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Post-Cardiac Arrest Care

Date Last Search Run: Feb 01, 2022
Table last updated: Aug 21, 2022
Data last added: Aug 19, 2022

Recommendation RECOMMENDATION FOR INTERVENTION
STRENGTH OF EVIDENCE FOR INTERVENTION   SUPPORTIVE (Green) NEUTRAL (Yellow) AGAINST (Red) NOT YET GRADED (White)
1 (strong evidence exists)  
2 (fair evidence exists)    
3 (weak evidence exists)      


Interventions

12-Lead ECG
Level Direction Primary Outcome Patient/Process Setting Reference
II Supportive (Green) Predictive value Process ED-MD Baldi E, Schnaubelt S, Caputo ML, Klersy C, Clodi C, Bruno J, et al. Association of Timing of Electrocardiogram Acquisition After Return of Spontaneous Circulation With Coronary Angiography Findings in Patients With Out-of-Hospital Cardiac Arrest. JAMA Netw Open 2021; 4(1):e2032875. Medline
II Neutral (Yellow) Detection of subarachnoid hemorrhage Process ED-MD Kim YJ., Min SY., Lee DH., Lee BK., Jeung KW., Lee HJ., et al. The Role of Post-Resuscitation Electrocardiogram in Patients With ST-Segment Changes in the Immediate Post-Cardiac Arrest Period. JACC Cardiovascular interventions 2017;10(5):451-9. Medline
III Neutral (Yellow) Classification change between out of hospital and ED 12 lead ECG Process ED-Paramedic & MD Aufderheide TP, 2nd Engel TW, Saleh HO, Gutterman DD, Weston BW, Pepe PE, et al. Change in out-of-hospital 12-lead ECG diagnostic classification following resuscitation from cardiac arrest. Resuscitation 2021; 169:45–52. Medline

Antiarrhythmic - Class I (Na+ channel blockers)
Level Direction Primary Outcome Patient/Process Setting Reference
II Supportive (Green) Frequency of re-arrest from VF/VT Patient PH-Paramedic Kudenchuk PJ., Newell C., White L., Fahrenbruch C., Rea T., Eisenberg M. Prophylactic lidocaine for post resuscitation care of patients with out-of-hospital ventricular fibrillation cardiac arrest. Resuscitation 2013; 84(11):1512-8. Medline

Fluid Resuscitation
Level Direction Primary Outcome Patient/Process Setting Reference

Inotrope
Level Direction Primary Outcome Patient/Process Setting Reference
I Supportive (Green) Mortality Patient Havel C., Arrich J., Losert H., Gamper G., et al. Vasopressors for Hypotensive Shock (Review). Cochrane Data Syst Rev 2011; (5):1-76. Medline
II Neutral (Yellow) 30 day survival Patient ED-MD Li C, Wu K, Chen C, Law Y, Chuang P, Chen Y. Comparison of Dopamine and Norepinephrine Use for the Treatment of Hypotension in Out-Of-Hospital Cardiac Arrest Patients with Return of Spontaneous Circulation. Emerg Med International 2020. Medline
X Not Yet Graded (White) - Bougouin W, Slimani K, Renaudier M, Binois Y, Paul M, Dumas F, et al. Epinephrine versus norepinephrine in cardiac arrest patients with post-resuscitation shock. Intensive Care Med 2022; 48(3):300–10. Medline

