What is the management protocol for cardiac arrest?

Cardiac Arrest Management Protocol

The management of cardiac arrest requires a structured approach following the chain of survival, which includes prompt recognition, early CPR, rapid defibrillation, effective advanced life support, and integrated post-arrest care to optimize outcomes. 1

Immediate Response and Recognition

• Cardiac arrest should be assumed in any collapsed and unresponsive individual 2
• Seizure-like activity and abnormal breathing or gasping must be considered as signs of cardiac arrest until proven otherwise 2
• Immediately activate the emergency medical response system and call for additional assistance 2

High-Quality CPR

• Begin hands-only (compression-only) CPR immediately if the patient is unresponsive and not breathing normally 2
• Push hard (at least 5 cm/2 inches deep) and fast (100-120 compressions/minute), allowing complete chest recoil 2
• Minimize interruptions in chest compressions to maintain perfusion 2
• Switch compressors every 2 minutes or sooner if fatigued to maintain effective compressions 2
• For patients without advanced airway, use a 30:2 compression-to-ventilation ratio 2
• Avoid excessive ventilation as it can impede venous return and decrease cardiac output 2

Defibrillation

• Apply an automated external defibrillator (AED) or manual defibrillator as soon as possible while CPR continues 2
• Stop CPR only for rhythm analysis and shock delivery if indicated 2
• Resume CPR immediately after shock delivery for 2 minutes before reassessing rhythm 2
• If no shock is delivered, continue CPR and life support measures until the patient becomes responsive or a non-cardiac etiology is established 2

Advanced Airway Management

• Establish an advanced airway (endotracheal intubation or supraglottic airway device) 2
• Confirm correct placement using waveform capnography 2
• After advanced airway placement, provide 1 breath every 6 seconds (10 breaths/min) with continuous chest compressions 2
• Monitor PETCO2 (typically 35-40 mm Hg) to assess CPR quality and detect return of spontaneous circulation 2

Medication Administration

• For shock-refractory ventricular fibrillation/pulseless ventricular tachycardia (VF/pVT), consider either amiodarone or lidocaine 2
• Amiodarone IV/IO dose: First dose 300 mg bolus, second dose 150 mg 2
• Lidocaine IV/IO dose: First dose 1-1.5 mg/kg, second dose 0.5-0.75 mg/kg 2
• Consider vasopressors according to standard ACLS protocols 2

Identify and Treat Reversible Causes

• Search for and treat the "H's and T's" of cardiac arrest 2:
  • Hypovolemia, hypoxia, hydrogen ion (acidosis), hypo/hyperkalemia, hypothermia
  • Tension pneumothorax, tamponade (cardiac), toxins, thrombosis (coronary or pulmonary)

Return of Spontaneous Circulation (ROSC) Indicators

• Presence of pulse and blood pressure 2
• Abrupt sustained increase in PETCO2 (typically >40 mm Hg) 2
• Spontaneous arterial pressure waves with intra-arterial monitoring 2

Post-Cardiac Arrest Care

• Optimize cardiopulmonary function and vital organ perfusion 2
• Transport to an appropriate hospital with comprehensive post-cardiac arrest care capabilities 2
• Control body temperature to optimize survival and neurological recovery 2
• Consider therapeutic hypothermia (32-34°C) for comatose survivors 2
• Identify and treat acute coronary syndromes 2
• Optimize mechanical ventilation to minimize lung injury 2
• Elevate head of bed 30° if tolerated to reduce cerebral edema, aspiration, and ventilator-associated pneumonia 2
• Titrate inspired oxygen to achieve arterial oxygen saturation of 94% to avoid potential oxygen toxicity 2
• Target ventilation to achieve PETCO2 of 35-40 mm Hg or PaCO2 of 40-45 mm Hg 2

Team Approach and Quality Improvement

• Implement performance-focused debriefing for resuscitation team members after in-hospital cardiac arrest 2
• Develop system-wide plans for proactive treatment of cardiac arrest patients 2
• Consider transport to specialized centers with higher cardiac arrest case volumes for improved outcomes 2

Special Considerations

• For cardiac arrest on a sports field, perform initial CPR and defibrillation at the location of collapse 2
• Only transfer the patient after careful consideration, as external chest compression during transit may be less effective 2
• For hypothermic patients, continue CPR until rewarming is achieved 1

By following this structured protocol for cardiac arrest management, healthcare providers can optimize the chances of successful resuscitation and improve patient outcomes.