Show Notes

Core EM Modular CME Course

Maximize your commute with the new Core EM Modular CME Course, featuring the most essential content distilled from our top-rated podcast episodes. This course offers 12 audio-based modules packed with pearls! Information and link below.

Course Highlights:

Credit: 12.5 AMA PRA Category 1 Credits™
Curriculum: Comprehensive coverage of Core Emergency Medicine, with 12 modules spanning from Critical Care to Pediatrics.
Cost:
- Free for NYU Learners
- $250 for Non-NYU Learners

Click Here to Register and Begin Module 1

I. Phase 1: Stabilization (Minutes 0–10)

The “Rearrest” Window & Pathophysiology

High-Risk Period: Rearrest rates reach 30% within the first minutes post-ROSC.
Shock Incidence: Two-thirds of patients develop profound hypotension/shock as initial resuscitative efforts subside.
Catecholamine Washout: Super-physiologic “code-dose” epinephrine (1mg IV) typically wears off within ~3 minutes post-ROSC, leading to predictable hemodynamic collapse.
Secondary Injuries: Evaluate for “CPR-induced trauma” (blunt thoracic trauma, rib fractures, pneumothorax, liver/splenic lacerations).

Immediate Resuscitative Actions

Vascular Access:
- Transition rapidly from IO to reliable IV access within 1–2 minutes.
- Prioritize Intraosseous (IO) placement within 5 minutes if IV attempts fail; intra-arrest data suggests no significant difference in early outcomes.
Vasoactive “Bridge”:
- Maintain a “bolus-dose” pressor at the bedside for immediate push-dose titration.
- Options: Phenylephrine, dilute Epinephrine, or dilute Norepinephrine (titrated to effect rather than rigid dosing).
Physician-Specific Task: Arterial Line:
- Goal: Placement within 5 minutes of ROSC.
- Preferred Site: Femoral (by landmarks/blind if necessary) for speed; should be a <2-minute procedure.
- Utility: Immediate detection of rearrest and beat-to-beat titration of vasopressors.

II. Phase 2: Diagnostic Workup (Minutes 10–40)

Etiology Epidemiology

ACS Shift: Acute Coronary Syndrome (ACS) is the cause in only 6–10% of resuscitated survivors (lower than historical estimates).
Common Etiologies:
Respiratory: COPD, pneumonia, mucus plugging.
- Cardiac: Arrhythmia (cardiomyopathy/scar), RV failure (PE), or LV failure.
- Neurological: Intracranial hemorrhage (SAH/ICH), status epilepticus (4–5%).
- Metabolic: Dialysis-related disarray/hyperkalemia.
- Toxicology: Overdose accounts for ~10% of cases in urban centers.

The “Broad Net” Strategy

“Rainbow Labs”: Comprehensive panel including toxicology and serial biomarkers.
Pan-Scan Protocol:
- Components: CT/CTA Head/Neck, Contrast CT Chest/Abdomen/Pelvis.
- Diagnostic Yield: 50% for clinically significant findings (causes or consequences of arrest).
- Contrast Risk: Negligible (1–2% increase in AKI risk) compared to the high diagnostic utility.
Avoid Anchoring: Do not assume ischemic EKG changes are the cause; they are frequently a consequence of the global arrest-induced ischemia.

III. Hemodynamic & Respiratory Targets

Mean Arterial Pressure (MAP)

Autoregulation Shift: In acute brain injury/post-arrest, the lower limit of cerebral autoregulation shifts right, often requiring MAPs of 110–120 mmHg for adequate perfusion.
Clinical Target: Aim for MAP >80 mmHg.
The BOX Trial Nuance: While the BOX trial showed no difference between MAP 63 vs. 77, its cohort (...