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cardio.stemi.with-out-of-hospital-arrest.v1

STEMI complicated by out-of-hospital cardiac arrest with ROSC

cardiologyacuteadultacuteinpatienttransitionoutpatient
Start encounter →Print handoutPRODUCTION

Phase E wave 8 cross-system synthesis composite — STEMI complicated by out-of-hospital cardiac arrest with ROSC. Inherits reperfusion bundle from cardio.stemi.core.v1 + TTM/post-arrest pathway from cardio.post-arrest.core.v1; both run in PARALLEL not sequential. The cath team coordinates with the TTM team during cooling. Composite framing: post-ROSC + STEMI on first 12-lead ECG → emergent cath PCI within 90 min (AHA 2020 Class I) + concurrent TTM 33-37.5 °C × 24 h (TTM2 PMID 34133859); multidisciplinary management (cardiology + interventional + intensivist + neurology). Antiplatelet absorption may be impaired during cooling — cangrelor IV bridge for high-risk anatomy or shock. Severity triggers include MCS-eligible CS (DanGer Shock subgroup with greatest mortality benefit per PMID 38587234) and multimodal poor neuro prognosis at ≥72 h post-rewarming per Sandroni ERC-ESICM 2021 (PMID 33745427). Manifest pointer reuses cardio.stemi.core.v1 manifest. Design-brief pointer reuses parent (composite-specific differences documented inline in this dossier). Status INTEGRATED until terminology + RxNav-validated drug codes are reconciled. Authored 2026-05-14 by shard-06-cardio-acute as Phase E wave 8 cross-system synthesis composite.

Entry points (3)

  • imaging
    STEMI on first post-ROSC 12-lead ECG → emergent cath within 90 min + TTM concurrent (AHA 2020 Class I)
    stemi_on_first_post_rosc_ecg
  • symptom
    Comatose ROSC + STEMI ECG → CONCURRENT cath PCI + TTM 33-37.5 °C × 24 h (TTM2)
    comatose_post_rosc_with_stemi
  • history
    Witnessed shockable arrest + ROSC + STEMI on subsequent ECG — composite engine activates
    witnessed_vfib_arrest_with_subsequent_stemi_ecg

Required inputs (16)

  • agerequired
    demographic • used at CONTEXT
    Age + frailty drive prognostic discussion + ICD eligibility post-recovery (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%; STEMI ECG confirms culprit; emergent cath per AHA 2020 Class I
  • low_flow_time_minrequired
    history • used at CONTEXT
    CPR duration → prognostic + ECPR eligibility (ARREST <60 min low-flow); informs neuroprognostication
  • sbprequired
    vital • used at RED_FLAGS
    Post-ROSC MAP ≥65 target; persistent hypotension after fluid + pressor → SCAI C+ shock + Impella per DanGer Shock
  • core_temprequired
    vital • used at TREATMENT
    TTM target 33-37.5 °C × 24 h (TTM2 PMID 34133859); start cooling within 6 h of ROSC; rewarm 0.25-0.5 °C/h
  • spo2required
    vital • used at TREATMENT
    Avoid hyperoxia post-ROSC: SpO2 92-98% (AHA 2020 Class IIa); brain injury from FiO2 100%
  • ecg_12_leadrequired
    imaging • used at INITIAL_WORKUP
    STEMI on first post-ROSC ECG → emergent cath within 90 min (AHA 2020 Class I)
  • troponinrequired
    lab • used at INITIAL_WORKUP
    Confirms infarct + serial trending; peak proportional to infarct size + outcomes
  • lactaterequired
    lab • used at INITIAL_WORKUP
    Hypoperfusion marker; trajectory predicts SCAI staging + neurologic recovery
  • creatininerequired
    lab • used at CONTEXT
    AKI common post-arrest; contrast nephropathy risk; DOAC dosing post-DAPT transition
  • potassiumrequired
    lab • used at CONTEXT
    Arrhythmogenic; goal K 4-4.5 to suppress recurrent VT/VF; correct aggressively (AHA 2020 Class I)
  • echo_post_roscrequired
    imaging • used at INITIAL_WORKUP
    LV function + RV strain + valvular cause + tamponade exclusion; drives MCS decision
  • cor_angiorequired
    imaging • used at TREATMENT
    Confirm STEMI culprit + lesion location; complete revasc decision per COMPLETE PMID 31475795
  • head_ct_post_rosc
    imaging • used at BRANCHING_WORKUP
    Exclude ICH or alternate cause of arrest if any concern (head trauma, focal exam); does NOT delay cath if STEMI on ECG
  • nse_72h
    lab • used at MONITORING
    Neuroprognostication marker at 48-72 h post-ROSC per Sandroni ERC-ESICM 2021; >60 µg/L poor prognosis when combined with other modalities

12-phase flow (10)

