ROSC... What do you typically do after?

[pinipig523]

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A good question was posed to me by a colleague - what do you do after a non-traumatic ROSC? Do you r/o an MI (get an EKG) and then if so push for cath? Or do you not and simply push for ICU admission for hypothermia protocol?

Or are there other things that you always do with all your ROSC that you'd like to do?

And if you have a routine (like bicarb amp to everyone or calcium for all esrd patients) - please do share.

Thanks!

 

[joeDO2]

-secure definitive airway and monitor etco2 via continuous waveform capnography
-obtain vitals and manage hypotension using pressors if necessary/warranted
-consider antiarrhythmic infusion depending on drugs used/arrest rhythm (although I sometimes have my doubts about this point and it's controversial depending on the situation)
-begin hypothermia protocol by placing esophageal temperature probe and boluses of chilled NS
-obtain 12-lead ECG- if STEMI or high likelihood of MI- to cath lab
-check for causes of arrest if not known.....physical, additional history gathering, etc.

....that was my tx plan in the field but i'm sure attendings here would have a few things to add

 

[SoCuteMD]

After ROSC:
- EKG to r/o MI.
- Consider therapeutic hypothermia
- Access - at least TLC and if initiating hypothermia, most likely TLC and A-line
- Manage hemodynamic parameters/rhythm
- Push for ICU bed ASAP if no STEMI
- Usually end up spending a TON of time with the family, explaining what happened and the prognosis.

 

[Rendar5]

Only stuff to add to above set of stuff is:
titrate SpO2 to ~95%
Start pressors for MAP >75-85

 

[RustedFox]

After ROSC:

1. Breathe out.
2. Check pants, ascertain presence of wetness.
3. Change if wet.

... and all the stuff above.

 

[dotcb]

at my shop cards takes all post arrest patients, even though they frequently end up having a non-cardiac etiology. we manage airway, hemodynamics, appropriate lines. Neuro gets involved to manage cooling (we cool comatose post-arrest regardless of rhythm, for better or worse). if stemi - off to cath. if not, then usually CTH on the way up to ICU, if they are stable enough to tolerate it.

 

[pinipig523]

Another attending told me that he does not get ekgs on post-ROSC patients because after CPR, you're already looking at likely damaged myocardium - thoughts?

 

[thorg12]

If documented v tach or v fib before I push for cath lab. What pressor do u use? If they responded to an epi do you put them on a epi drip and titrate off and put ok Levo or something else?

 

[SoCuteMD]

Another attending told me that he does not get ekgs on post-ROSC patients because after CPR, you're already looking at likely damaged myocardium - thoughts?

I don't know the breakdown as far as percentages, but we have patients who go to the cath lab and get stented post-arrest, then continue up to the CCU for their therapeutic hypothermia. I would not be ok with missing an intervenable lesion.

 

[deleted109597]

I usually cuss, because I've wasted a lot of resources and now I'm going to tie up an ICU bed.

Every now and then I get one that makes me happy though. Usually a younger person with something reversible. It's rare though.

 

[dotcb]

After a person dies and comes back to life, not getting an EKG would be a pretty significant omission. The EKG is used to make reperfusion, rhythm and etiology decisions. It does change the management. For pressor - Norepi. Less tachydysrhythmias than dopamine.

 

[WilcoWorld]

Agree with most of the above, assuming the patient isn't talking to you asking why he just got punched in the chest.

In order (or, preferably, in parallel)
-Is the MAP>65?
If yes start cooling (at first, simply by not warming).

-Manage airway.

-Is there a STEMI?
If yes, activate cath lab
If no, consider cath lab

-Think about other stuff (K+, Mg++, glucose)

 

[joeDO2]

If documented v tach or v fib before I push for cath lab. What pressor do u use? If they responded to an epi do you put them on a epi drip and titrate off and put ok Levo or something else?

epi causes too many dysrhythmias, especially in post arrest. and with the bad press lately from the sepsis studies, I wouldn't be running for the dopamine either. as another poster suggested, norepi is probably a good option although I don't have vast personal experience with it post arrest since it was not an option for me and was forced to use dopamine.

 

[joeDO2]

regarding the cath lab decision....

Immediate percutaneous coronary intervention is associated with better survival after out-of-hospital cardiac arrest: insights from the PROCAT (Parisian Region Out of hospital Cardiac ArresT) registry.
Dumas F, Cariou A, Manzo-Silberman S, Grimaldi D, Vivien B, Rosencher J, Empana JP, Carli P, Mira JP, Jouven X, Spaulding C
Circ Cardiovasc Interv. 2010;3(3):200.

the study found that 70% of patients that were cathed after vf/vt arrest had at least 1 significant coronary lesion. food for thought.

 

[Cerberus]

Another attending told me that he does not get ekgs on post-ROSC patients because after CPR, you're already looking at likely damaged myocardium - thoughts?