Optimal Trip Destination
Level Direction Primary Outcome Patient/Process Setting Reference
II Supportive (Green) Survival to discharge Patient PH-Paramedic Cha WC., Lee SC., Shin SD., Song KJ., Sung AJ., Hwang SS. Regionalisation of out-of-hospital cardiac arrest care for patients without prehospital return of spontaneous circulation. Resuscitation 2012; 83(11):1338-42. Medline
II Supportive (Green) Survival to hospital discharge Patient PH-Paramedic Cournoyer A., Notebaert E., de ML, Ross D., Cossette S., Londei-Leduc L., et al. Impact of the direct transfer to percutaneous coronary intervention-capable hospitals on survival to hospital discharge for patients with out-of-hospital cardiac arrest. Resuscitation 2018; 125 28-33. Medline
II Supportive (Green) ROSC Patient PH-Paramedic Davis DP., Fisher R., Aguilar S., Metz M., Ochs G., McCallum-Brown L., Ramanujam P., Buono C., Vilke GM., Chan TC., Dunford JV. The feasibility of a regional cardiac arrest receiving system. Resuscitation 2007; 74:44-51. Medline
II Supportive (Green) Neurological function at 1 month Patient PH-Paramedic Kajino K. OOHCA Impact transportation to critical care centres OOHCA. Resuscitation 2010; 81:549-54. Medline
II Supportive (Green) Mortality Patient Other Karasek J, Seiner J, Renza M, Salanda F, Moudry M, Strycek M, et al. Bypassing out-of-hospital cardiac arrest patients to a regional cardiac center: Impact on hemodynamic parameters and outcomes. Am J Emerg Med 2021; 44:95–9. Medline
II Supportive (Green) Survival Patient Kragholm K., Malta HC., Dupre ME., Xian Y., Strauss B., Tyson C., et al. Direct Transport to a Percutaneous Cardiac Intervention Center and Outcomes in Patients With Out-of-Hospital Cardiac Arrest. Circulation Cardiovascular Quality and Outcomes 2017; 10(6). Medline
II Supportive (Green) Survival to admission/ discharge Patient PH-Paramedic Ro YS., Shin SD., Song KJ., et al. A comparison of outcomes of out-of-hospital cardiac arrest with non-cardiac etiology between emergency departments with low- and high-resuscitation case volume. Resuscitation 2012; 83(7):855-61. Medline
II Supportive (Green) Survival to discharge Patient PH-Paramedic Spaite DW., et al. Effect of transport interval on OOHCA survival in the OPALS study: implications for triaging patients to specialized cardiac arrest centers. Ann Emerg Med 2008; 54(2): 248-55. Medline
II Supportive (Green) Survival to discharge Process PH-Paramedic von Vopelius-Feldt J, Perkins GD, Benger J. Association between admission to a cardiac arrest centre and survival to hospital discharge for adults following out-of-hospital cardiac arrest: A multi-centre observational study. Resuscitation 2021; 160:118-25. Medline
II Supportive (Green) Survival to 30 days Patient PH-Paramedic Yeo JW, Ng ZHC, Goh AXC, Gao JF, Liu N, Lam SWS, et al. Impact of Cardiac Arrest Centers on the Survival of Patients With Nontraumatic Out-of-Hospital Cardiac Arrest: A Systematic Review and Meta-Analysis. J Am Hear Assoc 2021; e023806. Medline
III Neutral (Yellow) All cause mortality Patient PH-Paramedic Iqbal MB., Al-Hussaini A., Rosser G., et al. Predictors of survival and favorable functional outcomes after an out-of-hospital cardiac arrest in patients systematically brought to a dedicated heart attack center (from the harefield cardiac arrest study). Am J Cardiol 2015; 115(6):730-7. Medline

Oxygen
Level Direction Primary Outcome Patient/Process Setting Reference
I Neutral (Yellow) Successfully aided tube passage Process ED-MD Kuisma M., et al. Comparison of 30 and 100% inspired oxygen concentrations during early post-resuscitation period: a randomized controlled pilot study. Resus 2005; 69:199-206. Medline
I Neutral (Yellow) Mortality at first follow up Patient Other Young PJ, Bailey M, Bellomo R, Bernard S, Bray J, Jakkula P, et al. Conservative or liberal oxygen therapy in adults after cardiac arrest: An individual-level patient data meta-analysis of randomised controlled trials. Resuscitation 2020; 157:15-22. Medline
II Neutral (Yellow) Neurological outcome at 6 months, Patient In-Patient Ebner F., Ulln S., Neman A., Cronberg T., Mattsson N., Friberg H., et al. Associations between partial pressure of oxygen and neurological outcome in out-of-hospital cardiac arrest patients an explorative analysis of a randomized trial. Crit Care 2019; 23(1) 30. Medline
III Neutral (Yellow) NSE (neuron-specific enolase) serum concentration at 48 h after cardiac arrest Patient ICU Jakkula P., Reinikainen M., Hastbacka J., Pettil V., Loisa P., Karlsson S., et al. Targeting low- or high-normal Carbon dioxide, Oxygen, and Mean arterial pressure After Cardiac Arrest and Resuscitation study protocol for a randomized pilot trial. Trials 2017; 18(1) 507. Medline

