EA21 Newsletter: Session 10S3 Management of cardiac arrest in special circumstances

Saturday December 18, 14:00 – 15:00 – Channel 3

This four-part session on Saturday afternoon will feature specialists from a range of disciplines.

The management of cardiac arrest with a focus on hypothermic patients will be presented by Dr Peter Paal, Hospitallers Brothers Hospital, Paracelsus Medical University, Salzburg, Austria, who will say: “Hypothermic compared to normothermic cardiac arrest differs in aetiology, pathophysiology, therapy, and outcome. Cardiac arrest patients have excellent chances of good neurological outcomes if they cool down first before the heart arrests and hypoxia sets in. A good outcome is even possible after unwitnessed cardiac arrest with asystole as presenting rhythm.”

He will explain that, in contrast to normothermic cardiac arrest asystole and unwitnessed cardiac arrest are no contraindications for extracorporeal cardiopulmonary resuscitation (eCPR). High-quality chest compressions and ventilation should be provided as in a normothermic patient. In a technically demanding transport consider delayed and intermittent CPR with a core temperature <28°C: After 5 minutes of CPR to load the brain and heart with oxygen, chest compressions can be interrupted for 5 minutes maximum if continuous CPR is not possible.

Dr Paal says: “Do not administer epinephrine <30°C, prolong intervals to 6-10 min >30°C. The outcome of extracorporeal rewarming of hypothermic cardiac arrest patients should be prognosticated with the HOPE score (www.hypothermiascore.org). Rewarming with veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is the gold standard. A post-resuscitation bundle should follow successful rewarming after hypothermic cardiac arrest. Even large centres rarely treat more than 20 patients per year, and thus the inclusion of hypothermic patients into the international hypothermia registry is welcome.” (www.hypothermia-registry.org).

Cardiac arrest in pregnant women will be covered by Professor Carolyn Weiniger, Chair of Obstetric Anaesthesiology at Tel Aviv Sourasky Medical Center, Israel. “Cardiac arrest in pregnancy occurs approximately 1:12, 000 deliveries. The management of cardiac arrest in pregnant women requires more than advanced life support skills, as special considerations are essential to optimise successful resuscitation and return of spontaneous circulation,” explains Prof Weiniger. “We will focus on recognition of maternal cardiac arrest, the new European Resuscitation Guidelines updates and the role of simulation.”

Two-thirds of in-hospital maternal cardiac arrests have preceding signs and symptoms. Robust screening using early warning systems can optimise the identification of maternal deterioration. Once a cardiac arrest is recognised, after a call for help, the appropriate response can be initiated. The talk will emphasise manual uterine displacement and perimortem Caesarean delivery. “We will discuss the decision for delivery timing, particularly relating to critically ill pregnant women with Covid-19. We will discuss potential reversible cardiac arrest causes specific to pregnancy. Multidisciplinary simulation of cardiac arrest in pregnancy is recommended and will enable the team to practice together. Importantly, simulation is an opportunity to identify rectifiable problems such as the lack of a scalpel in the resuscitation cart, overlooking manual uterine displacement or not performing perimortem Caesarean delivery.”

The final talk in this session will be given by Professor Jochen Hinkelbein of University Hospital Cologne, Germany, who will discuss the new ESAIC guidelines regarding cardiac arrest in the OR.

He explains: “Intraoperative Cardiac arrest is rare but a catastrophic event for the patient. The incidence is approx. 5 per 10,000 cases. The ESAIC guidelines will be published in 2022 and were built up by ESAIC, ERC, ESTES, and ASA via an evidence-based GRADE approach. Core topics of the guidelines are: primarily closed chest compressions should be used. Open chest cardiac massage may be considered if ROSC has not been achieved, the team is trained and experienced and the equipment available. In patients with exsanguinating and uncontrollable infra-diaphragmatic haemorrhage, immediate aortic occlusion should be considered.” More details on these and other aspects of the guidelines will be provided in his presentation.

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