Clinical Commander

All dossiers
cardio.post-arrest.non-shockable.v1

Post-cardiac-arrest care — initial non-shockable rhythm (PEA/asystole)

cardiologyacuteadultacuteinpatienttransitionoutpatient
Start encounter →Print handoutPRODUCTION

Phase E variant of cardio.post-arrest.core.v1 — narrowed to initial non-shockable rhythm (PEA/asystole) cohort. Lower neuro recovery rate; etiology often non-cardiac (Hs and Ts) but cardiac causes occur (massive MI, CS, tamponade). HYPERION (Lascarrou NEJM 2019 PMID 31532382) supports TTM 33 °C × 24h in non-shockable rhythm (improved CPC 1-2 at 90 d, NNT 22). Inherits manifest + design-brief pointer from parent. 5 setting playbooks (ed, icu, inpatient, transition, outpatient). 5 severity triggers: persistent low CPC at 72h (multimodal poor neuro), structured WLST timing at 72h, organ-donation evaluation post-WLST, reversible severe hyperK as PEA cause, cardiogenic shock if cardiac etiology. Reverse-Hs-and-Ts focus is the key differentiator from shockable-rhythm sibling; GOC discussion typically at 72h given baseline poor prognosis. Status INTEGRATED until terminology + RxNav-validated drug codes are reconciled. Authored 2026-05-14 by shard-06-cardio-acute.

Entry points (3)

  • symptom
    ROSC after PEA or asystole arrest — lower neuro recovery + etiology often non-cardiac (AHA 2020)
    rosc_after_pea_asystole_arrest
  • history
    Non-shockable rhythm + post-ROSC echo or troponin suggesting cardiac cause (massive MI, cardiogenic shock)
    non_shockable_with_cardiac_etiology
  • history
    Reverse Hs and Ts screen required for non-shockable rhythm (AHA 2020 Class I)
    reverse_h_t_screen_required

Required inputs (15)

  • agerequired
    demographic • used at CONTEXT
    Age + frailty + baseline functional status drive prognostic discussion at 72h (CAHP, OHCA scores)
  • arrest_witnessedrequired
    history • used at CONTEXT
    Witnessed + bystander CPR + low-flow time → favourable neuro prognosis weighting (CAHP PMID 26491110)
  • initial_rhythmrequired
    history • used at CONTEXT
    PEA vs asystole at first analysis; PEA with narrow-complex tachycardia + reversible cause has better prognosis than asystole
  • low_flow_time_minrequired
    history • used at CONTEXT
    CPR duration → neuro prognosis weighting; non-shockable + prolonged low-flow → very low survival
  • arrest_etiology_screenrequired
    history • used at CONTEXT
    Reverse Hs and Ts: hypoxia, hyperK, hydrogen ion, hypovolemia, hypothermia, hypoglycemia, tox, tamponade, tension PTX, thrombosis-coronary, thrombosis-pulmonary, trauma (AHA 2020 Class I)
  • sbprequired
    vital • used at TREATMENT
    MAP ≥65 target post-ROSC; vasopressor titration (AHA 2020 Class IIa; SOAP-II PMID 20200382)
  • core_temprequired
    vital • used at TREATMENT
    TTM 33 °C × 24h favoured per HYPERION in non-shockable rhythm (PMID 31532382)
  • spo2required
    vital • used at TREATMENT
    Avoid hyperoxia: SpO2 92-98% (AHA 2020 Class IIa)
  • potassiumrequired
    lab • used at CONTEXT
    Hyperkalemia is a reversible cause of PEA/asystole (Hs and Ts); replete to 4-4.5 if low (AHA 2020 Class I)
  • glucoserequired
    lab • used at CONTEXT
    Hypoglycemia is a reversible cause; check + replete (AHA 2020)
  • lactaterequired
    lab • used at INITIAL_WORKUP
    Tissue hypoperfusion + clearance trajectory (SCAI 2022 PMID 35718438)
  • creatininerequired
    lab • used at CONTEXT
    AKI common post-arrest; drug renal-adjustment (AHA 2020)
  • troponinrequired
    lab • used at INITIAL_WORKUP
    Cardiac etiology workup if non-shockable rhythm + suspicious post-ROSC ECG (massive MI can cause PEA)
  • ecg_12_leadrequired
    imaging • used at INITIAL_WORKUP
    STEMI → emergent cath; PE pattern → CTPA + thrombolysis decision; tamponade → emergent echo (AHA 2020)
  • echo_post_roscrequired
    imaging • used at INITIAL_WORKUP
    LV/RV function, valvular cause, tamponade exclusion, RV strain pattern for PE — drives reversible-cause workup (AHA 2020 Class I)

12-phase flow (12)

