What are the steps for managing cardiac arrest?

Cardiac Arrest Management

Immediate Recognition and Response

Any collapsed and unresponsive individual should be assumed to be in cardiac arrest until proven otherwise, and immediate CPR should be initiated without delay. 1

• Recognize cardiac arrest immediately: Unresponsiveness combined with absent or abnormal breathing (including gasping or seizure-like activity) indicates cardiac arrest 1
• Activate emergency response system immediately while simultaneously beginning resuscitation 1
• Do not waste time checking for a pulse if you are untrained; healthcare providers should take no more than 10 seconds to confirm pulse absence 1
• Agonal gasping occurs in over 50% of cardiac arrests and should never be mistaken for normal breathing 1

High-Quality CPR: The Foundation of Survival

Chest compressions are the single most critical intervention and must be started immediately and performed with minimal interruptions. 1, 2

Compression Technique

• Push hard: Compress at least 5 cm (2 inches) deep in adults 2, 3
• Push fast: Rate of 100-120 compressions per minute 2, 3
• Allow complete chest recoil between compressions to maximize venous return 2
• Minimize interruptions: Pauses should be limited to less than 10 seconds for rhythm checks and defibrillation 1, 2
• Switch compressors every 2 minutes to prevent fatigue and maintain compression quality 2, 3

Ventilation Strategy

• For lay rescuers: Hands-only CPR (compressions only) is acceptable and recommended 1
• For trained rescuers without advanced airway: Use 30:2 compression-to-ventilation ratio 2, 3
• After advanced airway placement: Provide continuous compressions with 1 breath every 6 seconds (10 breaths/minute) 2, 3
• Avoid excessive ventilation as it impedes venous return and decreases cardiac output 2

Early Defibrillation: Time is Critical

Apply an AED or manual defibrillator as soon as available—survival decreases 10% per minute without defibrillation (3-4% with CPR). 1

• Continue CPR while applying defibrillator pads; do not stop compressions during pad placement 1, 2
• Stop compressions only for rhythm analysis and shock delivery 1, 2
• For VF/pulseless VT: Deliver shock immediately 2
  • Biphasic: 120-200J per manufacturer recommendation 3, 4
  • Monophasic: 360J 3
• Resume CPR immediately after shock for 2 minutes before reassessing rhythm 1, 2

Advanced Airway Management

Establish an advanced airway (endotracheal tube or supraglottic device) but never delay chest compressions to do so. 2

• Confirm tube placement with continuous waveform capnography 2
• Monitor PETCO₂: Target 35-40 mmHg during CPR; abrupt rise above 40 mmHg suggests return of spontaneous circulation 2
• After airway secured: Deliver 10 breaths/minute with continuous compressions 2, 3
• Avoid hyperventilation: More than 10 breaths/minute is harmful 3

Medication Administration

Administer epinephrine early, particularly for non-shockable rhythms, as it improves survival. 1

For All Cardiac Arrests

• Epinephrine 1 mg IV/IO every 3-5 minutes during resuscitation 1

For Shock-Refractory VF/Pulseless VT

• Amiodarone: 300 mg IV/IO bolus, then 150 mg for second dose 2, 4
• OR Lidocaine: 1-1.5 mg/kg IV/IO, then 0.5-0.75 mg/kg for second dose 2, 4
• Neither amiodarone nor lidocaine has demonstrated superiority for long-term survival 4

Identify and Treat Reversible Causes (H's and T's)

Actively search for and treat reversible causes throughout resuscitation—this is essential for special circumstances. 2, 3, 5

The H's

• Hypovolemia: Rapid fluid bolus and blood products 4
• Hypoxia: Ensure adequate oxygenation and ventilation 2, 3
• Hydrogen ion (acidosis): Address underlying cause 2, 3
• Hypo/Hyperkalemia: Check and correct electrolytes immediately 2, 4
• Hypothermia: Continue CPR during rewarming 2, 3

