What is the immediate treatment for cardiac arrest?

Immediate Treatment for Cardiac Arrest

Begin high-quality chest compressions immediately at a rate of 100-120 per minute and depth of at least 2 inches (5 cm), call for help and activate the emergency response system, apply an automated external defibrillator (AED) as soon as available, and minimize any interruptions in compressions. 1, 2

Recognition and Initial Response

• Any collapsed and unresponsive person should be assumed to be in cardiac arrest until proven otherwise, particularly if they are not breathing normally or only gasping 1
• Agonal gasps occur in over 50% of cardiac arrest victims and must not be mistaken for normal breathing 1
• Do not waste time checking for a pulse, as this is unreliable even for trained rescuers and causes critical delays 1
• Immediately activate the emergency response system (call 911 or your institution's code team) 1, 3

High-Quality CPR: The Foundation

Chest compressions are the absolute priority and should be initiated before any other intervention, including ventilation. 1, 2

Compression Technique

• Compress at a rate of 100-120 compressions per minute 2
• Push hard: at least 2 inches (5 cm) depth in adults 1, 2
• Allow complete chest recoil between compressions 2
• Minimize interruptions—any pause in compressions dramatically reduces survival 1, 2
• Switch compressors every 2 minutes to prevent fatigue and maintain quality 3, 2

Compression-to-Ventilation Ratio

• 30:2 ratio if no advanced airway is in place 2
• Continuous compressions with 10 breaths per minute once an advanced airway is secured 2
• For lay rescuers unwilling or unable to provide ventilations, hands-only CPR (compressions only) is acceptable and should not delay initiation 1

Early Defibrillation: Time is Critical

Survival decreases by 10% per minute that defibrillation is delayed without CPR, or 3-4% per minute with CPR. 1

• Apply the AED/defibrillator immediately when available, ideally without interrupting chest compressions 1
• For ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT), deliver one shock and immediately resume CPR without checking for a pulse 2
• Use 120-200 joules for biphasic defibrillators (or manufacturer's recommendation), or 360 joules for monophasic 2
• Public access defibrillation programs have dramatically improved survival when AEDs are deployed within 3-5 minutes of collapse 1

Advanced Airway Management

• Begin bag-mask ventilation with 100% oxygen while preparing for advanced airway placement 3
• Open the airway with head tilt-chin lift unless cervical spine injury is suspected 3
• Place a supraglottic airway device or endotracheal tube when trained personnel are available 2
• Use continuous waveform capnography to confirm tube placement and monitor CPR quality (target PETCO2 >10 mmHg during CPR) 3
• Avoid hyperventilation—limit to 10 breaths per minute with advanced airway 3, 2

Medication Administration

Once IV/IO access is established:

• Epinephrine 1 mg IV/IO every 3-5 minutes for pulseless arrest 3
• For shockable rhythms (VF/VT): Amiodarone 300 mg IV/IO for first dose, then 150 mg for second dose 3

Address Reversible Causes (H's and T's)

Systematically evaluate and treat reversible causes using the H's and T's mnemonic: 3, 2

H's:

• Hypovolemia
• Hypoxia
• Hydrogen ions (acidosis)
• Hypo/hyperkalemia
• Hypothermia

T's:

• Tension pneumothorax
• Tamponade (cardiac)
• Toxins
• Thrombosis (pulmonary embolism)
• Thrombosis (coronary—acute MI)

Critical Time Windows

Early CPR by bystanders must begin within 4-6 minutes and be followed by advanced life support within 10-12 minutes to be effective. 4

• Witnessed cardiac arrest with immediate CPR has 32% survival versus 22% with delayed CPR 4
• In-hospital cardiac arrest survival depends heavily on response time—no patients survived when advanced support arrived after 6 minutes 5
• Cardiac arrest witnessed by trained personnel has 3.5 times better survival than unwitnessed arrest 6

Post-Resuscitation Care (After ROSC)

Once return of spontaneous circulation (ROSC) is achieved:

• Optimize oxygenation: maintain SpO2 ≥94%, avoid hyperventilation 3
• Target PETCO2 35-40 mmHg or PaCO2 40-45 mmHg 3
• Consider therapeutic hypothermia (32-34°C) for comatose survivors 3, 2
• Obtain 12-lead ECG immediately; if STEMI present, activate catheterization lab for emergent PCI 1
• Transport to a facility with comprehensive post-cardiac arrest care capabilities including PCI 1, 2

Common Pitfalls to Avoid

• Do not delay compressions to check for breathing or pulse—this is the most common error 1
• Do not interrupt compressions for rhythm checks, intubation, or IV access—these can be done during ongoing CPR 2
• Do not confuse agonal gasps with normal breathing—this leads to failure to initiate CPR 1
• Do not hyperventilate—excessive ventilation impairs venous return and worsens outcomes 3, 2
• In athletic settings, do not mistake seizure-like activity for a primary seizure—over 50% of SCA victims have brief myoclonic movements 1, 7