Post-resuscitation care following out-of-hospital and in-hospital cardiac arrest

Abstract

Cardiac arrest is a leading cause of death in developed countries. Although a majority of cardiac arrest patients die during the acute event, a substantial proportion of cardiac arrest deaths occur in patients following successful resuscitation and can be attributed to the development of post-cardiac arrest syndrome. There is growing recognition that integrated post-resuscitation care, which encompasses targeted temperature management (TTM), early coronary angiography and comprehensive critical care, can improve patient outcomes. TTM has been shown to improve survival and neurological outcome in patients who remain comatose especially following out-of-hospital cardiac arrest due to ventricular arrhythmias. Early coronary angiography and revascularisation if needed may also be beneficial during the post-resuscitation phase, based on data from observational studies. In addition, resuscitated patients usually require intensive care, which includes mechanical ventilator, haemodynamic support and close monitoring of blood gases, glucose, electrolytes, seizures and other disease-specific intervention. Efforts should be taken to avoid premature withdrawal of life-supporting treatment, especially in patients treated with TTM. Given that resources and personnel needed to provide high-quality post-resuscitation care may not exist at all hospitals, professional societies have recommended regionalisation of post-resuscitation care in specialised 'cardiac arrest centres' as a strategy to improve cardiac arrest outcomes. Finally, evidence for post-resuscitation care following in-hospital cardiac arrest is largely extrapolated from studies in patients with out-of-hospital cardiac arrest. Future studies need to examine the effectiveness of different post-resuscitation strategies, such as TTM, in patients with in-hospital cardiac arrest.

Figure 1

The Cardiac Arrest Survival Postresuscitation In-hospital (CASPRI) scorecard and nomogram for favourable neurological survival. For this in-hospital cardiac arrest risk score, points for each variable are determined, and a summary score is obtained. The corresponding likelihood of surviving to hospital discharge without severe neurological disability is determined from the risk table or plot. Adapted with permission from Chan et al. CPC, cerebral performance score; VF/VT, ventricular fibrillation or ventricular tachycardia.

Figure 2

Post-cardiac arrest treatment algorithm. Adapted with permission from Stub et al. AICD, automated internal cardioverter defibrillator; IABP, intra-aortic balloon pump; MAP, mean arterial blood pressure; SSEP, somatosensory evoked potentials; TTE, transthoracic echocardiogram.