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Post Cardiac Arrest Algorithm - Adult - Emergency Department/Inpatient

Post Cardiac Arrest Algorithm - Adult - Emergency Department/Inpatient - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Clinical Practice Guidelines, Cardiovascular, Related


Post Cardiac Arrest Algorithm- Adult – Emergency Dept/Inpatient
R
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N
G
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A
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T
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A
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C
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Presentation of
Post Cardiac
Arrest
Does patient
meet exclusion
criteria?
Proceed with
standard of care
(Outside scope of
guidance document)
1. IV bolus normal saline (2 L)
2. Initiate Surface Cooling (Initial goal temp.: 36°C)
3. Obtain:
ξ Non-contrasted head CT (if trauma/collapse)
ξ 12-Lead ECG
ξ Urgent echocardiogram
ξ Troponin
ξ Vital signs (including temperature at 2 sources)
STEMI?*
No
ACS or other
suspected cardiac
etiology?
Admit patient to
Critical Care Unit
Admit patient to
Cardiac Cath Lab
Admit patient to
CCU
Exclusion Criteria:
1. > 12 hours since ROSC
2. Motor component of Glasgow Coma Scale score > 5 (i.e., purposeful movement)
3. Minimal pre-morbid cognitive status (i.e., advanced dementia, metastatic cancer)
4. Sepsis as cause of arrest
5. DNR status
6. Core body temperature < 30°C
Continue Targeted
Temp Management
(TTM)?
Decision by Accepting Critical
Care Team
*Set goal core
temperature: 33°C
*Set goal core
temperature: 36°C
Goal
temperature
achieved within
2 hours?
Continue Surface
Cooling
Initiate
Intravascular
Cooling
Yes
No
ξ Arterial line placement
ξ EEG (continuous) and neurological assessment
ξ Wean FiO2 aggressively
ξ Maintain oxyhemoglobin > 94%
ξ Monitor ScVO2 > 70%. If < 70% consider PRBC, inotropic agents
ξ Moderate glucose control (140-180 mg/dL)
ξ Measure temperature continuously from 2 sources
ξ Consider neuromuscular blockade if shivering
ξ Draw electrolytes, BUN, creatinine, magnesium, phosphate,
calcium, lactate labs (at least every 6 hours)
MAP > 65 mmHg
achieved?
MAP < 65 mmHg
ξ IV fluids first
ξ Consider vasoactive
medications
MAP > 100 mmHg
ξ Consider IV nitroglycerin
No
Increase core temperature
by 0.25-0.5°C/hr to 37°C
Maintain goal core
temperature for
24 hours
Maintain core
temperature of
37°C for 48 hours
Continue care as appropriate by Critical Care team
Prognosticate neurological assessment after patient
warm for 72 hours
Note: If difficulty maintaining core temperature at 37°C or
rewarming faster than 0.5 °C/hr, consider:
ξ Continuation of intravascular or surface cooling
ξ Scheduled acetaminophen, if no significant liver disease
Last revised: 08/2016
UW Health Post Cardiac Arrest Clinical Practice Guideline
Yes
No No
Yes
Yes
Yes
No
Yes
Due to the severity of illness in post cardiac arrest patients, consider consulting Palliative Care.
If patient is pregnant, consult Obstertrics.
Goal Temperature
Goal core temperature of 32-36°C (AHA Class I, LOE B-R) for at least 24 hours (AHA Class IIa, LOE C-EO).
Evidence (2013) suggests 36°C may be an appropriate goal temperature, particularly in patients
not previously thought to be candidates for TTM (e.g., recent trauma, bleeding concerns, or
hemodynamic instability) or those unable to tolerate 33°C goal temperature.
Once the decision is made to proceed with TTM, the goal temperature is determined by the
accepting critical care team. This decision is made after careful and timely review of the clinical
data and patient factors that are available to the team at the time of the patient’s admission.
*Contact Interventional Cardiology. VF/VT arrest and shockable rhythm should be strongly considered for
emergent coronary angiography.
Copyright © 201� University of Wisconsin Hospital s and Clinics Authority
Contact: Lee Vermeulen, CCKM @uwhealth.org Last Revised: 08/2016CCKM@uwhealth.org