Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

When Does Post-Resuscitation Care Begin

In the comments to Cardiac Arrest Management is an EMT-Basic Skill, AZCEP wrote –

True enough, but it is an important part of resuscitation all the same. Post-arrest management has been de-emphasized to the point of absence from AHA guidelines until the latest version reintroduced it to us.

When we start post-resuscitation care before the patient is resuscitated, we are not doing any good. Post means after. Post-resuscitation means after resuscitation, not during resuscitation and definitely not before ROSC.

We are just making excuses for interrupting compressions and continuing experimental treatments that most likely decrease survival.

Post-resuscitation treatment should not be de-emphasized. I have always spent time teaching people what to do after ROSC (Return Of Spontaneous Circulation).

First. Assess. Don’t do too much.

Find out what is going on before doing anything.

Suppose the patient’s initial pressure is 60 by palpation.

What do we do?

Second. Reassess.

Things change, so we want to know what the trend is. We do not care what normal is. We are dealing with a patient who is not at all representative of what we do.

60/palp is not a good pressure for a normal patient, but there is nothing normal about this patient. We want to know what direction the blood pressure is going. A minute ago the pressure was 0/0, so things have improved. Rushing to give a catecholamine (something that is just a weaker version of epinephrine, or just epinephrine by drip) is a bad idea. The patient just had his systolic pressure rise by 60 points in one minute without any pressors. Adding a pressor to a dramatically rising blood pressure is a bad idea.

If the pressure stays at 60/palp, then some fluids are not a bad idea. Always listen to lung sounds before giving fluids, but crackles are not an absolute contraindication for a fluid challenge. Crackles may even be an indication for a fluid challenge.

If the next pressure is lower, then a fluids challenge is the first treatment – not a catecholamine!

We just resuscitated the patient. Let’s hold off on the drugs that can kill the patient. At least let him live for a few minutes.

What about cardioversion?

This patient definitely meets criteria for cardioversion.

No. This patient only meets criteria for cardioversion after a full assessment and not after cardiac arrest.

How much epinephrine has the patient received?

Is cardioversion going to metabolize any of that massive dose of epinephrine?

Absolutely not.

Just say NO.

Reassess and then reassess again.

The best management of a cardiac arrest is to prevent it from ever happening to begin with.

Preventing cardiac arrest is much better than responding to cardiac arrest, but should we assume that ALS that failed to prevent cardiac arrest is going to reverse cardiac arrest? These are very different medical presentations, even though they may be in the same patient.

I wrote about this in Dissecting the ACLS Guidelines on Cardiac Arrest from Toxic Ingestions. Calcium chloride is safe and effective at preventing arrest from hyperkalemia. Once the patient is dead (maybe medical command refused orders for calcium chloride, maybe the patient arrested prior to arrival, maybe we didn’t think it was that serious, . . . ), giving calcium chloride may not be anywhere near as successful.

There is an important difference in the way dead people and living people respond to treatments.

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Comments

  1. There needs to be more time spent educating prehospital providers (and in-hospital providers too, for that matter) about post-resuscitation care. There is a lot of emphasis on teaching what to do during the arrest, which drug for this rhythm or that rhythm, but post resuscitation care is usually only mentioned as an afterthought … unfortunately, there sometimes seems to be the attitude of “most of them probably won’t make it anyway, so we don’t really need to worry about that.”

    As a result of this lack of education, people sometimes want to do things during post resuscitation care that will more than likely harm the patient, and possibly cause him to go back into cardiac arrest. Someone who was clinically dead a couple minutes ago is not likely to have “good” vital signs, but even having a blood pressure at all is an improvement. A heart rate of 150 at rest isn’t a good thing in an otherwise healthy adult, but in someone who was just given IV epi, it’s an expected finding, not an indication for immediate cardioversion or IV adenosine.

    Appropriate post-resuscitation care is also going to vary depending on the underlying illness … is the patient in cardiac arrest due to coronary occlusion? Metabolic derangement? Secondary to a respiratory cause? We need to be prepared to deal with many different causes of cardiac arrest and treat them accordingly. In most ACLS classes, the “H’s and T’s” are briefly mentioned (and memorized) as reversible causes of cardiac arrest, but there is typically very little time devoted to how to care for the patient in each situation.