A 67-year-old man is brought to the emergency department after a sudden cardiac arrest. He collapsed at home while watching television. His son started CPR as instructed by the 911 operator. Emergency medical services arrived in 7 minutes. The initial rhythm was noted to be ventricular fibrillation, and the patient was successfully defibrillated to normal sinus rhythm with return of spontaneous circulation.
The patient was intubated in the field, and intravenous amiodarone was administered. His medical problems include stable angina, hypertension, and hypercholesterolemia. Home medications include aspirin, metoprolol, enalapril, and atorvastatin.
Blood pressure is 170/100 mm Hg and pulse is 85/min. Examination shows scattered bilateral crackles. Heart sounds are normal. There is no response to painful stimulation. Oculocephalic and corneal reflexes are intact.
ECG shows normal sinus rhythm with ST segment depression in leads I, aVL, and V4-V6. A CT scan of the head without contrast shows no acute intracranial abnormality.
Which of the following is most likely to increase the chance of complete neurologic recovery in this patient?

Question

A 67-year-old man is brought to the emergency department after a sudden cardiac arrest.  He collapsed at home while watching television.  His son started CPR as instructed by the 911 operator.  Emergency medical services arrived in 7 minutes.  The initial rhythm was noted to be ventricular fibrillation, and the patient was successfully defibrillated to normal sinus rhythm with return of spontaneous circulation.
The patient was intubated in the field, and intravenous amiodarone was administered.  His medical problems include stable angina, hypertension, and hypercholesterolemia.  Home medications include aspirin, metoprolol, enalapril, and atorvastatin.
Blood pressure is 170/100 mm Hg and pulse is 85/min.  Examination shows scattered bilateral crackles.  Heart sounds are normal.  There is no response to painful stimulation.  Oculocephalic and corneal reflexes are intact.
ECG shows normal sinus rhythm with ST segment depression in leads I, aVL, and V4-V6.  A CT scan of the head without contrast shows no acute intracranial abnormality.
Which of the following is most likely to increase the chance of complete neurologic recovery in this patient?

Quizplus · Accepted Answer

This patient has experienced a sudden cardiac arrest (SCA). Neurologic impairment is the most common cause of death following out-of-hospital SCA and is responsible for significant morbidity following in-hospital SCA. Temperature management (TM), consisting of avoidance of fever and maintenance of body temperature ≤36 C (96.8 F) for 24-48 hours following SCA, has been shown to decrease mortality and improve neurologic recovery. TM is indicated in patients who are unresponsive or lack purposeful movements following SCA and should be initiated as soon as possible unless there is a contraindication. Because low temperature inhibits the coagulation cascade, active noncompressible bleeding is a relative contraindication. Absolute contraindications to TM include patient wishes against aggressive care or a medical scenario in which such care would be futile. Methods of TM include infusion of cold saline and application of topical cooling blankets. Body temperature is typically maintained between 32 C (89.6 F) and 36 C (96.8 F); however, the benefit of lowering body temperature to <36 C (96.8 F) is not clear. (Choice A) Elevating blood pressure with fluid repletion is beneficial in hypotensive patients to maintain a mean arterial pressure (MAP) >80 mm Hg and optimize cerebral perfusion pressure. However, it is not indicated in this patient with adequate MAP who already appears slightly hypervolemic. (Choice B) Avoidance of hypoglycemia is important in post-SCA patients, and target serum glucose should be 140-180 mg/dL. However, TM is more important for improving neurologic recovery. (Choice C) Permissive hypercapnia is contraindicated in patients with known or suspected neurologic injury as it can raise intracranial pressure and further decrease cerebral perfusion pressure. (Choice E) Given the initial cardiac rhythm of ventricular fibrillation, this patient's SCA was most likely due to an acute coronary event. He needs coronary angiography with percutaneous coronary intervention as soon as possible to improve overall mortality. However, as he now has a perfusing heart rhythm with adequate MAP, such intervention is less likely to improve his level of neurologic recovery. Educational objective: Temperature management, consisting of avoidance of fever and maintenance of body temperature ≤36 C (96.8 F) for 24-48 hours, has been shown to reduce mortality and improve neurologic recovery following sudden cardiac arrest. __________ References: Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia. (http://www.ncbi.nlm.nih.gov/pubmed/11856794) Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest. (http://www.ncbi.nlm.nih.gov/pubmed/11856793)

A 67-Year-Old Man Is Brought to the Emergency Department After