Post-cardiac arrest syndrome: Update on brain injury management and prognostication

Treatment of cardiac arrest should focus on maximizing neurologic recovery as well as systemic recovery to ensure the best possible functional outcome. This article focuses on the neurologic care of patients after they have been resuscitated from cardiac arrest. Maximizing neurologic outcome after cardiac arrest requires attention to prevention of primary and secondary brain injury. Primary brain injury such as hypoperfusion and hypoxic injury should be avoided by optimizing hemodynamic goals to maximize cerebral perfusion and maintain normoxia and normocarbia. Secondary brain injury mediated by excitotoxicity and the inflammatory cascade may be mitigated by therapeutic hypothermia. Other strategies that may be beneficial include the treatment of seizures and maintaining normoglycemia. Finally, accurate and timely prognostication is crucial because it influences withdrawal of care and overall mortality. With the adoption of therapeutic hypothermia, the classic prognostic paradigm that was previously used needs to be reexamined. The application of our knowledge of risk factors for poor outcome, serial physical examinations, neurophysiological tests, neuroimaging, and biochemical markers may need to be delayed until after rewarming. We emphasize the importance of a shift in physicians' approach to the management of post-cardiac arrest syndrome, not only in prognostication, but also in the early and aggressive therapies that have been shown to improve survival and quality of life.