Patients display a wide spectrum of responses to resuscitation. Following return of spontaneous circulation, patients may respond by becoming awake and alert with adequate spontaneous respirations and hemodynamic stability. Others will remain comatose with an unstable circulation and no spontaneous breathing. Many will require 24 to 48 hours of invasive hemodynamic monitoring for optimal management after resuscitation.
Your immediate goal is to provide cardio-respiratory support to optimize oxygenation and perfusion, particularly to the brain. This is accomplished by assessing and treating the primary and secondary ABCD surveys:
- Airway = Secure the airway and confirm tracheal tube with primary assessments and secondary assessment which must include a chest x-ray.
- Breathing = Administer 100% oxygen with mechanical ventilation and monitor with oxygen saturation levels and blood gas analyses. Mechanical ventilation often requires paralysis and sedation.
- Circulation = Administer normal saline IV and monitor urine output to reflect tissue perfusion. Insert nasogastric tube and initiate an infusion of an antiarrhythmic for secondary prophylaxis.
- Differential Diagnosis = Search for specific cause for the arrest. Review the chest x-ray, 12- lead ECG, history, and serum electrolytes.
- Change IV lines placed without proper sterile technique.
- Replace deficient electrolytes
- Transport to higher level of care.
The following problems may develop:
- Hostile environment for the brain – control seizures that increase cerebral oxygen requirements. Elevate the head 30 degrees to decrease intracranial pressure.
- Hypotension – even mild hypotension can impair recovery of cerebral function.
- Recurrent VF/Pulseless VT – consider administration of an infusion of the antiarrhythmic used during resuscitation.
- Post-resuscitation of tachycardia – rapid SVTs that may develop in the immediate post- resuscitation period are best treated by leaving them alone.
- Post-resuscitation bradycardia – poor ventilation and oxygenation play a major role in post- resuscitation bradycardia.
- Post-resuscitation PVCs – improved oxygenation over time may eliminate the ectopic beats.
Post-resuscitation care includes support of the myocardial function with anticipation that myocardial “stunning” may be present, requiring vasoactive support. A healthy brain is the primary goal of cerebral and cardiopulmonary resuscitation. This may be accomplished by allowing moderate hypothermia.
- Hypothermia—The 2005 guidelines emphasize the importance of avoiding hyperthermia and the possible benefits of induced hypothermia (32ºC to 34ºC) for 12 to 24 hours for patients who remain comatose after resuscitation from cardiac arrest. Providers should monitor temperature and treat fever aggressively.
- Maintaining strict glucose control—Additional studies are needed to determine the precise blood glucose concentration that requires insulin therapy and the target range of blood glucose concentration. The 2005 guidelines recommend lowering of blood glucose in patients with acute ischemic stroke when serum glucose level is greater than 200 mg/dl
Arrhythmia Recognition and Management Skills Station
In this skills station, participants should be able to:
- Recognize and mange the following rhythms: bradycardia, wide- and narrow-complex tachycardia with poor perfusion, asystole, PEA, VF, and VT
- Recognize unstable conditions resulting from arrhythmias requiring urgent intervention
- Differentiate between SVT and Sinus Tachycardia and give appropriate treatments for each rhythm
- Deliver electrical shocks safely and appropriately with a manual defibrillator and AED
- Identify potentially reversible causes of unstable rhythms