Transcript Video Post-Arrest Management: Practical Aspects for Bedside Care in the ICU Hello, my name is Doctor Benjamin Abella. I am the chair of emergency medicine at the Mount Sinai Health System in New York City, where I'm also a practicing emergency physician there as well. Um, but one of the reasons I'm with you today is for 25 years, I've focused my research passions, interests, educational work, and other activities around cardiac arrest and post-arrest care. Uh, I've been part of the American Heart Association, uh, guidelines writing group, a number of cycles, etc. So this is an area of great interest to me, and the purpose of this lecture. is not so much to go through the evidence or uh the science around post-cardiac arrest care, but really to give a bit of a practical workbook, a practical guide for some of the issues that we deal with in the ICU and in particular, some of the nursing issues that come up around critical care for patients after arrest. As you know, patients after cardiac arrest are very sick and sometimes spend days to weeks in the ICU. And they have a complex physiology and a pathophysiology known as the post-cardiac arrest syndrome or PCAS, and this is this poorly understood pro-inflammatory set of problems. People get brain swelling, acute kidney injury. Uh, they can have seizures. They're very sick. And, and so the care for these patients in the ICU is, is sophisticated. Part of it involves targeted temperature management or TTM, which is the main topic of my other lecture on this platform. But in this lecture, I'll talk somewhat about TTM, but also just some of the general considerations on how to take excellent care of these patients to restore them to life and health. Now, first, important to mention my disclosures. I've had research funding and consulting and, and equity in a number of, um, of commercial entities. I have no equity whatsoever involved in uh Beckton Dixon, uh, and, and any of the, uh, their products. So, I'm really here to just talk about the science and here to talk about, uh, target temperature management in general. I don't represent any of these entities here today. The goals of this lecture are to talk a little bit about the guidelines. Every 5 years, the American Heart Association updates their resuscitation guidelines, both for cardiac arrest and post-arrest care, and some of that will be applicable when we talk about practicalities. But we'll also talk about what impacts survival and outcomes, and, and a little bit around the evidence around specifically nerve prognostication, an important activity, because after all, at the bedside, we're talking to families, and one of the biggest questions all families have following cardiac arrest is, will my loved one make it and how will we know? We'll then talk a little bit about protocol development and other aspects of care. So that's the goal today. So, first, to go through the guidelines. So, in 2025, the last iteration of the American Heart Association guidelines was produced, and Part 11 focused on post-cardiac arrest care, and this is all freely available online. I show you here a couple of excerpts. One of the key things is that when patients survive cardiac arrest initially, There's a branch point of whether they're following commands, that is to say, whether their Glasgow motor score, part of the Glasgow Coma Score, Glasgow motor score is 6. Glasgow motor score of 6 means when you say to someone, can you open your eyes or can you squeeze my hand, they do it volitionally. They can hear, they can process, and they can act. Well, if people can do that, they generally have a better prognosis than not, and they generally do not need TTM, but that is the minority of patients. The great majority of post-arrest patients don't follow commands, they may be moving a little, but they can't follow volitional commands. Their Glasgow motor score is not 6, it might be 543, or whatever. Those patients need a deliberate strategy for temperature control, they need TTM and they need a number of other critical care interventions. And you see here on the right, the guideline recommendations that speak to having a deliberate protocolized strategy for temperature control, among other things, and, and you're welcome to read the guidelines at great length. By the way, in case you're curious, the guidelines try to grade the strength of the evidence, uh, and so there's LOE stands for level of evidence, and um uh COR basically stands for sort of like the, the overall recommendation. Um, and, and so one is strongly recommended, and, and 3, there's no recommendation. Now, apart from the guidelines, there was a separate, this makes things a little confusing, but this is just the world we have. There was a separate, very detailed document that came from the American Association in partnership with the Neurocritical Care Society or NCS that was a scientific statement around all of the details of post-stress care. There was a complaint that the guidelines gave the big picture, but that bedside providers, nurses, docs, PAs really needed a more detail, like what do we do? What do we do with the ventilator? What do we do about sedation, etc. etc. So, this document attempted to address a number of these things, and I was on the authorship group, and we went into great detail around what to do and when to do it. And I show you here, just one, just to give you a flavor, one of the summary figures from this article. And we really got into the weeds