Please continue to use this guideline but be aware that it is in review (16/12/2024).

1. Age ≥ 18 years
2. Out of Hospital Cardiac Arrest (OOHCA) of presumed cardiac cause
3. Return of spontaneous circulation (ROSC- Sustained ROSC is when chest compressions have not been required for 20 consecutive minutes and signs of circulation persist.)
4. Intubated patients after sustained ROSC.

1. Suspected or confirmed acute intracranial bleeding
2. Suspected or confirmed acute stroke
3. Unwitnessed cardiac arrest with initial rhythm asystole
4. Known limitations in therapy or a Do Not Attempt Resuscitation order
5. Known pre-arrest Cerebral Performance Category 3, 4 or 5
6. Systolic blood pressure <80 mm Hg in spite of fluid loading/vasopressor and/or inotropic medication/intra-aortic balloon pump
7. Temperature on admission <30°C.

Following ROSC

Secure airway (if not already intubated)

• SpO₂ 94-96% (hyperoxia is associated with an increase in mortality and morbidity)
• Normocapnia

• Aim MAP> 65 (ensure adequate UO 0.5ml/kg- may require a higher MAP)
• Consider vasopressor and inotropes as appropriate
• Cardiovascular instability exclude reversible causes (consider echocardiogram in ED if patient too unstable for transfer)

• Lorazepam 4mg (repeat after 10 minutes)
• IV phenytoin 18mg/kg loading dose (slow IV infusion < 50mg/minute with ECG and blood pressure monitoring)

Perform 12 lead ECG if not done by ambulance crew

• Decision for intensive care admission
• Implement invasive monitoring if necessary
• Organise medical escort for on going care (general anaesthetist on call)

• Primary Coronary Intervention in cath lab
  • Criteria making immediate PCI likely- ST elevation, cardiac arrest during exercise, VF or VT
• Primary Coronary Intervention not indicated
  • Criteria making immediate PCI less likely- known heart failure, asystole or PEA, prolonged down time

Anaesthetic considerations

• Full anaesthetic equipment and monitoring (inc ETCO₂)
• Trained anaesthetic assistant/ Outreach nurse present
• Continue with ventilation and haemodynamic strategies as above
• NG/ OG tube placement to allow administration of Aspirin and Clopidogrel
• Treat seizures- anti-seizure medication. Deepen anaesthesia

Cardiology Considerations

• PCI as per cardiology decision
• Perform targeted echocardiogram prior to leaving cath lab

Perform CT head to exclude significant intracranial haemorrhage if PCI negative

Consider prior to Cath Lab if uncertain aetiology and on anticoagulants

Exclusions: severe haemodynamic instability

Haemodynamic Optimisation

• Urine output 0.5ml/kg
• Consider cardiovascular monitoring if indicated- LIDCO/ Oesophageal Doppler
• Consider echocardiograph if there are high inotrope requirements

Ventilation targets

• Target normocapnia
• Target SpO₂ 94-96%
• 6-8mls/kg tidal volume

Targeted Temperature Management

• Continuous core temperature monitoring in all patients for 72 hours
• Place Arctic Sun on patient and set target temperature 36℃
• Maintain for 24 hours after target temperature achieved Then rewarm at 0.5℃ per hour until 37℃
• Maintain normothermia (avoid pyrexia) until conscious or 72 hours post OOHCA

Sedation

• Remifentanil 6-18mcg/kg/hr. If BMI >30 use IBW (see ICU protocol)
• If 18mcg/kg/hr reached add in propofol
• Target RAS -1 to +1
• Use the minimum sedation necessary to tolerate interventions Consider weaning sedation once at 37℃ to allow neurological assessment

Seizure management

• Consider continuous BIS monitoring
• Anticonvulsant therapy
  • levetiracetam
  • sodium valproate

Infection monitoring

• Blind BAL on admission to ICU

Nutrition

• NG/ OG tube placement and feed as per ICU protocol

• ECG on arrival and repeated at 12 hour intervals as a minimum
• Echo performed within 24 hours if not performed in cath lab
• Troponin measured 24 hours post arrest
• Daily cardiology review

IABP and TPW

• Stop heparin 1 hour before removal

Medications

• Aspirin 300mg (if not received in cath lab)
• Clopidogrel 300mg (if not received in cath lab)
• Anti coagulation- Fondaparinex SC for 48 hours
  • Unless >75yo, CrCl <20 or on iv heparin for IABP
• Beta blocker consideration if not on inotropes
• ACE inhibitor consideration day 2

Clinical

• Myoclonic status
• Pupillary/ corneal reflexes at 72 hours
• Best motor response at 72 hours

Investigations

• EEG
• SSEP
• BIS

Findings allowing for discontinuation of active intensive care

• Brain death due to cerebral herniation
• Severe myoclonus status in the first 24 hours after admission and bilateral absence of N20-peak on median nerve SSEP
• Minimum 72 hours after intervention period: persisting coma with GCS motor score 1-2 and bilateral absence of N20-peak on median nerve SSEP
• Minimum 72 hours after intervention period: persisting coma with GCS motor score 1-2 and refractory status epilepticus
• Minimum 72 hours after intervention period: persisting coma with a GCS motor 1-2. If no SSEP score available re examine daily and if no improvement in GCS motor score