Cardiac arrest and follow up treatment

[4monadonis2]

Doctors and Nurses, I need some help trying to figure out some specifics about a character waking up from a cardiac arrest incident.

What time frame can a teenage patient be reasonably expected to stay unconscious after successful defibrillation from an in-hospital cardiac arrest incident (compressions beginning within minutes of it starting)? How much would this differ from an out-of-hospital cardiac arrest incident?

Would something like this prompt you to put such a patient on IV nutrition and/or urinary and rectal catheters? If it would take some amount of time to determine these as necessary treatments, how long would that be?

Would a patient being unconscious change whether or not ice packs are used to reduce swelling around broken/bruised ribs (from CPR)? If they are still used on an unconscious patient, how often would they be changed?

Comments

[mific]

It depends what else medical was going on. Was this solely a cardiac incident? No head injury from falling while arresting? If it was just a cardiac arrest it'd depend how long they were without life signs before resus was started. If they were down more than four minutes before getting CPR they might have brain damage and thus a coma. If they don't have brain damage then they could wake up fairly soon, like in a minute or two.
With an in-hospital arrest the best chances are if they were in the ER, ICU, or a Cardiac ward. Outside the hospital their chances of surviving plummet.

[4monadonis2]

Solely a cardiac incident; happened while the character was in their hospital bed (inpatient care for a pre-existing chronic condition; canon material doesn't explicitly state what it is).

[mific]

They’d probably have a fairly efficient CPR then, but a lot would depend on how soon someone noticed they were in arrest. If they were already on a monitor for some reason then ok. But if not, nurses and other patients or staff might just think they were sleeping.
If your story needs them surviving and not brain injured they need to be noticed almost as soon as they arrest, or at least within 3-4 min.
No idea if ice is used post CPR. If it was a successful resus with no brain damage then applying ice woukd wake them promptly if they weren’t already awake!

[mcbangle]

I agree with the feedback so far and would add that unless the patient had brain injury from extensive time before resuscitation, it is unlikely that they would be given IV nutrition or urinary catheters. On the other hand, they would very likely have IV fluids for hydration or to administer IV medications, if they aren't already receiving IV fluids or IV meds for their chronic condition.

I've not heard of ice packs being used after CPR.

[pallas_rose]

Trauma surgeon & ICU doc here!

Often times in an in-hospital arrest the patient gets intubated and put on a ventilator, which usually means sedation medications (what people often colloquially refer to as an "induced coma," though this term is so inaccurate it gives me hives). In that case, they would be unconscious or semiconscious for as long as they're on the meds, which are kept on as long as we need the patient to be on the ventilator or sedated for other reasons. Basically: what do you want to happen narratively? How long do you want them asleep? I can tell you what injuries or scenarios would produce that result!

Re: ice for broken ribs: not really a thing. Local anaesthetic patches or nerve blocks, NSAIDs, opiates, multimodal pain meds including muscle relaxers are the regimen. That said! Post cardiac arrest there is a cooling protocol for neuroprotection. Do you need him cold for some reason?

If intubated and on a ventilator, he would get IV fluids that carry his sedation meds at least, and a urinary catheter: these would be started as soon as they arrive in the ICU. Rectal tubes are only used if there is uncontrollable diarrhea which can cause skin breakdown. IV nutrition is only used if the gut can't be used for some reason... otherwise we give tube feeds (like a nutrition shake) via a tube in the nose or mouth down into the stomach. I start tube feeds as soon as I feel they aren't contraindicated by hemodynamic status or ability to remove the ventilator.

This would not vary much from an out of hospital arrest, except that out of hospital is much less likely to result in ROSC, or return of spontaneous circulation, eg, they came back to life.

Other questions??

[4monadonis2]

Ice questions were from being told that ice is common for swelling reduction for other breaks, so i just assumed that carried over.