on, on what things these patients need, and, and there's a lot there. So, I do strongly recommend you have this available, that you give it a read or at least keep a copy around the ICU because there's a lot there that is important to know about. Um, both the the ventilator management, who gets cathed or not, how to manage blood pressures and oxygen, there's, there's a lot to cover, but TTM is a key part of all of this. All right. Now, there's a number of things that predict survival that help us understand who needs all of this aggressive care. Because you might say, why are we doing all of this? Don't all post-arrest patients do poorly? Well, we don't know fully how to predict this, but we do know some things. We know that if you had a witnessed arrest, if someone saw you collapse, that generally means we should be aggressive and we should really take excellent care of them in the ICU with the hopes of some form of recovery. If patients get bystander CPR, that's a very good prognostic indicator. If they get bystante versus not, there can be up to even a two-fold difference in eventual survival, really big impact. Also, patients with ventricular fibrillation or ventricular tachycardia tend to have better survival rates than patients with PA or asystole. So, that also suggests we should be aggressive in our ICU care. And if there's a short time to ROSC or return of spontaneous circulation, that's getting your pulse back, that is to say, if the CPR episode was, say, 7 or 8 minutes as opposed to say, 30 minutes. Big difference in survival. So, if a patient arrives in your ICU and they had a witness arrest, they got bystander CPR, they had a VFib arrest, and they got their pulse back in say, 8, 1012 minutes, as opposed to longer, we need to stay on top of those patients. These are patients that a full recovery is possible, not guaranteed by any stretch, but, but we have a fighting chance and, and paying attention to the details really matters. Now, things that matter less, but many people think they matter. So these are sort of zombie myths, age. Age is a tricky one, and some hospitals have post-respiratory protocols that say, oh, we're not gonna do TTM if they're over 80, or we're not gonna do X-rays if they're over 80. I think that gets into some difficult terrain, because as many of you know, there are 90-year-olds who have a great quality of life, are playing tennis every day and live to 100. And there's 60 year olds who are on dialysis and have coronary disease and many other health problems and, and have a shorter lifespan with lower quality of life. So I, I tend to really encourage people not to think about age so much. I think about functional status. That's really the thing. Um, uh, also, comorbidities. I am amazed in 2026 how many hospitals say, oh, if they have metastatic cancer, don't do things. It's almost like metastatic cancer is like a death sentence from a hospital care perspective. Cancer care has changed tremendously over the last decade or two. Maybe the protocol writers in C-suites haven't caught up with this. Um, there are many patients who have metastatic cancer. A good example is colorectal cancer, where it is kept at bay and they have excellent quality of life with liver mets for decades, literally. And so I'm not saying that cancer patients should always get the most aggressive care. I'm saying again, it's more about the specifics, and we shouldn't say an 80 year old or a person with cancer doesn't get aggressive care. They may very well deserve fully aggressive care because they may have an excellent. Quality of life and, and lifespan for years to come. Sorry to delve into a little bit of ethics, but I think it was really important to make sure that everyone understand that aging comorbidities are very latent, challenging topics in this area. OK. So, This, this, those things are important with general predictions. But how do we actually tell when people are going to do well or, or not do well in the individual setting, not, not based on these sort of general characteristics. Well, We looked at when people wake up, because waking up, of course, is important, and one of the most common issues that bedside nurses have to deal with is a patient isn't waking up for a few days, and the family's getting worried, and the family says, hey, when's my loved one going to wake up? This is something that bedside. Providers have to deal with. And what we found was that patients are slow to wake up. And I, I kind of feel like this one figure is one of the more useful figures for folks to have at the bedside, because you can say to patients, families, not the patients, they haven't woken up, their families, you can say, look, there's published evidence that suggests many people take 234, even 5 days to wake up. Heck, some patients, patients even take 67, or 8 days to wake up, and some of them still make it out of the hospital intact. So, not waking up a day or two after cardiac arrest does not mean anything. They might do poorly, they might do well. Uh, we just don't know, and that's supported by the evidence. So you've got to give it at least 3 days, sometimes 456 days. It's very important to not rush to judgment on who's going to recover or not in the first few days following cardiac arrest. And one of the other zombie myths, and this is the 2015 guidelines, but it's exactly the same in 2020 and 2025. 