Cardiac Arrest

 

1. Scene Assessment

  • Ensure Scene Safety: Confirm that the environment is safe for you, your team, and the patient.
  • Assess Patient Responsiveness:
    • Tap the patient and shout.
    • If unresponsive, proceed immediately to the next step.

 

 

2. Activate the Emergency Response System

  • Call for help and activate the hospital or pre-hospital emergency response system.
  • Request a defibrillator or AED to be brought to the scene.

 

 

3. Airway and Breathing

  • Assess Breathing and Pulse:
    • Look for normal breathing or gasping (agonal breaths).
    • Simultaneously palpate the carotid pulse for no more than 10 seconds.
  • Decisions Based on Findings:
    • No normal breathing, no pulse:
      • Start CPR immediately.
    • No normal breathing, but pulse present:
      • Provide rescue breathing (1 breath every 6 seconds, 10 breaths/min).
    • Normal breathing, pulse present:
      • Monitor the patient and wait for emergency responders.

 

 

4. Begin High-Quality CPR (If No Pulse Found)

  • Chest Compressions:
    • Depth: At least 2 inches (5 cm), but not more than 2.4 inches (6 cm).
    • Rate: 100–120 compressions per minute.
    • Allow full chest recoil after each compression.
    • Minimize interruptions to chest compressions (<10 seconds for checks or interventions).
  • Compression-to-Ventilation Ratio:
    • 30:2 for single or multiple rescuers until advanced airway is placed.
  • Airway Management:
    • After 30 compressions, provide 2 breaths over 1 second each, ensuring visible chest rise.
    • Use a bag-valve mask (BVM) with a tight seal if available.

 

 

5. Defibrillation (Shockable Rhythms)

  • Attach AED/Defibrillator:
    • Power on the device and place adhesive pads on the chest (upper right chest and left lower chest).
  • Analyze Rhythm:
    • The defibrillator will indicate if the rhythm is shockable or non-shockable.

 

Shockable Rhythm:

VF or pulseless VT

  • Deliver 1 shock (200 J biphasic or as per device recommendation).
  • Resume CPR immediately for 2 minutes (do not delay CPR for rhythm recheck).
  • Continue rhythm analysis and shocks every 2 minutes as needed.

 

Non-Shockable Rhythm:

Asystole or PEA

  • Continue CPR without delay.
  • Adrenaline 1mg (1:1000) every 3 - 5 minutes followed by 20mL saline push.
  • Focus on addressing reversible causes.

 

 

6. Advanced Airway Placement

If advanced airway (e.g., endotracheal tube, supraglottic device) is placed:

  • Deliver 1 breath every 6 seconds without pausing compressions.
  • Use waveform capnography to confirm placement and monitor CPR quality (target ETCO₂ ≥10 mmHg).

 

 

7. Reassess Rhythm Every 2 Minutes

Stop CPR briefly (<10 seconds) to reassess rhythm.

  • If Pulse Restored (ROSC):
    • Move to Post-Cardiac Arrest Care (outlined below).
  • If No Pulse:
    • Continue CPR and reassess reversible causes (H’s and T’s).

 

 

8. Identify and Address Reversible Causes

Review potential H’s and T’s that could contribute to the arrest:

H’s

  • Hypoxia:
    • Ensure oxygenation and effective ventilation.
  • Hypovolemia:
    • Rapid IV/IO access and fluid resuscitation.
  • Hydrogen ion (acidosis):
    • Assess and manage with ventilation or bicarbonate if needed.
  • Hypo-/hyperkalemia:
    • Monitor electrolytes and correct as appropriate.
  • Hypothermia:
    • Rewarm gradually.

T’s

  • Tension pneumothorax:
    • Immediate needle decompression or chest tube placement.
  • Tamponade (cardiac):
    • Perform pericardiocentesis if indicated.
  • Toxins:
    • Identify and manage specific overdoses.
  • Thrombosis (pulmonary or coronary):
    • Consider thrombolysis or emergent PCI.
  • Trauma:
    • Address life-threatening injuries systematically.

