What are the guidelines for managing cardiac arrest in a hospital setting?

Guideline for Managing Cardiac Arrest in the Cardiac Reanimation Ward

Immediate Recognition and Response

Upon discovering an unresponsive patient with absent or abnormal breathing (gasping only), assume cardiac arrest and immediately activate your code team while simultaneously beginning chest compressions. 1

• Check for a pulse for no more than 10 seconds—if no definite pulse is felt, begin CPR immediately 1
• Do not delay compressions for airway management or rhythm analysis 2
• Activate the hospital-wide cardiac arrest response system (overhead page, team pager, or local alarm) 1

High-Quality CPR Protocol

Chest compressions are the single most critical intervention and must be performed with meticulous attention to quality metrics. 1, 2, 3

Compression Technique

• Rate: 100-120 compressions per minute (recent evidence suggests 121-140/min may optimize ROSC in hospital settings) 1, 4
• Depth: At least 2 inches (5 cm) in adults 1
• Recoil: Allow complete chest recoil between compressions 1
• Minimize interruptions: Maintain chest compression fraction >80% 2
• Rotate compressors every 2 minutes to prevent fatigue-related quality degradation 1

Ventilation Strategy

• Before advanced airway: 30:2 compression-to-ventilation ratio 1
• After advanced airway placement: 1 breath every 6 seconds (10 breaths/minute) with continuous chest compressions 1, 5
• Avoid hyperventilation—excessive ventilation rates increase intrathoracic pressure, decrease coronary perfusion, and worsen outcomes 1, 5

Rhythm Assessment and Defibrillation

Perform brief rhythm checks every 2 minutes; if VF/pulseless VT is identified, defibrillate immediately and resume CPR without pulse check. 1

Defibrillation Protocol

• Biphasic defibrillators: Use manufacturer recommendation (typically 120-200 J initial dose); if unknown, use maximum available 1
• Monophasic defibrillators: 360 J 1
• Subsequent shocks: Use equivalent or higher energy 1
• Minimize pre-shock pause to <5 seconds by charging during compressions 1
• Resume CPR immediately after shock delivery, beginning with compressions 1

Advanced Airway Management

Place a supraglottic airway or perform endotracheal intubation without prolonged interruption of chest compressions. 1, 5

• Confirm placement with continuous waveform capnography—this is mandatory, not optional 1, 5
• Target PETCO₂ >10 mmHg during CPR; if below this threshold, improve CPR quality 1
• An abrupt sustained increase in PETCO₂ to ≥40 mmHg indicates ROSC 1, 5

Medication Administration

Vascular Access

• Establish IV or intraosseous (IO) access without interrupting compressions 1, 5

Vasopressor Therapy

• Epinephrine 1 mg IV/IO every 3-5 minutes for all cardiac arrest rhythms 1, 5
• Continue throughout resuscitation until ROSC or termination of efforts 1, 5

Antiarrhythmic Therapy (for refractory VF/pulseless VT)

• Amiodarone: 300 mg IV/IO bolus first dose, then 150 mg second dose 1
• Alternative—Lidocaine: 1-1.5 mg/kg first dose, then 0.5-0.75 mg/kg second dose 1

Systematic Evaluation of Reversible Causes

During every resuscitation, systematically address the H's and T's to identify treatable causes. 1, 5

The H's

• Hypovolemia: Administer IV fluid boluses 1, 5
• Hypoxia: Ensure adequate oxygenation and ventilation 1, 5
• Hydrogen ion (acidosis): Optimize ventilation 1, 5
• Hypokalemia/Hyperkalemia: Check point-of-care potassium and correct aggressively 1, 5
• Hypothermia: Rewarm if accidental hypothermia present 1, 5

The T's

• Tension pneumothorax: Perform immediate needle decompression if suspected 1, 5
• Tamponade (cardiac): Consider bedside ultrasound and emergent pericardiocentesis 1, 5
• Toxins: Administer specific antidotes when applicable 1, 5
• Thrombosis (pulmonary): Consider thrombolytics for massive PE 1, 5
• Thrombosis (coronary): Obtain 12-lead ECG immediately upon ROSC; activate cath lab for STEMI 5, 6

Monitoring CPR Quality

Use real-time feedback devices and physiologic monitoring to optimize resuscitation quality. 1

• PETCO₂ monitoring: If <10 mmHg, immediately improve compression quality 1
• Arterial line monitoring (if available): If diastolic pressure <20 mmHg, improve CPR quality 1
• Monitor compression depth and rate with feedback devices when available 1, 7

Post-ROSC Care

Once ROSC is achieved, immediately transition to comprehensive post-cardiac arrest management. 5, 6

Immediate Stabilization

• Confirm ROSC by pulse, blood pressure, and sustained PETCO₂ ≥40 mmHg 1, 5
• Maintain systolic blood pressure with vasopressors as needed 5, 6
• Titrate oxygen to SpO₂ 94-98% (avoid both hypoxemia and hyperoxemia) 5, 6
• Maintain normocapnia with waveform capnography guidance 5, 6

Diagnostic Evaluation

• Obtain 12-lead ECG immediately to identify STEMI 5, 6
• Draw arterial blood gas, electrolytes, glucose, complete blood count, cardiac biomarkers 5, 6
• Activate cardiac catheterization lab emergently for patients with ST-elevation or high suspicion for acute coronary syndrome 5, 6

Neuroprotective Measures

• Initiate targeted temperature management for all comatose patients (those not following commands) 1, 2, 5, 6
• Consider therapeutic hypothermia (32-34°C) for 24 hours 2, 6
• Monitor for and treat seizures aggressively 5, 6

Transfer Considerations

• Transfer patients to facilities with comprehensive post-cardiac arrest systems including coronary intervention capabilities, advanced neurological care, and targeted temperature management 2, 6

Team Leadership and Crisis Resource Management

Designate a clear team leader who directs the resuscitation while remaining hands-off to maintain situational awareness. 1

• Team leader assigns specific roles (compressor, airway, medications, recorder, defibrillator) 1
• Use closed-loop communication: team members repeat back orders 1
• Perform "all clear" safety checks before every defibrillation attempt 1
• Maintain a 24/7 dedicated resuscitation team with regular training 1

Quality Improvement and Documentation

Participate in continuous quality improvement by measuring and reviewing all cardiac arrest events. 1, 8

• Document compression fraction, depth, rate, and interruption times 1
• Review cases at regular morbidity and mortality conferences 1, 8
• Track survival to discharge and neurological outcomes 1, 8
• Implement corrective actions based on performance data 1, 8

Critical Pitfalls to Avoid

• Never delay compressions for rhythm checks, airway placement, or IV access 2
• Never hyperventilate—this decreases cerebral blood flow and cardiac output 1, 5
• Never allow compression fatigue—rotate compressors every 2 minutes without exception 1
• Never perform prolonged pulse checks—limit to 10 seconds maximum 1
• Never prematurely withdraw care—avoid prognostication during active resuscitation 8

Prevention Strategies

Implement rapid response teams to identify and intervene on deteriorating patients before cardiac arrest occurs. 1

• Establish early warning systems using vital sign triggers 1
• Deploy rapid response teams for at-risk patients 1
• Discuss goals of care and DNAR orders appropriately for patients with terminal conditions or poor prognosis 1