Basildon EM Handbook 2018

Introduction

Post resuscitation care as all-too-often regarded as the little sibling in the world of Advanced Life Support, which should of course not be the case.  Difficulties arise because of an often awkward transition between the care of Emergency Medicine and the receiving (or declining) specialty, namely Intensive Care, General Medicine or Cardiology.  As Emergency Physicians we must prepare ourselves for this and ensure a smooth transition.  The best preparation is knowledge and experience.  Below are some cardinal evidential facts regarding the so-called 'ROSC and comatose' patients;

•The best predictor of outcome we have is neurological outcome at 72 hours.   (Resuscitation Council (UK) 2005)

•The pH on the initial ABG has not been correlated with survival.  (Mullner et al, 1997).

•An arterial lactate must be more than 16 to be specific for poor neurological outcome.  (Mullner et al, 1997).

•Retention of respiratory effort immediately after CPR is a predictor of good functional outcome.  (Kaye P 2005)

•Absent pupillary light reflexes and an absent motor response to pain are of no value in prognosticating in the first few hours post ROSC. (Resuscitation Council (UK) 2005)

•A non-cardiac cause of arrest, or asystole as the initial monitor trace on commencement of CPR, are unreliable as predictors of poor outcome.  (Neumar et all 2008)

•Organ donation should be considered as a usual part of ‘end-of-life care’ planning.  (Organ donation for transplantation (NICE clinical guideline 135)).

 As a rule, post ROSC comatose patients without significant pre-arrest co-morbidities should be taken to the ICU for supportive care and their individual prognosis decided later by the intensive care team.  (Resuscitation Council (UK) 2005; RCEM 2017)

The mandatory checklist as team leader (TM1)

If you have been acting as team leader during the arrest, you must memorise (or have immediately to hand) the latest Resus Council ROSC guidelines.  You must visually confirm the following and audibly acknowledge;

•Capnography to confirm ET tube placement.  This is via a side-stream capnograph in the Phillips monitor OR a combined HME filter capnograph on the Mindray monitor if in the trauma / HDU bay. Should be kept in the drawer below the defib if there is trouble finding this(!).

•Verbal confirmation of satisfactory ventilation via BVM or anesthetic circuit by the airway clinician at the head-end. Here we can troubleshoot suspected endobronchial intubation or bronchospasticity.

•Ventilate to normocapnoea (by hand or by ventilator at airway clinician's discretion).  

•Reliable access if not already achieved. (low threshold for IO or emergency central access by nominated individual) and arterial line

•ROSC and comatose patients can tolerate liberal IV fluids.  Run stat to achieve SBP ~100

oConsider emergency 'push-dose pressors' as a temporizing measure only (evidence free: ephedrine, adrenaline, phenylephrine popular).

•12 lead ECG

•Quick bedside echo (everyone gets shy: so it will probably have to be you!)

•Once euvolaemic ask nurses to prepare noradrenaline 4mg in 50ml Normal Saline which is then run through a syringe driver centrally at around 2-5 mls / hour and dobutamine 250mg in 500ml dextrose which is run through a pump at 20 mls / hour (preferably centrally)

•Take a temperature and if >36 degrees, strip the patient and make sure fluids are ice cold.  This often gets forgotten.

•Then as per Resus Council: if suspected cardiac cause, refer to cath lab, if non-cardiac consider CTPA or CTB (to rule out ICH NOT for prognostication).

 Resuscitation to recovery: a National Framework to improve care of people with out-of-hospital cardiac arrest (OHCA) in England. This document aims to integrate current management recommendations and to describe the whole clinical pathway for patients with OHCA.
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