Optimising the post-arrest patient

The return of the pulse is the beginning of the post-arrest care, and the bundle is applied now. The patient is managed in a critical-care setting, intubated and ventilated, sedated and monitored, with the arterial line and the continuous EEG where available.^[2]

Oxygenation: titrate the fraction down from 100 per cent to a saturation target of 94 to 98 per cent, avoiding both the hypoxia and the hyperoxia. Ventilation: to normocapnia (PaCO2 4.5 to 6.0 kPa), avoiding the hypocapnia of hyperventilation; take an early arterial blood gas. Circulation: this patient is hypotensive at 88/50, which is associated with a worse outcome — give a fluid challenge and start a vasopressor (noradrenaline) to a mean arterial pressure of 65 mmHg or more. Temperature: he is febrile at 37.8, and the fever is treated actively; the target is normothermia (around 37 degrees), with the TTM2 trial having shown that targeted hypothermia at 33 degrees is not superior and causes more arrhythmia.^[1] Glucose: to a moderate 8 to 10 mmol per litre. Seizures: detected with the continuous EEG and treated.

The cause is investigated and treated: a 12-lead electrocardiogram once stable, the bedside echocardiography, and the urgent coronary angiography with percutaneous intervention for the presumed cardiac cause (the ST elevation or the high-risk non-ST-elevation). The prognostication is deferred for at least 72 hours, multimodal, after the sedation is off. The patient is admitted to the intensive care unit, and the bundle is continued.