ACLS Post-Cardiac Arrest Care 5 — Questions and Answers
Question 1: A post-cardiac arrest patient maintained at 33°C develops QTc prolongation to 520 ms. What is the priority action?
- Review and discontinue QT-prolonging medications while continuing TTM (Correct answer)
- Immediately rewarm the patient to terminate TTM
- Administer magnesium sulfate 2g IV and increase cooling rate
- Initiate prophylactic amiodarone infusion
Correct answer: Review and discontinue QT-prolonging medications while continuing TTM
Hypothermia itself prolongs QTc; review for concurrent QT-prolonging drugs (antiarrhythmics, antibiotics) that compound the risk, and discontinue them while maintaining TTM.
Question 2: What does the concept of 'self-fulfilling prophecy' refer to in post-cardiac arrest prognostication?
- Withdrawal of care based on premature poor prognosis leading to the predicted death (Correct answer)
- Accurate early prediction of neurological recovery based on clinical signs
- The brain's ability to recover after the clinician predicts good outcomes
- EEG patterns that reliably predict their own continuation
Correct answer: Withdrawal of care based on premature poor prognosis leading to the predicted death
Self-fulfilling prophecy occurs when early withdrawal of life-sustaining therapy, based on inaccurate or premature prognostication, causes the predicted death rather than the underlying injury.
Question 3: Which of the following is the most appropriate initial tidal volume setting for mechanical ventilation in a post-cardiac arrest patient?
- 6–8 mL/kg of predicted body weight (Correct answer)
- 10–12 mL/kg of actual body weight
- 4–5 mL/kg of predicted body weight
- 12–15 mL/kg of predicted body weight
Correct answer: 6–8 mL/kg of predicted body weight
Lung-protective ventilation using 6–8 mL/kg of predicted body weight reduces ventilator-induced lung injury in post-arrest patients.
Question 4: A post-arrest patient has return of spontaneous circulation but remains hypotensive despite adequate volume resuscitation. Bedside echocardiography shows severely reduced left ventricular ejection fraction. The MOST appropriate next step is:
- Add dobutamine to norepinephrine for inotropic support (Correct answer)
- Increase norepinephrine dose alone to achieve MAP >65 mmHg
- Administer 1L fluid bolus to improve preload
- Begin immediate coronary angiography without hemodynamic stabilization
Correct answer: Add dobutamine to norepinephrine for inotropic support
Post-arrest myocardial stunning with severely reduced EF requires inotropic support; dobutamine added to a vasopressor addresses both cardiac output and vascular tone.
Question 5: According to ACLS guidelines, at what point should fever (>37.7°C) be actively treated following the TTM maintenance phase?
- Immediately and for at least 72 hours post-arrest (Correct answer)
- Only if the patient has signs of infection
- Only during the maintenance phase of TTM, not after rewarming
- When temperature exceeds 38.5°C for more than 2 hours
Correct answer: Immediately and for at least 72 hours post-arrest
Active fever prevention is recommended for at least 72 hours post-ROSC because fever worsens neurological outcomes from increased cerebral metabolic demand.
Question 6: Which clinical sign at 72 hours post-arrest, when combined with other predictors, is associated with poor neurological prognosis?
- Absent pupillary light reflex bilaterally (Correct answer)
- Localizing motor response to pain
- Eye opening to voice
- Presence of cough reflex
Correct answer: Absent pupillary light reflex bilaterally
Bilaterally absent pupillary light reflexes at 72 hours are a strong multimodal indicator of poor neurological prognosis after cardiac arrest.
Question 7: A patient presents after out-of-hospital cardiac arrest with ROSC. Family states the arrest occurred due to a drug overdose (opioids). Regarding TTM and coronary angiography, which statement is MOST accurate?
- TTM is still recommended if comatose; emergent angiography is not indicated without ECG evidence of ischemia (Correct answer)
- Both TTM and emergent angiography should proceed as with any post-arrest patient
- Neither TTM nor angiography is indicated since the cause is non-cardiac
- Angiography should precede TTM initiation regardless of ECG findings
Correct answer: TTM is still recommended if comatose; emergent angiography is not indicated without ECG evidence of ischemia
TTM remains indicated for comatose post-arrest patients regardless of cause; however, emergent angiography is reserved for those with ECG evidence of acute coronary syndrome, not all post-arrest patients.
ACLS Post-Cardiac Arrest Care 5
A post-cardiac arrest patient maintained at 33°C develops QTc prolongation to 520 ms.
What is the priority action?