Cardiac arrest resident survival guide

For cardiac arrest physician extender algorithm click here

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

Definition

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

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated. Cardiac arrest is a life-threatening condition and must be treated as such irrespective of the causes.

Common Causes

• Arrhythmia
• Cardiomyopathy
• Ischemic heart disease

Reversible Causes

H's

• Hypovolemia
• Hypoxia
• Hydrogen ions (acidosis)
• Hyperkalemia or Hypokalemia
• Hypothermia
• Hypoglycemia or Hyperglycemia

T's

• Tablets or Toxins (tricyclic antidepressants, phenothiazines, beta blockers, calcium channel blockers, cocaine, digoxin, aspirin, acetominophen)
• Cardiac Tamponade
• Tension pneumothorax
• Thrombosis (myocardial infarction)
• Trauma (hypovolemia)

Management

Cardiac Arrest Care

❑ High Quality CPR Compressions: Push hard (>2 inches) & fast (>100/min) Minimize interruptions; rotate compressor every 2 mins Airway: Open airway Breathing: Pressure ventilation; 2 breaths every 30 compressions Bagmask also acceptable ❑ Attach monitor/defibrillator ❑ Check rhythm

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Continous CPR every 2 mins

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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 3mg/Kg Consider advanced airway: ❑ Endotracheal intubation or supraglottic advanced airway ❑ Assess : Bilateral chest expansion & breath sounds ❑ Check tube placement ❑ 8-10 breaths per min with continous compressions Treat reversible causes: ❑ Hypovolemia: Volume ❑ Tension Pneumothorax ❑ Hypoxia: Oxygenate ❑ Tamponade: Pericardiocentesis ❑ H+ ions: NaHCo3 ❑ Toxins ❑ Hypo/Hyper K: Replace ❑ Thromb. (PE) ❑ Hypothermia: Warm ❑ Thromb. (ACS)

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Continous CPR every 2 mins

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❑ Shockable rhythm? (VF/Pulseless VT) Deliver shock (120-200 J biphasic; 360 J monophasic) ❑ Rhythm not shockable? (Asystole/PEA) Resume CPR ❑ On Return of spontaneous circulation (ROSC) ↓ Post-arrest care

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.

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.

Do's

• Guideline changes from 2005:

• Continuous quantitative waveform capnography is recommended for confirmation and monitoring of endotracheal tube placement.
• Cardiac arrest algorithms are simplified and redesigned to emphasize the importance of high-quality CPR (including chest compressions of adequate rate and depth, allowing complete chest recoil after each compression, minimizing interruptions in chest compressions and avoiding excessive ventilation).
• Atropine is no longer recommended for routine use in the management of pulseless electrical activity (PEA)/asystole.
• There is an increased emphasis on physiologic monitoring to optimize CPR quality and detect ROSC.
• 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 atleast 600 ml of tidal volume, sufficient to produce chest rise over atleast 1 sec.
• 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 assist in bag and mask ventilation in unconscious patients.
• Continuous waveform capnography is now recommended to confirm placement of endotracehal tube.
• Early defibrillation for VF/Pulseless VT has been found to prolong survival.
• If and when cardiac rhythm changes, shift to appropriate rhythm based strategy.
• If unsure of defibrillator's recommended energy levels, use maximum output level.

Dont's

• Do not interrupt compressions or use of defibrillator for placement of an advanced airway, securing IV/IO access, delivering drugs.
• Do not hyperventilate the patient.
• Do not use femoral pulse to assess ROSC, veins being valveless serve as much less reliable indicators. The pause in compressions should be used to assess pulse.