Cardiac Care Show – Episode 2: Post-Resuscitation Care

Cardiac Care Show – Episode 2: Post-Resuscitation Care

Hello, and welcome to the Cardiac Care Show! I’m your host Tom Bouthillet. In today’s episode we’re going to be talking about post-resuscitation care – specifically, prehospital post-resuscitation care. In other words, all of the things that should happen after your patient experiences return of spontaneous circulation (ROSC).

This is an extremely important topic especially for EMS systems that are implementing High Performance CPR, because it is very predictable that you are going to see a lot more patients with return of pulses in the field, and if you don’t have a plan, lots of things can go wrong before arriving at the hospital.

We need to make sure these patients receive excellent care, and we need to make sure they are conveyed to the hospital in a safe manner that maximizes their odds of survival. This is not a comprehensive treatment of post-resuscitation care. It’s just an overview of some things you should consider from a system standpoint when taking care of cardiac arrest patients.

There’s a reason I’m taking on this topic right now.

We hosted the inaugural South Carolina Resuscitation Academy April 29-30 on Hilton Head Island, which was very successful, but some of the feedback we received from our attendees was that they would have liked to receive more information about our post-resuscitation care checklist.

In my EMS system, we have a process before we move the patient. This is sometimes referred to as a “10-minute time out”. Initially, the concept was that if the patient was going to re-arrest, we’d rather have it happen in middle of the living room, with the patient surrounded by rescuers, rather than in the elevator, or rolling down the sidewalk.

That doesn’t mean we’re standing around doing nothing for 10 minutes. If you’re doing everything you’re supposed to be doing, it should take about 10-minutes anyway. This is not a time to rush. In fact, the more you rush, the higher the odds that you’re going to make a mistake.

This is what our updated checklist looks like.

We’re going to break this down but first, let’s talk about how we know we have ROSC in the first place. That’s really straight forward, right? Well, not always, and we don’t have POCUS in the field, so what criteria do we use to determine that our patient has a return of pulses?

capnography histogram

Generally speaking we look for 3 things to confirm ROSC.

  1. There is an organized rhythm on the monitor. For witnessed VF arrest we usually sense this during post-shock compressions, where you can see an organized rhythm underneath the CPR artifact.
  2. There is a sudden rise in ETCO2. I can’t give you an exact number. It’s simply a deviation from your baseline. So if the ETCO2 was 28 mm Hg during HP-CPR, and now you see an underlying rhythm and the ETCO2 is 34 mm Hg, that’s a change. It’s possible to have ROSC without a sudden rise in ETCO2 but in almost all of the cases I’ve reviewed over the past 7 years, there was a change.
  3. Confirmed with a pulse check. This is potentially problematic because we’re not that good assessing pulses! So be careful that your zeal to minimize CPR interruption (and maximize CPR fraction time) does not lead you to falsely assume that you’re dealing with PEA.

There are two things you can do to improve your pulse check. First, consider assessing the femoral pulse during chest compressions. If you have a good femoral pulse during compressions, you know that your CPR is probably effective. It also means that your fingers are already on the right spot for the pulse check. Second, you can attach pulse oximetry and look for a pleth waveform.

Keep in mind that when you stop CPR for a pulse check, the patient still requires ventilations! Many times I’ve seen the team leader give the command to “stop CPR” for the pulse check and both the rescuer on chest compressions and the rescuer airway stop what they are doing, because that’s what happens during a peri-shock pause. So make sure you continue to ventilate the patient.

trend summary

When we first attach pulse oximetry our patients with ROSC frequently have an SpO2 below 90%, and sometimes much lower. We want to gingerly bring up their SpO2 without blowing off all their CO2. We also want to re-assess the airway and listen to breath sounds. Hypoxia and hypotension are frequent complications of post-arrest patients, so we need to have SpO2 attached at all times. If you use a rigid plastic SpO2 sensor, consider switching to the finger probes with the sticker. Otherwise, the SpO2 will fall off constantly, which can be a real problem.

These patients will frequently start trying to breath on their own, which means the rescuer on the BVM needs to be skilled enough not to fight the patient’s spontaneous ventilations. We don’t want to hyperventilate, but it’s fine to give a little bag squeeze when the patient takes a gasp, especially if you’re still trying to get the sats above 90%.

These patients will often re-gain their airway reflexes over the next 10 minutes or so, and when they do, they will start to gag on the OPA or tracheal tube. That’s a problem because the patient may start to vomit, and you can end up with an airway problem. Some of you might ask, why not just sedate them? It’s because sedation is going to confound our neuro exam, and we don’t want patients to be subjected to Targeted Temperature Management unless it’s really indicated. So just be mindful of the fact that these patients may require extubation, and they may need to be changed over to a NRB mask.

