Immediate Management of Cardiac Arrest
The immediate management of cardiac arrest requires recognition of the arrest, activation of emergency response, high-quality chest compressions, early defibrillation if indicated, and addressing reversible causes, with minimal interruptions to chest compressions throughout the resuscitation effort. 1, 2
Recognition and Initial Response
Recognition
- Identify cardiac arrest by checking for:
- Unresponsiveness
- Absence of normal breathing (or only gasping)
- No definite pulse within 10 seconds (for healthcare providers) 1
Immediate Actions
- Activate emergency response system immediately upon recognition
- Get AED/defibrillator or send someone to retrieve it
- Begin high-quality CPR starting with chest compressions 1
High-Quality CPR
Compression Technique
- Rate: 100-120 compressions per minute
- Depth: At least 2 inches (5 cm) in adults
- Recoil: Allow complete chest recoil after each compression
- Minimize interruptions: Keep pauses less than 10 seconds
- Avoid excessive ventilation 1, 2
Compression-to-Ventilation Ratio
- Without advanced airway: 30:2 for adults
- With advanced airway in place: Continuous compressions with 1 breath every 6-8 seconds (8-10 breaths/minute) 1
Provider Rotation
- Switch compressors every 2 minutes to prevent fatigue and maintain quality 1
Defibrillation
When AED/Defibrillator Arrives
- Apply pads while continuing CPR
- Analyze rhythm with minimal interruption to compressions
- If shockable rhythm (VF/pulseless VT):
Shock Energy
- Biphasic: Use manufacturer's recommended dose (typically 120-200J); if unknown, use maximum available
- Monophasic: 360J 1
Advanced Interventions
Airway Management
- Consider supraglottic airway or endotracheal intubation
- Use waveform capnography to confirm and monitor tube placement
- For patients on mechanical ventilation who arrest, switch to manual ventilation 1, 4
Vascular Access and Medications
- Establish IV/IO access without interrupting compressions
- Administer medications per ACLS protocol:
- Epinephrine: 1mg IV/IO every 3-5 minutes
- Amiodarone: 300mg IV/IO for refractory VF/VT after 3 shocks 1
Monitoring During CPR
Quality Metrics
- If available, use:
- Waveform capnography (PETCO₂)
- Arterial pressure monitoring
- PETCO₂ <10 mmHg suggests need to improve CPR quality
- Abrupt sustained increase in PETCO₂ (≥40 mmHg) may indicate ROSC 1
Addressing Reversible Causes
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
Special Circumstances
Hypothermia
- For hypothermic patients, continue resuscitation efforts until patient is warmed
- If VF/VT persists after initial shock, further defibrillation attempts may be reasonable during rewarming 1
Prone Position
- For patients who arrest while prone with advanced airway in place:
- If immediate supination is not feasible, consider CPR in prone position
- For patients without advanced airway, turn supine as quickly as possible 1
Post-Resuscitation Care
After ROSC
- Monitor vital signs closely
- Consider targeted temperature management for comatose patients
- Arrange transport to facility capable of post-cardiac arrest care 1
Common Pitfalls to Avoid
- Delayed recognition of cardiac arrest
- Interrupted compressions for prolonged periods
- Delayed defibrillation when indicated
- Excessive ventilation causing decreased venous return
- Premature pulse checks after defibrillation (resume CPR immediately after shock) 2, 3
Remember that survival rates decrease by 7-10% for every minute defibrillation is delayed without CPR, and by 3-4% with bystander CPR 2. Immediate recognition, high-quality CPR, and early defibrillation are the cornerstones of successful cardiac arrest management.