Table Multiple System Approach to PostCardiac Arrest Care by mikesanye

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									Table 1. Multiple System Approach to Post–Cardiac Arrest Care


Ventilation                        Hemodynamics                 Cardiovascular              Neurological                Metabolic

       Capnography               Frequent Blood              Continuous Cardiac         Serial Neurological        Serial Lactate
           o Rationale:            Pressure                     Monitoring                  Exam                            o Rationale:
              Confirm              Monitoring/Arterial-            o Rationale:                 o Rationale:                    Confirm
              secure airway        line                                Detect                       Serial                      adequate
              and titrate               o Rationale:                   recurrent                    examinations                perfusion
              ventilation                  Maintain                    arrhythmia                   define coma,
           o Endotracheal                  perfusion and           o No                             brain injury,
              tube when                    prevent                     prophylactic                 and prognosis
              possible for                 recurrent                   antiarrhythmic           o Response to
              comatose                     hypotension                 s                            verbal
              patients                  o Mean arterial            o Treat                          commands or
           o PETCO2 35–                    pressure 65                 arrhythmias as               physical
              40 mm Hg                     mm Hg or                    required                     stimulation
           o Paco2 40–45                   systolic blood          o Remove                     o Pupillary light
              mm Hg                        pressure 90                 reversible                   and corneal
                                           mm Hg                       causes                       reflex,
                                                                                                    spontaneous
                                                                                                    eye movement
                                                                                                o Gag, cough,
                                                                                                    spontaneous
                                                                                                    breaths


       Chest X-ray               Treat Hypotension           12-lead ECG/Troponin       EEG Monitoring If          Serum Potassium
           o Rationale:                o Rationale:                 o Rationale:            Comatose                        o Rationale:
               Confirm                    Maintain                      Detect Acute           o Rationale:                    Avoid
               secure airway              perfusion                     Coronary                  Exclude                      hypokalem
           and detect     o     Fluid bolus if              Syndrome/ST-                 seizures                     ia which
           causes or            tolerated                   Elevation                o   Anticonvulsant               promotes
           complication   o     Dopamine 5–                 Myocardial                   s if seizing                 arrhythmia
           s of arrest:         10 mcg/kg per               Infarction;                                               s
           pneumonitis,         min                         Assess QT                                             o   Replace to
           pneumonia,     o     Norepinephrin               interval                                                  maintain K
           pulmonary            e 0.1–0.5                                                                             >3.5
           edema                mcg/kg per                                                                            mEq/L
                                min
                          o     Epinephrine
                                0.1–0.5
                                mcg/kg per
                                min


   Pulse Oximetry/ABG        ...                   Treat Acute Coronary        Core Temperature            Urine Output,
        o Rationale:                                 Syndrome                     Measurement If               Serum Creatinine
           Maintain                                      o Aspirin/hepari         Comatose                         o Rationale:
           adequate                                         n                        o Rationale:                     Detect
           oxygenation                                   o Transfer to                   Minimize brain               acute
           and minimize                                     acute coronary               injury and                   kidney
           FIO2                                             treatment                    improve                      injury
        o SpO2 94%                                          center                       outcome                   o Maintain
        o PaO2 100                                       o Consider                  o Prevent                        euvolemia
           mm Hg                                            emergent PCI                 hyperpyrexia              o Renal
        o Reduce FIO2                                       or fibrinolysis              >37.7°C                      replaceme
           as tolerated                                                              o Induce                         nt therapy
        o Pao2/FIO2                                                                      therapeutic                  if indicated
           ratio to                                                                      hypothermia if
           follow acute                                                                  no
                                                                                         contraindicatio
           lung injury                                                 ns
                                                                   o   Cold IV fluid
                                                                       bolus 30
                                                                       mL/kg if no
                                                                       contraindicatio
                                                                       n
                                                                   o   Surface or
                                                                       endovascular
                                                                       cooling for
                                                                       32°C–34°Cx24
                                                                       hours
                                                                   o   After 24 hours,
                                                                       slow
                                                                       rewarming
                                                                       0.25°C/hr


   Mechanical           ...      Echocardiogram              Consider Non-               Serum Glucose
    Ventilation                       o Rationale:              enhanced CT Scan                 o Rationale:
       o Rationale:                       Detect global            o Rationale:                     Detect
            Minimize                      stunning, wall-              Exclude                      hyperglyce
            acute lung                    motion                       primary                      mia and
            injury,                       abnormalities,               intracranial                 hypoglyce
            potential                     structural                   process                      mia
            oxygen                        problems or                                            o Treat
            toxicity                      cardiomyopath                                             hypoglyce
       o Tidal                            y                                                         mia (<80
            Volume 6–8                                                                              mg/dL)
            mL/kg                                                                                   with
       o Titrate                                                                                    dextrose
            minute                                                                               o Treat
    ventilation to                                                                            hyperglyce
    PETCO2 35–                                                                                mia to
    40 mm Hg                                                                                  target
    Paco2 40–45                                                                               glucose
    mm Hg                                                                                     144–180
o   Reduce Fio2                                                                               mg/dL
    as tolerated                                                                          o   Local
    to keep Spo2                                                                              insulin
    or Sao2 94%                                                                               protocols


                     ...      Treat Myocardial          Sedation/Muscle             Avoid Hypotonic
                               Stunning                   Relaxation                   Fluids
                                   o Fluids to                o Rationale: To              o Rationale:
                                      optimize                    control                     May
                                      volume status               shivering,                  increase
                                      (requires                   agitation, or               edema,
                                      clinical                    ventilator                  including
                                      judgment)                   desynchrony as              cerebral
                                   o Dobutamine                   needed                      edema
                                      5–10 mcg/kg
                                      per min
                                   o Mechanical
                                      augmentation
                                      (IABP)

								
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