Oxygen-titrated
Level Direction Primary Outcome Patient/Process Setting Reference
I Neutral (Yellow) Blood oxygen saturation Patient PH-Paramedic Kuisma M., et al. Comparison of 30 and 100% inspired oxygen concentrations during early post-resuscitation period: a randomized controlled pilot study. Resus 2005; 69:199-206. Medline
I Neutral (Yellow) Mortality at first follow up Patient Other Young PJ, Bailey M, Bellomo R, Bernard S, Bray J, Jakkula P, et al. Conservative or liberal oxygen therapy in adults after cardiac arrest: An individual-level patient data meta-analysis of randomised controlled trials. Resuscitation 2020; 157:15-22. Medline
III Supportive (Green) SpO2 =94% on arrival at hospital Patient PH-Paramedic Bray JE., Hein C., Smith K., Stephenson M., Grantham H., Finn J., et al. Oxygen titration after resuscitation from out-of-hospital cardiac arrest: A multi-centre, randomised controlled pilot study (the EXACT pilot trial). Resuscitation 2018; 128:211-5. Medline

Post-arrest cooling
Level Direction Primary Outcome Patient/Process Setting Reference
I Supportive (Green) Neurologic outcome Patient ED-MD Arrich J., Holzer M., Herkner H., Mullner M. Hypothermia for Neuroprotection in Adults after Cardiopulmonary Resuscitation. The Cochrane Library 2010; 110(4):1239. Medline
I Supportive (Green) Survival to discharge with good neuro outcomes Patient PH-Paramedic Bernard SA., Gray TW., Buist MD., et al. Treatment of Comatose Survivors of Out-of hospital Cardiac Arrest with Induced Hypothermia N Engl J Med 2002; 346(8):557-63. Medline
I Supportive (Green) Feasibility Process PH-Paramedic Cullen D., et al. Therapeutic Hypothermia Initiated in the Prehospital Setting: A Meta-Analysis. AENJ 2011; 33(4):314-21. Medline
I Supportive (Green) Feasibility Process ICU Diao M., Huang F., Guan J., et al. Prehospital therapeutic hypothermia after cardiac arrest: A systematic review and meta-analysis of randomized controlled trials. Resuscitation 2013; 84(8):1021-8. Medline
I Supportive (Green) Temperature at arrival to ED Process PH-Paramedic Kamarainan A., Virkkinun I., Tenhunen J., Yli-Hankala A., Silfvast T. Prehospital therapeutic hypothermia for comatose survivors of cardiac arrest: A randomized controlled trial. Acta Anaesthesiol Scand 2009; 53(7):900-7. Medline
I Supportive (Green) Feasibility Process PH-Paramedic Kim F., et al. Pilot randomized clinical trial of prehospital induction of mild hypothermia in out-of-hospital cardiac arrest patients with a rapid infusion of 4C saline. Circ 2007; 115:3064-70. Medline
I Supportive (Green) Favorable neurologic outcome within six months of cardiac arrest Patient ED-MD The Hypothermia after Cardiac Arrest Study Group. Mild Therapeutic Hypothermia to Improve the Neurologic outcome after cardiac arrest. New England Journal of Medicine2002; 346(8):549-556. Medline
I Neutral (Yellow) Long term and short term survival as well as neurological status. Patient Arrich J., Holzer M., Havel C., Warenits AM., Herkner H. Pre-hospital versus in-hospital initiation of cooling for survival and neuroprotection after out-of-hospital cardiac arrest. The Cochrane database of systematic reviews 2016. Medline
I Neutral (Yellow) Functional outcome at discharge Patient PH-Paramedic Bernard SA., Smith K., Cameron P., Masci K., Taylor DM., Cooper DJ., et al. Induction of prehospital therapeutic hypothermia after resuscitation from nonventricular fibrillation cardiac arrest*. Crit Care Med 2012; 40(3):747-53. Medline
I Neutral (Yellow) Functional outcome at discharge Patient PH-Paramedic Bernard SA., Smith K., Cameron P., Masci K., Taylor DM., Cooper DJ., et al. Induction of therapeutic hypothermia by paramedics after resuscitation from out-of-hospital ventricular fibrillation cardiac arrest: a randomized controlled trial. Circulation 2010; 122(7):737-42. Medline
