Intensive Care Paramedic

Transcription

1 Doc Control Ref: TEM-003 Version 2.0 (Admin use only) Version no: (Admin use only) Effective Date: (Admin use only) 1. Principle Post-return of spontaneous circulation (ROSC) management is an important link in the chain of survival. Interventions in the post-cardiac arrest period are likely to significantly influence the final outcome.¹ Employing an evidenced-based, targeted approach to every aspect of care aims to minimise and address the components of post-cardiac arrest syndrome, which include brain injury, myocardial dysfunction, systemic ischaemia / reperfusion response and persistent precipitating pathology.² While a targeted approach is considered best practice, optimal care for a patient s particular dysfunction or disease should occur. Management and treatment priorities of posttraumatic cardiac arrest patients may differ and should be tailored to the patient s needs and injuries, following relevant CPGs. The aims of therapy following cardiac arrest are to continue respiratory support, maintain cerebral perfusion, treat and prevent cardiac arrhythmias, and determine and treat the cause of the arrest.¹ As soon as practical, rapid transport to hospital should occur. Airway and Breathing It is important to re-assess the airway following ROSC. If indicated, consider the most appropriate advanced airway for the patient and circumstances to ensure optimal airway and ventilatory management. Raising the patient s head up to 30 o (when clinically appropriate) may help to prevent passive regurgitation. Sub-optimal respiratory management following cardiac arrest can result in negative patient outcomes.³ Optimal clinical management will vary depending on individual patient and resuscitation factors. Thus, constant awareness and reassessment of ventilation strategies are essential. Unnecessary hypo/hyperventilation, excessive ventilation volumes, hypo/hyperoxaemia, and hypo/hypercapnia should be avoided where possible. Waveform capnography is useful post-rosc for monitoring EtCO2 trends, monitoring ventilation rates, indicating early loss of ROSC and displaying characteristic waveform patterns. Circulation Blood Pressure Management Adequate blood pressure (BP) for optimal organ perfusion will vary between post-cardiac arrest patients, and will be influenced by individual pre-morbid pathophysiology and factors associated with resuscitation.⁴ Observational studies have frequently reported increased negative outcomes associated with hypotension in post-cardiac arrest patients.⁵ Hypotension may exacerbate postcardiac arrest brain injury and must be managed appropriately. Coronary Reperfusion Considerations The majority of out-of-hospital cardiac arrest cases are reported to be of cardiac origin, with obstructive coronary artery disease being the most dominant aetiology.⁶ Persistent ST-elevation on the post-rosc 12 lead ECG has frequently been associated with acute coronary occlusion. In INFORMAL COPY WHEN PRINTED For Official Use Only I# - A# Page 1 of 5

2 these patients, early coronary angiography and percutaneous intervention has been reported to increase survival.³ A Code STEMI activation is appropriate in such circumstances. Other Considerations Blood Glucose Control BGL monitoring should occur following cardiac arrest. If treating hypoglycaemia, administer the minimum amount of glucose to achieve a BGL within normal limits. A strong association exists between high BGL after resuscitation from cardiac arrest and poor neurological outcome. 3,7 Temperature Management Attempt to maintain a temperature within normal range. Hyperthermia may aggravate ischemiareperfusion injury and neuronal damage and should be avoided.⁸ Passive cooling is appropriate in these circumstances and includes removing blankets and exposing the patient. Hospital Destination Within metropolitan Adelaide: Any patient with ROSC should be transported to a spine hospital or TQEH if safe to do so. Paediatric Considerations Many of the key post-rosc considerations for paediatric patients are the same as adults, however there are some important differences which will alter management strategies. o Paediatric cardiac arrest is less likely to be precipitated by a cardiac cause. o Correction and avoidance of hypoxia is paramount to the outcome of paediatric patients. o Maintaining BP appropriate for age is important post-rosc, and hypotension should be addressed. Refer to SAAS paediatric RDR chart for normative values. o Post-ROSC hyperthermia has increased prevalence in children, and is associated with poorer outcomes. Avoid hyperthermia accordingly. o There is an increased risk of hypoglycaemia. Greater emphasis must be placed on early post-rosc BGL, and its management. 9 INFORMAL COPY WHEN PRINTED For Official Use Only I# - A# Page 2 of 5

3 2. Details Re-evaluate ABCDE and provide basic care. Treat precipitating causes. Prepare for rapid transport. Treat in accordance with relevant CPGs. Airway and Breathing Reassess and optimise airway. Avoid hyperventilation. Start at breaths/min and consider ventilation strategy. o For paediatric patients, ventilate at an age-appropriate rate, refer to SAAS paediatric RDR chart. Continue high-flow oxygen therapy. o For patients requiring assisted ventilations, continue oxygen 15L/min. o For patients not requiring assisted ventilations, re-assess and apply optimal oxygen to maintain SpO %. If SpO2 is unreliable, maintain high-flow oxygen. Continue waveform capnography monitoring. o In patients with a prolonged time to hospital with persisting or increasing hypercapnia (EtCO2 >45 mmhg), cautiously increase ventilation rate to slowly decrease EtCO2 (as a guide, aim to decrease EtCO2 by 1 mmhg/min if safe to do so). Avoid excessive ventilation volumes. Consider gastric decompression, especially in paediatric patients. Optimise posture. Perform chest examination, including auscultation of the lungs. Circulation Blood Pressure Management Treat hypotension. For adults, maintain SBP>100 mmhg o Judicious fluid administration of sodium chloride 0.9% IV/IO in 250 ml aliquots, reassessing after each aliquot. o Adrenaline (epinephrine) up to 50 microgram IV/IO bolus increments titrated to effect, OR Adrenaline (epinephrine) 5-20 microgram/min IV/IO via syringe driver titrated to effect, OR Adrenaline (epinephrine) 1 microgram/1ml saline 0.9% IV/IO infusion titrated to effect. For paediatrics, maintain a SBP within the predictive normal range for their age (refer to SAAS paediatric RDR chart). If hypotensive: o Initiate fluid administration of sodium chloride 0.9% IV/IO up to 10 ml/kg. Reassess and repeat once if required. o Consult with a SAAS Medical Practitioner via the EOC Clinician for further treatment. Anti-arrhythmic Considerations Treat arrhythmias, following relevant CPGs o For adults with recurrent episodes of VF/VT, or non-sustained episodes of VT, administer 300 mg amiodarone infusion over 20 minutes, OR 150 mg over 10 minutes (if 300 mg already administered during arrest). NB do not exceed a total of 450 mg of amiodarone In 250 ml 10% glucose IV/IO In 50 ml with 10% glucose via syringe driver o For paediatrics with recurrent episodes of VF/VT, or non-sustained episodes of VT, consult with a SAAS Medical Practitioner via the EOC Clinician. INFORMAL COPY WHEN PRINTED For Official Use Only I# - A# Page 3 of 5