Ideal amount of time for her to be asleep would be 1-3 days. Is that standard practice for post-cardiac arrest sedation? I just want enough time to make another character who was on a phone call with them and hung up in a panic when it happened think they died for a decent bit, so I can swing it to as low as 8-12 hours to make the actual check-in happen the next day

Already posted a chapter where initial nurse response to the cardiac arrest happened within a few minutes. Patient was being monitored for some unspecified chronic condition. Canon material doesn't state one in particular, but some other characters are recorded as saying she has a bad heart; perhaps cardiac in nature? symptoms shown in canon material include dizziness and lightheadedness. condition is bad enough to require hospitalization throughout her junior high years, where this fic is set.

What's the process for getting a patient off of sedation meds like? Got any patient anecdotes on that front?

[pallas_rose]

Post cardiac arrest care depends on if the person is responsive or not when their heart starts beating again. If unresponsive, then they are cooled and kept sedated for 24h and then slowly rewarmed (this is changing to kept normal temperature, but many places still cool), all the while kept deeply sedated.

If responsive after their heart starts beating again, then the sedation medications would be kept going only until the breathing tube can be removed. Our criteria for removing the breathing tube depends on lung function but also alertness: we turn off the sedation and see if the patient is able to interact with us (follow commands like "squeeze your left hand" or "open your eyes") as well as take deep breaths without difficulty oxygenating.

If your character has a cardiac arrhythmia--an electrical conduction problem--this can cause cardiac arrest that can be recoverable, as well as palpitations or fainting which could work for your previous hospitalization ideas, though in the modern era any of those events would ideally trigger a definitive fix so she wouldn't end up in the case we are describing, with a cardiac arrest!

Perhaps she was in the hospital getting some tests for this: a cardiac catheterization maybe, or electrical studies. If during the resuscitation (CPR, etc: when done by professionals in a hospital we follow the ACLS guidelines instead of the simplified bystander CPR protocols, since we can give medications and do other interventions) she was intubated and put on the ventilator, we would check to see if she was alert after the intubation medications wear off. If she was able to follow commands and interact, then she would likely stay on the ventilator in the ICU for at least one night, potentially more, while her cardiac problems were worked up and potentially fixed (she might need an ablation or a pacemaker, for example) and then the sedation medications weaned off and the breathing tube removed.

The process for weaning sedation can be easy or hard, depending on the patient's reactions: some are calm and cooperative coming off the meds, and others panic and tear at tubes and lines, which can be very dangerous. In the latter case we may have to try several regimens of medications and ways of weaning to get a situation where the tube can safely be removed.

The meds used vary but are almost always IV drips where the dose can be slowly decreased or rapidly stopped. For trying to get them off a ventilator, I like to switch to very short acting medications (like propofol) that dissipate rapidly once stopped, allowing the patient to be rapidly alert once the tube is removed, ensuring they can breathe on their own and don't need to tube put right back in to prevent aspiration or complications from medication induced respiratory depression (think painkiller overdoses). There are also some sedation medications (like dexmedetomidine and ketamine) which don't interfere with the respiratory drive at all and which we can continue while removing the breathing tube. To backtrack a little, sedation is required while a breathing tube is in place and a ventilator doing the work of the lungs because both of those things are incredibly uncomfortable and would be torturous without sedation.

Functionally, what this looks like is: the nurse decreases the drips' rates until the patient is alert enough to communicate (nodding, squeezing hands, etc: can't talk because breathing tube; sometimes can write but honestly they usually write nonsense), their respiratory function is checked with certain ventilator tests, all medication drips which depress the respiratory drive are stopped (narcotics, benzodiazepines, propofol) and the tube is removed and oxygen via nasal cannula or mask supplied. Like coming out of anesthesia, there is often a period of confusion and amnesia that she might not remember from that first period off the meds. But some people remember more than others!

What other details would be useful?

[4monadonis2]

I think I'm good with this for now. Thanks a ton for your help! You've given me a lot to work with and a solid sense of direction.

Current game plan is some form of cardiomyopathy/other slow-progressing heart failure, with eventual treatment being a heart transplant. All the visible health issues displayed in the canon timeframe can probably be taken as the result of transplant complications based on what else I've looked up. If not, well, frankly I've done enough poking around for answers to give myself a freebie here and there, and the average reader isn't going to sweat THAT many details.