Cardiac Arrest

 

 

1. Immediate Recognition and Scene Assessment

First, ensure the scene is safe for yourself, your team, and the patient. Then assess responsiveness by tapping the patient and shouting.

If the patient is unresponsive:

  • Shout for help.

  • Activate the emergency response system immediately.

  • Ask for the AED/defibrillator, airway equipment, and resuscitation trolley.

 


2. Simultaneous Breathing and Pulse Check

Assess for:

  • No breathing or only gasping

  • Carotid pulse, checked for no more than 10 seconds

If a pulse is not definitely felt within 10 seconds, treat the patient as being in cardiac arrest and start CPR immediately. 

Decision points:

  • Normal breathing + pulse present → monitor until advanced care arrives.

  • No normal breathing but pulse present → provide rescue breathing.

  • No normal breathing or only gasping + no definite pulse → start CPR immediately.

 

 

3. If Pulse Present but Apneic or Agonal: Rescue Breathing

Provide:

  • 1 breath every 6 seconds

  • About 10 breaths/min

Reassess pulse every 2 minutes. If the pulse is lost, transition immediately to full CPR.

 

 

4. Start High-Quality CPR

For adult cardiac arrest:

  • Compression depth: at least 2 inches (5 cm)

  • Compression rate: 100–120/min

  • Allow complete chest recoil

  • Minimize interruptions

  • Avoid excessive ventilation

  • Change compressor every 2 minutes or sooner if fatigued

 

If no advanced airway is in place:

  • Use a 30:2 compression-to-ventilation ratio

 

Ventilations:

  • Deliver each breath over 1 second

  • Aim for visible chest rise

  • Use bag-mask ventilation with good seal and oxygen if available.

 

 

5. Apply Monitor/Defibrillator as Soon as Available

As soon as the defibrillator/AED arrives:

  • Attach pads

  • Analyze rhythm

  • Categorize rhythm into:

    • Shockable: ventricular fibrillation (VF), pulseless ventricular tachycardia (pVT)

    • Non-shockable: asystole, pulseless electrical activity (PEA)

 

 

6. Shockable Rhythm Pathway: VF / Pulseless VT

If the rhythm is shockable:

First shock

  • Deliver 1 shock

  • Biphasic: use manufacturer recommendation, usually 120–200 J

  • If unknown, use the maximum available energy

  • Monophasic: 360 J

  • Resume CPR immediately for 2 minutes after shock; do not pause to check pulse right away.

 

During CPR after first shock

  • Establish IV/IO access

 

If still shockable after next rhythm check

  • Deliver second shock

  • Resume CPR for 2 minutes

  • Give adrenaline 1 mg IV/IO every 3–5 minutes

  • Consider advanced airway and waveform capnography.

 

If still shockable after further rhythm check

  • Deliver third shock

  • Resume CPR for 2 minutes

  • Give amiodarone or lidocaine

    • Amiodarone: 300 mg IV/IO bolus, then 150 mg

    • Lidocaine: 1–1.5 mg/kg, then 0.5–0.75 mg/kg

 

At every cycle:

  • Continue to search for reversible causes

  • Keep pauses under 10 seconds

 

 

7. Non-Shockable Rhythm Pathway: Asystole / PEA

If the rhythm is non-shockable:

  • Resume CPR immediately for 2 minutes

  • Obtain IV/IO access

  • Give adrenaline 1 mg IV/IO as soon as possible

  • Continue adrenaline every 3–5 minutes

  • Consider advanced airway and capnography

  • Actively identify and treat reversible causes

 

 

8. Advanced Airway

An advanced airway is not mandatory in the first seconds of arrest, but can be placed when the team is ready and it will not compromise compressions.

Options:

  • Endotracheal tube

  • Supraglottic airway

 

After advanced airway placement:

  • Continue continuous compressions

  • Ventilate 1 breath every 6 seconds

  • Use continuous waveform capnography to confirm and monitor tube placement.

