Written by Alex Clark
Spoon Feed
This scientific statement from the American Heart Association provides guidance on post-resuscitation management of cardiac arrest patients requiring interfacility transfer.
You don’t have to go to the fancy cardiac arrest center, but you can’t stay here!
The management of the post-cardiac arrest patient is tricky. Here’s how to successfully perform an interfacility transfer (IFT) of these critically ill patients:
- Modalities of Transport: Use a dedicated specialty care transport team if you can (ie. 2 acquainted clinicians including respiratory therapy, advanced paramedics, nurses, physicians, etc., …) rather than ad hoc teams.
- Stability for Transport: These patients are highly unstable, at risk for hypoxia/hypotension, and often re-arrest. Provide clear communication about clinical status, correction of unstable vital signs, identification of arrest etiology/sequelae, and appropriate equipment/monitoring devices prior to transport.
- Airway: An advanced airway device (ie. ETT preferred or supraglottic airway) by the most advanced clinician should be placed for transfer. Use continuous end-tidal CO2 monitoring during transport.
- Access: IV access is preferable, but IO is a (very) suitable back-up. Vasopressors are SAFE to run peripherally via IV or IO, which is helpful to remember, as not all EMS agencies are cleared to access central lines.
- Oxygenation: An SpO2 range of 92-98% is safe. However, err on the side of hyperoxia during IFT.
- Ventilation: Target eucapnia (PaCO2 between 35-45) or even mild hypercapnia via low tidal volume ventilation, low driving pressures, and reasonable respiratory rates. Unless there is concern for elevated ICP requiring hyperventilation, mild hypercapnia is less likely to worsen anoxic brain injury.
- Sedation: There is no evidence to support one sedative over another. Titrate sedatives based on a validated consciousness scale (eg. RASS). Prioritize patient safety, comfort, and temperature control during transport using sedation over withholding sedation to facilitate neuro-prognostication.
- Arrhythmias: Go with a “pads-on” protocol in which defib pads are left in place during transport, reducing time to defibrillation. Consider prophylactic lidocaine in patients at risk of recurrent VF/VT.
- BP Management: They don’t recommend an exact number, but suggest slightly higher MAPs to mitigate risk of intra-transport hypotension.
- Temperature Control: There is debate here. For now, continue the transferring facility’s temperature plan, monitor continuous core temperature (ie. not rectal temps), and avoid of uncontrolled rewarming. For cardiac arrest due to accidental hypothermia, avoid warming faster than 0.5° C per hour. If actively cooling, sedation and anti-shivering measures such as neuromuscular blockade may be necessary.
- Acidosis: Outcomes are worse with pH < 7.2. While correcting respiratory acidosis seems reasonable (using surrogate end-tidal CO2 or blood gas if available), there is less evidence to support the threshold at which to correct metabolic acidosis.
- Glucose Management: Target 81 – 180 mg/dL in adults.
- Equity: The authors call for data collection specifically related to diversity, equity, and inclusion in future cardiac arrest registries and clinical trials to identify potential factors such as age, socioeconomic status, and geographical location.
- Family Communication: Avoid inappropriate early neuro-prognostication. Risk stratification should be reserved for clinicians with considerable experience in post-arrest care.
- Future areas of study: All of it…?
How will this change my practice?
My takeaway is that good post-cardiac arrest equals good supportive care. This is an excellent reminder that our sickest patient in the department is the one who just died. As a result, it’s important to emphasize effective communication, evidenced-based EMS protocols, and experienced teams to accompany these patients during transport. Although evidence is lacking on many fronts, the potential association between targeted care (ie. BG levels, SpO2, MAP goals, etc.) and neurologic outcomes after IFT seems ideal for future study.
Source
Management of Patients With Cardiac Arrest Requiring Interfacility Transport: A Scientific Statement From the American Heart Association. Circulation. 2024 Oct 29;150(18):e316-e327. doi: 10.1161/CIR.0000000000001282. Epub 2024 Sep 19. PMID: 39297198
Great!!