From the Guidelines
Critical care of a coding adult requires immediate implementation of the ACLS (Advanced Cardiac Life Support) protocol, starting with high-quality CPR, providing chest compressions at a rate of 100-120 per minute and a depth of 2-2.4 inches, as recommended by the 2020 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care 1.
Key Components of Cardiac Arrest Management
- High-quality CPR with a compression rate of 100-120 per minute and a depth of 2-2.4 inches, allowing for complete chest recoil between compressions
- Establishment of IV/IO access promptly and application of cardiac monitoring
- For ventricular fibrillation or pulseless ventricular tachycardia, delivery of a shock at 120-200J biphasic (or 360J monophasic), then immediate resumption of CPR
- Administration of epinephrine 1mg IV/IO every 3-5 minutes
- For persistent shockable rhythms, consideration of amiodarone 300mg IV/IO bolus, followed by 150mg if needed
- For asystole or PEA, focus on high-quality CPR and epinephrine while identifying and treating potential reversible causes (the H's and T's): hypoxia, hypovolemia, hydrogen ion (acidosis), hypo/hyperkalemia, hypothermia, tension pneumothorax, tamponade, toxins, thrombosis (pulmonary/coronary) ### Airway Management and Ventilation
- Securing the airway with endotracheal intubation or supraglottic device
- Providing ventilation at 10 breaths per minute with minimal interruption to compressions
- Use of continuous waveform capnography to confirm tube placement and monitor CPR quality
- Compression-to-ventilation ratio of 30:2 if no advanced airway is in place ### Post-Resuscitation Care
- Targeted temperature management
- Hemodynamic optimization
- Treatment of the underlying cause As emphasized by the 2020 guidelines, high-quality CPR is fundamental to the management of all cardiac arrest rhythms, and periodic pauses in CPR should be as brief as possible and only as necessary to assess rhythm, shock VF/VT, perform a pulse check when an organized rhythm is detected, or place an advanced airway 1. Additionally, the importance of early defibrillation with concurrent high-quality CPR is critical to survival when sudden cardiac arrest is caused by ventricular fibrillation or pulseless ventricular tachycardia 2.
From the Research
Critical Care Management of Adult Cardiac Arrest
The critical care management of an adult in cardiac arrest involves cardiopulmonary resuscitation (CPR) with specific guidelines for chest compressions and ventilation.
- The American Heart Association (AHA) recommends two breaths to be delivered for every 30 compressions for an adult cardiac arrest victim 3.
- For patients with an advanced airway, such as an endotracheal tube, one breath should be given every 6 seconds without interruptions in chest compression, resulting in 10 breaths per minute 3.
- Avoiding excessive ventilation is crucial as it can decrease venous return, cardiac output, and affect intra-thoracic pressure, thereby adversely affecting intra-arterial pressure 3.
- Manual ventilation with devices such as volume-marked resuscitation bags or manual breathing devices is recommended for delivering breaths synchronized with the compression phase of CPR at a rate of 10 breaths per minute with an advanced airway in place 3.
Chest Compression Techniques
- Continuous chest compression CPR without rescue breathing has been shown to improve survival to hospital discharge compared to interrupted chest compression with pauses for rescue breathing 4.
- The recommended chest compression depth and rate are 5-6 cm and 100-120 compressions per minute, respectively 5.
- A compression-to-ventilation ratio of 30:2 is acceptable even for rescuers with a duty to respond if they are alone 5.
- The 30:2 ratio is rated as more exhausting, but it delivers more chest compressions, and the quality of chest compressions remains unchanged 6.
Ventilation Strategies
- The use of automated external defibrillators (AEDs) and AED use in CPR needs to be examined, as well as whether continuous chest compression CPR is appropriate for pediatric cardiac arrest 4.
- Inspired oxygen should be titrated to obtain an arterial oxygen saturation of 94-98% during postresuscitation care to avoid possible damage from hyperoxemia 5.
- The role of pulse palpation for the diagnosis of cardiac arrest has been de-emphasized in pediatric resuscitation 5.
Ongoing Research and Trials
- The Resuscitation Outcomes Consortium is conducting a randomized trial comparing survival with hospital discharge after continuous chest compressions without interruption for ventilation versus currently recommended American Heart Association cardiopulmonary resuscitation with interrupted chest compressions in adult patients with out-of-hospital cardiac arrest 7.
- The primary outcome of this trial is survival to hospital discharge, with secondary outcomes including neurologically intact survival and adverse events 7.