based on the recently updated European Resuscitation Council (ERC) guidelines on post-resuscitation care (2021) and the Australian Resuscitation Council (ARC) guidelines (2016).
Coronary Angiography
If ST-Elevation (STE) present –> Cath Lab.
If STE not present then the decision to go to cath lab is a bit more contentious. The newly released ERC guidelines state that emergent catheterisation should be considered in all those in whom there is a high estimated probability of coronary occlusion (e.g. haemodynamic instability, electrical disturbance).
Targeted Temperature Management (TTM)
TTM is the process by which temperature can be controlled. Cooling methods can include external cooling blankets or venous cooling venous catheters. All the systems include a feedback system by which temperature is maintained at a set level.
Each unit will have their own TTM policy, and the recently published TTM2 trial may result in modifications of these. There will be further debate as to what temperature is ideal, however the both the TTM and TTM2 trials have never compared TTM to no temperature control (e.g. allowance of fever).
Deeper sedation +/- neuromuscular blockade may be needed if shivering is a problem.
General ICU care
General principles include:
- Avoid hypotension (MAP > 65)
- Avoid hypoxia or hyperoxia (SpO2 94-98%)
- Normocarbia
- Glucose 4 – 10 mmol/L (an insulin infusion is often required)
- Use of short acting sedatives and opiates
- Treat seizures but no routine seizure prophylaxis is required (Sodium Valproate or Levetiracetam)
- Stress ulcer prophylaxis
- DVT prophylaxis (note patients may already be on treatment dose heparin or LMWH for acute coronary syndrome)
- No routine indication for prophylactic antibiotics
- Enteral feeds at low rates can be started during TTM
Prognostication
No attempt to prognosticate should be made until > 72 hours post ROSC.
There is no single, specific test that can prognosticate with high sensitivity and specificity; and it is important to ensure no confounders (i.e. ongoing effect of sedatives despites stopping) present when trying to prognosticate.
Important findings suggestive of a poor prognosis are a motor score of ≤ 3 combined with 2 or more of:
- Absent pupillary light reflexes or corneal reflexes
- Status Myoclonus
- Malignant EEG
- Diffuse anoxic injury on CT or MRI
- High levels of NSE (Neuron Specific Enolase)
- Bilaterally absent SSEP (Somatosensory Evoked Potential)
It is often a decision based on serial clinical examinations, and in the context of ongoing discussions with family and other treating teams (e.g. neurology).
References and Further Reading
ERC and ARC guidelines which are linked above
Author: George Walker