Respiratory Arrest in CVICU: Recognition and Management
Immediate recognition and intervention for respiratory arrest in the CVICU is critical for patient survival, with prompt initiation of high-quality CPR and advanced airway management being the cornerstone of treatment.
Definition and Recognition
Respiratory arrest is the cessation of effective breathing that, if not promptly treated, leads to cardiac arrest. In the CVICU setting, early recognition is crucial for preventing progression to full cardiopulmonary arrest.
Signs and Symptoms
- Absence of breathing or only gasping respirations 1
- Cyanosis 1
- Unresponsiveness or decreased level of consciousness 1
- Absence of breath sounds on auscultation 1
- Bradycardia progressing to asystole if untreated 1
- Hypotension 1
Immediate Management
Initial Actions
- Immediately check for responsiveness and breathing 1
- Call for help and activate the emergency response system 1
- Position patient supine if possible 1
- Begin high-quality CPR if pulseless 1
- Apply cardiac monitor/defibrillator 1
Airway Management
- Open airway using head tilt-chin lift maneuver (unless cervical spine injury is suspected) 1
- For patients with suspected cervical spine injury, use jaw thrust without head tilt 1
- Begin bag-mask ventilation with 100% oxygen while preparing for advanced airway placement 1
- For patients already in prone position with an advanced airway in place, CPR may be initiated in the prone position if immediate supination poses significant risk 1
Advanced Airway Management
- Endotracheal intubation or supraglottic airway placement should be performed by experienced providers 1
- Always confirm advanced airway placement using waveform capnography 1
- After advanced airway placement, provide 1 breath every 6 seconds (10 breaths/minute) with continuous chest compressions 1
- Avoid hyperventilation as it increases intrathoracic pressure and decreases cardiac output 1, 2
Medication Administration
- Establish IV/IO access if not already present 1
- For pulseless arrest, administer epinephrine 1 mg IV/IO every 3-5 minutes 1
- For shockable rhythms (VF/pVT), administer amiodarone 300 mg IV/IO for the first dose, followed by 150 mg for the second dose; or lidocaine 1-1.5 mg/kg for the first dose, followed by 0.5-0.75 mg/kg 1
Monitoring During Resuscitation
- Continuous waveform capnography to confirm airway placement and assess CPR quality 1
- Arterial line monitoring (if present) to assess blood pressure during CPR 1
- Monitor for signs of ROSC: pulse, blood pressure, abrupt sustained increase in PETCO2 (≥40 mmHg), or spontaneous arterial pressure waves 1
CVICU-Specific Considerations
- Utilize invasive monitoring already in place (arterial lines, central venous catheters) 1
- For patients on mechanical ventilation, check for disconnection, obstruction, or equipment failure 1
- Consider reversible causes using the H's and T's mnemonic 1:
- Hypovolemia, Hypoxia, Hydrogen ion (acidosis), Hypo/hyperkalemia, Hypothermia
- Tension pneumothorax, Tamponade, Toxins, Thrombosis (pulmonary), Thrombosis (coronary)
- For patients in prone position (common during COVID-19 treatment):
- If advanced airway is already in place and immediate supination poses risk, initiate CPR in prone position 1
- If no advanced airway is in place, turn patient supine as quickly as possible 1
- For shockable rhythms in prone position where immediate supination isn't possible, attempt defibrillation in prone position 1
Post-Resuscitation Care
- Elevate head of bed 30° if tolerated to reduce cerebral edema, aspiration, and ventilator-associated pneumonia 1
- Avoid hyperventilation and maintain PETCO2 between 35-40 mmHg or PaCO2 between 40-45 mmHg 1
- Titrate oxygen to maintain arterial oxygen saturation ≥94% to avoid potential oxygen toxicity 1
- Consider therapeutic hypothermia for comatose survivors 1
- Identify and treat the precipitating cause of the arrest 1
Prognostic Considerations
- Survival rates after cardiac arrest in ICU settings vary, with approximately 30% surviving to ICU discharge and 27% to hospital discharge 3
- Poor prognostic factors include:
CVICU Tips for Improving Outcomes
- Ensure all staff are trained in high-quality CPR and advanced airway management 1
- Maintain crash carts with readily accessible equipment 5
- Consider implementing a comprehensive, structured treatment protocol to improve survival 1
- Minimize interruptions in chest compressions during CPR 1
- Change compressor every 2 minutes to prevent fatigue and maintain compression quality 1
- Use CPR feedback devices when available to ensure adequate depth and rate of compressions 1
- Consider cardiocerebral resuscitation approach for primary cardiac arrests, emphasizing continuous chest compressions 6