Huh? That seems insane to me. Aside from all the underlying rhythms which could precipitate arrest (hypo-hyper K, afib w/ WPW, brugadas, etc, etc) I've not seen anyone post arrest with an infarct pattern without a blockage. Sure I see a lot of myocardial depression, but if I get a post-arrest EKG showing an inferior wall MI, that patient is going to cath as fast as possible. Further, how much does an EKG cost and how much time does it take to perform? We're not talking about getting a MRI/MRA and sending the pt to radiology for 2 hrs, we're talking about 2-3 minutes getting an EKG. I'd probably go apoplectic if a junior resident suggested we forego the EKG in a post-arrest pt.

 

[Cerberus]

If documented v tach or v fib before I push for cath lab. What pressor do u use? If they responded to an epi do you put them on a epi drip and titrate off and put ok Levo or something else?

If bradycardic I'd go norepi or dopamine, if tachycardic, I'm a big fan on phenylephrine. I never use epi outside of pediatrics.

 

[pinipig523]

Huh? That seems insane to me. Aside from all the underlying rhythms which could precipitate arrest (hypo-hyper K, afib w/ WPW, brugadas, etc, etc) I've not seen anyone post arrest with an infarct pattern without a blockage. Sure I see a lot of myocardial depression, but if I get a post-arrest EKG showing an inferior wall MI, that patient is going to cath as fast as possible. Further, how much does an EKG cost and how much time does it take to perform? We're not talking about getting a MRI/MRA and sending the pt to radiology for 2 hrs, we're talking about 2-3 minutes getting an EKG. I'd probably go apoplectic if a junior resident suggested we forego the EKG in a post-arrest pt.

Yes you are correct and that's how I was trained. I just wanted to make sure that I'm not in the minority of grabbing an EKG post arrest.

 

[Rendar5]

Yes you are correct and that's how I was trained. I just wanted to make sure that I'm not in the minority of grabbing an EKG post arrest.

hell no, if you spot anything, patients do a lot better with catheterizations than without.

 

[la gringa]

i usually cuss, because i've wasted a lot of resources and now i'm going to tie up an icu bed.

Every now and then i get one that makes me happy though. Usually a younger person with something reversible. It's rare though.

+1

 

[Hamhock]

If bradycardic I'd go norepi or dopamine, if tachycardic, I'm a big fan on phenylephrine. I never use epi outside of pediatrics.

I don't imagine that vasospastic -- occasionally nearly occluded -- coronary arteries feeding ischemic myocardium like phenylepherine too much...and I don't suspect that a stunned, ischemic heart likes trying to pump against the severely clamped afterload just to make reach a randomly selected MAP due to pheynlepherine... (ensuring a sufficient diastolic pressure -- to ensure coronary perfusion -- is a different story, however)

The choice of pressor, in my opinion, should be based on pre-arrest senario, course of the resuscitation, and serial ECHOs...and should be concurrent with calcium and aggressive IVF (preferably 4 degrees, if you can prevent warming and if there is a set hypothermia protocol in place at your shop)...

HH

 

[Cerberus]

I don't imagine that vasospastic -- occasionally nearly occluded -- coronary arteries feeding ischemic myocardium like phenylepherine too much...and I don't suspect that a stunned, ischemic heart likes trying to pump against the severely clamped afterload just to make reach a randomly selected MAP due to pheynlepherine... (ensuring a sufficient diastolic pressure -- to ensure coronary perfusion -- is a different story, however)

The choice of pressor, in my opinion, should be based on pre-arrest senario, course of the resuscitation, and serial ECHOs...and should be concurrent with aggressive IVF (preferably 4 degrees, if you can prevent warming and if there is a set hypothermia protocol in place at your shop)...

HH

I agree with what you're saying, having more history is essential in choosing the right pressor and my original answer was a bit to cut and dry. In a case were I have a severely tachycardic patient with a tenous BP, I'm reluctant to start a pressor that will make them even more tachycardic, possibly agitating his myocardium into vtach/fib and further decrease filling time, thus decreasing CO. I'm also not sure which is worse on stunned myocardium and ****ty coronaries, increasing the rate and increasing risk of arrythmia and myocardial depression, or increasing afterload by clamping down with a vasoconstrictor. If the evidence shows a clear winner in the pressor battle, I haven't seen it yet.

Of course, pressors are never first line though and I'll start with IVFH and trying to correct whatever the underlying cause of the arrest was.

 

[Apollyon]

The choice of pressor, in my opinion, should be based on pre-arrest senario, course of the resuscitation, and serial ECHOs...

Really? Are you calling your bedside US an echo? I mean, I don't think I shall ever have the confidence to think I can estimate EF from a transthoracic US; after all, even cardiologists can do a subfellowship in it (after 6+ PG years). It's not a casual thing. And, even then, it is all eyeball anyhow - no science to the measurement.

So, educate me, please!

 

[Hamhock]

Really? Are you calling your bedside US an echo? I mean, I don't think I shall ever have the confidence to think I can estimate EF from a transthoracic US; after all, even cardiologists can do a subfellowship in it (after 6+ PG years). It's not a casual thing. And, even then, it is all eyeball anyhow - no science to the measurement.

So, educate me, please!

I normally document my ultrasounds as "limited beside ultrasound..." and don't use the term "ECHO" when speaking in the ED. I used the term ECHO here to better communicate with readers.

