Description
Rapid response systems (RRS) have been implemented in ICUs to provide early recognition and intervention for patients at risk of cardiac arrest.Advanced monitoring systems allow for continuous monitoring of vital signs, including electrocardiography (ECG), blood pressure, and oxygen saturation. The use of automated external defibrillators (AEDs) has become standard practice in many ICUs, allowing for immediate defibrillation in the event of cardiac arrest. Telemedicine and remote monitoring technologies enable real-time assessment and guidance from off-site experts during cardiac arrest resuscitation efforts. The development of high-fidelity patient simulators has revolutionized cardiac arrest training in ICUs, providing a realistic environment for healthcare providers to practice their skills.
Résumé
- A 55-year-old businessman collapsed at work and was found pulseless. CPR was initiated by colleagues, and EMS arrived within 5 minutes to find the patient in VF. Standard ACLS protocols were initiated, including shocking, intubation, and transport to the ED.
- Upon ED arrival, the patient was 7 minutes post-cardiac arrest, having received two epinephrine doses, one amiodarone dose, and two shocks, but remained in PEA. ET tube placement was confirmed, and bedside ECHO showed cardiac motion. Another epinephrine dose was given, and ROSC was achieved with normal sinus rhythm.
- In the ICU, the patient's heart rate was 112, blood pressure MAP 48, rectal temperature 26.5°C, and SpO2 100% with ETCO2. Examination revealed GCS of 3, absent reflexes, and 30 pack-year smoking history. The ACLS algorithm emphasizes scene safety, responsiveness, AED use, and CPR, focusing on reversible causes.
- Post-cardiac arrest syndrome is a complex combination of postcardiac arrest brain injury, myocardial dysfunction, and systemic ischemic reperfusion response. It's often complicated by the unresolved pathological process that caused the initial cardiac arrest.
- The immediate phase of post-arrest care is the first 20 minutes. The early phase is 20 minutes to 6-12 hours, the intermediate phase is 6-12 hours to 72 hours, and the recovery phase is from 3 days until disposition. These phases guide therapeutic interventions.
- Four components of postcardiac arrest syndrome are: postcardiac arrest brain injury (cerebrovascular impairment, hypoxia induced cerebral edema, neurodegeneration), myocardial dysfunction (global hypokinesis, myocardial stunning, acute cardiac syndrome), ischemic reperfusion systemic response (impaired vasoregulation, adrenal suppression, impaired tissue oxygen delivery), and persistent precipitating pathology.
- Management includes early hemodynamic optimization (MAP > 65, < 90), treatment of acute cardiac syndrome, therapeutic hypothermia, seizure control, and management of hyperglycemia and adrenal dysfunction. Continuous monitoring of urine output, lactate levels, and oxygen saturation (92-96%) is also crucial.
- Therapeutic hypothermia should be considered for patients with out-of-hospital VF/PVT arrest or in-hospital VF arrest, as well as those with pyrexia within 72 hours. Target core temperature should be 32-34°C for 12-24 hours. Complications include shivering, hemodynamic instability, electrolyte abnormalities, and increased risk of bleeding and infection.
- Prognostication for neurological recovery should be delayed until after 72 hours. Factors indicating poor prognosis include absence of pupillary and corneal reflexes, absent motor response, myoclonic status epilepticus, and high NSE levels (>33 mcg/L). EEG, SSEP, and CT scans can also provide additional information.
- Cardiac catheterization is recommended for patients successfully resuscitated from sudden cardiac death, even without evidence of ACS, to exclude underlying coronary artery disease. Thrombolysis should only be considered in cardiac arrest patients with proven or suspected PE.
- ECMO may be considered as a rescue therapy for selected patients when conventional CPR efforts fail. It requires skilled providers and rapid deployment. In hospital cardiac arrest often has a worse prognosis due to hypoxemia or hyperventilation leading to PEA and Asystole.
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