Cardiac Arrest 

Initial management of cardiac arrest

• On finding an unconscious individual, follow the three SSS’s: safety, shake, shout
  • Safety: ensure it is safe to approach
  • Shake: ask the patient “Are you alright?” whilst shaking their shoulder
  • Shout: if the patient responds, assess them from an ABCDE perspective; if they do not respond, shout for help and put out a cardiac arrest call
• Open the airway with a head tilt/chin lift manoeuvre, palpate the carotid pulse and look, listen and feel for breathing for 10 seconds
  • If there is a risk of a cervical spine injury, open the airway using a jaw thrust whilst an assistant applies manual in-line stabilisation (MILS)
• If there is no pulse, no signs of life, or if in any doubt, commence cardiopulmonary resuscitation (CPR) immediately in a ratio of 30 compressions to 2 ventilationcompressions should be applied to the lower half of the sternum to a depth of 5-6 cm at a rate of 100 per minute
  • Ventilations should ideally be applied via a bag-valve-mask (BVM) attached to an oxygen supply, but if these are unavailable can be given via a pocket mask or mouth-to-mouth
• Attach defibrillator pads and pause CRP to analyse the rhythm; further management will depend of whether the rhythm is shockable (ventricular fibrillation [VF] or pulseless ventricular tachycardia [VT]) or non-shockable (asystole or pulseless electrical activity [PEA])

Management of shockable rhythms (VF and pulseless VT)

• On recognising a shockable rhythm, resume chest compressions immediately
• First shock
  • Warn all other individuals to stand clear and remove any oxygen delivery device whilst the defibrillator is charged to 150 J (this is the value on most machines, check local protocols)
  • Once the defibrillator is charged, instruct the individual performing chest compressions to stand clear and then deliver the first shock
  • Resume CPR immediately and continue for two minutes
  • After two minutes, pause CPR to check the rhythm; on recognising a shockable rhythm, resume chest compressions immediately
• Second shock
  • Warn all other individuals to stand clear and remove any oxygen delivery device whilst the defibrillator is charged to 150 J
  • Once the defibrillator is charged, instruct the individual performing chest compressions to stand clear and then deliver the second shock
  • Resume CPR immediately and continue for two minutes
  • After two minutes, pause CPR to check the rhythm; on recognising a shockable rhythm, resume chest compressions immediately
• Third shock
  • Warn all other individuals to stand clear and remove any oxygen delivery device whilst the defibrillator is charged to 150 J
  • Once the defibrillator is charged, instruct the individual performing chest compressions to stand clear and then deliver the third shock
  • Resume CPR immediately and continue for two minutes
• Medications
  • After the third shock, give adrenaline 1 mg IV (10 ml of 1:10,000) and amiodarone 300 mg IV
  • Continue giving adrenaline after alternate shocks ie fifth, seventh, ninth, eleventh etc
• If organised electrical activity is seen during a rhythm check, seek evidence of return of spontaneous circulation (ROSC)
  • If present, commence post-resuscitation care
  • Iif absent (PEA), resume CPR immediately and switch to the non-shockable algorithm
• If asystole is recognised during a rhythm check, switch to the non-shockable algorithm

Management of non-shockable rhythms (asystole or PEA)

• On recognising asystole, resume chest compressions immediately and continue for two minutes
• On recognising organised electrical activity, seek evidence of ROSC and if absent (PEA), resume chest compressions immediately and continue for two minutes
• After the first rhythm check, give adrenaline 1 mg IV (10 ml of 1:10,000)
• After two minutes, pause CPR to check the rhythm; on recognising asystole, resume chest compressions immediately and continue for two minutes; on recognising organised electrical activity, seek evidence of ROSC and if absent (PEA), resume chest compressions immediately and continue for two minutes
• After two minutes, pause CPR to check the rhythm; on recognising asystole, resume chest compressions immediately and continue for two minutes; on recognising organised electrical activity, seek evidence of ROSC and if absent (PEA), resume chest compressions immediately and continue for two minutes
• After the third rhythm check, given adrenaline 1 mg IV (10 ml of 1:10,000); continue giving adrenaline after alternate rhythm checks ie fifth, seventh, ninth, eleventh etc
• If a shockable rhythm is identified during a rhythm check, switch to the shockable algorithm but continue giving adrenaline after alternate rhythm checks: do not withhold until after the third shock

Factors to consider during CPR

• Ensure good quality CPR with minimal interruptions
• Establish and maintain a patent airway
• Consider airway adjuncts, supraglotic airway devices and definitive airways such as an endotracheal tube
• Once a definitive airway has been established, compressions and ventilations can be delivered continuously and simultaneously
• Establish intravenous (IV) access and take bloods including a venous blood gas (VBG)If IV access fails, use intraosseous (IO) access. You should switch to IO is access cannot be gained in under two minutes.
• If unable to obtain venous blood, do a femoral stab, which can be sent for all routine bloods and an arterial blood gas (ABG). An ABG should be obtained in either case as soon as possible.
• Recognise and treat reversible causes (4 H’s and 4 T’s)
  • Hypoxia: ensure a patent airway and delivery of high flow oxygen
  • Hypovolaemia: commence IV fluid resuscitation
  • Hypo/hyperkalaemia and other metabolic derangements: check the VBG for any metabolic derangements and correct accordingly
  • Hypothermia: check the patients temperature and if low re-warm to 32-34 degrees celcius
  • Tension pneumothorax: auscultate the patient’s lung fields during ventilations and perform needle decompression as indicated
  • Tamponade (cardiac): obtain a beside echocardiogram (echo) and perform pericardiocentesis as indicated
  • Toxins: check the patient’s drug chart and/or enquire about recent medications in the collateral history
  • Thrombosis: obtain a bedside ultrasound and identify symptoms and risk factors in the collateral history

Organise your team

• Delegate the tasks of airway management and ventilation, chest compressions, defibrillator operation, drug administration and time keeping to appropriate individuals; effective chest compressions are tiring so alternate individuals as necessary; as the team leader maintain an overview of the whole resuscitation attempt: stand at the foot of the bed, give clear instruction and do not get drawn in to performing individual tasks

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Advanced Life Support (ALS) Algorithm

Advanced Life Support (ALS) Algorithm