Post resuscitation care

1. Post Resuscitation Care Post Resuscitation Care
““
Restart the Heart and Keep it Restarted Restart the Heart and Keep it Restarted
””
Dr. Rashidi Ahmad Dr. Rashidi Ahmad
Malaysian Association of Emergency Medicine Malaysian Association of Emergency Medicine
(MAEM) (MAEM)

2. AimAim
„„
To create an awareness that post To create an awareness that post
resuscitation intervention is as important resuscitation intervention is as important
as resuscitation itself as resuscitation itself
„„
To highlight the proper resuscitation care To highlight the proper resuscitation care
„„
To save human lives To save human lives

3. Outline Outline
„„
Understanding post resuscitation phase & Understanding post resuscitation phase &
care care
„„
Causes of failure post resuscitation Causes of failure post resuscitation
„„
Principles post resuscitation care Principles post resuscitation care MxMx
„„
Discuss by an examples Discuss by an examples

4. Introduction Introduction
„„
Phases of Resuscitation: resuscitation & post Phases of Resuscitation: resuscitation & post
resuscitation resuscitation „„
Outcome: death or ROSC Outcome: death or ROSC
„„
Upon ROSC patient may: Upon ROSC patient may:
„„
Awake with stable hemodynamic Awake with stable hemodynamic
„„
Remain comatose with unstable circulation Remain comatose with unstable circulation
„„
Half of death occurs first 24 hrs Half of death occurs first 24 hrs
„„
Over 1 to 3 days: sepsis syndrome and MOF Over 1 to 3 days: sepsis syndrome and MOF
„„
Days later; rapid deterioration Days later; rapid deterioration →→Death Death
„„
Post resuscitation syndrome Post resuscitation syndrome

5. Post resuscitation syndrome Post resuscitation syndrome
„„
Reperfusion failure Reperfusion failure
„„
Reperfusion injury Reperfusion injury
„„
Cerebral intoxication from ischemic Cerebral intoxication from ischemic
metabolites metabolites „„
Coagulopathy Coagulopathy

6. CPR related injuries CPR related injuries
„„
In a study of CPR related autopsy findings: In a study of CPR related autopsy findings:
„„
40% of patients had injuries related to 40% of patients had injuries related to
closed chest CPR, i.e. fractured ribs, closed chest CPR, i.e. fractured ribs,
sternum, bone marrow emboli to lung, sternum, bone marrow emboli to lung,
mediastinal mediastinalbleeding, etc. bleeding, etc.

7. What is post resuscitation What is post resuscitation
care? care?
„„
Post resuscitation care is referred to a period Post resuscitation care is referred to a period
between restoration of a spontaneous circulation between restoration of a spontaneous circulation
and transfer of patient care to another healthcare and transfer of patient care to another healthcare
provider who assumes responsibility. provider who assumes responsibility.
„„
In general, this period will be less than 30 In general, this period will be less than 30
minutes (CRUCIAL TIME) minutes (CRUCIAL TIME) „„
The immediate goal is to provide cardio The immediate goal is to provide cardio-
-
respiratory support to optimize tissue perfusion, respiratory support to optimize tissue perfusion, especially to the brain. especially to the brain.

8. Principles of Post Principles of Post
resus resus
MxMx
„„
Avoid CPA recurrence Avoid CPA recurrence
„„
Restore perfusion & oxygenation of regional Restore perfusion & oxygenation of regional
organ & cell tissues organ & cell tissues „„
Continuous Continuous ABCDs ABCDsof Primary and Secondary of Primary and Secondary
surveys surveys „„
Evaluate and monitor neurologic functions Evaluate and monitor neurologic functions
(restoration of cerebral circulation) (restoration of cerebral circulation) „„
Support other dysfunction organs Support other dysfunction organs
„„
Resolve the situation that promoted CPA Resolve the situation that promoted CPA

9. Scenario 1 Scenario 1
„„
46 years old man, had severe ischemic chest 46 years old man, had severe ischemic chest
pain since an hour ago. pain since an hour ago. „„
Suddenly he had Suddenly he had pulseless pulselessventricular ventricular
tachycardia. tachycardia. „„
Immediate Immediate asynchronized asynchronizedcardioversion cardioversion
reverted the rhythm. reverted the rhythm. „„
What is your next step? What is your next step?

10. Scenario 2 Scenario 2
„„
6 years old boy, near drowning 6 years old boy, near drowning
„„
Cardiopulmonary resuscitation was Cardiopulmonary resuscitation was
commenced commenced
„„
ROSC after 45 minutes ROSC after 45 minutes
„„
What is your next step? What is your next step?

11. Scenario 3 Scenario 3
„„
37 years old man had MVA (high velocity 37 years old man had MVA (high velocity
injury) injury) „„
He sustained head injury & He sustained head injury & intraabdominal intraabdominal
injury injury „„
Hemodynamic unstable Hemodynamic unstable
„„
While on fluid resuscitation he developed VT While on fluid resuscitation he developed VT
„„
What is your next step? What is your next step?

