Part 8: Post–Cardiac Arrest Care

Abstract

of Key Issues and Major Changes Key issues and major changes in the 2015 Guidelines Update recommendations for post-cardiac arrest care include the following: Emergency coronary angiography is recommended for all patients with ST elevation and for hemodynamically or electrically unstable patients without ST elevation for whom a cardiovascular lesion is suspected. TTM recommendations have been updated with new evidence suggesting that a range of temperatures may be acceptable to target in the post-cardiac arrest period. After TTM is complete, fever may develop. While there are conflicting observational data about the harm of fever after TTM, the prevention of fever is considered benign and therefore is reasonable to pursue. Identification and correction of hypotension is recommended in the immediate post-cardiac arrest period. Prognostication is now recommended no sooner than 72 hours after the completion of TTM; for those who do not have TTM, prognostication is not recommended any sooner than 72 hours after ROSC. All patients who progress to brain death or circulatory death after initial cardiac arrest should be considered potential organ donors. Coronary Angiography 2015 (Updated): Coronary angiography should be performed emergently (rather than later in the hospital stay or not at all) for OHCA patients with suspected cardiac etiology of arrest and ST elevation on ECG. Emergency coronary angiography is reasonable for select (eg, electrically or hemodynamically unstable) adult patients who are comatose after OHCA of suspected cardiac origin but without ST elevation on ECG. Coronary angiography is reasonable in post-cardiac arrest patients for whom coronary angiography is indicated, regardless of whether the patient is comatose or awake. 2010 (Old): Primary PCI (PPCI) after ROSC in subjects with arrest of presumed ischemic cardiac etiology may be reasonable, even in the absence of a clearly defined STEMI. Appropriate treatment of acute coronary syndromes (ACS) or STEMI, including PCI or fibrinolysis, should be initiated regardless of coma. Why: Multiple observational studies found positive associations between emergency coronary revascularization and both survival and favorable functional outcome. In the absence of cardiac arrest, guidelines already recommend emergency treatment of STEMI and emergency treatment of non-ST-segment elevation ACS with electrical or hemodynamic instability. Because the outcome of coma may be improved by correction of cardiac instability, and the prognosis of coma cannot be reliably determined in the first few hours after cardiac arrest, emergency treatment of post-cardiac arrest patients should follow identical guidelines. Targeted Temperature Management 2015 (Updated): All comatose (ie, lacking meaningful response to verbal commands) adult patients with ROSC after cardiac arrest should have TTM, with a target temperature between 32°C and 36°C selected and achieved, then maintained constantly for at least 24 hours.