What is the critical care management of an adult in cardiac arrest (CA)?

From the Guidelines

Critical care of an adult in cardiac arrest involves immediate initiation of high-quality CPR, with chest compressions to a depth of at least 2 inches and a rate of 100 to 120/min, along with early defibrillation and administration of epinephrine as soon as feasible. The American Heart Association guidelines 1 emphasize the importance of chest compression quality and the need for early defibrillation in cases of ventricular fibrillation or pulseless ventricular tachycardia.

Key aspects of critical care management include:

• Initiating CPR with 30 chest compressions followed by 2 rescue breaths if trained, or continuous compressions if untrained in rescue breathing
• Using an automated external defibrillator (AED) if available and following the voice prompts
• Establishing an airway, often through endotracheal intubation, and administering medications such as epinephrine (1 mg IV/IO every 3-5 minutes) and amiodarone (300 mg IV/IO for the first dose, then 150 mg for subsequent doses)
• Establishing intravenous access for fluid and medication administration, with normal saline typically given at rates determined by the patient's condition
• Focusing on post-resuscitation care, including identifying and treating the underlying cause, maintaining organ perfusion, controlling body temperature, and preventing secondary injury, as outlined in the 2020 American Heart Association guidelines 1.

The guidelines also highlight the importance of specialized management for certain conditions, such as electrolyte abnormalities, pregnancy, and cardiac surgery, and the need for prompt initiation of targeted temperature management for patients who do not follow commands after return of spontaneous circulation 1. Overall, the critical care management of an adult in cardiac arrest requires a coordinated approach that addresses the immediate threats to life and supports vital organ function until the underlying cause can be addressed.

From the FDA Drug Label

In cardiac arrest, a rapid intravenous dose of one to two 50 mL vials (44.6 to 100 mEq) may be given initially and continued at a rate of 50 mL (44. 6 to 50 mEq) every 5 to 10 minutes if necessary (as indicated by arterial pH and blood gas monitoring) to reverse the acidosis. In cardiac arrest, however, the risks from acidosis exceed those of hypernatremia.

The critical care management of an adult in cardiac arrest (CA) may involve the administration of sodium bicarbonate (IV) to reverse acidosis, with a dose of 44.6 to 100 mEq given initially and repeated every 5 to 10 minutes as necessary, based on arterial pH and blood gas monitoring 2.

• Key considerations:
  • Monitor arterial pH and blood gas
  • Risk of hypernatremia is outweighed by the risk of acidosis in cardiac arrest
  • Administer with caution, as bicarbonate solutions are hypertonic
• Epinephrine (IV) may also be used in cardiac arrest, but the provided label does not directly address its use in this context 3.

From the Research

Critical Care Management of Adult Cardiac Arrest

The critical care management of an adult in cardiac arrest (CA) involves several key components, including:

• Early chest compressions and rapid defibrillation, as emphasized by the American Heart Association (AHA) 4
• Ventilation, with a recommended rate of 10 breaths per minute for patients with an advanced airway, such as an endotracheal tube (ETT) 4
• Use of manual ventilation devices, such as volume-marked resuscitation bags or manual self-inflating resuscitation bags, to deliver breaths synchronized with chest compressions 4

Pharmacologic Management

The pharmacologic management of cardiac arrest involves the use of various medications, including:

• Epinephrine, which is the mainstay of drug therapy during CPR 5
• Lidocaine, which is used in patients with ventricular tachycardia 5
• Atropine, which can be administered in bradyasystolic cardiac arrest, but has not been shown to improve outcomes 5
• Magnesium, which has been shown to be useful in refractory pulseless ventricular tachycardia and fibrillation 5

Route of Drug Administration

The route of drug administration during cardiac arrest is also important, with:

• Intravenous administration being the preferred route, but endotracheal administration being an option if intravenous access has not been established 5, 6
• The currently recommended doses of epinephrine and atropine administered endotracheally being rarely effective in the setting of cardiac arrest and CPR 6

Postresuscitation Care

Postresuscitation care is also critical, and involves:

• Mechanical ventilation to optimize oxygenation and ventilation, if necessary 5
• Maintenance of vital organ function and optimal brain protection, including avoidance of hypertension, hypotension, and hyperglycemia 5
• Titration of inspired oxygen to obtain an arterial oxygen saturation of 94-98%, to avoid possible damage from hyperoxemia 7