However, I certainly feel confident (with good images) giving a qualitative estimation of EF. And there are actually plenty of metrics used to give quantitative measurements of EF, although the validity of these measurements are suspect in my opinion and certainly debatable. I agree with the cardiologists who argue that EF should be reported qaulitatively, not quatitatively and interpreted with respect to HR, rhythmn, diastolic dysfunction, and the clinical scenario.

Although I have much more experience with ECHO and spend many more hours with an ultrasound in hand than the average ED doc, I don't think a qualitative estimation of EF is that far from the norm for current senior residents and attendings who have recently graduated. In fact, I think this has been published. I will take a look and try to get back to you.

HH

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EDIT:

As I may not have time to get back to SDN with a list of references soon, I thought I would list these papers. I have not reviewed some of these papers in a long time and I have not reviewed others at all, but I think that these three found with just a quick pubmed search and cursory review of the abstract give SOME evidence that estimation of EF by an EP is not that out of the question:

Acad Emerg Med. 2002 Mar;9(3):186-93.
Acad Emerg Med. 2011 Nov;18(11):1223-6. doi: 10.1111/j.1553-2712.2011.01196.x. Epub 2011 Nov 1.
Acad Emerg Med. 2003 Sep;10(9):973-7.

 

[Rendar5]

Really? Are you calling your bedside US an echo? I mean, I don't think I shall ever have the confidence to think I can estimate EF from a transthoracic US; after all, even cardiologists can do a subfellowship in it (after 6+ PG years). It's not a casual thing. And, even then, it is all eyeball anyhow - no science to the measurement.

So, educate me, please!

With some experience, you can tell a hyperdynamic heart from a poorly contracting heart, so I agree with him that you can make qualitative assessments of heart function. In a post-arrest pt, I'm not sure how it would guide my choice of pressors, though.

 

[docB]

Another attending told me that he does not get ekgs on post-ROSC patients because after CPR, you're already looking at likely damaged myocardium - thoughts?

I disagree. It's a non-invasive test and even in the setting of confounders we are expected to be able to tell what is important, what isn't and what we have to prioritize. Many if not most of these people will have another cardiac event and soon. If there's no EKG done the "experts" will crush.

regarding the cath lab decision....

Immediate percutaneous coronary intervention is associated with better survival after out-of-hospital cardiac arrest: insights from the PROCAT (Parisian Region Out of hospital Cardiac ArresT) registry.
Dumas F, Cariou A, Manzo-Silberman S, Grimaldi D, Vivien B, Rosencher J, Empana JP, Carli P, Mira JP, Jouven X, Spaulding C
Circ Cardiovasc Interv. 2010;3(3):200.

the study found that 70% of patients that were cathed after vf/vt arrest had at least 1 significant coronary lesion. food for thought.

Interesting. My concern with this approach is that there are a lot of causes of VT/VF arrest that I don't want to send straight to cath. If I think it was a primary cardiac event then fine. But if it was a primary metabolic event or other then putting them in the cath lab may not be for the best.

 

[Apollyon]

HH, thanks.

 

[SoCuteMD]

Really? Are you calling your bedside US an echo? I mean, I don't think I shall ever have the confidence to think I can estimate EF from a transthoracic US; after all, even cardiologists can do a subfellowship in it (after 6+ PG years). It's not a casual thing. And, even then, it is all eyeball anyhow - no science to the measurement.

So, educate me, please!

Where I am, we call it a limited echo and look for 5 things
1) Global contractility - hyperdynamic, normal, mildly decreased, severely decreased. We don't address wall motion abnormalities at all. We never apply a number to the EF, just one of the terms above.
2) Aortic root size
3) Size of RV relative to LV
4) Pericardial effusion
5) IVC

We don't have to document all 5 of these on every echo we do, but it's appreciated if we do. We submit our reads for QA, and receive feedback within a day or two from an ultrasound attending or fellow.

 

[Apollyon]

Where I am, we call it a limited echo and look for 5 things
1) Global contractility - hyperdynamic, normal, mildly decreased, severely decreased. We don't address wall motion abnormalities at all. We never apply a number to the EF, just one of the terms above.
2) Aortic root size
3) Size of RV relative to LV
4) Pericardial effusion
5) IVC

We don't have to document all 5 of these on every echo we do, but it's appreciated if we do. We submit our reads for QA, and receive feedback within a day or two from an ultrasound attending or fellow.

Fair enough, but are you doing serial exams, and doing that for each one, on critical patients in real time?

 

[SoCuteMD]

Fair enough, but are you doing serial exams, and doing that for each one, on critical patients in real time?

Rarely do serial exams, but have at times. Most critical patients get a limited echo. It's often done before the x-ray techs are even there to take the portable CXR.

Why do you ask?

 

[Apollyon]

Rarely do serial exams, but have at times. Most critical patients get a limited echo. It's often done before the x-ray techs are even there to take the portable CXR.

Why do you ask?

Because that seems quite in-depth, which is fine, but Hamhock was speaking of post-resuscitation patients, and I picture that (serial exams) as being not feasible as far as time goes.