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cardio.post-arrest.non-shockable.v1PRODUCTION
cardio.post-arrest.non-shockable.v1

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

cardiologyacuteadult
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12/12 authored

Canonical 12-phase frame with authored status for this dossier.

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Detailed

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

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non-shockable rhythm confirmed + reverse-cause screen initiated

Patient inputs (15)

Age + frailty + baseline functional status drive prognostic discussion at 72h (CAHP, OHCA scores)

Witnessed + bystander CPR + low-flow time → favourable neuro prognosis weighting (CAHP PMID 26491110)

PEA vs asystole at first analysis; PEA with narrow-complex tachycardia + reversible cause has better prognosis than asystole

CPR duration → neuro prognosis weighting; non-shockable + prolonged low-flow → very low survival

Reverse Hs and Ts: hypoxia, hyperK, hydrogen ion, hypovolemia, hypothermia, hypoglycemia, tox, tamponade, tension PTX, thrombosis-coronary, thrombosis-pulmonary, trauma (AHA 2020 Class I)

Hyperkalemia is a reversible cause of PEA/asystole (Hs and Ts); replete to 4-4.5 if low (AHA 2020 Class I)

Hypoglycemia is a reversible cause; check + replete (AHA 2020)

AKI common post-arrest; drug renal-adjustment (AHA 2020)

Tissue hypoperfusion + clearance trajectory (SCAI 2022 PMID 35718438)

Cardiac etiology workup if non-shockable rhythm + suspicious post-ROSC ECG (massive MI can cause PEA)

STEMI → emergent cath; PE pattern → CTPA + thrombolysis decision; tamponade → emergent echo (AHA 2020)

LV/RV function, valvular cause, tamponade exclusion, RV strain pattern for PE — drives reversible-cause workup (AHA 2020 Class I)

MAP ≥65 target post-ROSC; vasopressor titration (AHA 2020 Class IIa; SOAP-II PMID 20200382)

TTM 33 °C × 24h favoured per HYPERION in non-shockable rhythm (PMID 31532382)

Avoid hyperoxia: SpO2 92-98% (AHA 2020 Class IIa)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (5)

5 need judgement
  • informationallife_threateningreversible_cause_severe_hyperkalemia
    K >6.5 + ECG changes (peaked T, wide QRS) — reversible cause of PEA/asystole (AHA 2020 Class I)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningcardiogenic_shock_post_rosc_non_shockable
    Post-ROSC SBP <90 + lactate ≥2 — massive MI causing PEA arrest + ongoing cardiogenic shock (SCAI 2022 stage C+)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepersistent_low_cpc_at_72h
    GCS motor ≤2 off sedation + status myoclonus + bilateral absent N20 SSEP + diffuse anoxic injury on MRI at ≥72h post-rewarm — multimodal poor neuro prognosis (Sandroni 2021)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverewithdrawal_of_care_timing_72h
    Structured GOC family meeting at 72h post-rewarm (per AHA 2020 + Sandroni 2021) given baseline poor prognosis in non-shockable cohort
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereorgan_donation_evaluation_post_wlst
    WLST decision made + patient meets brain death or DCD criteria → organ-donation evaluation by OPO
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