12. Airway & respiratory system Airway & respiratory system
1. Is the patient intubated? „
YES: rapidly assess patency, position, security,
and oxygenation
„
NO: rapidly assess the need for intubation, i.e.
oxygenation, mental status, other considerations.
INTUBATE if any indication for it exists.

13. Airway & respiratory system Airway & respiratory system
2. All patients will receive supplemental oxygen.
Assessment of adequate ventilation and
oxygenation:
„
Pulse oximetry
„
ABG's(if already available)
„
Physical exam (i.e. breath sounds, symmetrical chest expansion
„
Respiratory character, skin color, midline trachea)

14. Airway & respiratory system Airway & respiratory system
3. Consider mechanical impediments to adequate
respiration, and pursue treatment of these when
feasible:
„
Tension pneumothorax, pneumothorax, and hemothorax
„
Flail chest
„
Mucous plugging
„
Interstitial edema
„
Improperly places endotrachealtube

15. Mechanical Ventilation Mechanical Ventilation
„„
Volume ventilator Volume ventilator-
-
assist assist
--
control or control or
intermittent mandatory ventilation (IMV) intermittent mandatory ventilation (IMV)
„„
Tidal volume = ideal weight in kg x 10 Tidal volume = ideal weight in kg x 10
„„
I:E ratio 1:2 or 1:1.5 I:E ratio 1:2 or 1:1.5
„„
Respiratory rate: 10 Respiratory rate: 10-
-
12 times/min 12 times/min
„„
Oxygen FiO2 Oxygen FiO2 -
-
1.0 (100%) 1.0 (100%)
„„
Sensitivity: 2 cmH2O for assist Sensitivity: 2 cmH2O for assist -
-
control control
„„
Humidifier: 36 Humidifier: 36°
°
CC
„„
PEEP: 5 cmH2O, increased as required PEEP: 5 cmH2O, increased as required

16. Circulatory system Circulatory system
1. Assess the status of the circulatory system: „
Clinical indicators: skin temperature, capillary
refill, quality of pulses, level of consciousness
„
Monitor parameters: heart rate and rhythm, BP,
urine output (use of Foley catheter when
available)
„
PMH and current medications

17. Circulatory system Circulatory system
2. Support inadequate circulatory system: „
Hypotension -if there is evidence of bleeding,
treat with IV crystalloids and blood products „
For evidence of cardiogenicshock, septic shock or spinal shock –treat appropriately
„
Prophylactic drugs for reverted VF/VT
„
Well function cardiac pace maker
„
Maintain the drug infusion preferably via central line

18. General survey General survey
„
After stabilization of the respiratory and
circulatory systems, a general survey of the
entire patient should be performed.
„
Look for a cause and precipitating causes of CA
„
Serial exams of areas of particular concern
should be performed.
„
Serial review of vital signs
„
Review ECG and Chest x ray
„„
Review ABG, and pH, serum electrolytes, Review ABG, and pH, serum electrolytes,
magnesium and calcium magnesium and calcium

19. Chest X Chest X
--
RayRay
„„
Position of Position of endotracheal endotrachealtube tube
„„
Position of central venous catheter Position of central venous catheter
„„
Pneumothorax, Pneumothorax, hemothorax hemothorax, hydrothorax , hydrothorax
„„
Pulmonary edema, CHF Pulmonary edema, CHF
„„
Cardiac Cardiac silhoutte silhoutte
„„
Diaphragms Diaphragms
„„
Rib fracture Rib fracture

21. Other considerations Other considerations
„
Optimally, there should be two well-secured,
functioning intravenous lines.
„
A nasogastrictube (or orogastric) is useful to
keep the stomach decompressed, especially in
patients receiving positive-pressure ventilation.
„
Preserve body temperature.
„
Stop the seizure

22. Communication & documentation Communication & documentation
„
It is important to maintain a collaborative
approach to patient care utilizing the referring
physicians/nurses' report and suggestions prior
to liftoff.
„
Resusnotes should include the history, assessment
„
findings, and any treatments done by the referring EMS or hospital personnel.
„
It is acceptable to state "see transfer notes,"
for particular details, and write out only the
most prominent interventions.

23. Transfer Transfer
„„
Transfer to special care unit as soon as possible Transfer to special care unit as soon as possible
by senior most experience personal by senior most experience personal „„
Support ventilation and provide oxygenation Support ventilation and provide oxygenation
„„
Monitor ECG, oxygen saturation and BP Monitor ECG, oxygen saturation and BP
„„
Prior to transport, make sure IV is secured Prior to transport, make sure IV is secured
„„
Transport with portable monitor, defibrillator Transport with portable monitor, defibrillator
„„
Oxygen with connections to bag Oxygen with connections to bag-
-
valve valve
--
system system
„„
Resus Resusdrugs must accompany the patient drugs must accompany the patient

24. Take Home Message Take Home Message
„„
Resuscitated the heart, restore the brain Resuscitated the heart, restore the brain
„„
Treat the patient, not the arrhythmia Treat the patient, not the arrhythmia
„„
The value of unbroken Chain of Survival: The value of unbroken Chain of Survival:
„„
Time is critical Time is critical
„„
Seek and treat the cause, not just the Seek and treat the cause, not just the
condition condition