2015 was the first time they made it explicit. So, in the HA guidelines, there's a statement that we have to wait at least 3 days and we cannot use the bedside exam within the first three days to determine prognostication. What do I mean by that? This is a very important point. Many patients in the 1st 3 days following arrest have dilated blown pupils. That is to say, they do not have corneal reflexes. This does not mean anything. Of course, it's better to have functioning pupils than not, but many patients have blown ded pupils, and they, they make full recoveries. So, there's a zombie myth out there that blown dead pupils equals death. It does not, at least not in the 1st 3 days. So be very careful about using your bedside neurologic exam to make a statement to family that, oh, the things are looking really bad. There may be other reasons why things are looking bad, but the pupils are not one of them. Now What do we do with TTM and neurop prognostication and this whole sort of suite of care? How do we, how do we develop our protocol? And, and many of you have dealt with protocol development and maintenance at your hospitals. It's not simple. Uh, we have a committee, Institute of Critical Care Medicine Committee that reviews these things on a regular basis, and, and we do have a TTM protocol for out of hospital, uh, patients. And, and the exclusions include if you're Glasgow mortar score of 6, if you're following commands, you don't need TTM. We, our hospital feels. Certainly, another exclusion would be if someone is on comfort care or moribund. Note, I didn't say DNR DNI. DNR DNI does not mean do not treat, it just means don't resuscitate. But, but certainly, many of us have patients who arrive in the ICU and it's clear they're dying. The post-arres patient who is now on 3 pressors, their kidneys are worsening. They came into the hospital really sick with sepsis. Are we really going to do a TTM and give false hope to family for that patient? Probably not. Now these are things that are hard to define, but, but we believe there are patients post arrest who are clearly, clearly dying, and, and we shouldn't do aggressive care for those patients. In our hospital, we have a default of 36 for most patients, but sometimes we do cool uh to deeper temperatures, and if you're curious about that, see my other lecture uh in this resource uh site that will help you learn more about temperature selection. We're not gonna talk about temperature selection in this lecture. Now, what do we do about devices? Well, first off, we definitely believe at Mount Sinai that using a device is important. It is really hard to do TTM, targeted temperature management, with a, uh, with ice packs, with cold fluids. It's just hard to get it precise. And so we use a gel surface pad system with a temperature monitoring and data collection. And, and the data capture is actually really important to us, and I think to many hospitals, because you need to do QA, you need to see how you're doing, and uh the devices we use also have water bath temperature collection so we can see if patients are trying to get a fever or trying to shiver, which we find very useful. Now, an important part about post-dress care and protocolization is to include everybody. This shouldn't just be an ICU thing. It shouldn't just be an ER thing. Patients come in and out of the hospital, they're in the ED, then they go upstairs. And so, you really need everybody at the table to agree on a system of care. Neurology is often involved, right? Cause they're going to be doing the neuroprognostication. Pharmacies involved, they're managing medications, and some medicines may need to be titrated. Appropriately if you're calling the 33. So you really need to get everybody on the same page, and this is hard. This is actually a weak spot for many hospitals. Maybe there's egos involved, maybe people don't get along, or maybe there's just not convenient meeting places where these folks can normally get together to work out any differences or complexities. So, so you just need to be mindful of it, and someone needs to be a captain of the ship and get these folks together once a year, twice a year, quarterly to review cases, to discuss the protocol, to review any updated evidence, and so forth. I, I think a twice a year meeting at many hospitals is probably sufficient, but larger centers may want to do it more frequently. And you really ideally want to have one protocol for the whole hospital system. What are some of the things that you need to do, uh, early, early, uh, in cardiac arrest with regard to uh target temperature management? Well, first off, When, when you get somebody back, you get Rosk, you say, wow, you know, we got a pulse back, that's great. Immediately, someone should go get the temperature cooling equipment. It takes a little while to set up, it takes a little while to get, sometimes we need a little quick in-service refresher for 5 minutes on how to turn this thing on and use it. So, that should start the minute you get the pulse back, so that you're ready to go. Obviously, you want to make sure that your tube is in good place, you want to make sure the patient's on the ventilator and stabilized, and that you have access. So, all the sort of basics of initial post-resuscitation care. Then within the first hour, if you're going to place a Foley, a urinary catheter, it should be a temperature sensing one. Most hospitals and most EDs and most ICUs stock these, and the reason why is that's going to go into the temperature device, the cooling device, so that you can use closed loop feedback