I Neutral (Yellow) Short, mid, and long term survivial Patient Other Granfeldt A, Holmberg MJ, Nolan JP, Soar J, Anderson LW. Targeted temperature management in adult cardiac arrest: Systematic review and meta-analysis. Resuscitation 2021; 167:160–72. Medline
I Neutral (Yellow) Survival to hospital discharge Patient PH-Paramedic Hunter BR., O'Donnell DP., Allgood KL., Seupaul RA. No benefit to prehospital initiation of therapeutic hypothermia in out-of-hospital cardiac arrest: A systematic review and meta-analysis. Acad Emerg Med 2014; 21(4):355-64. Medline
I Neutral (Yellow) survival to hospital discharge Patient PH-Paramedic Kim F., Nichol G., Maynard C., et al. Effect of prehospital induction of mild hypothermia on survival and neurological status among adults with cardiac arrest: A randomized clinical trial. JAMA 2014; 311(1):45-52. Medline
I Neutral (Yellow) Successful TTM Process Scales DC., Cheskes S., Verbeek PR., Pinto R., Austin D., Brooks SC., et al. Prehospital cooling to improve successful targeted temperature management after cardiac arrest: A randomized controlled trial. Resuscitation 2017; 121:187-94. Medline
I Neutral (Yellow) 6-month mortality Patient ICU Shrestha DB, Sedhai YR, Budhathoki P, Gaire S, Adhikari A, Poudel A, Aryal BB, Yadullahi Mir WA, Dahal K, Kashiouris MG. Hypothermia versus normothermia after out-of-hospital cardiac arrest: A systematic review and meta-analysis of randomized controlled trials. Ann Med Surg 2022; 74:103327. Medline
I Opposes (Red) Survival with good neuro outcomes at discharge Patient ED-Paramedic & MD Fernando SM, Do Santo P, Sadeghirad B, Lascarrou JB, Rochwerg B, Mathew R, et al. Targeted temperature management following out-of-hospital cardiac arrest: a systematic review and network meta-analysis of temperature targets. Intensive Care Med 2021; 47(10):1078–88. Medline
II Supportive (Green) Good neurological outcome Patient Choi SW., Shin SD., Ro YS., Song KJ., Lee EJ., Ahn KO. Effect of therapeutic hypothermia on the outcomes after out-of-hospital cardiac arrest according to initial ECG rhythm and witnessed status: A nationwide observational interaction analysis. Resuscitation 2016; 100:51-9. Medline
II Supportive (Green) Survival to hospital discharge Patient Rao MP., Dupre ME., Pokorney SD., Hansen CM., Tyson C., Monk L., et al. Therapeutic Hypothermia for Patients with Out-of-Hospital Cardiac Arrest in North Carolina. PEC 2016; 20(5):630-6. Medline
II Supportive (Green) Decrease of tympanic temperature Patient PH-Paramedic Skulec R., Truhlar A., Seblova J., Dostal P., Cerny V. Pre-hospital cooling of patients following cardiac arrest is effective using even low volumes of cold saline. Crit Care 2010; 14(6):R231. Medline
II Supportive (Green) Survival to discharge Patient ICU Wang CJ., Yang SH., Lee CH., Lin RL., Peng MJ., Wu CL. Therapeutic hypothermia application vs standard support care in post resuscitated out-of-hospital cardiac arrest patients. Am J Emerg Med 2013; 31(2):319-325. Medline
II Neutral (Yellow) Efficacy and Safety Process PH-Paramedic Hammer L., Vitrat F., Savary D., et al. Immediate prehospital hypothermia protocol in comatose survivors of out-of-hospital cardiac arrest. Am J Emerg Med 2009; 27(5):570-3. Medline
II Neutral (Yellow) Long term quality of life Patient Patel JK., Parikh PB. Association between therapeutic hypothermia and long-term quality of life in survivors of cardiac arrest: A systematic review. Resuscitation 2016; 103:54-9. Medline
