Monday Morning Medical Director’s Message
This month we continue our focus on cardiac arrest care. After staying on scene to provide aggressive resuscitation to the patient, we were able to achieve the return of spontaneous circulation (ROSC) successfully. Great! Today, we will review the steps we should take after we obtain ROSC.
Post-arrest patients are stay and play
Once we obtain ROSC, there is often a lot of inertia to immediately extricate and transport. However, the best thing we can do is stay on scene a little longer to continue resuscitation. The reason for this is that we have two major goals for post-arrest patients:
- Prevent re-arrest
- Prevent further brain injury
| 
|
When we get ROSC, we likely have not corrected the underlying reason for the cardiac arrest. This means that the process is still active and can cause the patient to re-arrest. We should look for reversible causes and try and correct these ASAP. In addition, post-arrest patients are often hemodynamically unstable. Drops in blood pressure and oxygen sats can also cause the patient to re-arrest.
The post-arrest brain often has anoxic brain injury from decreased blood flow during the arrest. Hypotension and hypoxia are each associated with further brain injury in this setting. The more severe and longer the duration of the hypotension and hypoxia, the more severe the brain damage. In addition, when these both occur at the same time, they are synergistic, meaning the total brain injury is worse than the sum of each individually.
The way that we achieve our main two goals is to immediately get a full set of vitals after obtaining ROSC and aggressively correct any vital sign derangement. In addition, we want to re-check vitals often to make sure we are identifying hypotension and hypoxia as soon as possible. We want to correct hypoxia with hi flow oxygen, use of positive end-expiratory pressure (PEEP) valves, and use of advanced airways. We want to correct hypotension with fluids and push dose epinephrine (PDE). We want to correct arrhythmias with antiarrhythmics and electrical cardioversion. The key is that re-arrest and further brain damage are more likely to occur from unaddressed vital sign abnormalities. If we extricate the patient before doing this, the patient is more likely to be in arrest when we get to the ambulance.
Use of a post-arrest ROSC check list
I recommend having a checklist to use as a reminder of all the things we should be doing before extricating post-arrest patients. This checklist should include:
- Obtain a full set of vitals: This will address abnormalities (discussed above).
- Obtain a 12-lead EKG: This is to look for STEMI since this might guide transport destination. If present, we would want to call the receiving facility to activate their cath lab right away to give them time to mobilize resources. Ideally, we should transmit the EKG and call it in prior to extrication to give them as much time as possible to prepare.
- Ensure good vascular access: If we only have an IO, we should consider upgrading to an IV for better access. In addition, we should consider placing a second line as a backup since it is easy to lose one during extrication.
- Ensure the airway is managed based on the patient’s needs: Some patients will already have an advanced airway. For those that do not, if they are awake enough that they are protecting their own airway, great! For those that are not, we should consider placing one before extrication since it is hard (if not impossible) to adequately bag a patient using a BVM while we are carrying a patient to the rig. If a supraglottic airway is currently in place, consider escalating to an endotracheal tube, especially if the patient is still hypoxic.
- Prepare for hypotension: If your patient is not already hypotensive, assume he/she will be soon. Post-arrest patients often receive a dose of epinephrine just before ROSC which is rapidly metabolized out of the blood stream. We can prepare for hypotension by spiking a bag of fluids and mixing a vasopressor. For us that means we will mix PDE if we have not already done so. Given how bad hypotension is, we should assume it is coming and be ready to treat it.
- Use of antiarrhythmics: This is not routinely needed. It should only be administered if the patient is having large amounts of ventricular ectopy or recurrent episodes of ventricular tachycardia or ventricular fibrillation.
Once the patient is as stable as possible, then we should proceed with extrication.
We work very hard for our patients in cardiac arrest. Once we get ROSC, our work is not done! We should continue to provide aggressive EMS care on the scene to decrease the patient’s chance of re-arrest and give them their best chance of a good outcome.
Be safe and keep up the awesome work!
Jordan Singer, MD
EMS Medical Director, UH EMS Training and Disaster Preparedness Institute
Emergency Physician, UH Cleveland Medical Center
Emergency Physician, UH Elyria Medical Center
Assistant Professor, CWRU School of Medicine