What is the first line treatment in primary care for cardiac arrest?

First Line Treatment in Primary Care for Cardiac Arrest

The first line treatment for cardiac arrest in primary care is to immediately start high-quality chest compressions at a rate of 100-120 compressions per minute, at least 2 inches (5 cm) deep, followed by using an automated external defibrillator (AED) as soon as it becomes available. 1

Initial Response Algorithm

1. Recognition of cardiac arrest:

   • Check for responsiveness
   • Check for no breathing or only gasping
   • No pulse check required for lay rescuers (healthcare providers should check pulse within 10 seconds)

2. Immediate actions:

   • Activate emergency response system
   • Get AED/defibrillator (or send someone to retrieve it)
   • Begin chest compressions immediately

3. High-quality CPR:

   • Push hard (at least 2 inches/5 cm deep)
   • Push fast (100-120 compressions per minute)
   • Allow complete chest recoil after each compression
   • Minimize interruptions in chest compressions
   • Avoid excessive ventilation

CPR Technique

For Healthcare Providers:

• Perform cycles of 30 compressions to 2 breaths until an advanced airway is placed 1
• After advanced airway placement, provide continuous compressions with 1 breath every 6 seconds (10 breaths/minute) 1
• Change compressor every 2 minutes or sooner if fatigued to maintain compression quality 1

For Lay Rescuers:

• Perform cycles of 30 compressions to 2 breaths 1
• If untrained or unwilling to provide rescue breathing, compression-only CPR is appropriate 1

Defibrillation

• Use AED as soon as it becomes available 1
• For shockable rhythms (VF/pVT):
  • Deliver one shock
  • Resume CPR immediately for 2 minutes before next rhythm check
  • Minimize pre-shock and post-shock pauses in compressions 1, 2
• For non-shockable rhythms:
  • Continue CPR for 2 minutes before rechecking rhythm 1

Advanced Interventions (if available in primary care setting)

• Establish IV/IO access
• Administer epinephrine 1 mg IV/IO every 3-5 minutes 1
• For persistent VF/pVT after initial shock:
  • Consider amiodarone (first dose: 300 mg bolus; second dose: 150 mg) or
  • Consider lidocaine (first dose: 1-1.5 mg/kg; second dose: 0.5-0.75 mg/kg) 1

Common Pitfalls and How to Avoid Them

1. Delayed recognition and response

   • Train staff to quickly recognize cardiac arrest
   • Implement clear protocols for emergency response

2. Poor-quality compressions

   • Ensure proper depth (at least 2 inches/5 cm)
   • Maintain appropriate rate (100-120/min)
   • Allow complete chest recoil between compressions
   • Use feedback devices when available to monitor quality 1

3. Excessive interruptions in chest compressions

   • Minimize pauses for rhythm checks (limit to <10 seconds)
   • Resume compressions immediately after defibrillation
   • Coordinate team actions to reduce interruptions 3

4. Delayed defibrillation

   • Have AEDs readily accessible throughout the facility
   • Train all staff in AED use
   • Remember that early defibrillation (within first minute) is associated with survival rates up to 90% 2

5. Inadequate post-resuscitation care

   • Be prepared to transfer to higher level of care
   • Monitor for return of spontaneous circulation (ROSC)
   • Be ready to treat reversible causes (Hs and Ts) 1

The 2020 American Heart Association guidelines emphasize that high-quality CPR with minimal interruptions and early defibrillation are the cornerstones of successful resuscitation for cardiac arrest patients 1. These interventions have the strongest evidence for improving survival with good neurological outcomes.