Resuscitated MWDs will require intensive care to optimize long-term outcome. Many MWDs will arrest again, and most do so in the first 4 hours after resuscitation.2,3 Successful return of spontaneous circulation and resuscitation are unlikely if an MWD arrests again, and HCPs should balance resources against repeated attempts at resuscitation. Key management issues for MWDs in the post-resuscitation phase follow.
- Control seizures that develop with diazepam or midazolam (0.3 mg/kg; IV, IO, or intranasally), repeated every 15-30 minutes if necessary. If available, give phenobarbital (15 mg/kg IV or IO) loading dose, and 2.5 mg/kg IV every 12 hours thereafter if seizures persist or status epilepticus develops.
- Prevent and reduce cerebral edema. Use mannitol (1 gram/kg, IV, twice, 4-6 hrs apart), avoid hyperventilation, give a single dose of dexamethasone (0.5 mg/kg IV) or methylprednisolone sodium succinate (30 mg/kg, IV, once), avoid jugular vein compression, and maintain normoxemia and normotension.
- Maintain adequate ventilation, maintaining a patent airway and using manual IPPV at 8-10 breaths per minute, targeting an ETCO2 of 25-60 mmHg.
- Maintain adequate oxygenation, targeting a SpO2 > 95% using supplemental oxygen for a minimum of 12 hours.
- Maintain normotension using IV fluids in bolus challenges, targeting a MAP > 65 mmHg or Sys > 90 mmHg. Isotonic crystalloids at 10-15 mL/kg over 15 minutes are usually effective.
- Use synthetic colloids if 2-3 bolus challenges do not achieve normotension. Give 2-3 bolus challenges of hydroxyethyl starch (HES) at 10 mL/kg over 15 minutes. Once normotension is achieved, give crystalloid IV fluids at 3-5 mL/kg/hour for maintenance. Given the dismal outcome in post-resuscitation MWDs that require vasopressor support, there is no role in the deployed setting for vasopressor therapy in MWDs in the post-resuscitation phase.
- Control pathologic ventricular arrhythmias with a lidocaine CRI (50-75 mcg/kg/min).
- Do not attempt tight control of blood glucose with insulin. Supplement IV fluids if hypoglycemia is present (5% dextrose), but avoid hyperglycemia.
- There is no role for therapeutic hypothermia in MWDs during the post-resuscitation period. Avoid hyperthermia; tolerate mild hypothermia (>92° F) if it develops.