Management of Cardiac Arrest Secondary to Brain Hemorrhage

Initial Resuscitation Approach

The American Heart Association recommends beginning high-quality CPR immediately with chest compressions at a rate of 100-120 compressions per minute and a depth of at least 2 inches (5 cm), allowing complete chest recoil between compressions 1, 2
The American Heart Association suggests minimizing interruptions in chest compressions to maintain cerebral and coronary perfusion 1, 2
Apply defibrillator/AED as soon as possible to identify and treat shockable rhythms if present, as recommended by the American Heart Association 1, 3
For patients with brain hemorrhage as the suspected cause, the traditional A-B-C approach may be more appropriate than C-A-B due to the likely hypoxic nature of the arrest, according to the American Heart Association 3
Rotate compressors every 2 minutes to maintain effective compressions, as recommended by the American Heart Association 1, 2

The American Heart Association recommends establishing an advanced airway (endotracheal tube or supraglottic airway) 1, 4
Confirm proper placement using waveform capnography, as suggested by the American Heart Association 1, 4
After advanced airway placement, provide 8-10 breaths per minute with continuous chest compressions, according to the American Heart Association 1, 4
Avoid hyperventilation as it can decrease cerebral blood flow and worsen neurological outcomes, as recommended by the American Heart Association 4, 5

Titrate inspired oxygen to achieve arterial oxygen saturation of 94% to avoid potential oxygen toxicity, as suggested by the American Heart Association 5, 6
Maintain normocarbia (PETCO2 35-40 mmHg or PaCO2 35-45 mmHg) to prevent cerebral vasoconstriction from hypocapnia, according to the American Heart Association 4, 6
Monitor oxygenation continuously with pulse oximetry, as recommended by the American Heart Association 5, 6

Consider and address the "H's and T's" with particular attention to hypovolemia, hydrogen ion (acidosis), tension pneumothorax, tamponade (cardiac), and thrombosis (pulmonary or coronary), as suggested by the American Heart Association 1, 4
Identify and treat the precipitating cause of the brain hemorrhage if possible, according to the American Heart Association 5, 4

Implement targeted temperature management (TTM) for comatose survivors, as recommended by the European Society of Intensive Care Medicine 6, 4
Consider therapeutic hypothermia (32-34°C) for 24 hours in comatose patients after ROSC, according to the European Society of Intensive Care Medicine 4
Elevate the head of the bed 30° if tolerated to reduce cerebral edema, aspiration, and ventilator-associated pneumonia, as suggested by the American Heart Association 5, 2
Avoid hypotension (maintain systolic BP >100 mmHg) to ensure adequate cerebral perfusion, according to the European Society of Intensive Care Medicine 6, 7
Control seizures with appropriate anticonvulsants if they occur, as recommended by the British Medical Journal 4, 8
Obtain urgent neuroimaging (CT scan) to evaluate the extent of brain hemorrhage, according to the European Society of Intensive Care Medicine 6, 7

Consider neurosurgical consultation for potential intervention (e.g., evacuation of hematoma, external ventricular drain placement), as suggested by the European Society of Intensive Care Medicine 6, 7
Monitor for signs of increased intracranial pressure and treat accordingly, according to the European Society of Intensive Care Medicine 6
Maintain blood glucose within normal range (avoid hyperglycemia >180 mg/dL and hypoglycemia), as recommended by the American Heart Association 9, 4

Avoid early prognostication as many accepted predictors of poor outcome are unreliable, especially if the patient has been treated with therapeutic hypothermia, according to the American Heart Association 9, 4
Implement a comprehensive, structured treatment protocol which may improve survival after cardiac arrest, as suggested by the American Heart Association 9
Consider transfer to a specialized center with expertise in post-cardiac arrest care and neurocritical care capabilities, according to the American Heart Association 10

Brain injury and cardiovascular instability are major determinants of survival after cardiac arrest, as suggested by the American Heart Association 5
Avoid hyperoxia and hyperventilation which can worsen cerebral injury, according to the American Heart Association 5, 6
Consider hemodynamic monitoring to guide management in unstable patients, as recommended by the European Society of Intensive Care Medicine 6, 7