Skip to main content

Advertisement

SpringerLink
Log in

Post–Cardiac Arrest Syndrome: Update on Brain Injury Management and Prognostication

  • Critical Care Neurology
  • Published:
Current Treatment Options in Neurology Aims and scope Submit manuscript

Opinion statement

Treatment of cardiac arrest should focus on maximizing neurologic recovery as well as systemic recovery to ensure the best possible functional outcome. This article focuses on the neurologic care of patients after they have been resuscitated from cardiac arrest. Maximizing neurologic outcome after cardiac arrest requires attention to prevention of primary and secondary brain injury. Primary brain injury such as hypoperfusion and hypoxic injury should be avoided by optimizing hemodynamic goals to maximize cerebral perfusion and maintain normoxia and normocarbia. Secondary brain injury mediated by excitotoxicity and the inflammatory cascade may be mitigated by therapeutic hypothermia. Other strategies that may be beneficial include the treatment of seizures and maintaining normoglycemia. Finally, accurate and timely prognostication is crucial because it influences withdrawal of care and overall mortality. With the adoption of therapeutic hypothermia, the classic prognostic paradigm that was previously used needs to be reexamined. The application of our knowledge of risk factors for poor outcome, serial physical examinations, neurophysiological tests, neuroimaging, and biochemical markers may need to be delayed until after rewarming. We emphasize the importance of a shift in physicians’ approach to the management of post–cardiac arrest syndrome, not only in prognostication, but also in the early and aggressive therapies that have been shown to improve survival and quality of life.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References and Recommended Reading

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Neumar RW, Nolan JP, Adrie C, et al.: Post–cardiac arrest syndrome: epidemiology, pathophysiology, treatment, and prognostication. A consensus statement from the International Liaison Committee on Resuscitation (American Heart Association, Australian and New Zealand Council on Resuscitation, European Resuscitation Council, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation Council of Asia, and the Resuscitation Council of Southern Africa); the American Heart Association Emergency Cardiovascular Care Committee; the Council on Cardiovascular Surgery and Anesthesia; the Council on Cardiopulmonary, Perioperative, and Critical Care; the Council on Clinical Cardiology; and the Stroke Council. Circulation 2008, 118:2452–2483.

    Article  PubMed  Google Scholar 

  2. Peberdy MA, Callaway CW, Neumar RW, et al.: Part 9: Post–cardiac arrest care: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2010, 122(18 Suppl 3):S768–86.

    Article  PubMed  Google Scholar 

  3. Eisenberg MS, Mengert TJ: Cardiac resuscitation. N Engl J Med 2001, 344:1304–1313.

    Article  PubMed  CAS  Google Scholar 

  4. Nichol G, Thomas E, Callaway CW, et al.: Regional variation in out-of-hospital cardiac arrest incidence and outcome. JAMA 2008, 300:1423–1431.

    Article  PubMed  CAS  Google Scholar 

  5. Meaney PA, Nadkarni VM, Kern KB, et al.: Rhythms and outcomes of adult in-hospital cardiac arrest. Crit Care Med 2010, 38(1):101–8.

    Article  PubMed  Google Scholar 

  6. Laver S, Farrow C, Turner D, Nolan J: Mode of death after admission to an intensive care unit following cardiac arrest. Intensive Care Med 2004, 30(11):2126–8.

    Article  PubMed  Google Scholar 

  7. Langhelle A, Tyvold SS, Lexow K, et al.: In-hospital factors associated with improved outcome after out-of-hospital cardiac arrest. A comparison between four regions in Norway. Resuscitation 2003, 56:247–263.

    Article  PubMed  CAS  Google Scholar 

  8. Sunde K, Pytte M, Jacobsen D, et al.: Implementation of a standardised treatment protocol for post resuscitation care after out of hospital cardiac arrest. Resuscitation 2007, 73:29–39.

    Article  PubMed  Google Scholar 

  9. Hypothermia After Cardiac Arrest Study Group: Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest. N Engl J Med 2002, 346:549–56.

    Article  Google Scholar 

  10. 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, 346:557–563.

    Article  PubMed  Google Scholar 

  11. Polderman KH: Mechanisms of action, physiological effects, and complications of hypothermia. Crit Care Med 2009, 37(7 Suppl):S186–202.

    Article  PubMed  Google Scholar 

  12. Trzeciak S, Jones AE, Kilgannon JH, et al.: Significance of arterial hypotension after resuscitation from cardiac arrest. Crit Care Med 2009, 37(11):2895–903.

    Article  PubMed  Google Scholar 

  13. Bratton SL, Chestnut RM, Ghajar J, et al.: Guidelines for the management of severe traumatic brain injury. IX. Cerebral perfusion thresholds. J Neurotrauma 2007, 24(Suppl 1):S59–64.

    PubMed  Google Scholar 

  14. Sundgreen C, Larsen FS, Herzog TM, et al.: Autoregulation of cerebral blood flow in patients resuscitated from cardiac arrest. Stroke 2001, 32:128–132.

