Treat the cause, control physiology, and delay prognostication
Expansion
Targets after return of spontaneous circulation
- Oxygen: titrate to 94 to 98 per cent. Avoid hyperoxia, which worsens reperfusion injury
- Carbon dioxide: aim for normocapnia. Hypocapnia causes cerebral vasoconstriction
- Blood pressure: a mean arterial pressure sufficient for urine output and lactate clearance
- Glucose: avoid hypoglycaemia and marked hyperglycaemia
- Temperature: actively prevent fever for at least 72 hours, targeted temperature management in selected patients
- Seizures: treat, and consider EEG
Investigate the cause: 12 lead ECG, and immediate coronary angiography if there is ST elevation or a strong suspicion of a coronary cause. Echocardiography, CT head and CT pulmonary angiogram where the cause is unclear.
“Treat the cause, normalise the physiology, and do not prognosticate early.”
Prognostication should be delayed at least 72 hours after rewarming and off sedation, and must be multimodal: clinical examination, bilateral absent pupillary and corneal reflexes, absent N20 on somatosensory evoked potentials, EEG, neuron specific enolase and imaging. No single test is sufficient, and early prediction based on the arrest circumstances alone is unreliable.