Now let’s talk about targeted temperature management (shortened down to TTM).
The latest national guidelines update for CPR and ECC recommends that targeted temperature
management interventions be administered to comatose (which means lacking meaningful response
to verbal commands) adult patients with ROSC after cardiac arrest, by selecting and maintaining
a constant temperature somewhere between 32 degrees celsius and 36 degrees celsius which
would translate to be (89.6 degrees fahrenheit and 95.2 degrees fahrenheit) for at least
24 hours.
Secondly, hemodynamic and ventilation optimization is the next intervention post arrest.
Though ACLS providers often use 100% oxygen while their performing the initial resuscitation,
they should titrate inspired oxygen during the post-cardiac arrest phase to the lowest
level required to achieve an arterial oxygen saturation of 94% or greater, whenever possible.
Now doing this may help to prevent any potential complications associated with oxygen toxicity.
Remember, excessive ventilation with high oxygen levels can actually have adverse hemodynamic
effects especially when intrathoracic pressures are increased and because of the potential
decreases in cerebral blood flow when partial pressure of carbon dioxide in arterial blood,
which would be abbreviated as PaCO2, decreases.
It’s so important that healthcare providers start ventilation rates at that 10 per minute.
The goal is to achieve normocarbia (which is a partial pressure of end-tidal carbon
dioxide, or PetCO2, of 30 to 40 mm of Mercury, or a PaCO2, of 35 to 45 mm of Mercury, and
may be a reasonable goal unless patient factors prompt more individualized treatments.
Other PaCO2 targets may be tolerated for specific patients.
For example, a higher PaCO2 may be more appropriate in patients with acute lung injury or high
airway pressures.
Likewise, mild hypocapnia might be beneficial treatment as a temporary measure when treating
cerebral edema, but hyperventilation could cause cerebral vasoconstriction.
Providers should note that when a patient's temperature is below normal, laboratory values
reported for PaCO2 might be higher than the actual values.
In addition, Healthcare professionals should titrate fluid administration and vasoactive
or inotropic agents as needed to optimize blood pressure, cardiac output, and systemic
perfusion.
Now though the optimal post-cardiac arrest blood pressure remains unknown; a mean arterial
pressure of 65 mm of Mercury or greater is a reasonable goal per scientific studies and
current guidelines.
When treating for ROSC in patients where coronary artery occlusion is suspected, rescuers should
transport the patient to a capable and reliable facility known for providing coronary reperfusion,
otherwise known as PCI, and other goal-directed post-cardiac arrest care therapies.
The decision to perform PCI can be made irrespective of the presence of coma or the decision to
induce hypothermia, because concurrent PCI and hypothermia are feasible and safe and
have reported good outcomes.
Next, we’re gonna look at glycemic control.
Altering glucose concentration within a lower range of 80 to 110 should not be attempted
because of the increased risk of hypoglycemia.
The latest guidelines update for CPR and ECC does not really have a recommended specific
target range of glucose management in adult patients with return of spontaneous circulation
after cardiac arrest.
Okay, so now let’s talk about the neurological and prognostication part of return of spontaneous
circulation.
See, the American Heart Association guidelines have established the following: that the goal
of post-cardiac arrest management is to return patients to their pre-arrest functional levels.
Reliable early prognostication of neurologic outcome is an essential component of post-cardiac
arrest care, but the optimal timing is important to consider.
In patients treated with TTM, prognostication using clinical examination should be delayed
for at least 72 hours after return of normothermia.
For those not treated with TTM, the earliest time is 72 hours after cardiac arrest and
potentially longer if the residual effect of sedation or paralysis confounds the clinical
examination.