Clinical Commander

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cardio.post-arrest.core.v1

Post-cardiac-arrest care (cardiology-driven, ischemic-OHCA pathway)

cardiologyacuteadultacuteinpatienttransitionoutpatient
Start encounter →Print handoutPRODUCTION

New engine authored 2026-05-14 by shard-06-cardio-acute. Distinguished from cc.post-arrest-care.core.v1 by cardiology-team ownership (cath lab + TTM coordination + EP + structural workup + ICD/WCD pathway). 5 phenotypes encoded as regimen_axes.steps: shockable+STEMI / shockable-no-STEMI (delayed cath per COACT/TOMAHAWK) / refractory-VF (ARREST-criteria ECPR) / non-shockable-cardiac / channelopathy-structural. 5 setting playbooks (ed, icu, inpatient, transition, outpatient) covering ROSC bundle through 12-month post-arrest cardiology surveillance. 7 severity triggers including refractory VF, STEMI on post-ROSC ECG, ARREST-criteria ECPR, post-ROSC cardiogenic shock, shivering during TTM, hyperoxia post-ROSC, multimodal poor neuro prognosis at 72h. Bayesian linkage (§5.5.2): seed file authored separately under prisma/seed/ros-and-ddx/cardio.post-arrest.core.v1.* with LR anchors for shockable-rhythm (cardiac etiology LR+ ≥4), STEMI on ECG (cardiac LR+ ≥10), CAHP/OHCA score bands (neuro prognosis LR), bilateral absent N20 SSEP at 72h (poor neuro LR+ ≈100 per Sandroni 2021). Status INTEGRATED until terminology arrays + RxNav-validated drug codes are reconciled (rxnav script needs DB; deferred to next session). All RxCUIs in regimen are sourced from the existing cardio.acute-hf and cardio.stemi dossiers. Panel + manifest files authored as companion stubs in this batch — see commit body for paths.

Entry points (5)

  • symptom
    ROSC after VF/pVT cardiac arrest (AHA 2020 §3; ARREST 2020)
    rosc_after_vfib_pvt_arrest
  • imaging
    STEMI on first post-ROSC ECG (AHA 2020 Class I; ESC 2023 ACS)
    stemi_post_rosc
  • symptom
    Comatose ROSC with suspected cardiac etiology — TTM candidate (TTM2 Dankiewicz NEJM 2021)
    comatose_post_rosc_cardiac_etio
  • history
    Known CAD / prior MI / cardiomyopathy + ROSC (AHA 2020)
    known_cad_post_rosc
  • imaging
    Severely reduced LVEF / new wall-motion abnormality on bedside echo (AHA 2020)
    echocardiographic_lv_dysfunction_post_rosc

Required inputs (15)

  • agerequired
    demographic • used at CONTEXT
    Age + frailty drive prognostic discussion + ICD eligibility (AHA 2020; MADIT-II PMID 11907286)
  • arrest_witnessedrequired
    history • used at CONTEXT
    Witnessed + bystander CPR + low-flow time → favorable neuro prognosis (AHA 2020; CAHP / OHCA scores)
  • initial_rhythmrequired
    history • used at CONTEXT
    Shockable (VF/pVT) → cardiac etiology > 80% probability; emergent cath if STEMI (AHA 2020 Class I; COACT NEJM 2019; TOMAHAWK NEJM 2021)
  • low_flow_time_minrequired
    history • used at CONTEXT
    CPR duration → ECPR eligibility (ARREST PMID 33197396 — selection: <60 min low-flow); neuro prognosis
  • cardiac_history
    history • used at CONTEXT
    Prior MI / EF / valvular / device → ICD vs WCD post-discharge (MADIT-II; DINAMIT PMID 15590950)
  • sbprequired
    vital • used at TREATMENT
    MAP ≥65 target post-ROSC; vasopressor titration (AHA 2020 Class IIa)
  • core_temprequired
    vital • used at TREATMENT
    TTM target 33–37.5 °C per TTM2 (Dankiewicz NEJM 2021 PMID 34133859) + HYPERION (Lascarrou NEJM 2019 PMID 31577396 for non-shockable)
  • spo2required
    vital • used at TREATMENT
    Avoid hyperoxia: target SpO2 92–98% (AHA 2020 Class IIa)
  • ecg_12_leadrequired
    imaging • used at INITIAL_WORKUP
    STEMI → emergent cath within 90 min (AHA 2020 Class I; ESC 2023 ACS)
  • troponinrequired
    lab • used at INITIAL_WORKUP
    Cardiac etiology + STEMI/NSTEMI workup; serial trending (AHA 2020; 4th UDMI 2018)
  • lactaterequired
    lab • used at INITIAL_WORKUP
    Tissue hypoperfusion + clearance trajectory (SCAI 2022 CS staging Baran PMID 31104355)
  • creatininerequired
    lab • used at CONTEXT
    AKI common post-arrest; contrast / drug dosing (AHA 2020)
  • potassiumrequired
    lab • used at CONTEXT
    Arrhythmogenic; correct to 4–4.5 mmol/L (AHA 2020 Class I)
  • echo_post_rosc
    imaging • used at INITIAL_WORKUP
    LV function / RV strain / valvular cause / tamponade — drives MCS decision (AHA 2020 Class I)
  • cor_angio
    imaging • used at BRANCHING_WORKUP
    STEMI → emergent (Class I); shockable non-STEMI → routine vs delayed per COACT/TOMAHAWK (AHA 2020 Class IIb)

12-phase flow (12)