The T's

• Tension pneumothorax: Needle decompression 4, 5
• Tamponade (cardiac): Bedside echocardiography and pericardiocentesis 4, 5
• Toxins: Specific antidotes as indicated 2, 3
• Thrombosis (coronary or pulmonary): Consider fibrinolysis or mechanical intervention 2, 5

Point-of-care ultrasound should be used to identify reversible causes without interrupting CPR 5

Recognition of Return of Spontaneous Circulation (ROSC)

An abrupt sustained increase in PETCO₂ (typically >40 mmHg) is the most reliable indicator of ROSC during ongoing CPR. 2

• Palpable pulse and measurable blood pressure 2
• Spontaneous arterial pressure waves on invasive monitoring 2
• Do not stop CPR to check for pulse unless PETCO₂ rises or rhythm clearly changes 2

Post-Cardiac Arrest Care: The Fifth Link

Immediately after ROSC, initiate a comprehensive, protocolized approach focusing on neuroprotection, hemodynamic optimization, and treatment of the underlying cause. 1

Immediate Priorities (First Minutes)

• Optimize oxygenation: Target SpO₂ 92-98% to avoid both hypoxia and hyperoxemia 2, 4
• Optimize ventilation: Target PETCO₂ 35-40 mmHg or PaCO₂ 40-45 mmHg 2
• Maintain adequate perfusion: Target MAP ≥65 mmHg with vasopressors if needed 4
• Obtain 12-lead ECG immediately and consider emergent coronary angiography for suspected ACS 2, 4

Targeted Temperature Management

Initiate targeted temperature management (32-34°C) for all comatose survivors who do not follow commands after ROSC. 1, 2

• This is a critical intervention for optimizing neurological recovery 1
• Maintain temperature control for at least 24 hours 1

Transport and Systems of Care

• Transport to a comprehensive cardiac arrest center with capabilities for coronary intervention, neurological care, and goal-directed critical care 1
• Hospitals with higher cardiac arrest volumes demonstrate better survival outcomes 1

Ongoing Management

• Elevate head of bed 30° if hemodynamically tolerated to reduce cerebral edema and aspiration risk 2
• Identify and treat precipitating cause (acute coronary syndrome, pulmonary embolism, etc.) 1, 2
• Optimize mechanical ventilation to minimize lung injury 1, 2
• Monitor for and prevent multiorgan dysfunction 1, 3

Neurological Prognostication

Delay prognostication for at least 72 hours after achieving normothermia to avoid premature withdrawal of care in patients with potential for recovery. 1

• Use multimodal assessment including clinical examination, imaging, electrophysiology, and biomarkers 1
• Avoid premature care withdrawal based on single prognostic factors 1

Special Considerations

Post-Cardiac Surgery Patients

In post-cardiac surgery arrest, rapidly assess for reversible surgical causes BEFORE initiating external chest compressions. 4

• Perform bedside echocardiography immediately to identify tamponade, hypovolemia, or ventricular dysfunction 4
• Consider up to 3 stacked shocks for VF/pulseless VT before compressions 4
• Prepare for emergency resternotomy if standard measures fail 4

Opioid-Associated Cardiac Arrest

The mainstay remains high-quality CPR and early defibrillation; administer naloxone per protocol if available. 1

Quality Improvement

Implement performance-focused debriefing after every resuscitation and participate in national quality improvement registries. 1

• Develop system-wide protocols for cardiac arrest management 1
• Ensure data interoperability between EMS and hospital systems 1
• Create a resuscitation learning health system through continuous measurement and reporting 1

Common Pitfalls to Avoid

• Do not delay CPR to obtain a definitive pulse check—if uncertain, start compressions 1
• Do not mistake agonal gasping for adequate breathing 1
• Do not interrupt compressions for prolonged periods during rhythm checks or procedures 1, 2
• Do not hyperventilate—this decreases cardiac output and worsens outcomes 2, 3
• Do not withdraw care prematurely in the post-arrest period without comprehensive prognostication 1
• Do not delay defibrillation to establish IV access or administer medications 1