4 Coronary Reperfusion Considerations If ST elevation diagnostic of STEMI persists on the 12 lead ECG, activate the receiving hospital PCI team using the Code STEMI line (refer to Coronary Care (Acute) CPG) and notify the receiving hospital early. Other Considerations Disability Manage pain and agitation, refer to relevant CPGs. Blood Glucose Control For adults with hypoglycaemia o Administer glucose (10%) IV/IO titrated to achieve a BGL between 4-10 mmol/l. o Sodium chloride 0.9% 100 ml IV/IO flush must be given before and after glucose IV/IO. o Avoid hyperglycaemia. For paediatrics with hypoglycaemia o Administer glucose (10%) IV/IO starting at 2 ml/kg titrated to achieve a BGL between 4-10 mmol/l. The maximum dose is 5 ml/kg. o Sodium chloride 0.9% 1 ml/kg IV/IO flush must be given before and after glucose IV/IO. Temperature Management Maintain temperature within normal range ( C). Rapid transport and notify the receiving facility. 3. Appendices Nil 4. References/Associated Documents Doc. Ref. Number Document Title or Information Source 1. ANZCOR Guideline Post-resuscitation Therapy in Adult Advanced Life Support (2016). 1st ed. [ebook] Australian Resuscitation Council. Available at: [Accessed 10 Jun. 2017] 2. Nolan JP, Neumar RW, Adrie C, et al. Post-cardiac arrest syndrome: Epidemiology, pathophysiology, treatment, and prognostication: A Scientific Statement from the International Liaison Committee on Resuscitation; the American Heart Association Emergency Cardiovascular Care Committee; the Council on Cardiovascular Surgery and Anesthesia; the Council on Cardiopulmonary, Perioperative, and Critical Care; the Council on Clinical Cardiology; the Council on Stroke. Resuscitation 2008; 79: Nolan JP, Soar J, Cariou A, et al. European Resuscitation Council and European Society of Intensive Care Medicine Guidelines for Post-resuscitation Care 2015: Section 5 of the European Resuscitation Council Guidelines for Resuscitation Resuscitation 2015;95: Callaway CW, Donnino MW, Fink EL, et al. Part 8: post-cardiac arrest care: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation 2015;132:S465 S Wong GC, van Diepen S, Ainsworth C et al. Canadian Cardiovascular Society/Canadian Cardiovascular Critical Care Society/Canadian Association INFORMAL COPY WHEN PRINTED For Official Use Only I# - A# Page 4 of 5

5 of Interventional Cardiology Position Statement on the Optimal Care of the Postarrest patient. Canadian Journal of Cardiology 2017;33: Rab T, Kern KB, Tamis-Holland JE et al. Cardiac Arrest: A treatment algorithm for emergent invasive cardiac procedures in the resuscitated comatose patient. J Am Coll Cardiol 2015;66: Rittenberger JC, Callaway CW Post-cardiac arrest management in adults. UpToDate 2017, Retrieved 5/7/2017 from 8. Callaway CW, Soar J, Aibiki M et al. on behalf of the Advanced Life Support Chapter Collaborators, 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations - Part 4: Advanced Life Support. Circulation 2015;132:S84- S145, 9. ANZCOR Guideline 12.7 Management after ROSC (Infants and Children) (2016). Available at: ALS/ANZCOR-Guideline-12.7-Management-after-ROSC-Jan16.pdf [Accessed 31st Jan. 2018] 5. National Safety and Quality Health Service Standards Standard 1 Governance for Safety and Quality in Health Service Organisations Standard 2 Partnering with Consumers Standard 3 Preventing & Controlling Healthcare associated infections Standard 4 Medication Safety Standard 5 Patient Identification & Procedure Matching Standard 6 Clinical Handover Standard 7 Blood and Blood Products Standard 8 Preventing & Managing Pressure Injuries Standard 9 Recognising & Responding to Clinical Deterioration Standard 10 Preventing Falls & Harm from Falls Version control and change history Version Date from Date to Amendment /12/2002 Current Original version Document control information Objective File Number: Admin use only Document classification: Currently not in use Key Words: Document developed by: Author: Endorser Approver: Review Date: March 2023 Post-ROSC management cardiac arrest Clinical Performance and Patient Safety Joseph Schar, Chantelle Skinner s Keith Driscoll, Executive Director Clinical Performance and Patient Safety Approval authority Document Endorse Approve Clinical Governance Committee Executive Leadership Team (Chair) INFORMAL COPY WHEN PRINTED For Official Use Only I# - A# Page 5 of 5