  1. 1FRAME
    Cardiology-driven post-arrest pathway: ROSC after presumed cardiac etiology — confirm shockable rhythm OR ischemic ECG OR known CAD; if non-cardiac etiology, route to cc.post-arrest-care.core.v1 (AHA 2020)
    inputs: initial_rhythm, arrest_witnessed, low_flow_time_min
    advance: cardiac etiology confirmed or strongly suspected
  2. 2ENTRY
    Recognize ROSC + mobilize cardiology / cath-lab team; bedside echo + ECG within 10 min (AHA 2020 Class I)
    inputs: age
    advance: cards consult activated + ECG obtained
  3. 3CONTEXT
    Prior CAD/EF/device, family history sudden death, code status / advance directives, current GDMT (AHA 2020)
    inputs: cardiac_history, sbp, core_temp, spo2
    advance: context complete + GOC documented
  4. 4RED_FLAGS
    Re-arrest (recurrent VF/pVT), refractory cardiogenic shock (SCAI C+), STEMI on ECG, mechanical complication (papillary rupture, VSR, free-wall), severe acidosis < 7.1, hyperkalemia >6 (AHA 2020; SCAI 2022)
    inputs: sbp, spo2, potassium
    actions: protocol.stemi, protocol.cardiogenic_shock
    advance: red flags screened or escalated
  5. 5INITIAL_WORKUP
    ECG + serial troponin + BMP + ABG + lactate + CBC + INR + CXR + echo + blood cultures (sepsis-arrest exclusion); trend troponin q2h × 3 (AHA 2020; 4th UDMI 2018)
    inputs: ecg_12_lead, troponin, lactate, creatinine, potassium, echo_post_rosc
    actions: post_arrest_care, panel.cardiac, panel.renal
    advance: workup complete + STEMI/non-STEMI decided
  6. 6BRANCHING_WORKUP
    STEMI → emergent cath within 90 min (AHA 2020 Class I); shockable non-STEMI without ongoing instability → delayed cath per COACT (Lemkes NEJM 2019 PMID 31291529) + TOMAHAWK (Desch NEJM 2021 PMID 34459570); refractory VF arrest meeting ARREST criteria → ECPR (Yannopoulos Lancet 2020 PMID 33197396)
    inputs: cor_angio
    actions: acs_pathway
    advance: reperfusion / non-cath decision made
  7. 7DIFFERENTIAL
    Etiology refinement: ACS / structural CAD / ischemic CMP / non-ischemic CMP / channelopathy (LQT, Brugada, CPVT) / WPW / commotio cordis / takotsubo (AHA 2020; HRS expert consensus 2017 PMID 29097319)
    advance: working etiology established + driving downstream workup (ICD/EP)
  8. 8RISK_STRATIFICATION
    CAHP score (Maupain Eur Heart J 2016 PMID 26497161) + OHCA score (Adrie Eur Heart J 2006 PMID 17082207) for neuro prognosis; SCAI shock stage (Baran 2022 PMID 31104355) for hemodynamic risk; LVEF + troponin peak for ICD eligibility horizon (MADIT-II PMID 11907286)
    inputs: initial_rhythm, low_flow_time_min, sbp, lactate
    actions: calc.map, calc.heart, calc.ckd_epi_2021
    advance: risk class + neuroprognosis time-window documented
  9. 9TREATMENT
    Reperfusion if STEMI (PCI within 90 min, AHA 2020 Class I); TTM 33–37.5 °C × 24h then rewarm 0.25–0.5 °C/h (TTM2 PMID 34133859); avoid hyperoxia (target SpO2 92–98%); avoid hyperthermia post-rewarm × 72h; MAP ≥65 with norepinephrine (SOAP-II PMID 20200382); inotrope if low CI (dobutamine 2.5–10 µg/kg/min); MCS for refractory CS (Impella CP per DanGer Shock PMID 38587239; VA-ECMO for refractory VF arrest meeting ARREST criteria PMID 33197396); antiplatelet/AC per ACS regimen if PCI; sedation + analgesia (propofol + fentanyl); shivering control (buspirone, magnesium, neuromuscular blockade if refractory)
    inputs: sbp, core_temp, spo2, potassium, creatinine
    actions: protocol.cardiogenic_shock
    advance: TTM target reached + perfusion adequate + ACS reperfusion delivered (if applicable)
  10. 10DISPOSITION
    CICU / ICU per local pathway; cardiology-led care; advanced HF / EP consult based on etiology + LVEF (AHA 2020 Class I)
    advance: unit + service-line ownership assigned
  11. 11MONITORING
    Continuous telemetry + arterial line + central line + Foley; q1h UOP; lactate q2-4h; BMP q6-12h; serial troponin until peak; daily echo if cardiogenic shock; multimodal neuroprognostication ≥72h after rewarm (Sandroni ERC-ESICM 2021 PMID 33773827: bilateral absent N20 SSEP + status myoclonus + EEG burst-suppression + NSE > 60 + diffuse anoxic injury on MRI)
    inputs: creatinine, potassium
    actions: panel.renal, panel.cardiac
    advance: monitoring plan + neuroprog timeline documented
  12. 12FOLLOWUP
    Cardiology + electrophysiology follow-up at 1-2 weeks; LVEF reassessment at 40-90 days for primary-prevention ICD eligibility (MADIT-II); WCD bridge if EF <35% during waiting period (VEST trial PMID 30280654); cardiac rehab (AHA 2020 Class I); sudden-cardiac-death prevention bundle
    advance: cards + EP follow-up booked + WCD decision + family screening if channelopathy