2010年12月28日 星期二

Post–Cardiac Arrest Care

Post–Cardiac Arrest Care 2010 AHA Guidelines for CPR and ECC Circulation 2010;122:S768-S786 Multiple System Approach to Post–Cardiac Arrest Care 1. Ventilation Capnography
  • Rationale: Confirm secure airway and titrate ventilation
  • PETCO2 ~35–40 mmHg
  • PaCO2 ~40–45 mmHg
Pulse Oximetry/ABG 
  • Rationale: Maintain adequate oxygenation and minimize FiO2 
  • SpO2 ~94%; PaO2 ~100 mmHg 
  • Reduce FiO2 as tolerated 
  • PaO2/FiO2 ratio to separate acute lung injury/ARDS (<300 or <200)
Mechanical Ventilation
  • Rationale: Minimize acute lung injury,potential oxygen toxicity
  • Tidal Volume 6–8 mL/kg
  • Titrate minute ventilation to PETCO2 ~35–40 mm Hg; PaCO2 ~40–45 mm Hg
  • Reduce FiO2 as tolerated to keepSpO2 or SaO2 ≧94%
    2. Hemodynamics Frequent BP Monitoring/Arterial-line
    • Rationale: Maintain perfusion and prevent recurrent hypotension
    • MAP≧65 mmHg or SBP≧90 mmHg
    Treat Hypotension
    • Rationale: Maintain perfusion
    • Fluid bolus if tolerated
    • Dopamine 5–10 mcg/kg per min
    • Norepinephrine 0.1–0.5 mcg/kg per min
    • Epinephrine 0.1–0.5 mcg/kg per min
    3. Cardiovascular Continuous Cardiac Monitoring
    • Rationale: Detect recurrent arrhythmia
    • No prophylactic antiarrhythmicsTreat arrhythmias as required
    12-lead ECG/Troponin
    • Rationale:Detect ACS/STEMI; Assess QT interval.
    Treat Acute Coronary Syndrome
    • Aspirin/heparin
    • Transfer to acute coronary treatment center
    • Consider emergent PCI or fibrinolysis
    Echocardiogram
    • Rationale: Detect global stunning, wall-motion abnormalities, structural problems or cardiomyopathy
    Treat Myocardial Stunning
    • Fluids to optimize volume status
    • Dobutamine 5–10 mcg/kg per min
    • Mechanical augmentation (IABP)
    4. Neurological Serial Neurological Exam
    • Rationale: Serial examinations define coma, brain injury, and prognosis
    • Response to verbal commands or physical stimulation
    • Pupillary light and corneal reflex, spontaneous eye movement
    • Gag, cough, spontaneous breaths
    EEG Monitoring If Comatose
    • Rationale: Exclude seizures
    • Anti-convulsants if seizing
    Core Temperature Measurement If Comatose
    • Rationale: Minimize brain injury and improve outcome
    • Prevent hyperpyrexia >37.7°C
    • Induce therapeutic hypothermia
    • Cold IV fluid bolus 30 mL/kg
    • Surface or endovascular cooling for 32–34°C x24 hours
    • After 24 hours, slow rewarming 0.25°C/hr
    Consider Non-enhanced CT
    • Rationale: Exclude primary intracranial process
    Sedation/Muscle Relaxation
    • Rationale: To control shivering, agitation, or ventilator desynchrony as needed
    5. Metabolic Serial Lactate
    • Rationale: Confirm adequate perfusion
    Serum Potassium
    • Rationale: Avoid hypokalemia which promotes arrhythmias
    • Replace to maintain K >3.5 mEq/L
    Urine Output, Serum Creatinine
    • Rationale: Detect acute kidney injury
    • Maintain euvolemia
    • Renal replacement therapy if indicated
    Serum Glucose
    • Rationale: Detect hyperglycemia and hypoglycemia
    • Treat hypoglycemia (<80 mg/dL) with dextrose
    • Treat hyperglycemia to target glucose144–180 mg/dL
    • Local insulin protocols
    相關文章: Post-Cardiac Arrest Syndrome

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