II Neutral (Yellow) Time from ROSC to target temperature (33.9 C). Process ED-Paramedic & MD Uray T, Mayr FB, Stratil P, Aschauer S, Testori C, Sterz F, et al. Prehospital surface cooling is safe and can reduce time to target temperature after cardiac arrest. Resuscitation 2015; 87:51-6. Medline
II Neutral (Yellow) 30-day survival with favourable neurological outcome Process PH-Paramedic Watanabe M, Matsuyama T, Oe H, Sasaki M, Nakamura Y, Miyamoto Y, et al. Impact of cooling method on the outcome of initial shockable or non-shockable out of hospital cardiac arrest patients receiving target temperature management: a nationwide multicentre cohort study. Ann Intensive Care 2021; 11(1):163. Medline
II Neutral (Yellow) Survival, Neurological outcome Patient ICU Wolfrum S., Pierau C., Radke PW., Schunkert H., Kuorwski V. Mild therapeutic hypothermia in patients after OOHCA due to STEMI undergoing immediate PCI. Crit Care Med 2008; 36:1780-6. Medline
II Opposes (Red) Mortality Patient Hovdenes J., Roysland K., Nielsen N., Kjaergaard J., Wanscher M., Hassager C., et al. A low body temperature on arrival at hospital following out-of-hospital-cardiac-arrest is associated with increased mortality in the TTM-study. Resuscitation 2016; 107:102-6. Medline
III Supportive (Green) Temperature change, survival Process PH-Paramedic Cabanas JG., Brice JH., De Maio VJ., Myers B., Hinchey PR. Field-induced therapeutic hypothermia for neuroprotection after out-of hospital cardiac arrest: A systematic review of the literature. J Emerg Med 2011; 40(4):400-9. Medline
III Supportive (Green) Feasibility Process ED-MD Hachimi-Idrissi S., Corne L., Ebinger G., Michotte Y., Huyghens L. Mild hypothermia induced by a helmet device: A clinical feasibility study. Resuscitation 2001; 51(3):275-81. Medline
III Supportive (Green) Survival to discharge Patient ED-MD Silfvast T., Tiainen M., Poutiainen E., Roine RO. Therapeutic hypothermia after prolonged cardiac arrest due to non-coronary causes. Resus 2003; 57:109-12. Medline
III Supportive (Green) Feasibility Process PH-Paramedic Uray T., Malzer R. Out-of-hospital surface cooling to induce mild hypothermia in human cardiac arrest: a feasibility trial. Resus 2008; 77:331-8. Medline
III Supportive (Green) Feasibility Patient PH-Paramedic Virkkunen I., Yli-Hankala A., Silfvast T. Induction of therapeutic hypothermia after cardiac arrest in prehospital patients using ice-cold Ringer's solution: a pilot study. Resus 2004; 62:299-302. Medline
III Supportive (Green) 30 Day Survival Patient PH-Paramedic Werling M., Thoren AB., Axelsson C., Herlitz J. Treatment and outcome in post-resuscitation care after OOHCA when a modern therapeutic approach was introduced. Resus 2007; 73:40-5. Medline
III Neutral (Yellow) Target Temperature Process PH-Paramedic Kamarainen A., et al. Prehospital induction of therapeutic hypothermia during CPR: A pilot study. Resus 2008; 76:360-3. Medline
III Neutral (Yellow) Feasibility Patient PH-Paramedic Storm C., et al. Prehospital cooling with hypothermia caps (PreCoCa): a feasibility study. Clin Res Cardiol 2008; 97(10):768-72. Medline
III Neutral (Yellow) Survival Patient Other Suen KF., Leung R., Leung LP. Therapeutic Hypothermia for Asphyxial Out-of-Hospital Cardiac Arrest Due to Drowning A Systematic Review of Case Series and Case Reports. Therapeutic hypothermia and temperature management 2017; 7(4) 210-21. Medline
X Not Yet Graded (White) - Watanabe M, Matsuyama T, Oe H, Sasaki M, Nakamura Y, Miyamoto Y, et al. Impact of cooling method on the outcome of initial shockable or non-shockable out of hospital cardiac arrest patients receiving target temperature management: a nationwide multicentre cohort study. Ann Intensive Care 2021; 11(1):163. Medline