    PubMed  CAS  Google Scholar 

  15. Gaieski DF, Band RA, Abella BS, et al.: Early goal-directed hemodynamic optimization combined with therapeutic hypothermia in comatose survivors of out-of-hospital cardiac arrest. Resuscitation 2009, 80(4):418–24.

    Article  PubMed  Google Scholar 

  16. Rivers E, Nguyen B, Havstad S, et al.: Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001, 345:1368–77.

    Article  PubMed  CAS  Google Scholar 

  17. Bederson JB, Connolly ES, Batjer HH, et al.: Guidelines for the management of aneurysmal subarachnoid hemorrhage: a statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association. Stroke 2009, 40:994–1025.

    Article  PubMed  Google Scholar 

  18. McIntyre LA, Fergusson DA, Hutchison JS, et al.: Effect of a liberal versus restrictive transfusion strategy on mortality in patients with moderate to severe head injury. Neurocrit Care 2006, 5:4–9.

    Article  PubMed  Google Scholar 

  19. Hazelton JL, Balan I, Elmer GI, et al.: Hyperoxic reperfusion after global cerebral ischemia promotes inflammation and long-term hippocampal neuronal death. J Neurotrauma 2010, 27(4):753–62.

    Article  PubMed  Google Scholar 

  20. Brücken A, Kaab AB, Kottmann K, et al.: Reducing the duration of 100% oxygen ventilation in the early reperfusion period after cardiopulmonary resuscitation decreases striatal brain damage. Resuscitation 2010, 81(12):1698–703.

    Article  PubMed  Google Scholar 

  21. Balan IS, Fiskum G, Hazelton J, Cotto-Cumba C, Rosenthal RE: Oximetry-guided reoxygenation improves neurological outcome after experimental cardiac arrest. Stroke 2006, 37(12):3008–13.

    Article  PubMed  Google Scholar 

  22. Kilgannon JH, Jones AE, Shapiro NI, et al.: Association between arterial hyperoxia following resuscitation from cardiac arrest and in-hospital mortality. JAMA 2010, 303(21):2165–71.

    Article  PubMed  CAS  Google Scholar 

  23. Kuisma M, Boyd J, Voipio V, et al.: Comparison of 30 and the 100% inspired oxygen concentrations during early post-resuscitation period: a randomised controlled pilot study. Resuscitation 2006, 69(2):199–206.

    Article  PubMed  CAS  Google Scholar 

  24. Coles JP, Fryer TD, Coleman MR, et al.: Hyperventilation following head injury: effect on ischemic burden and cerebral oxidative metabolism. Crit Care Med 2007, 35:568–78.

    Article  PubMed  CAS  Google Scholar 

  25. Aufderheide TP: The problem with and benefit of ventilations: should our approach be the same in cardiac and respiratory arrest? Curr Opin Crit Care 2006, 12(3):207–12.

    Article  PubMed  Google Scholar 

  26. Davis DP, Idris AH, Sise MJ, et al.: Early ventilation and outcome in patients with moderate to severe traumatic brain injury. Crit Care Med 2006, 34(4):1202–8.

    Article  PubMed  Google Scholar 

  27. Belliard G, Catez E, Charron C, et al.: Efficacy of therapeutic hypothermia after out-of-hospital cardiac arrest due to ventricular fibrillation. Resuscitation 2007, 75:252–259.

    Article  PubMed  Google Scholar 

  28. Arrich J: Clinical application of mild therapeutic hypothermia after cardiac arrest. Crit Care Med 2007, 35:1041–1047.

    Article  PubMed  Google Scholar 

  29. Storm C, Steffen I, Schefold JC, et al.: Mild therapeutic hypothermia shortens intensive care unit stay of survivors after out-of-hospital cardiac arrest compared to historical controls. Crit Care 2008, 12:R78.

    Article  PubMed  Google Scholar 

  30. Bernard SA, Smith K, Cameron P, 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.

    Article  PubMed  Google Scholar 

  31. Nagao K, Kikushima K, Watanabe K, et al.: Early induction of hypothermia during cardiac arrest improves neurological outcomes in patients with out-of-hospital cardiac arrest who undergo emergency cardiopulmonary bypass and percutaneous coronary intervention. Circ J 2010, 74:77–85.

    Article  PubMed  Google Scholar 

  32. Chamorro C, Borrallo JM, Romera MA, Silva JA, Balandín B: Anesthesia and analgesia protocol during therapeutic hypothermia after cardiac arrest: a systematic review. Anesth Analg 2010, 110(5):1328–35.

    Article  PubMed  CAS  Google Scholar 

  33. Nielsen N, Sunde K, Hovdenes J, et al.: Adverse events and their relation to mortality in out-of-hospital cardiac arrest patients treated with therapeutic hypothermia. Crit Care Med 2010 (in press).

