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cc.post-arrest-care.core.v1

Post-cardiac-arrest care (ROSC bundle)

critical_careacuteadultacuteinpatient
Start encounter →Print handoutPRODUCTION

Manifest is a batch-23 scaffold (defineBatch23ScaffoldManifest); evidenceIds is the placeholder ev_post_arrest_care_guideline_review_required. Package critical.post_arrest_care.inpatient is the most fully-built sibling: has _design-brief.md, atoms split (assessment/monitoring/red-flags/treatment/workup), context, phenotypes, regimen, evidence, interlinks. Promote content into the manifest on next pass. Calculator gaps in clinical-tools-registry.ts: PCAS (post-cardiac-arrest syndrome) score, OHCA-CASS, CAHP score — not registered as calc.* entries. Regimen axes empty until norepinephrine, vasopressin, amiodarone, sedatives are RxNav-validated and seeded as a post-arrest regimen. PRODUCTION blockers: calculator registry entries (PCAS / OHCA-CASS / CAHP), regimen seeds for propofol/fentanyl/rocuronium/hypertonic RxCUIs, dedicated tests, neuroprognostication protocol entry. Deepened 2026-04-27: regimen ladder (TTM 32-36°C → MAP ≥65 with norepi/vaso/hydrocort → reperfusion if STEMI → ventilation), ED + ICU playbooks, action plan (family communication / WLST), 7 severity triggers (comatose, STEMI, refractory shock, hyperthermia, hyperoxia/hypocapnia, cerebral edema, GOC), siblings vs sepsis_bridge / TTM-ineligible / cardiogenic-shock. RxCUIs reused: 7512 norepi, 8163 vasopressin, 5489 hydrocort, 703 amiodarone, 7407 NS, 8814 MgSO4, 8591 KCl. Propofol/fentanyl/rocuronium/hypertonic RxCUIs left undefined (not in seed unambiguously). Deepened 2026-05-12 (B.5 ID/CC lane): evidence.pmids previously cited POINT (29766750 — stroke DAPT trial) and QUEST (29782217 — COPD ICS trial), neither of which are post-arrest trials. Replaced with the 7 landmark PMIDs the primary_guideline text already named: TTM2 (34133859), HYPERION (31577396), COACT (30883057), TOMAHAWK (34459570), ARREST (33197396), ERC-ESICM 2021 (33773827), AHA 2020 ACLS (33084391). last_reconciled bumped to 2026-05-12.

Entry points (4)

  • symptom
    Return of spontaneous circulation after cardiac arrest (AHA 2020)
    rosc_after_cardiac_arrest
  • symptom
    Comatose after ROSC (not following commands) (AHA 2020)
    comatose_post_rosc
  • imaging
    STEMI on post-ROSC ECG (AHA 2020)
    stemi_post_rosc_ecg
  • symptom
    OHCA with shockable initial rhythm (VF/pVT) (TTM2 Dankiewicz NEJM 2021)
    shockable_rhythm_arrest

Required inputs (18)

  • agerequired
    demographic • used at CONTEXT
    Older adults higher post-arrest mortality; goals-of-care discussion (AHA 2020 Panchal)
  • arrest_witnessedrequired
    history • used at CONTEXT
    Witnessed + bystander CPR + rhythm dictates prognosis (AHA 2020)
  • initial_rhythmrequired
    history • used at CONTEXT
    Shockable (VF/pVT) vs non-shockable (asystole/PEA) — TTM and intervention decisions (TTM2 Dankiewicz NEJM 2021; HYPERION Lascarrou NEJM 2019)
  • time_to_rosc_minrequired
    history • used at CONTEXT
    Longer downtime → worse neurologic prognosis (AHA 2020)
  • arrest_etiology_suspectedrequired
    history • used at CONTEXT
    Cardiac vs respiratory vs toxic vs neuro — drives workup (AHA 2020)
  • sbprequired
    vital • used at TREATMENT
    MAP ≥65 target; vasopressor titration (AHA 2020; ERC-ESICM 2021)
  • core_temprequired
    vital • used at TREATMENT
    TTM target 33°C vs 37.5°C per TTM2 (Dankiewicz NEJM 2021)
  • spo2required
    vital • used at TREATMENT
    AVOID hyperoxia — target SpO2 92–98% (AHA 2020; ERC-ESICM 2021)
  • lactaterequired
    lab • used at INITIAL_WORKUP
    Tissue hypoperfusion + clearance trajectory (AHA 2020)
  • arterial_phrequired
    lab • used at INITIAL_WORKUP
    Severity of post-arrest acidosis (AHA 2020)
  • troponinrequired
    lab • used at INITIAL_WORKUP
    Cardiac etiology + STEMI/NSTEMI workup (AHA 2020)
  • creatininerequired
    lab • used at INITIAL_WORKUP
    AKI common post-arrest; renal-dose abx if shock (AHA 2020)
  • potassiumrequired
    lab • used at INITIAL_WORKUP
    Arrhythmogenic; correct to 4–4.5 mmol/L (AHA 2020)
  • ecg_12_leadrequired
    imaging • used at INITIAL_WORKUP
    STEMI → emergent cath; COACT Lemkes NEJM 2019: non-STEMI benefit absent
  • echo
    imaging • used at INITIAL_WORKUP
    LV function, RV strain, tamponade, valvular cause (AHA 2020)
  • cxrrequired
    imaging • used at INITIAL_WORKUP
    ETT placement, pulmonary edema, aspiration (AHA 2020)
  • ct_head
    imaging • used at BRANCHING_WORKUP
    Rule out intracranial cause / cerebral edema (AHA 2020; ERC-ESICM 2021)
  • gcs_motor_72h
    symptom • used at MONITORING
    Multimodal neuroprognostication delayed ≥72 h (ERC-ESICM 2021; AHA 2020)