Post-Arrest Cooling (CCT)
Level Direction Primary Outcome Patient/Process Setting Reference
I Supportive (Green) Temperature at arrival to ED Process PH-Paramedic Kamarainan A., Virkkinun I., Tenhunen J., Yli-Hankala A., Silfvast T. Prehospital therapeutic hypothermia for comatose survivors of cardiac arrest: A randomized controlled trial. Acta Anaesthesiol Scand 2009; 53(7):900-7. Medline
I Neutral (Yellow) All-cause mortality Patient Mahmoud A., Elgendy IY., Bavry AA. Use of Targeted Temperature Management After Out-of-hospital Cardiac Arrest: A Meta-Analysis of Randomized Controlled Trials. Am J Med 2016; 129(5):522-7.e2. Medline
I Neutral (Yellow) Mortality Process ICU Shrestha DB, Sedhai YR, Budhathoki P, Gaire S, Adhikari A, Poudel A, Aryal BB, Yadullahi Mir WA, Dahal K, Kashiouris MG. Hypothermia versus normothermia after out-of-hospital cardiac arrest: A systematic review and meta-analysis of randomized controlled trials. Ann Med Surg 2022; 74:103327. Medline
I Opposes (Red) 24 hour post-ROSC lactate levels Process ED-MD Lee BK, Cho IS, Oh JS, Choi WJ, Wee JH, Kim CS, et al. Continuous neuromuscular blockade infusion for out-of-hospital cardiac arrest patients treated with targeted temperature management: A multicenter randomized controlled trial. PloS one 2018; 13(12):e0209327. Medline
II Neutral (Yellow) Survival Patient ED-MD Hsu CH., Haac B., McQuillan KA., Tisherman SA., Scalea TM., Stein DM. Outcome of suicidal hanging patients and the role of targeted temperature management in hanging-induced cardiac arrest. The journal of trauma and acute care surgery. 2017;82(2):387-391. Medline
II Neutral (Yellow) 30-day survival Patient Martinell L., Herlitz J., Karlsson T., Nielsen N., Rylander C. Mild induced hypothermia and survival after out-of-hospital cardiac arrest. Am J Emerg Med 2017; 35(11):1595-600. Medline
II Neutral (Yellow) Mortality and poor neurologic outcome. Patient Stanger D., Mihajlovic V., Singer J., Desai S., El-Sayegh R., Wong GC. Effects of targeted temperature management on mortality and neurological outcome: A systematic review and meta-analysis. Eur Heart J Acute Cardiovasc Care 2018; 7(5):467-477. Medline
III Supportive (Green) Survival Patient Godinjak A., Iglica A., Kukuljac A., Tančica I., Jusufović S., Ajanović A., Rožajac Š. Targeted temperature management after out-of-hospital cardiac arrest in three young patients. Acta medica academica 2017; 46(1):50-4. Medline
III Neutral (Yellow) Feasibility, Temperature change Process PH-Paramedic Bruel C., Parienti JJ., Marie W., et al. Mild hypothermia during advanced life support: A preliminary study in out-of-hospital cardiac arrest. Crit Care 2008; 12(1):R31. Medline


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