emDocs - April 29, 2015 - By Manpreet Singh
“I’ve got a pulse,” you hear the nurse shout. Finally, a sigh of relief comes over the crowded resuscitation room and you take a moment to reflect on what just happened… but, your work is just now about to truly begin. It is up to you to determine why the patient died in the first place and determine which crucial steps need to be initiated to increase your patient’s chance of survival.
A detailed history is paramount to the survival of your patient. Question the paramedics if this was a prehospital arrest. How long was the down time, how long have they worked the arrest, what was going on at the scene, were there any empty pill bottles at the scene or reported exposure to any toxins? Was there prolonged exposure to extreme temperatures? Take the time to question the family about the recent symptoms that led up to the arrest, were there any medication changes, or new diagnoses?
A brief differential diagnosis for most all cardiac arrest adult patients should include:
- ACS, arrhythmias
- Electrolyte disorders
- Tamponade
- Airway obstruction, asthma, COPD, pneumonia, PE, tension pneumothorax
- Trauma, GI bleed, AAA rupture, ICH,
- Overdose either intentional or accidental
CONCLUSION:
The post arrest phase may potentially be as hectic as the arrest phase. You have multiple systems to think about and often must be thinking about them all simultaneously. In summary, keep the following in mind:
- Perform a focused and detailed history and physical examination
- Evaluate the airway and ETT placement, control the ventilator settings to maintain a PaCO2 to 35 to 45 mmHg and an oxygen saturation of above 94% while keeping the PaO2 below 300 mmHg
- Assess for neurological dysfunction in absence of neuromuscular blockade
- Send labs including CBC, CMP, troponin, coagulation studies
- Obtain a plain film chest X-Ray, Point of Care Ultrasound, and ECG
- Early consultation of interventional cardiology for patients in VF/VT or with ST segment changes on ECG
- Pressor support and isotonic crystalloid boluses to maintain a MAP of 85-100
- Infusion of chilled IV isotonic normal saline to 4℃ to induce therapeutic hypothermia to a goal of 33℃ to 36℃
http://www.emdocs.net/ive-got-a-pulse-now-what-post-arrest-care-in-the-acute-setting/