Therapeutic strategies in managing cardiac arrest

• Updated resuscitation guidelines emphasize the need for minimally interrupted high quality chest compressions as a prerequisite for successful resuscitation outcome.
• Resuscitation involves the integration of complex systems and the interdisciplinary coordination of multispecialty emergency and critical care providers.
• The immediate period following return of spontaneous circulation (ROSC) is crucial and is dominated by the presence of two critical goals- identification of pathophysiological cause, and the assessment and initiation of time- dependent interventions, directed at preventing recurrent arrest, and improving immediate and long- term outcome.
• There is no vasopressor or anti-arrhythmic agent whose use is associated with improved outcome at discharge. In-hospital resuscitation should focus on the provision of high quality chest compressions and the search for immediate treatable precipitants of the arrest in those patients who achieve ROSC.
• A systematic checklist may aid in the systematic evaluation of patients following ROSC.

Management after resuscitation from cardiac arrest

• Following return of spontaneous circulation, the quality of the treatment provided in the post-arrest period influences outcome.
• Most patients resuscitated after a prolonged period of cardiac arrest will develop the post-cardiac arrest syndrome.
• All survivors of out-of-hospital cardiac arrest should be considered for urgent coronary angiography unless the cause of cardiac arrest was clearly non-cardiac or continued treatment is considered futile.
• Several interventions may impact on neurological out-come, the most significant of these is targeted temperature management.
• In patients remaining comatose after resuscitation from cardiac arrest, prediction of the final outcome in the first few days may be unreliable. Prognostication should normally be delayed until at least 3 days after return to normothermia and should involve more than one than one mode (e.g. clinical examination combined with another investigation).

Key components of the post-cardiac arrest syndrome.

• Post- cardiac arrest brain injury- this manifests as coma and seizures.
• Post- cardiac-arrest myocardial dysfunction –this can be severe and usually recovers after 48 hours.
• Systemic ischemia/reperfusion response –tissue reperfusion can cause programmed cell death (apoptosis) effecting all organ systems.
• Persisting precipitating pathology-coronary artery disease is the commonest precipitating cause after OHCA