Transported Cardiac Arrests

Transported Cardiac Arrests
When possible, EMS personnel should direct patients to hospital centers specializing in comprehensive cardiac arrest care management. Specialized centers should have capacity to take patients directly to the cardiac catheterization laboratory for percutaneous coronary interventions (PCI), perform temperature management, specialized ICU care, cardiac electrophysiological evaluation and treatment and potentially offer extracorporeal membrane oxygenation (ECMO) when available.

Cardiac/PCI Catheterization ASAP
EKG should be performed immediately after ROSC and patients demonstrating STEMI should be taken emergently for percutaneous coronary intervention (PCI). Selected NSTEMI patients, as well as those with initial rhythm of VF/VT or with refractory shock, may benefit from an early invasive cardiac strategy after cardiac arrest as well. Preferred receiving centers should have a demonstrated history of early PCI for resuscitated cardiac arrest patients. Additionally, these centers should be prepared and willing to take patients for PCI even in the setting of ongoing cardiac arrest, particularly in the setting of refractory VF. If the patient is still in cardiac arrest automated CPR can be useful to maintain some perfusion during transport and PCI procedure in an attempt to restore spontaneous circulation. Pre-arrival notification and coordination between EMS, the emergency department personnel and cardiology teams increases the likelihood of survival with good brain function after cardiac arrest.

Targeted Temperature Management
If a patient is comatose after cardiac arrest and/or does not have purposeful response to commands, therapeutic temperature management has been shown to improve the likelihood of good neurological recovery. The sooner a comatose patient is cooled, the better the outcome. Cooling can be started outside the hospital. The target temperature is somewhat controversial due to a recent publication showing similar outcomes when patients were cooled to either 33˚ C or 36˚ C for 24 hours but with either temperature target, active cooling strategy was used. The target temperature should be tightly controlled. It has been shown that fevers in the post-resuscitation timeframe can lead to a worse neurological outcome. Most experts recommend a gradual rewarming at a rate of 0.5˚ C per hour. Both invasive and non-invasive methods to accomplish TTM are effective. Please refer to the 2015 AHA guidelines for past arrest care.

Specialized ICU care
After cardiac arrest, patients who are unconscious or hemodynamically unstable require specialized ICU care. Efforts are taken to deliver patients to tertiary care centers as quickly as possible after cardiac arrest. Board certified specialists should care for this extraordinarily sick patient population.

Post resuscitation O2 administration should be governed by the factors discussed above, regarding titrating to > 95%, with efforts to avoid insufficient and excessive amount of supplemental O2.

Hyperglycemia is common after cardiac arrest. Adequate control of blood glucose with insulin reduces hospital mortality rates in critically ill adults in a surgical ICU and may protect the central and peripheral nervous system for cardiac arrest patients as well. This has been debunked to some degree. Keep them euglycemic.

Seizures, myoclonus or both occur in 5%-15% of adult patients after cardiac arrest and 10%-40% of those who remain comatose. Seizures increase cerebral metabolism by up to 3-fold. Prolonged seizures should be treated promptly and effectively with benzodiazepines, phenytoin, sodium valproate, propofol or a barbiturate. No studies have directly assessed the use of prophylactic anticonvulsant drugs after cardiac arrest in adults and, as such, the optimal choice is unknown. Each of these drugs can cause hypotension, and this must be treated accordingly. Clonazepam is the drug of choice for the treatment of myoclonus.

Efforts should be made to allow patients to wake up after rewarming: it can take over a week for some patients to wake up after cardiac arrest.

Extracorporeal Membrane Oxygenation (ECMO)
Recent studies show that ECMO is effective in saving patients with ongoing CPR and refractory VF. ECMO can be placed in the emergency department or cardiac catheterization laboratory. It can be used to maintain circulation, sometimes for many days, until the heart and brain recover.

Pharmacological Management of Blood Pressure and Arrhythmias
Vasopressor and anti-arrhythmic support needs to be individualized on a patient-by-patient basis. Nore epi is the primary choice for shock in the literature. Similarly, intravenous amiodarone is generally used as the first line anti-arrhythmic agent but other anti-arrhythmic drugs should be used as needed. Recent case reports suggest that Esmolol is effective in patients with refractory VF despite treatment with amiodarone and lidocaine and normalization of electrolytes.

Note the AHA recommendations and European CCC guidelines on this subject.

2015 AHA Guidelines
The earliest time for prognostication using clinical examination in patients treated with TTM, where sedation or paralysis could be a confounder, may be 72 hours after normothermia (Class IIb, LOE C-EO).

We recommend the earliest time to prognosticate a poor neurologic outcome using clinical examination in patients not treated with TTM I 72 hours after cardiac arrest (Class I, LOE B-NR).

This time until prognostication can be even longer than 72 hours after cardiac arrest if the residual effect of sedation or paralysis confounds the clinical examination (Class IIa, LOE C-LD).

In comatose patients who are not treated with TTM, the absence of pupillary reflex to light at 72 hours or more after cardiac arrest is a reasonable exam finding with which to predict poor neurologic outcome (FPR, 0%; 95% CI, 0%-8%; Class IIA, LOE B-NR).

In comatose patients who are treated with TTM, the absence of pupillary reflex to light at 72 hours or more after cardiac arrest is useful to predict poor neurologic outcome(FPR, 1%; 95% CI, 0%-3%; Class I, LEO B-NR).

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EP evaluation/ICD placement
Patients should be treated with an implantable cardioverter defibrillator (ICD) after cardiac arrest unless the cause of the arrest is completely reversible. ICD placement after cardiac arrest prevents recurrence of lethal arrhythmias and allows the patient to take certain anti-arrhythmic drugs that would otherwise be considered potentially harmful without the ICD as a backup. In the subgroup of patients with a completely reversible cause of arrest, those with no prior warning should be considered ICD candidates as the risk of cardiac arrest recurrence is usually high enough to justify the risks and costs of the device.

Track and report outcomes
Without the ability to accurately measure outcomes, it is not possible to know how well any given system is doing, how the presence, absence, or timeliness of certain steps affects outcomes, and how to improve outcomes further. Multiple cardiac arrest registries exist, including the AHAs ‘Get with the Guidelines’ and the CDC’s Cardiac Arrest Registry to Enhance Survival (CARES). When these registries are implemented correctly, which includes assuring that the data collection and input process is comprehensive and thorough, they provide a means to assess outcomes on a consistent year-to-year basis and can be used to guide continuous quality improvement efforts. One of the most important outcome measures includes the total number of patients who have a cardiac arrest and the number of patients who survive with good brain function to hospital discharge.

Transported Cardiac Arrest