 

 

9. Post-Cardiac Arrest Care (After ROSC)

i. Optimize Oxygenation:

- Maintain SpO₂ between 94–99%.

- Consider advanced airway if not already done.

ii. Support Blood Pressure:

- Target systolic BP >90 mmHg or MAP ≥65 mmHg.

- Administer IV fluids or vasopressors as needed.

iii. Obtain 12-Lead ECG:

- Identify STEMI or other acute coronary syndromes.

- If STEMI detected, consider emergent PCI.

iv. Assess Neurological Status:

- Monitor responsiveness and consider therapeutic hypothermia for comatose patients.

v. Address Underlying Causes:

- Continue to monitor and treat the causes identified during the arrest.

 

 

10. Special Considerations

  • Avoid hyperventilation (can decrease cardiac output).
  • Monitor CPR effectiveness using ETCO₂:
    • <10 mmHg: Suggests poor CPR quality or need for reassessment.
    • ROSC likely when ETCO₂ rises >40 mmHg.

 

 

References:
  1. American Heart Association. (2020). Advanced Cardiovascular Life Support Provider Manual. Dallas, TX: American Heart Association.
  2. Panchal, A. R., Bartos, J. A., Cabañas, J. G., Donnino, M. W., Drennan, I. R., Hirsch, K. G., ... & Morley, P. T. (2020). 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Part 3: Adult basic and advanced life support. Circulation, 142(16_suppl_2), S366–S468. https://doi.org/10.1161/CIR.0000000000000916
  3. Soar, J., Böttiger, B. W., Carli, P., Couper, K., Deakin, C. D., Drummond, D., ... & Nolan, J. P. (2021). European Resuscitation Council Guidelines 2021: Adult advanced life support. Resuscitation, 161, 115–151. https://doi.org/10.1016/j.resuscitation.2021.02.010
  4. Perkins, G. D., Graesner, J. T., Semeraro, F., Olasveengen, T. M., Soar, J., Lott, C., ... & Zideman, D. (2021). European Resuscitation Council Guidelines 2021: Executive summary. Resuscitation, 161, 1–60. https://doi.org/10.1016/j.resuscitation.2021.02.003
  5. Neumar, R. W., Nolan, J. P., Adrie, C., Aibiki, M., Berg, R. A., Böttiger, B. W., ... & Callaway, C. W. (2008). Post–cardiac arrest syndrome: Epidemiology, pathophysiology, treatment, and prognostication: A consensus statement from the International Liaison Committee on Resuscitation (American Heart Association, Australian and New Zealand Council on Resuscitation, European Resuscitation Council, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation Council of Southern Africa, Resuscitation Council (UK), and the European Society of Intensive Care Medicine). Circulation, 118(23), 2452–2483. https://doi.org/10.1161/CIRCULATIONAHA.108.190652
  6. Meaney, P. A., Bobrow, B. J., Mancini, M. E., Christenson, J., de Caen, A. R., Bhanji, F., ... & Leary, M. (2013). Cardiopulmonary resuscitation quality: Improving cardiac resuscitation outcomes both inside and outside the hospital: A consensus statement from the American Heart Association. Circulation, 128(4), 417–435. https://doi.org/10.1161/CIR.0b013e31829d8654
  7. Resuscitation Council UK. (2021). Resuscitation Guidelines 2021: Adult Advanced Life Support. Resuscitation Council UK. Kleinman, M. E., Brennan, E. E., Goldberger, Z. D., Swor, R. A., Terry, M., Bobrow, B. J., ... & Travers, A. H. (2015). Part 5: Adult basic life support and cardiopulmonary resuscitation quality: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation, 132(18_suppl_2), S414–S435. https://doi.org/10.1161/CIR.0000000000000259