  1. 1FRAME
    Composite engine: post-ROSC + STEMI on first ECG → CONCURRENT cath PCI within 90 min + TTM 33-37.5 °C × 24 h; reperfusion arc routes to cardio.stemi.core.v1; post-arrest arc routes to cardio.post-arrest.core.v1; both run in parallel
    inputs: ecg_12_lead, initial_rhythm
    advance: composite criteria met (post-ROSC + STEMI ECG)
  2. 2ENTRY
    STAT cath lab activation + TTM device + intensivist + neurology; multidisciplinary briefing (cath + TTM coordination); MCS team standby for SCAI C+ shock during cooling
    inputs: age, arrest_witnessed, low_flow_time_min
    advance: multidisciplinary team activated + cath + TTM coordinated
  3. 3CONTEXT
    Witnessed status, bystander CPR, low-flow time, initial rhythm, prior cardiac history, allergies, current AC, DAPT contraindication screen
    inputs: arrest_witnessed, initial_rhythm, low_flow_time_min, creatinine, potassium
    advance: composite context complete
  4. 4RED_FLAGS
    Cardiogenic shock post-ROSC (SCAI C+ — high probability given STEMI + arrest combination; DanGer Shock subgroup with greatest benefit); refractory VF (failed ROSC) → ECPR per ARREST; ICH on head CT → STOP DAPT/heparin; severe acidosis (pH <7.0) limits cath safety
    inputs: sbp, lactate
    actions: cardiogenic_shock, post_arrest_care
    advance: red flags screened + immediate stabilization documented
  5. 5INITIAL_WORKUP
    12-lead ECG (STEMI confirmation); STAT cor_angio if STEMI; troponin + BMP + lactate + ABG + coagulation; bedside echo (LV/RV/tamponade); CXR (ETT placement, pulmonary edema); head CT if any concern for non-cardiac cause
    inputs: ecg_12_lead, troponin, lactate, echo_post_rosc
    actions: acs_pathway, post_arrest_care, panel.cardiac, panel.renal
    advance: STEMI confirmed + cath activated + composite workup documented
  6. 6BRANCHING_WORKUP
    Primary PCI of culprit; complete revasc decision per COMPLETE if multivessel; ICH exclusion via head CT (does not delay STEMI cath if ECG diagnostic); MCS evaluation if SCAI C+ (Impella per DanGer Shock subgroup)
    inputs: cor_angio
    advance: reperfusion delivered + MCS decision documented
  7. 7TREATMENT
    CONCURRENT (not sequential): (1) Reperfusion: ASA + ticagrelor + UFH + atorvastatin per cardio.stemi.core.v1; (2) TTM 33-37.5 °C × 24 h per TTM2; sedation with propofol or fentanyl; cisatracurium for shivering if needed; (3) Post-ROSC supportive: MAP ≥65 (norepinephrine first-line per SOAP-II); SpO2 92-98%; PaCO2 35-45; K 4-4.5; (4) MCS escalation if SCAI C+ — Impella CP per DanGer Shock; VA-ECMO for SCAI D-E; (5) Antiplatelet/AC during cooling — altered metabolism, bleed risk monitoring; (6) Anti-arrhythmic (IV amiodarone or lidocaine) if recurrent VT/VF post-PCI
    inputs: core_temp, sbp, spo2
    actions: protocol.stemi
    advance: reperfusion delivered + TTM at goal + MAP/SpO2 stable + sedation plan documented
  8. 8DISPOSITION
    CICU mandatory; multidisciplinary (cardiology + interventional + intensivist + neurology); arterial line + telemetry continuous; deep sedation during TTM; rewarm 0.25-0.5 °C/h after 24 h
    advance: unit assigned + multidisciplinary plan documented + TTM phase plan (cooling + maintenance + rewarm) booked
  9. 9MONITORING
    Continuous telemetry + arterial line + temperature monitoring; serial K + Mg q6 h; troponin trend; daily exam off sedation if possible; daily echo for LV recovery; consider EEG for non-convulsive seizure (post-arrest 10-20% incidence)
    inputs: core_temp, creatinine, potassium
    actions: panel.cardiac
    advance: TTM completed + neuro exam off sedation documented + ICD eligibility timeline planned
  10. 10FOLLOWUP
    Multimodal neuroprognostication ≥72 h post-rewarming per Sandroni ERC-ESICM 2021 (clinical exam + EEG + SSEP + NSE + neuroimaging); ICD secondary-prevention per AVID once acute reversible cause addressed (any sustained VT/VF arrest in setting of STEMI usually qualifies); cardiology + EP + neurology follow-up; cardiac rehab; mental health (PTSD/anoxic injury cognitive screening)
    inputs: nse_72h
    advance: neuroprognostication complete + ICD pathway documented + multidisciplinary follow-up booked