This is part 2 of our series on the ACLS Guidelines 2015 Post Arrest Care with Dr. Laurie Morrison and Dr. Steve Lin. After listening to part 1, my friend Scott Weingart of EMCrit asked me if he could chime in to give us his take on the controversies discussed in this series; and of course, I obliged. So in this episode we discuss the controversies in post-arrest care with some of the most important researchers in ACLS and co-authors of The Guidelines as well as one of the most influential critical care educators in the world.

Post-arrest care is as important as intra-arrest care.

Once we've achieved ROSC our job is not over. Good post-arrest care involves maintaining blood pressure and cerebral perfusion, adequate sedation, cooling and preventing hyperthermia, considering antiarrhythmic medications, optimization of tissue oxygen delivery while avoiding hyperoxia, getting patients to PCI who need it, and looking for and treating the underlying cause. Dr. Lin and Dr. Morrison offer us their opinion on the new simplified approach to diagnosing the underlying cause of PEA arrests. We'll also discuss when it's time to terminate resuscitation or 'call the code' as well as some fascinating research on gender differences in cardiac arrest care. These co-authors of the guidelines will give us their vision of the future of cardiac arrest care and we'll wrap up the episode with a third opinion, so to speak: Dr. Weingart's take on the whole thing....

 

Written Summary and blog post prepared by Dr. Anton Helman, November 2015
A Novel Approach to PEA Arrest

The Guidelines continue to recommend running through the H’s and T’s in order to arrive at a specific diagnosis and guide treatment in PEA arrest. This approach may not be ideal because the H's and T's are difficult to remember in the heat of a stressful resuscitation and some of the H's and T's are rare causes of PEA (hypoxia, hypokalemia and hypoglycemia) or are obvious (hypoxia, hypothermia). In contrast, the approach to PEA arrest proposed in the article 'A simplified and structured teaching tool for the evaluation and management of pulseless electrical activity' focuses on the more likely diagnoses that require immediate treatment beyond your C-A-Bs to achieve ROSC.

This new way of thinking about PEA combines initial ECG morphology with the clinical scenario to guide the clinician to the most likely causes, and offer further diagnostic certainty using point of care ultrasound (POCUS). The first key step is to distinguish between narrow complex and wide complex PEA, with POCUS being used to help differentiate the causes of narrow complex PEA in particular.

Our experts caution that this approach should be used only when a highly skilled ultrasonographer is present and in a way that does not interrupt high quality chest compressions. Ideally, a designated team member provides the specific POCUS role independent of the other team members.

 
Antiarryhthmics in Post-Arrest Care

While we know that intra-arrest antiarrhythmic medications may improve rates of ROSC in ventricular fibrillation (VF) and pulseless ventricular tachycardia (pVT) arrests, there has never been a trial to show improvements in long term survival with any antiarryhthmic medication.

There has never been a trial to show improvements in long term survival with any antiarryhthmic medication in cardiac arrest

When it comes to giving antiarrhythmic medication post-ROSC,