What are the steps in managing cardiac arrest?

Management of Cardiac Arrest

The management of cardiac arrest requires immediate recognition, high-quality CPR, early defibrillation, and systematic administration of medications according to the 2020 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. 1

Initial Recognition and Response

1. Check for responsiveness:

   • Shout for nearby help
   • Activate emergency response system
   • Get AED and emergency equipment 1

2. Assess breathing and pulse simultaneously:

   • Look for no breathing or only gasping
   • Check pulse for no more than 10 seconds
   • If no pulse is detected, begin CPR immediately 1

High-Quality CPR Components

• Compression rate: 100-120 compressions per minute
• Compression depth: At least 2 inches (5 cm) in adults
• Chest recoil: Allow complete chest recoil after each compression
• Minimize interruptions: Keep pauses in chest compressions to less than 10 seconds
• Avoid excessive ventilation: 30:2 compression-to-ventilation ratio without advanced airway 1, 2
• Rotate compressors: Change person performing compressions every 2 minutes to prevent fatigue 2

Defibrillation

• Apply AED/defibrillator as soon as available
• For shockable rhythms (VF/pVT):
  • Deliver one shock (biphasic: 120-200J or manufacturer recommendation; monophasic: 360J)
  • Resume CPR immediately after shock for 2 minutes before rhythm check
  • Do not delay CPR for rhythm check after shock 1, 2

Medication Administration

• Epinephrine:

  • Administer 1 mg IV/IO every 3-5 minutes for all cardiac arrest rhythms
  • First dose should be given as early as possible for non-shockable rhythms
  • For shockable rhythms, administer after initial defibrillation attempts 2, 3

• Antiarrhythmic drugs (for shockable rhythms):

  • Amiodarone: 300 mg IV/IO bolus for first dose, followed by 150 mg if needed
  • Alternative: Lidocaine 1-1.5 mg/kg IV/IO first dose, then 0.5-0.75 mg/kg if needed 2

Airway Management

• Initial management: Begin with bag-mask ventilation

• Advanced airway options:

  • Consider supraglottic airway or endotracheal intubation after initial CPR cycles
  • Confirm placement with waveform capnography
  • After advanced airway placement, provide 1 breath every 6 seconds (10 breaths/min) with continuous compressions 1, 2, 4

• Important: Do not interrupt chest compressions for more than 10 seconds for intubation attempts 4

Systematic Approach to Cardiac Arrest Management

1. Begin high-quality CPR immediately
2. Apply monitor/defibrillator when available
3. Assess rhythm:

   • Shockable (VF/pVT):

     • Shock once
     • Resume CPR for 2 minutes
     • Establish IV/IO access
     • Give epinephrine every 3-5 minutes
     • Consider advanced airway
     • Consider antiarrhythmics after second shock

   • Non-shockable (PEA/Asystole):

     • Continue CPR
     • Give epinephrine as soon as possible, then every 3-5 minutes
     • Consider advanced airway
     • Reassess rhythm every 2 minutes 1, 2

Identifying and Treating Reversible Causes

Search for and treat the "H's and T's":

• H's: Hypovolemia, Hypoxia, Hydrogen ion (acidosis), Hypo/Hyperkalemia, Hypothermia
• T's: Tension pneumothorax, Tamponade (cardiac), Toxins, Thrombosis (pulmonary), Thrombosis (coronary) 1, 2

Post-Cardiac Arrest Care

• Return of spontaneous circulation (ROSC) indicators:

  • Pulse and blood pressure
  • Abrupt sustained increase in PETCO₂ (typically ≥40 mm Hg)
  • Spontaneous arterial pressure waves with monitoring 1

• Post-ROSC management:

  • Optimize oxygenation and ventilation
  • Maintain hemodynamic stability (MAP ≥65 mmHg)
  • Consider targeted temperature management
  • Perform early coronary angiography for suspected cardiac cause 2

Common Pitfalls to Avoid

• Delaying CPR to check for pulse longer than 10 seconds
• Interrupting chest compressions frequently or for prolonged periods
• Delivering excessive ventilation (too fast or too large volume)
• Failing to rotate compressors every 2 minutes
• Delaying epinephrine administration
• Not identifying and treating reversible causes 2

By following this systematic approach to cardiac arrest management with emphasis on high-quality CPR, early defibrillation when indicated, and appropriate medication administration, you can optimize the chance of survival with good neurological outcomes for cardiac arrest patients.