Inpatient / Cardiology
Post Cardiac Arrest Care and TTM
# Post Cardiac Arrest
# TTM
Assessment:
-- History: *** likely etiology of arrest, site of arrest, CPR time, CPR cycles, meds administered
-- Data: *** EKG, echo/POCUS, glucose, ABG, lytes
-- Etiology/DDx: *** MI, VT/VFib, PE, overdose, septic shock, PTX
Plan:
Workup
-- If no idea what happened, CT pan-scan and BSA
-- Neuroprognostication: *** at 72-hour mark, continuous video EEG monitoring, consider CT head non-con to assess for bleed, trend neuron-specific enolase daily at 24h, 48h, 72h
Treatment
-- Vent: ** settings to achieve normoxia and avoid hypercapnia
-- Sedation: *** preference for propofol and precedex > fentanyl and versed
-- Pressor: *** for MAP goal >65-75
-- TTM: Cool to 36 degrees if unable to follow commands using an adaptive cooling system - 24 hours followed by re-warming
-- Shivering - *** Tylenol q6 scheduled, buspirone 30mg q8, mag >2mg, warm hands/feet, precedex, zofran 4mg IV q8; fentanyl bolus or paralysis if needed, but gets in way of neuroprognostication
-- Asp PNA ppx: *** amox-clav vs CTX for 48 hours
-- ACS pathway (ASA load, statin, heparin, etc) if underlying concern for an event
If You Remember Nothing Else
Identifying the cause of the arrest is more important than focusing on temperature management. In general, TTM goal should be 36 degrees with the intent of avoiding fevers. Other care is based around addressing aspiration, treating shivering, and not interfering with neuroprognostication at 72 hours. EF post-arrest will likely be reduced, but depending on etiology can recover.
Clinical Pearls
- Identifying the cause of the arrest is more important than focusing on temperature management
- Shivering happens more commonly at 36 degrees vs 32 - at 32 degrees your shivering response is not working anymore; shivering leads to lactic acidosis, rhabdo, elevated ICP
- Precedex helps treat shivering and doesn’t mess with neuroprognostication
- Treating for aspiration pneumonia is not the worst idea - will be masking fevers with temperature management, and many people who arrest and get intubated are at risk - up to 20-30% of patients
- Should be on the lookout for PTX, hemothorax, splenic/liver laceration, and rib fractures after CPR
- You will likely need pressors - the post-arrest EF on TTE is usually reduced 2/2 stress cardiomyopathy and reperfusion injury, but often improved with time - may also need pressor due to BP drop with sedation
- Damage associated with cardiac arrest (aside from CPR) is 2/2 ischemia, but also whole-body reperfusion injury that leads to SIRS 2/2 cytokine surge
- Neuroprognostication is performed at the 72 hour mark, though if the patient is brain-dead it doesn’t make a difference
- Myoclonus Status Epilepticus - very poor outcomes if you see this - spontaneous repetitive movement not responding to treatments
Trials and Literature
- 2010 AHA Guidelines - Post-Cardiac Arrest Care (AHA, 2010)
- TTM to 33 vs. 36 - no difference in all cause mortality or neurological outcomes - the big idea is to avoid fevering (NEJM, 2013)
- COACT Trial - post-arrest, go to cath lab if evidence of STEMI, otherwise wait for the results of neuroprognostication - waiting showed no difference in mortality at 1 year (NEJM, 2020)
- Neuron Specific Enolase (NSE) as a Predictor of Death or Poot Neurological Outcomes After Out-of-Hospital Cardiac Arrest and TTM (JACC, 2015)
Other Resources
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