Non-shockable OHCA phenotype — reversible-cause therapy + HYPERION TTM 33 °C + GOC trajectory (AHA 2020 + HYPERION + Sandroni 2021)
axis: non_shockable_post_arrest_phenotype
Selected axis "Non-shockable OHCA phenotype — reversible-cause therapy + HYPERION TTM 33 °C + GOC trajectory (AHA 2020 + HYPERION + Sandroni 2021)" by default fallback (first axis)
  • norepinephrine
    first line
    vasopressor
    0.05 µg/kg/min IV → titrate MAP ≥65 • IV • continuous
    triggers: post_rosc_hypotension, sbp_below_90
    AHA 2020 Class IIa; SOAP-II PMID 20200382 — preferred over dopamine in shock
    rxcui 7512
  • dobutamine
    second line
    inotrope_beta1
    2.5 µg/kg/min • IV • continuous; titrate to perfusion + UOP
    triggers: low_ci_post_rosc
    AHA 2020; defer if isolated hypotension without low CI
    rxcui 3616
  • propofol
    first line
    sedative_gaba_a_agonist
    5-50 µg/kg/min • IV • continuous; titrate RASS
    triggers: intubated_post_rosc, TTM_active
    PADIS 2018 PMID 30113379 — preferred sedative for TTM
    rxcui 8782
  • fentanyl
    first line
    opioid_analgesic
    25-100 µg IV bolus → 25-200 µg/h infusion • IV • continuous
    triggers: intubated_post_rosc, TTM_active
    PADIS 2018
    rxcui 4337
  • magnesium sulfate
    add on
    electrolyte_anti_arrhythmic
    2 g IV q6h scheduled during cooling • IV • q6h
    triggers: ttm_active, shivering_present
    Sandroni 2021 — anti-shivering + arrhythmia prevention
    rxcui 6585
  • calcium gluconate
    first line
    electrolyte_membrane_stabilizer
    1-2 g IV • IV • PRN for hyperK ECG changes
    triggers: hyperkalemia_with_ecg_changes, reversible_cause_hyperK
    AHA 2020 Class I — membrane stabilization for hyperK as reversible PEA cause
    rxcui 1908
  • insulin regular
    first line
    insulin
    10 U IV with 50 g D50W • IV • one-time + repeat PRN
    triggers: hyperkalemia_K_above_6.5
    AHA 2020 — intracellular K shift; 30-60 min duration
    rxcui 253182
  • acetaminophen
    first line
    analgesic_antipyretic
    650-1000 mg PO/IV q6h × 72h post-rewarm • PO/IV • q6h × 72h
    triggers: post_rewarm_fever_prevention
    AHA 2020 + Sandroni 2021 — fever prevention × 72h post-rewarm
    rxcui 161

outpatient playbook — drug actions (2)

  1. 1. GDMT maintenance for HFrEF
    rxcui 1656328
    ARNI + BB + MRA + SGLT2i max tolerated • PO • as scheduled
    trigger: HFrEF post-arrest
    ACC/AHA 2022 HF 4-pillar
  2. 2. high-intensity statin maintenance
    rxcui 83367
    atorvastatin 80 mg daily • PO • daily
    trigger: CAD
    IMPROVE-IT

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: ROSC after PEA or asystole arrest — lower neuro recovery + etiology often non-cardiac (AHA 2020); Non-shockable rhythm + post-ROSC echo or troponin suggesting cardiac cause (massive MI, cardiogenic shock); Reverse Hs and Ts screen required for non-shockable rhythm (AHA 2020 Class I).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Post-cardiac-arrest care — initial non-shockable rhythm (PEA/asystole)** (cardio.post-arrest.non-shockable.v1).
Phenotype framing: 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)
Scope: 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

No severity triggers fired against current inputs.

Plan

Regimen axis: **Non-shockable OHCA phenotype — reversible-cause therapy + HYPERION TTM 33 °C + GOC trajectory (AHA 2020 + HYPERION + Sandroni 2021)**.
1. norepinephrine 0.05 µg/kg/min IV → titrate MAP ≥65 IV continuous (vasopressor, first line) — AHA 2020 Class IIa; SOAP-II PMID 20200382 — preferred over dopamine in shock
2. dobutamine 2.5 µg/kg/min IV continuous; titrate to perfusion + UOP (inotrope_beta1, second line) — AHA 2020; defer if isolated hypotension without low CI
3. propofol 5-50 µg/kg/min IV continuous; titrate RASS (sedative_gaba_a_agonist, first line) — PADIS 2018 PMID 30113379 — preferred sedative for TTM
4. fentanyl 25-100 µg IV bolus → 25-200 µg/h infusion IV continuous (opioid_analgesic, first line) — PADIS 2018
5. magnesium sulfate 2 g IV q6h scheduled during cooling IV q6h (electrolyte_anti_arrhythmic, add on) — Sandroni 2021 — anti-shivering + arrhythmia prevention
6. calcium gluconate 1-2 g IV IV PRN for hyperK ECG changes (electrolyte_membrane_stabilizer, first line) — AHA 2020 Class I — membrane stabilization for hyperK as reversible PEA cause
7. insulin regular 10 U IV with 50 g D50W IV one-time + repeat PRN (insulin, first line) — AHA 2020 — intracellular K shift; 30-60 min duration
8. acetaminophen 650-1000 mg PO/IV q6h × 72h post-rewarm PO/IV q6h × 72h (analgesic_antipyretic, first line) — AHA 2020 + Sandroni 2021 — fever prevention × 72h post-rewarm

