Cardiac arrest resident survival guide

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.

Causes

Life Threatening Causes

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

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: Algorithm 1

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: ❑ Hypovolemia ❑ Tension Pneumothorax ❑ Hypoxia ❑ Cardiac tamponade ❑ H+ ions ❑ Toxins ❑ Hypo/Hyper K ❑ PE ❑ Hypothermia ❑ ACS 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.

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.

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

• 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.