 

 

9. Capnography During Arrest

Waveform capnography:

  • Helps confirm endotracheal tube placement

  • Helps monitor CPR quality

  • If ETCO₂ is low or falling, reassess compression quality, ventilation strategy, and overall resuscitation mechanics

 

A sudden rise in ETCO₂ may suggest ROSC, but do not use capnography in isolation. Correlate clinically.

 

 

10. Rhythm Reassessment Every 2 Minutes

Every 2 minutes:

  • Pause briefly, ideally <10 seconds

  • Reassess rhythm

  • If an organized rhythm appears, check for pulse quickly

  • If no ROSC, resume algorithm immediately

 

 

11. Reversible Causes: H’s and T’s

 

H’s

  • Hypovolemia

  • Hypoxia

  • Hydrogen ion (acidosis)

  • Hypo-/hyperkalemia

  • Hypothermia

 

T’s

  • Tension pneumothorax

  • Tamponade, cardiac

  • Toxins

  • Thrombosis, pulmonary

  • Thrombosis, coronary

 

 

12. Return of Spontaneous Circulation (ROSC) Care

Once ROSC occurs:

Airway

  • Assess need for advanced airway placement or exchange

  • Confirm placement with waveform capnography/capnometry if advanced airway is used.

 

Oxygenation and ventilation

  • Titrate FiO₂ to achieve SpO₂ 90%–98%

  • Or target PaO₂ 60–105 mm Hg

  • Adjust ventilation to target PaCO₂ 35–45 mm Hg

 

Hemodynamics

  • Give fluids and/or vasopressors as needed

  • Target MAP ≥65 mm Hg

 

Early diagnostics

  • Obtain 12-lead ECG

  • Consider CT imaging when clinically indicated

  • Point-of-care ultrasound or echocardiography may help identify major diagnoses requiring intervention.

 

Coronary Reperfusion and Cardiac Intervention

Consider urgent coronary angiography/cardiac intervention when appropriate, especially if there is:

  • Persistent ST-segment elevation

  • Cardiogenic shock

  • Recurrent/refractory ventricular arrhythmias

  • Severe myocardial ischemia

 

Targeted Temperature Management

If the patient is not following commands after ROSC, initiate a deliberate temperature control strategy with target 32°C–37.5°C as soon as possible, for at least 36 hours.

 

Neurologic and Critical Care Follow-Through

For patients not following commands:

  • Evaluate for seizure

  • Obtain EEG when indicated

  • Use multimodal prognostication

  • Avoid premature neurological prognostication

  • Delay formal prognostic impressions until ≥72 hours from ROSC or from achieving normothermia.

 

Glucose and General Critical Care Targets

During ongoing post-arrest care:

  • Avoid hypoglycemia: glucose < 3.9 mmol/L (70 mg/dL)

  • Avoid hyperglycemia: glucose > 10 mmol/L (180 mg/dL)

  • Continue MAP, oxygenation, and ventilation optimization

  • Continue cause-directed treatment.

 

References:
  1. American Heart Association. (2025). Adult basic life support algorithm for health care professionals. https://cpr.heart.org/-/media/CPR-Files/CPR-Guidelines-Files/2025-Algorithms/Algorithm-BLS-Adult-Healthcare-250701.pdf
  2. American Heart Association. (2025). Adult cardiac arrest algorithm (VF/pVT/asystole/PEA). https://cpr.heart.org/-/media/CPR-Files/CPR-Guidelines-Files/2025-Algorithms/Algorithm-ACLS-CA-250527.pdf
  3. American Heart Association. (2025). Adult post–cardiac arrest care algorithm. https://cpr.heart.org/-/media/CPR-Files/CPR-Guidelines-Files/2025-Algorithms/PCAC-Algorithm-ACLS-PCAC-250527.pdf
  4. American Heart Association. (2025). Part 7: Adult basic life support. https://cpr.heart.org/en/resuscitation-science/cpr-and-ecc-guidelines/adult-basic-life-support
  5. American Heart Association. (2025). Highlights of the 2025 American Heart Association guidelines for CPR and ECC. https://cpr.heart.org/-/media/CPR-Files/2025-documents-for-cpr-heart-edits-posting/Resuscitation-Science/252500_Hghlghts_2025ECCGuidelines.pdf