Setting playbook (outpatient) — Long-term cognitive + cardiac surveillance for survivors; GDMT maintenance; mental health; caregiver support; ICD/WCD management if applicable
9. GDMT maintenance for HFrEF ARNI + BB + MRA + SGLT2i max tolerated PO as scheduled — HFrEF post-arrest (ACC/AHA 2022 HF 4-pillar)
10. high-intensity statin maintenance atorvastatin 80 mg daily PO daily — CAD (IMPROVE-IT)

Non-pharmacologic actions:
- Cardiac rehab maintenance phase (modified if cognitive limitations)
- Caregiver respite resources
- Family CPR/AED training
- Driving restriction per state law

AVOID / contraindication checks:
- Hypothermia_avoid_pre_ROSC_cooling (ARCTIC)
- Hyperoxia_avoid_post_rosc (AHA 2020 Class IIa: SpO2 92 98%)
- Hyperthermia_avoid_post_rewarm × 72h (Sandroni 2021)
- Hyperventilation_avoid_post_rosc (target PaCO2 35 45)

Monitoring

Regimen monitoring:
- continuous ecg telemetry (AHA 2020 Class I)
- arterial line + MAP q1min during pressor titration
- core temperature continuous via bladder or esophageal probe (HYPERION 33 °C target)
- lactate q2-4h until normalized (SCAI 2022)
- BMP q6-12h + Mg + Phos + ionized Ca (AHA 2020)
- continuous EEG for 24-48h (Sandroni 2021)
- NSE at 24h 48h 72h (Sandroni 2021)
- SSEP N20 bilateral at 72h after rewarm (Sandroni 2021)
- MRI brain days 2-7 (Sandroni 2021)
- structured family meeting at 72h for GOC review (AHA 2020 Class I)

Setting (outpatient) monitoring:
- Quarterly BP + weight + symptom score
- Annual ECG ± Holter if structural disease
- Annual echo if HFrEF

Follow-up plan: 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)
- Close-out criterion: cards + EP + cognitive + mental-health follow-up booked OR organ-donation evaluation completed if appropriate

Monitoring phase: 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

Disposition

Current setting: outpatient — Long-term cognitive + cardiac surveillance for survivors; GDMT maintenance; mental health; caregiver support; ICD/WCD management if applicable

Disposition criteria:
- Long-term continuation; cross-link to cardio.hf.core.v1 if HFrEF persists

Escalation triggers (move to higher acuity):
- New cognitive decline → mental health + neuropsych
- Worsening HF → advanced HF eval
- Caregiver burnout → palliative + social work

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] K >6.5 + ECG changes (peaked T, wide QRS) — reversible cause of PEA/asystole (AHA 2020 Class I)
- [LIFE_THREATENING] Post-ROSC SBP <90 + lactate ≥2 — massive MI causing PEA arrest + ongoing cardiogenic shock (SCAI 2022 stage C+)
- [SEVERE] GCS motor ≤2 off sedation + status myoclonus + bilateral absent N20 SSEP + diffuse anoxic injury on MRI at ≥72h post-rewarm — multimodal poor neuro prognosis (Sandroni 2021)

Citations

- 2020 AHA ACLS / Post-Cardiac-Arrest Care + 2021 ERC-ESICM Post-Resuscitation Guideline [PMID:33081530](https://pubmed.ncbi.nlm.nih.gov/33081530/)
- Cited evidence (PMID 31532382) [PMID:31532382](https://pubmed.ncbi.nlm.nih.gov/31532382/)
- Cited evidence (PMID 33745427) [PMID:33745427](https://pubmed.ncbi.nlm.nih.gov/33745427/)
- Cited evidence (PMID 26491110) [PMID:26491110](https://pubmed.ncbi.nlm.nih.gov/26491110/)
- Cited evidence (PMID 16424733) [PMID:16424733](https://pubmed.ncbi.nlm.nih.gov/16424733/)

Last reconciled with current guidelines: 2026-05-14.
References