to manage your temperature. Now, ideally in the ED, but not always possible, but ideally before ICU transfer, patients also get a central line in an arterial line. That's important because for post-stress patients, they're sick enough that they warrant these both for medication administration, that's for the central line, and also for really careful blood pressure monitoring, that's their arterial line. Now, An important part of all protocols should be that any out of hospital cardiac arrest patient should get a head CT, a non-infused plain brain, as it's often called, a plain brain head CT before targettemporary arrangement ICU admission. Now, not in, in hospital arrests, only out of hospital arrest. Now, why would that be the case? Why, why would we do this? Well, it's important to note, we do not get the head CT initially to make prognostic information. There are numerous studies that show the initial head CT is wildly inaccurate with regarding to outcome. Patient's brain can look great and they can do poorly. Patient's brain can look swollen, and they can do well. The main reason to get a head CT initially after cardiac arrest is to look for blood or no blood. Was there bleeding and why? Well, patients had a cardiac arrest in the field, you don't know if they fell and hit their head and has a subdural, as shown in the bottom panel here, a subdural hematoma. You also don't know if they had intracranial bleeding that caused the arrest. So you really are there just to look for blood, but it's very important because you want to be able to say head CT was done, there's no bleeding, let's proceed with critical care. So, many times, uh, a head CT has gotten and people say, oh, it looks bad. Well, it's hard to know what that means, so I caution all of us to take it, take a beat and, and not overinterpret an initial head CT. Now, for in-hospital arrests, because we usually know why they were rested, they were deteriorating, maybe they were septic, and because we know they didn't suffer trauma, they were lying in their bed in most cases, head CT is probably not required. So, you, in most cases, you don't need to get a head CT after a no rest, unless, of course, they collapsed in the bathroom in their room and hit their head on the sink. Then, then you probably do need a head CT. So, how do we use head CT? Well, um, When patients are very sick and we might consider a deeper cooling, we won't do it if there's blood in the head. Why? Because there's evidence that when you cool people to 33 °C, it can worsen crap coagulopathy. They may have bleeding from that. Um, 36 is very safe from that standpoint. So, some hospitals just manage everyone at 36. Again, refer to my other lecture for more details on this. But if you're gonna cool more deeply, you have to make sure there's no blood in the brain. The other sort of key thing in any protocol around post-arrest care is who goes to cath. So, as you know, many cardiac arrests are from STEMI, ST segment elevation myocardial infarction. So who should go to the cath lab following arrest? Well, if they have a STEMI on post-arrest EKG, they have a, a STEMI evidence, and I show you here an EKG on the left that shows a STEMI, and those of you who know how to interpret EKGs can see this, they should go right to the cath lab. It is a class one recommendation from the American Heart Association that a patient with STEMI and poster cath, uh, sorry, and poster EKG goes to the cath. They need a PCI emergently, so can't wait till the next day. Right then and there, within the hour or two, following the same criteria you'd have for any stemming. On the other hand, if you get an EKG within the first, say, 30 to 60 minutes following cardiac arrest, and it does not show a STEMI, may be abnormal, but it doesn't show a STEMI, they go to the ICU, they get TTM and other care, but they do not need to go to the cath lab right away. That much is very clear. So, a, a key branch point here for who goes to the cath lab that night following cardiac arrest care, or that day if it's the daytime arrest. Now, there have been papers looking at this, and they found that if you don't have a STEMI, you may need a cath, but it can probably wait a day or two. Cardiologists are very happy with that statement. Uh, they don't have to come in at 2 in the morning after a 1:00 a.m. arrest if the EKG does not show a STEMI. So, how do we do this? Well, um, if, if someone has a semi, they go to cath. Uh, however, um, there's, there's a lot of other issues that come up that we might consider. For example, for example, Maybe they've known coronary disease. Maybe they were having chest pain before they collapsed. So there might be some reasons you might encourage an earlier cath versus a later cath, but the evidence is unclear. So, so, the only clear evidence is the STEMmy part. These other things that are factors, it's important to collect, for example, it's really important to know if someone is having chest, chest pain before their cardiac arrest, because it may suggest etiology. It may help you order the right test to figure out why they are arrested. Now, it turns out from the ED it's very hard to tell this. Uh, for example, initial troponin, not so good. Initial troponin could be negative, and it could be SEI and, and, or an MI and maybe only the second troponin, because after all, we know that it takes several hours for the troponin to rise in the bloodstream after a heart attack. Also, some people can have an elevated