UMEM Educational Pearls

For those of us living in a world where ED boarding is a reality and ICU beds are in short supply, a re-up on the basic tenets of post-arrest care to optimize survival and neurologic outcomes in patients with sustained ROSC after OHCA:

1. Actively prevent fever in comatose patients. (“Comatose” = lack of meaningful response to verbal commands.) There may be a subset of patients comatose after ROSC who benefit from actual therapeutic hypothermia, but fever is definitely harmful. Tylenol is not going to cut it; be ready to start active cooling methods to avoid fever, and give yourself a cushion. Starting cooling efforts at 37.9 is probably not going to work to avoid reaching 38.0 deg C.
2. Avoid hypotension and maintain a MAP > 65mmHg; in patients with signs of increased ICP or chronic uncontrolled hypertension, consider a MAP goal > 80mmHg. The literature is still not quite clear that higher MAP targets improve outcomes, but MAPs <65 are associated with poorer neurologic recovery. 
3. Target normoxia with an oxygen saturation between 92-98%. Hypoxia and hyperoxia are associated with poorer neurologic function. An O2 sat of 100% doesn’t tell you whether your PaO2 is 100 or 300, so aim for a lower value. 
4. Target normocarbia to mild hypercarbia (PCO2 35-55).  Arterial PCO2 affects cerebrovascular tone, but the data indicates no difference in outcomes between normocarbia and mild hypercarbia up to 55mmHg.
5. Monitor for seizures with EEG as soon as possible in comatose patients. Treating seizures with Keppra is appropriate and burst suppression with propofol is reasonable. “Prophylactic” antiepileptics are not beneficial and are discouraged.
6. Early coronary angiography is only clearly indicated for ST elevations on EKG post-ROSC. Studies have not found a benefit in short or longer term survival for early catheterization in patients without ST elevations, although it may still be beneficial depending on the patient’s clinical scenario.
7. Utilize bedside (or formal) echocardiography to help guide management in patients with hypotension after cardiac arrest. Whether fluids, vasopressors, or inotropes are needed, bedside echo can inform what you do.
8. Early neuroprognostic determination acutely in the ED is largely impossible. Except in cases with clear goals of care refusing life-support, life sustaining measures should not be removed based on comatose state, prolonged downtime, presence of cerebral edema without herniation, etcetera.

References

• Hirsch KG, Abella BS, Amorim E, et al.; American Heart Association, Neurocritical Care Society. Critical Care Management of Patients After Cardiac Arrest: A Scientific Statement from the American Heart Association and Neurocritical Care Society. Neurocrit Care. 2024 Feb;40(1):1-37. doi: 10.1007/s12028-023-01871-6.
• Eastwood G, Nichol AD, Hodgson C, et al.; TAME Study Investigators. Mild Hypercapnia or Normocapnia after Out-of-Hospital Cardiac Arrest. N Engl J Med. 2023 Jul 6;389(1):45-57. doi: 10.1056/NEJMoa2214552. 
• Shanmugavel Geetha H, Teo YX, Ravichandran S, Lal A. Ventilator-Associated Pneumonia After Cardiac Arrest and Prevention Strategies: A Narrative Review. Medicina (Kaunas). 2025 Jan 5;61(1):78. doi: 10.3390/medicina61010078.