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

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

↓

Continous CPR every 2 mins

↑

↓

↑

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)

↓

Continous CPR every 2 mins

↑

↓

↑

❑ 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.