They do not necessarily need to be transported on a backboard, and in fact, if they start breathing on their own you’ll probably want to place them in a semi-Fowlers position, and there’s no easy way to do that if the patient’s on a backboard. Generally speaking, the backboard should be used to carry patient’s down steps. But this is a judgement call. Do what’s right for the patient considering all of the circumstances.

Next we want to obtain a full set of vital signs, including a baseline temperature. It doesn’t have to be a core temperature. All we’re doing is establishing that the patient is not hypothermic at baseline. This is particularly important for unwitnessed arrests, or situations where the patient was found on the floor with no clothes.

We basically want to know whether or not the patient’s temperature is already below 96.8 F / 36.0 C. We understand that it’s just a temporal thermometer, so we’re not trying to guide Targeted Temperature Management, we’re just getting a ballpark estimate. Conversely, we’d also like to know if the patient is hyperthermic in which case we’re going to provide external cooling prior to hospital arrival. Hilton Head Island is a subtropical climate, and sometimes our patients go into cardiac arrest on the beach, and the ambient temperature can be quite warm.

12-Lead 2

We also want to obtain a 12-lead ECG with excellent data quality, and with post-ROSC patients, the data quality is frequently not excellent. This is something that most EMS systems struggle with. So take your time and obtain a 12-lead ECG before you load the patient for transport, and before they have seat belts and straps all over the place.

If it was a shockable rhythm, and the ECG is showing clear-cut STEMI, we want to activate the cardiac cath lab. In my system, we announce CODE-STEMI over the radio and get a time stamp, and we follow up with ECG transmission. Our receiving hospital is a PCI hospital so we don’t need to consider bypassing the local non-PCI hospital.

Be sure to ask if the patient (or the patient’s surrogate decision maker) has a preferred cardiologist on staff. This will prevent the wrong cardiologist from being called in from home if the patient is taken to the cardiac cath lab.

Finally, we want to assemble the right team to transport the patient to the hospital. If it’s 0300 you might want to release the engine company, so the guys can go back to the station, but don’t do it. All of your practice has just paid off. If you’ve got a patient with a shot at surviving a sudden cardiac arrest, don’t allow yourself to be under-staffed in the back of the ambulance, and have a plan if the patient re-arrests. That could mean applying the LUCAS device or AutoPulse as a precaution, it could mean pulling over to the side of the road and re-implementing HP-CPR, or it could mean continuing the resuscitation en route to the hospital, but that shouldn’t mean high flow diesel with rescuers being thrown around in the back of the ambulance.

If you follow all of these steps, you won’t experience many of the problems my EMS system experienced when we first started saving patients who suffered an out-of-hospital cardiac arrest. We learned some of these lessons from systems like Seattle / King County and Wake County EMS, and some of them we learned through the school of hard knocks, and post-event review, so I hope that this has been helpful.

Got an opinion about post-resuscitation care? Leave us a comment! If there’s a topic you’d like us to cover on the Cardiac Care Show you can email me directly at tbouthillet@ecgmedicaltraining.com or tweet with the hashtag #CardiacCareShow! Thanks for joining us. See you next time.

References

Callaway C, Donnino M, Fink E et al. Part 8: Post–Cardiac Arrest Care. Circulation. 2015;132(18 suppl 2):S465-S482. doi:10.1161/cir.0000000000000262.

Eberle B, Dick W, Schneider T, Wisser G, Doetsch S, Tzanova I. Checking the carotid pulse check: diagnostic accuracy of first responders in patients with and without a pulse. Resuscitation. 1996;33(2):107-116. doi:10.1016/s0300-9572(96)01016-7.

Hartke A, Mumma B, Rittenberger J, Callaway C, Guyette F. Incidence of re-arrest and critical events during prolonged transport of post-cardiac arrest patients. Resuscitation. 2010;81(8):938-942. doi:10.1016/j.resuscitation.2010.04.012.

Pokorná M, Nečas E, Kratochvíl J, Skřipský R, Andrlík M, Franěk O. A Sudden Increase in Partial Pressure End-Tidal Carbon Dioxide (PETCO2) at the Moment of Return of Spontaneous Circulation. The Journal of Emergency Medicine. 2010;38(5):614-621. doi:10.1016/j.jemermed.2009.04.064.

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Tom Bouthillet
Tom Bouthillet - 25 posts

Tom Bouthillet (@tbouthillet) is Editor-in-Chief of ECGMedicalTraining.com (@ECGTraining) and Fire Captain/Paramedic in South Carolina where he is the Emergency Cardiac Care Program Manager and the STEMI and CARES Site Coordinator of his fire department.

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