troponin, and it's not A micro infarction, because troponin can be elevated just from a prolonged arrest with CPR and with defibrillation. So it's really, really tough, and we've published some evidence on that. OK, so, uh, what about, um, uh, some of the impacts of TTM? So, you know, some people worry about side effects, about target temperature management. Well, I can tell you that if you do TTM at 36, there's essentially no impact, uh, very safe. After all, normal body temperature is 37. Many people walk around every day at 36.5. So 36 is very safe. However, some patients manage at 36 and certainly some patients managed at 33, kind of shivering. Know side effect. They can also increase risk of coagulopathy. We discussed that before. At 36, there's essentially no risk. At 33, there's a little bit of a risk of that, as well as electrolyte derangement. Um, also you can have a prolonged QT and bradycardia, so we're gonna go through some of these. The most important thing I can tell you upfront, cooling to 33 or managing temperature at 36 is very safe, very, very safe. The adverse effect rate is very small. The adverse effect rate. If something actually leading to harm is even smaller. So for example, with regard to coagulopathy, clinically significant bleeding that can be attributed to char 33, it's 1 or 2% of patients. So 1 in 100, 1 in 50, very, very uncommon. Now, bradycardia on the other hand, is very, very common with cooling, especially to 33. 36, no, but when you manage patients at 33, they get bradycardia, and it's important to talk about this for a minute. Don't give atropine, don't speed up the heart rate, in general, in general, because you'd just be treating a number. Many patients tolerate this low heart rate very, very, very well. This is just our opinion and that experience of many providers. There isn't really a literature on this, but many of us have found that, that not only is this heart rate acceptable to the patient, their blood pressure is fine, everything, all their parameters look good, it may actually be good, it may be cardiac protective, much like we give beta blockers to patients after an MI. Well, The key thing is a patient assessment. Look at their mamacular pressure, look at their urine output, look at their cardiac output, and if all these things check out, they can be at 40 or 50. Now, if they don't tolerate the bradycardia, and you think maybe a drop in blood pressure is due to profound bradycardia, just raise their temperature, just don't do 33, do something slightly higher. You know, with regard to coagulopathy and this risk of bleeding, it's a very, very small risk. In the most majority of cases, it's just bruising or maybe a little pink in the foy uh urinary catheter. As I mentioned before, significant bleeding that might involve a treatment like FFP or transfusion or stopping TTM is less than 2%, very, very, very uncommon. But there might be some things to avoid risks. I, I certainly in a post-arrest patient who's getting cool to 33, it doesn't matter for 36, cool to 33, I might do STDs as opposed to heparin for DVT prophylaxis. You might raise the temperature, for example, if there is some big concern for bleeding or if they are bleeding. If they are bleeding, certainly you can consider FFP or red blood cell transfusion, the usual things. But in the vast majority of cases, no management is required. You don't have to do anything. Now, I will say that you can cool people at 33 if they're on heparin, that is fine. And, and that has been the experience of many, many hospitals and ours as well. I would say though that PTT is often prolonged. So you often need a lower dose of heparin, if you're gonna cool to 33. At 36, none of this matters. But if you've cooled to 33, uh, adjust your heparin dose because PTT will be prolonged. That is to say, heparin uh degradation is, is reduced at 33. So How do we decide what to do? Well, if you chose one temperature for all your patients, it would be 36. But if you're thinking about 33 for some patients, and we've talked a little bit about this, it turns out the only patients you really need to avoid 33 are the ones who have an active GI bleed or an intracranial bleed, because those patients are, are potentially sick from bleeding, and you don't want to worsen coagulopathy. However, in our experience, if they're On Coumadin, if they're on a NA, if they're on heparin, if they've had a history of a GI bleed, these are not significant risk factors, and you can consider 33 as you need to. Again, my opinion, the opinion of other hospitals, uh, and, and certainly in context, if any of you have you have a TPA for other agents, thrombolytic agents for stroke, the, the risk profile is much worse, much, much higher for those than anything in the TTM space. Now, what about um shivering? That's an important one to talk about a little bit. Many patients shiver when they receive TTM care. It's the natural response to being cooled. Well, there's a number of firm, first off, shivering at 36 is, is, is not so significant and it still can happen. Um, there are a number of approaches to this. Certainly, increasing sedation is often all that's required. Some people who have really, really pronounced shivering need to be paralyzed, but very few need that. Sometimes it's just a a magnesium administration. It's a tocolytic, that is to say, a muscle relaxant, and if you give 2 g or 4 g of magnesium, very safe to give IV infusion, that alone can take care of shivering. There's