  1. 1FRAME
    Initial non-shockable-rhythm (PEA/asystole) cohort: baseline poor prognosis; etiology often non-cardiac (Hs and Ts) but cardiac causes occur; HYPERION supports TTM 33 °C; goals-of-care discussion typically at 72h
    inputs: initial_rhythm, arrest_etiology_screen
    advance: non-shockable rhythm confirmed + reverse-cause screen initiated
  2. 2ENTRY
    Reverse Hs and Ts screen within 10 min: BMP + glucose + ABG + lactate + bedside echo (tamponade, RV strain) + temp + tox screen (AHA 2020 Class I)
    inputs: age, arrest_witnessed, low_flow_time_min
    advance: reverse-cause screen complete
  3. 3CONTEXT
    Baseline functional status, prior advance directives, family contact, comorbidity burden — informs prognostic discussion at 72h (AHA 2020)
    inputs: sbp, core_temp, spo2, potassium, glucose, creatinine
    advance: context complete + GOC documented
  4. 4RED_FLAGS
    Tension PTX (decompression), tamponade (pericardiocentesis), massive PE (thrombolysis), STEMI (cath), severe hyperkalemia (Ca + insulin/dextrose + dialysis), profound hypothermia (rewarming) — all reversible causes (AHA 2020 Class I)
    inputs: sbp, spo2, potassium
    actions: protocol.cardiogenic_shock
    advance: reversible causes screened or treated
  5. 5INITIAL_WORKUP
    ECG + troponin + BMP + ABG + lactate + CBC + INR + CXR + echo + blood cultures + tox screen (AHA 2020; 4th UDMI 2018)
    inputs: ecg_12_lead, troponin, lactate, echo_post_rosc
    actions: post_arrest_care, panel.cardiac, panel.renal
    advance: workup complete + leading etiology identified
  6. 6BRANCHING_WORKUP
    Etiology-driven branching: STEMI → cath (AHA 2020 Class I); massive PE → CTPA + thrombolysis; tamponade → pericardiocentesis; sepsis → blood cx + abx; intracranial cause → CT head
    actions: acs_pathway
    advance: etiology-specific workup launched
  7. 7DIFFERENTIAL
    Cardiac (massive MI, cardiogenic shock, tamponade) vs non-cardiac (Hs and Ts: hypoxia / hyperK / acidosis / hypovolemia / hypothermia / hypoglycemia / tox / tamponade / tension PTX / coronary thrombosis / pulmonary thrombosis / trauma) (AHA 2020)
    advance: working etiology established + handoff to non-cardiac engine if applicable
  8. 8RISK_STRATIFICATION
    CAHP score (PMID 26491110) + OHCA score (PMID 16424733) for neuro prognosis — non-shockable cohort skews toward poor prognosis bands; SCAI shock stage for hemodynamics
    inputs: initial_rhythm, low_flow_time_min, sbp, lactate
    actions: calc.map, calc.heart, calc.ckd_epi_2021
    advance: risk class + neuroprog timeline documented
  9. 9TREATMENT
    TTM 33 °C × 24h per HYPERION (Lascarrou NEJM 2019 PMID 31532382 — improved CPC 1-2 at 90 d in non-shockable, NNT 22); avoid hyperoxia (SpO2 92-98%); MAP ≥65 with norepinephrine (SOAP-II); etiology-specific therapy (cath if STEMI, thrombolysis if PE, pericardiocentesis if tamponade, dialysis if hyperK); sedation propofol + fentanyl
    inputs: sbp, core_temp, spo2, potassium, creatinine
    actions: protocol.cardiogenic_shock
    advance: TTM target reached + etiology-specific therapy delivered
  10. 10DISPOSITION
    ICU level care; if etiology non-cardiac, route to cc.post-arrest-care.core.v1 as primary; cardiology continues to follow if structural cardiac disease identified (AHA 2020)
    advance: unit + service-line ownership assigned
  11. 11MONITORING
    Continuous telemetry + arterial line + central line + Foley; lactate q2-4h; BMP q6-12h; multimodal neuroprog ≥72h post-rewarm (Sandroni ERC-ESICM 2021 PMID 33745427); structured GOC family meeting at 72h given baseline poor prognosis
    inputs: creatinine, potassium
    actions: panel.renal, panel.cardiac
    advance: monitoring + neuroprog + GOC plan documented
  12. 12FOLLOWUP
    For survivors with meaningful recovery: cardiology + EP follow-up if structural disease; LVEF reassessment for ICD eligibility; cardiac rehab; mental health; significant cognitive impairment common post non-shockable arrest (AHA 2020 Class I)
    advance: cards + EP + cognitive + mental-health follow-up booked OR organ-donation evaluation completed if appropriate