Post-Arrest Care & Targeted Temperature Management (TTM)
Our goal during resuscitation is to keep the patient’s brain and vital organs oxygenated as best we can with high quality CPR until the heart can resume pumping on its own. If, while doing good CPR, the CPR coach (or another team member) notices a sudden jump in the End Tidal CO2 wave form, usually above 30 mm Hg, a pulse should be checked at the conclusion of the current compression cycle. If the patient has a carotid pulse that’s great! We have Return of Spontaneous Circulation or ROSC. The post-arrest care we deliver after identifying ROSC is today’s Pass ACLS Tip topic.
After identifying an increase in end tidal CO2 and the presence of a carotid pulse, indicating ROSC, the patient must be further assessed.
- What’s their heart rate, Blood Pressure, and O2 sat?
- Does the patient have any attempts at spontaneous respirations?
- What’s the patient’s level of consciousness?
Post-Arrest Goals
Ideally, we’d like the patient’s heart rate between 60 and 100, a blood pressure of at least 90 systolic, and mean arterial pressure above 65. This can be accomplished by ensuring an adequate airway, IV fluids, and medications such as Atropine, Dopamine, Levophed, or an Epinephrine drip depending on the patient’s condition.
We should attempt to keep the patient’s O2 sat between 92 and 98% and End Tidal CO2 at 35-45 mm Hg. For intubated patients, this is accomplished by adjustments to O2 concentration, tidal volume, and ventilation rate on the vent. Give the desired parameters to Respiratory Therapy and let them manage the vent.
After we’ve stabilized the patient’s heart rate, blood pressure, Oxygenation and CO2 – what is their Glasgow Coma Scale (GCS) or level of consciousness?
Targeted Temperature Management (TTM)
If the patient can’t obey verbal commands – targeted temperature management (TTM) is indicated. We should maintain the patient’s core temperature at 32-36 degrees Celsius for at least 24 hours.
An EEG, CT, MRI, and PCI can all be done while the patient is being cooled.
Two studies looking at TTM have been published since the 2020 ECC Guidelines. One showing better outcomes when 33 degrees is maintained verses 36 and another that demonstrated no statistical difference in 6 month survivability in patients that received TTM. Until these studies are reviewed by the committee and guidelines (possibly) updated, The current standard is to cool patients that can’t obey verbal commands for at least 24 hours.
There are many different cooling devices that work by various mechanisms. Similar to the different types of cooling devices, there are several internal body temperature monitors. During TTM we need to monitor the patient’s core temperature. Forehead, axillary, and oral thermometers don’t provide the patient’s core temp. Esophageal, bladder, and rectal are three temperature probes commonly used during initiation of TTM. Ideally, the cooling device should be connected to the temperature monitor to provide continuous, real-time feedback. You should be familiar with the cooling and temperature monitoring equipment SOPs for your work setting.