also a wonderful non-pharmacologic approach to shivering that many hospitals have baked into their TTM protocols, which is counterwarming. It's kind of a body hack. It turns out that the human body has the most temperature sensors in the hands and feet. This makes sense. They're usually your early warning sensors for being out in the cold. If you go out in the wintertime, your hands and feet get cold first, usually. Well, if you use a temperature device, say, on the chest or body to cool. And you put hot packs on the hands and feet. The surface area is small. It will not override your temperature control device, but it will confuse the brain to thinking that we're fine, we're warm. You've all done this, by the way. If you've ever been out on a cold day or just sitting in a cold house, and you're having a cup of coffee or tea, you may have this natural instinct to cup that cup of coffee or tea in your hands, and put your palms against. You didn't know what you were doing, perhaps, but it felt good to warm your hands. Why? Because your brain is responding to cold hands. Warm hands feel good. Warm hands tell your body you're OK. So even if you're out on a snowy day, but you're cupping a nice Starbucks or a mug of coffee, uh, you're doing counterwarming. And we do that post-arrest, and it often reduces or makes shivering go away altogether. It's amazing. Now, there's something called the BSAS Bedside shivering Assessment Scale, that's very commonly used in post-stress care protocols, and I show you that scale here. It can be done by nurses at the bedside to just chart on an ongoing basis, hourly or every 6 hours or however often you, you do this, um, to give a sense of, of shivering and, and are you going the right direction. Uh, many hospitals don't do this every hour. That seems a little crazy, but, but every few hours is, is certainly reasonable, and you can adjust your sedation and or give magnesium and or do these other things if necessary. Well, many very practical questions come up when, when I give lectures or talk to people about post-res care, and I just want to address a few of them upfront because this is not an interactive platform. Uh, what if a patient comes in at 33 or 34? Do you warm them to 36, or do you keep them where they are? And the general consensus, again, based on essentially no evidence, is it's better to keep them where they are. If they're, if they're relatively stable, you don't warm them up. And why is that? Well, While most evidence suggests TTMA 36 is fine. The first hours following cardiac arrests are the most vulnerable. People get brain swelling, people are inflamed, and somehow turning on the heat, warming someone up when they're having ongoing inflammatory conditions feels wrong. So we generally keep people where they are. Unless they're lower than 33, then we'll warm them to 33. And the reason why I say that is once you get down to 30 or 31, this is the zone of environmental hypothermia, and this may have its own life risks. 33 is not risky. So, again, what many places do, not in the literature, if you're below 33, you bring them to 33, but if they come in at 34, 35, leave them there, don't warm them to 36. What about kids and pediatric cardiac arrest? Well, there's only been one randomized controlled trial for kids that showed no benefit of cooling the 33 versus managing at 37, so no one exactly knows what to do. Um, that said, I would suggest that, um, Our legal definition of pediatrics, which is in many hospitals 18, is not the biologic definition of pediatrics, which is pre-puberty. And a 15-year-old who has a VFib, cardiac arrest and gets CPR and so forth, they're, in, in the eyes of biology, they're an adult. And so if you do TTM for adults, I would say a, a postpubescent pediatric patient should be treated like an adult and get a TTM protocol. Again, in my opinion. Are there any clear contraindications to TTM? If someone is awake post-rest, if they get a shock from an AED in the health club or the airport, and they're awake and talking to you, they do not need TTM. They're going to be fine. No need for TTM if someone is following commands. So, but again, that's the minority of patients, but it is an important consideration. What do we tell families? Well, the most important thing that I told you to tell families is that it takes time. We need several days to, to assess patients. And what I always tell families is, look, this is a marathon, not a sprint. I say it just like that. People all know what a marathon versus sprint is. And so I say, look, You need to pace yourself. This is gonna take some time. Self-care of families, very important in the first several days following arrest. I've seen this numerous times where in the hours following cardiac arrest, the family gets very stressed out, very scared, very confused, and they sit at the bedside grasping the bed rail, and, and they're sort of freaking out, honestly. And I tell families, look, you have to be our partner. You have to work with us. It's really important you get some food. It's really important you get a nap. It's really important you bring in friends or other family members to help you. Why? Because the first day or two, we're not gonna necessarily be making big decisions. We're just gonna like do our thing. We're gonna see where the dust settles. However, on day 3 or 4 or 5, as the patient may or may not be waking up. There may be difficult decisions to make, and we need you not fried. We need you slept, we