Management of Congestive Cardiac Failure During CPR
During cardiopulmonary resuscitation (CPR), the management of congestive cardiac failure (CCF) should focus on high-quality chest compressions with minimal interruptions while addressing the underlying cardiac dysfunction through appropriate medication administration and post-ROSC care.
Initial Management During CPR
High-Quality CPR Fundamentals
- Push hard (at least 2 inches/5 cm) and fast (100-120 compressions/minute) 1
- Allow complete chest recoil after each compression 1
- Minimize interruptions in chest compressions 1
- Avoid excessive ventilation 1
- Rotate compressor every 2 minutes to avoid fatigue 1
- Use a 30:2 compression-to-ventilation ratio without advanced airway 1
Ventilation Considerations in CCF
- Use 100% inspired oxygen during CPR to optimize arterial oxyhemoglobin content 1
- After advanced airway placement, provide 1 breath every 6 seconds (10 breaths/minute) with continuous chest compressions 1
- Avoid excessive ventilation, which can increase intrathoracic pressure and reduce venous return, particularly problematic in CCF 1
Medication Administration
Vasopressors
- Administer epinephrine 1 mg IV/IO every 3-5 minutes for all cardiac arrest rhythms 1, 2
- For patients with CCF, epinephrine's alpha-adrenergic effects help increase coronary perfusion pressure and cerebral perfusion pressure during CPR 2
- Be aware that epinephrine may increase cardiac output and cause peripheral vasoconstriction, which could potentially worsen pulmonary edema after ROSC 3
Fluid Management
- For patients with known CCF, avoid excessive fluid administration during resuscitation
- After ROSC, carefully titrate fluids based on hemodynamic parameters and signs of congestion
Rhythm-Specific Management
Shockable Rhythms (VF/pVT)
- Deliver one shock (biphasic: 120-200J; monophasic: 360J) 1
- Resume CPR immediately after shock for 2 minutes before rhythm check 1
- For refractory VF/pVT, consider amiodarone 300 mg IV/IO bolus, followed by 150 mg if needed 1, 2
Non-Shockable Rhythms (PEA/Asystole)
- Focus on high-quality CPR and epinephrine administration 1
- Identify and treat potential reversible causes, particularly those related to CCF:
Physiologic Monitoring During CPR
- Use quantitative waveform capnography to monitor CPR quality and detect ROSC 1
- If PETCO₂ < 10 mm Hg, attempt to improve CPR quality 1
- Consider arterial line monitoring if available; if relaxation phase (diastolic) pressure < 20 mm Hg, improve CPR quality 1
- Monitor for signs of ROSC:
- Pulse and blood pressure
- Abrupt sustained increase in PETCO₂ (typically ≥ 40 mm Hg)
- Spontaneous arterial pressure waves with intra-arterial monitoring 1
Post-ROSC Management for CCF
Immediate Post-ROSC Care
- Continuously monitor vital signs with target mean arterial pressure (MAP) ≥ 65 mmHg 2
- Carefully titrate vasopressors (norepinephrine 0.05-3 mcg/kg/min) to maintain adequate perfusion 2
- Use low tidal volume ventilation strategy (6 mL/kg predicted body weight) 2
- Obtain 12-lead ECG to assess for acute coronary syndrome 2
CCF-Specific Considerations
- Initiate or resume heart failure medications as appropriate after hemodynamic stabilization
- Consider early echocardiography to assess cardiac function and guide therapy
- Monitor for signs of pulmonary edema and adjust ventilation parameters accordingly
Common Pitfalls to Avoid
- Interrupting chest compressions for extended periods, which reduces coronary perfusion pressure 4, 5
- Excessive ventilation, which increases intrathoracic pressure and reduces venous return 1
- Failure to identify and treat reversible causes of cardiac arrest 2
- Administering large fluid boluses post-ROSC in patients with known CCF
- Delaying vasopressor support when needed 2
By focusing on high-quality CPR with minimal interruptions while addressing the specific challenges of CCF, providers can optimize the chances of successful resuscitation and favorable neurological outcomes in these complex patients.