12-phase flow (12)

  1. 1FRAME
    Establish post-arrest care scope; document arrest characteristics for prognosis (AHA 2020 Panchal)
    inputs: arrest_witnessed, initial_rhythm, time_to_rosc_min
    advance: Arrest narrative captured (AHA 2020)
  2. 2ENTRY
    Recognize ROSC and mobilize bundle within minutes (AHA 2020)
    inputs: age
    advance: ROSC documented and bundle initiated (AHA 2020)
  3. 3CONTEXT
    Etiology hypothesis (5 H/5 T), comorbidities, code status / advance directives (AHA 2020)
    inputs: arrest_etiology_suspected, sbp, core_temp, spo2
    advance: Etiology hypothesis + GOC documented
  4. 4RED_FLAGS
    Re-arrest, refractory shock, malignant arrhythmia, STEMI, cerebral edema, hyperoxia, hyperthermia, severe acidosis (AHA 2020; ERC-ESICM 2021)
    inputs: sbp, spo2, arterial_ph
    actions: protocol.stemi, protocol.cardiogenic_shock
    advance: Red flags acted upon (cath/MCS/anti-arrhythmic/cooling)
  5. 5INITIAL_WORKUP
    ECG, troponin, BMP, ABG, lactate, CBC, INR, LFTs, CXR, echo, blood cultures if sepsis-arrest, toxicology (AHA 2020)
    inputs: ecg_12_lead, troponin, lactate, arterial_ph, creatinine, potassium, cxr
    actions: post_arrest_care, panel.abg, panel.cardiac, panel.renal
    advance: Workup complete and STEMI/non-STEMI status decided
  6. 6BRANCHING_WORKUP
    STEMI → cath lab (PCI <90 min); non-STEMI shockable → routine cath strategy (COACT Lemkes NEJM 2019); refractory → ECMO eligibility (ARREST Yannopoulos 2020); toxic etiology → tox workup; PE → CTPA
    inputs: ecg_12_lead, echo, ct_head
    advance: Etiology pathway selected
  7. 7DIFFERENTIAL
    ACS, PE, tamponade, tension PTX, hyperkalemia/electrolyte, hypoxia, hypothermia, tox, trauma, ICH, sepsis-arrest (AHA 2020 5H/5T)
    advance: Working etiology established
  8. 8RISK_STRATIFICATION
    TTM2 candidacy (Dankiewicz NEJM 2021); OHCA-CASS / CAHP score; ECMO candidacy (ARREST Yannopoulos 2020); multimodal neuroprognostication plan (ERC-ESICM 2021)
    inputs: initial_rhythm, time_to_rosc_min
    advance: TTM target temp set; neuroprognostication scheduled ≥72 h
  9. 9TREATMENT
    Targeted temperature management (33° vs 37.5° per TTM2 Dankiewicz NEJM 2021); MAP ≥65 with norepi first-line (AHA 2020); SpO2 92–98% (avoid hyperoxia; ERC-ESICM 2021); PaCO2 35–45; lung-protective ventilation; sedation/paralysis during cooling; treat hyperkalemia + arrhythmia; STEMI → cath; consider ECMO if refractory (ARREST 2020)
    inputs: sbp, core_temp, spo2
    actions: protocol.stemi
    advance: TTM active + MAP/SpO2/PaCO2 targets met
  10. 10DISPOSITION
    ICU admission mandatory; cath lab if STEMI; cardiothoracic if ECMO; transfer if no PCI/ECMO on site (AHA 2020)
    advance: Disposition + transfer (if needed) executed
  11. 11MONITORING
    Continuous core temp, MAP, SpO2, end-tidal CO2, EEG (esp. seizure-prone), serial lactate/ABG/BMP, neuro exam q4h after rewarming, multimodal neuroprognostication ≥72 h (ERC-ESICM 2021; AHA 2020)
    inputs: core_temp, lactate, gcs_motor_72h
    actions: panel.abg, panel.cardiac, panel.renal
    advance: Targets met + neuroprognostication panel documented
  12. 12FOLLOWUP
    Rehabilitation referral, cardiology follow-up (ICD/CRT eligibility), neurology if anoxic injury, PICS screening, family + GOC continuity (AHA 2020; ERC-ESICM 2021)
    advance: Discharge plan + outpatient follow-up booked