need you fed. We need you feeling as best you can, able to be our partners in figuring out the best care for your loved one. So, that's the speech I give to a lot of patients in the first hours following cardiac rest, and I, I recommend trying that on in your ICU as well. Now, if patients do survive or if families are asking for resources, there are some things online. There's something called the Southern Cardiac Rest Foundation, and they run a survivors network. American Heart Association has started their own survivors network. So if you Google these resources, uh, It's not great, honestly, um, uh, it's not as robust as say some of the cancer survivor groups, but, but there's something, and there's certainly online resources of what to expect and what kind of problems happen after cardiac arrest and and and so for some families, they may find that helpful or comforting. Now, the reason why families know a thing or two about this is there's cardiac arrest in the world, in, in, in the literature, and not the literature, in, in public media, I should say, and certainly a number of public figures, especially athletes, have had cardiac arrest in very public ways. DeMar Hamlin, uh Buffalo Bills football player, had cardiac arrest in 2023 on primetime TV during a playoff game, done well, back to playing football. Christian Eriksson, for those who follow European football, um, he's a Danish gentleman who had a cardiac arrest and again, full recovery back to playing what they would say football, we would say soccer. Bronnie James, LeBron James' son, had a cardiac arrest and is in full recovery and now playing for the Lakers. And for those of you with young children, or children who were once young, there was a musical group for kids called The Wiggles, and the Yellow Wiggle, Greg Page. If you have, if you had kids about 10 years ago, you know about The Wiggles, uh, 10 or more years ago, I should say. Um, Greg Page had a cardiac arrest and has made a full recovery now does a lot of advocacy work around cardiac arrest as well. And he actually one time, uh, actually reached out to me on social media and I, I had a sort of a fan crush moment because my kids all watched The Wiggles and I couldn't believe I was talking to Greg Page. But there it was. And so people have heard of this, and they, they, they wonder about recovery and they wonder if their loved one is going to be like these people, one of the lucky ones who makes a full survival possible. Now, there's a medical rock star who you may have heard about who also had a cardiac arrest. Um, those of us in the medical world may have heard of this person, Glaucom Flecken, that's his stage name. His real name, and he's been public about it, so I'm not, uh, divulging anything, is, uh, Will Flannery. Will Flannery, Doctor Flannery is an ophthalmologist in Portland, Oregon, but he, um, he had a cardiac arrest. His, his stage, social media, Instagram, TikTok name is Glaucom Flecken. And this is his wife. His wife did bystander CPR on him in their bedroom when he had cardiac arrest. And they actually have developed a bit of a, a, a, a lecture, a bit of a, a, a gig, if you will, around talking about their experiences with life and death. In fact, they often title their, their presentation, Wife and Death. Wife and death, like life and death. So, get a joke, Wife and death. And they, and they talk about cardiac arrest, they talk about what the experience is like, they talk about survivorship. And, and you can find some of their content online and actually, some of their content is excellent. You can hear them reflecting on survival. And, and, and since he's a comedian, they do it in a light-hearted way, which makes it a little bit easier for some people to digest. And, and so you might even recommend this to some families, uh, when appropriate as well. So, as far as take on points, targeted temperature management is the cornerstone of what we do. It's crucial for all post-rest patients, and you can look at my other content if you want more specifics on that. Some patients need cardiac cath, but most can wait a little bit. The key initial moves, you've got to get an ECG on all post-stress patients in the 1st 30 minutes. You gotta get a head CT in the first hour, and all patients need some form of TTM of targeted temperature management. The specific temperature, again, I'll leave to the other lecture, they may need fluids, they need supportive care, etc. etc. There's some evidence that earlier TTM is better. So, so you really wanna be on top of this, which is why I recommend you get the cooling equipment the minute you get the pulse back. The side effects of TTM, shivering, and such are very mild and very manageable and should not scare you about delivering this care. Well, thanks for listening uh to this presentation today. And I just want to acknowledge the people that I work with at Mansane, a terrific team, and we have an entity there called the Center for Resuscitation Science and Innovation, where we do research and educational work around cardiac arrest and post-rest care. We are, uh, working on our website. So if you Google us, you will not see a CRESSI website. By the way, the acronym, we call it CRESSI for Center for Cessation Size and Innovation, but that will be up soon. Um, maybe by the time you're watching this, it will be up and available, where we'll have also educational materials, uh, for the public as well as for healthcare providers. Thanks very much. Created by