  34. Jirsch J, Hirsch LJ: Nonconvulsive seizures: developing a rational approach to the diagnosis and management in the critically ill population. Clinical Neurophys 2007, 118(8):1660–1670.

    Article  CAS  Google Scholar 

  35. Rossetti AO, Oddo M, Liaudet L, Kaplan PW: Predictors of awakening from postanoxic status epilepticus after therapeutic hypothermia. Neurology 2009, 72(8):744–9.

    Article  PubMed  Google Scholar 

  36. Claassen J, Mayer SA, Kowalski RG, Emerson RG, Hirsch LJ: Detection of electrographic seizures with continuous EEG monitoring in critically ill patients. Neurology 2004, 62(10):1743–8.

    PubMed  CAS  Google Scholar 

  37. Prakash A, Matta BF: Hyperglycaemia and neurological injury. Curr Opin Anaesthesiol 2008, 21(5):565–9.

    Article  PubMed  Google Scholar 

  38. Beiser DG, Carr GE, Edelson DP, et al.: Derangements in blood glucose following initial resuscitation from in-hospital cardiac arrest: a report from the national registry of cardiopulmonary resuscitation. Resuscitation 2009, 80:624–630.

    Article  PubMed  CAS  Google Scholar 

  39. Finfer S, Chittock DR, NICE-SUGAR Study Investigators, et al.: Intensive versus conventional glucose control in critically ill patients. N Engl J Med 2009, 360(13):1283–97.

    Article  PubMed  Google Scholar 

  40. Losert H, Sterz F, Roine RO, et al.: Strict normoglycaemic blood glucose levels in the therapeutic management of patients within 12 h after cardiac arrest might not be necessary. Resuscitation 2008, 76(2):214–20.

    Article  PubMed  Google Scholar 

  41. Oksanen T, Skrifvars MB, Varpula T, et al.: Strict versus moderate glucose control after resuscitation from ventricular fibrillation. Intensive Care Med 2007, 33:2093–2100.

    Article  PubMed  CAS  Google Scholar 

  42. Damian MS, Ellenberg D, Gildemeister R, et al.: Coenzyme Q10 combined with mild hypothermia after cardiac arrest: a preliminary study. Circulation 2004, 110(19):3011–6.

    Article  PubMed  CAS  Google Scholar 

  43. Wijdicks EF, Hijdra A, Young GB, et al.: Practice parameter: prediction of outcome in comatose survivors after cardiopulmonary resuscitation (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2006, 67(2):203–10.

    Article  PubMed  CAS  Google Scholar 

  44. Young GB: Neurologic prognosis after cardiac arrest. N Engl J Med 2009, 361:605–611.

    Article  PubMed  CAS  Google Scholar 

  45. Al Thenayan E, Savard M, Sharpe M, Norton L, Young B: Predictors of poor neurologic outcome after induced mild hypothermia following cardiac arrest. Neurology 2008, 71:1535–7.

    Article  PubMed  CAS  Google Scholar 

  46. Bouwes A, Binnekade JM, Zandstra DF, et al.: Somatosensory evoked potentials during mild hypothermia after cardiopulmonary resuscitation. Neurology 2009, 73(18):1457–61.

    Article  PubMed  CAS  Google Scholar 

  47. Zandbergen EG, Hijdra A, Koelman JH, et al.: Prediction of poor outcome within the first 3 days of postanoxic coma. Neurology 2006, 66(1):62–8.

    Article  PubMed  CAS  Google Scholar 

  48. Inamasu J, Miyatake S, Suzuki M, et al.: Early CT signs in out-of-hospital cardiac arrest survivors: Temporal profile and prognostic significance. Resuscitation 2010, 81(5):534–8.

    Article  PubMed  Google Scholar 

  49. Wijman CA, Mlynash M, Caulfield AF, et al.: Prognostic value of brain diffusion-weighted imaging after cardiac arrest. Ann Neurol 2009, 65(4):394–402.

    Article  PubMed  Google Scholar 

  50. Morris MC, Nadkarni VM: Pediatric cardiopulmonary-cerebral resuscitation: an overview and future directions. Crit Care Clin 2003, 19:337–64.

    Article  PubMed  Google Scholar 

Download references

Disclosure

No potential conflicts of interest relevant to this article were reported.

Author information

Authors and Affiliations

  1. Neurosciences Critical Care Division, Johns Hopkins Hospital, 600 N. Wolfe Street, Meyer 8-140, Baltimore, MD, 21287, USA

    Navaz Karanjia MD & Romergryko G. Geocadin MD

Authors
  1. Navaz Karanjia MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Romergryko G. Geocadin MD
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Navaz Karanjia MD.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Karanjia, N., Geocadin, R.G. Post–Cardiac Arrest Syndrome: Update on Brain Injury Management and Prognostication. Curr Treat Options Neurol 13, 191–203 (2011). https://doi.org/10.1007/s11940-011-0112-2

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11940-011-0112-2

Keywords

Search

Navigation