Brief Overview

  • Higher incidence of reversible causes
  • Higher survival rate for post-cardiac surgery patients
  • AHA algorithm for the post-cardiac surgery within the first ~10 days

First steps:

Hold compressions

Code cart

Maintain finger on pulse

Check your chest tubes

Recs for epi in cardiac arrest in post-cardiac surgery

  • European Society Cardiology guidelines
  • Some addressed in AHA
  • Mostly based off expert opinion
  • Don’t give full code-dose epi -> b/c there’s high likelihood for re-sternotomy or restoring sinus rhythm via defib -> can give 100 mcg (i.e. one full stick of push dose epi)
  • Also in the Duning Ann Thorac Surg 2017 -> 50 mcg – 300 mcg
  • Caution with too much epinephrine in these post-cardiac surgery pts -> increases O2 consumption and demand -> can also cause severe hypertension which causes bleeding
    • Can counteract with vasodilator prn

Approach to external cardiac massage/compressions is different in the post-cardiac surgery patient

  • Deviates from ACLS normal cardiac arrest algorithm
  • Can attempt defib or pacing prior to initiating compressions
    • Provided that can be done in less than one minute
    • Prior to compressions, you can do three stacked shocks <- defib first prior to the ACLS algorithm
  • Asynch pace (i.e. DDD mode or aka “emergency” mode) -> careful if the pacer is in AAI mode and getting amio or something blocking the node <- need to be able to pace the ventricles (i.e. hit up that DDD mode but really all you really need is the V-wires to be working)

HOW-TO -> it’s all about the rhythm

Vfib or pulseless vtach

  • Instead of ext cardiac massage, should try to defib (if available within the first minute); also, can administer three stacked shocks prior to external cardiac massage
  • Amiodarone 300 mg via CVC
  • Eventually c/w resternotomy

Asystole or profound bradycardia

  • DDD pacing at max output if available within 1 min
  • Atropine 3mg <- took out of the European guidelines; still in there for the American STS guidelines
  • Eventually c/w resternotomy

All pulseless cardiac arrests

  • No epi; no vaso <- reduce epi dose to 100 mcg pre-arrest
  • Take the pacing wires out with PEA <- need to make sure it is not fine vfib
  • Rapid re-sternotomy if no response to initial therapies (<5 min)
  • Lidocaine evidence decent for post-cardiac surgery patients

CODE with a IABP

  • Pause the IABP to make sure you’re actually pulseless


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