Cardiac arrest resident survival guide

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Rim Halaby; Vidit Bhargava, M.B.B.S [2]

Synonyms and Keywords: cardiorespiratory arrest, cardiopulmonary arrest, circulatory arrest, Advanced life support, ACLS, Basic life support, BLS

Overview

A cardiac arrest is the abrupt cessation of normal blood flow circulation due to the failure of the heart to contract effectively during systole.[1]

Causes

Life Threatening Causes

Cardiac arrest is a life-threatening condition and must be treated as such irrespective of the underlying cause.

Common Causes

Reversible Causes

H's

T's

Management

Cardiac Arrest Care: Algorithm 1

Cardiac arrest.PNG
High Quality CPR:
Compressions:
❑ Push hard (>2 inches) & fast (>100/min) and
allow complete chest recoil
❑ Minimize interruptions; rotate compressor every 2 mins
❑ If an advanced airway is not in place
ventilation:compression ratio should be 30:2

Ventilation:

❑ Avoid excessive ventilation
❑ Monitor quantitative waveform capnography; If PETco2 <10mm Hg
try to improve the quality of the CPR
❑ Monitor intra-arterial pressure; if diastolic pressure <20 mm Hg
try to improve the quality of the CPR

Drug therapy:

❑ Establish IV/IO access (do not interrupt CPR)
❑ Vasopressor:
Epinephrine 1 mg IV Q3-5 min (or 2 mg via ETT)
Vasopressin 40 U can replace 2nd or 3rd doses of epinephrine)
❑ Antiarrythmic:
Amiodarone 300 mg IV bolus + 150 mg 3-5 min later
lidocaine 1-1.5 mg/kg IV, max 3 mg/kg

Advanced airway:

❑ Endotracheal intubation or supraglottic advanced airway
❑ Assess bilateral chest expansion & breath sounds
❑ Check tube placement
❑ 8-10 breaths per min with continuous compressions

Reversible causes:

HypovolemiaTension Pneumothorax
HypoxiaCardiac tamponade
❑ H+ ions ❑ Toxins
❑ Hypo/Hyper K ❑ PE
HypothermiaACS

Shock energy:

Biphasic: 120-200 J based on manufacturers recommendation
If unknown use maximum available. Subsequent shocks should be equivalent.
Monophasic: 360 J

Return of Spontaneous Circulation (ROSC):

❑ Recordable pulse and BP
❑ Sudden sustained increase in PETco2 > 40 mm Hg
❑ Sustained arterial pressure waves on intra-arterial monitoring
 

Adapted from 2010 AHA guidelines for cardiopulmonary resuscitation and emergency cardiovascular care, part 8.[2]

Cardiac Arrest Care: Algorithm 2

 
 
 
 
 
 
 
 
 
 
 
 
Adult Cardiac Arrest
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Shout for help
❑ Activate emergency response
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Start CPR
❑ Give oxygen
❑ Attach monitor/defibrillator
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Rhythm shockable?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
VF/VT
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Asystole / PEA
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Shock
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Box A:

CPR 2 min
❑ Obtain IV/IO access
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Rhythm shockable?
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Shock
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Box B:

CPR 2 min
Epinephrine every 3-5 min
❑ Consider advanced airway
and capnography
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Box C:

CPR 2 min
❑ ObtaimIV/IO access
❑ Administer Epinephrine every 3-5 min
❑ Consider advanced airway
and capnography
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Rhythm shockable?
 
No
 
 
 
 
 
 
 
 
 
 
 
Rhythm shockable?
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Shock
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
CPR 2 min
❑ Administer Amiodarone
❑ Treat reversible causes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Box D:

CPR 2 min
❑ Treat reversible causes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Go back to box A
 
 
 
 
 
 
 
 
 
 
 
No
 
Rhythm shockable?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Shock
Then, go to box A or box B
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If no signs of return of spontaneous circulation:
Go to box C or box D

If return of spontaneous circulation:
Start post cardiac arrest care
 
 
 
 
 
 
 
 
 
 

Adapted from 2010 AHA guidelines for cardiopulmonary resuscitation and emergency cardiovascular care, part 8.[2]

Acute Immediate Post-Cardiac Arrest Care

 
 
 
 
 
 
Return of spontaneous circulation
(ROSC)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Optimize ventilation and oxygenation
❑ Maintain oxygen saturation ≥ 94%
❑ Consider advanced airway and waveform capnography
❑ Do not hyperventilate
♦ Start at 10-12 breaths/min
♦ Titrate to target PETCO2 of 35-40 mmHg
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Treat hypotension (SBP<90 mmHg)
❑ IV/IO bolus
♦ 1-2 L normal saline or lactated Ringer's

Vasopressor infusion

Epinephrine IV infusion: 0.1-0.5 mcg/kg/min, or
Dopamine IV infusion: 5-10 mcg/kg/min, or
Norepinephrine IV infusion: 0.1-0.5 mcg/kg/min

❑ Consider treatable causes


❑ 12-Lead ECG
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Follow commands?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Consider induced hypothermia
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
STEMI
Or
High suspicion of AMI
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Coronary reperfusion
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Advanced critical care
 
 
 
 
 
 
 
 
 

Adapted from 2010 AHA guidelines for cardiopulmonary resuscitation and emergency cardiovascular care, part 9.[3]

Do's

  • Chronotropic drug infusions are recommended as an alternative to pacing in symptomatic and unstable bradycardia.
  • Adenosine is recommended as a safe and potentially effective therapy in the initial management of stable undifferentiated regular monomorphic wide-complex tachycardia.
  • If using bag and mask ventilation, use adult mask to deliver at least 600 ml of tidal volume, sufficient to produce chest rise, over at least 1 second.
  • Perform a head tilt-chin lift maneuver to open the airway, and ensure there is an airtight seal when using bag mask ventilation.
  • Oropharyngeal and nasopharyngeal airways may be used to assist in bag and mask ventilation in unconscious patients.
  • Continuous waveform capnography is recommended to confirm the placement of endotracehal tube.
  • If the cardiac rhythm changes, shift to the appropriate rhythm based strategy.
  • If you are not sure of the defibrillator's recommended energy levels, use maximum output level.

Dont's

  • Do not use atropine in the management of pulseless electrical activity (PEA)/asystole.
  • Do not interrupt the compressions or the use of defibrillator to place an advanced airway, secure IV/IO access or deliver drugs.
  • Do not hyperventilate the patient.
  • Do not use femoral pulse to assess return of spontaneous circulation (ROSC). The pause in compressions should be used to assess pulse.

References

  1. Harrison's Principles of Internal Medicine 16th Edition, The McGraw-Hill Companies, ISBN 0-07-140235-7
  2. 2.0 2.1 Neumar RW, Otto CW, Link MS, Kronick SL, Shuster M, Callaway CW; et al. (2010). "Part 8: adult advanced cardiovascular life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care". Circulation. 122 (18 Suppl 3): S729–67. doi:10.1161/CIRCULATIONAHA.110.970988. PMID 20956224.
  3. Peberdy MA, Callaway CW, Neumar RW, Geocadin RG, Zimmerman JL, Donnino M; et al. (2010). "Part 9: post-cardiac arrest care: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care". Circulation. 122 (18 Suppl 3): S768–86. doi:10.1161/CIRCULATIONAHA.110.971002. PMID 20956225.