What is the protocol for managing a patient in cardiac arrest in the ward?

Managing Cardiac Arrest in the Ward

Immediately begin high-quality chest compressions at 100-120/minute with a depth of 5-6 cm while simultaneously calling for help and retrieving the defibrillator—these are the most critical actions that determine survival. 1, 2

Initial Response (First 10 Seconds)

Verify scene safety first before approaching to avoid becoming a second victim. 2, 3

Rapid assessment sequence:

• Shout and tap the patient to check responsiveness 1, 2, 3
• Simultaneously assess breathing and pulse within 10 seconds—look for absent breathing or only gasping while checking for a pulse 1, 2, 3
• If no pulse is detected or you are uncertain after 10 seconds, immediately start CPR 3

Critical pitfall: Healthcare providers often take too long checking for a pulse, delaying compressions. If uncertain after 10 seconds, start CPR immediately. 4, 3

Immediate Actions (Within First Minute)

Call for help and activate the code team:

• Shout for nearby help 1, 2
• Have someone activate the emergency response system/code team immediately 1, 2
• Send someone to retrieve the crash cart with defibrillator and emergency medications 1, 2

Start CPR immediately—do not delay for any reason: 2, 3

High-Quality CPR Technique

Chest compressions are the absolute priority and should be started immediately rather than beginning with ventilation. 2

Compression parameters:

• Depth: 5-6 cm (at least 2 inches) in adults 1, 2, 4
• Rate: 100-120 compressions per minute 1, 2, 4
• Location: Center of chest on a firm surface 2
• Recoil: Allow complete chest recoil between compressions—incomplete recoil prevents cardiac refilling and is a critical error 1, 2, 4
• Interruptions: Minimize pauses to less than 10 seconds 1, 2

Compression-to-ventilation ratio:

• 30:2 ratio for adults (30 compressions followed by 2 breaths) 1, 2, 4
• Change compressor every 2 minutes or sooner if fatigued 1

Critical pitfall: Leaning on the chest between compressions prevents adequate cardiac refilling—ensure complete recoil. 2, 3

Early Defibrillation (Within 3 Minutes)

Apply the defibrillator/AED immediately when it arrives at the bedside—do not delay CPR to retrieve it, but apply it the moment it becomes available. 1, 2, 4

Rhythm assessment and shock delivery:

• Check rhythm to determine if shockable (VF/pulseless VT) 1, 2
• If shockable: Deliver one shock immediately, then resume CPR for 2 minutes before reassessing rhythm 1, 2, 4
• If non-shockable (PEA/asystole): Resume CPR immediately for 2 minutes 1, 2

Shock energy:

• Biphasic: 120-200 Joules initially (use manufacturer recommendation or maximum available) 1
• Monophasic: 360 Joules 1

Recheck rhythm every 2 minutes during ongoing CPR. 1, 3

Advanced Life Support Interventions

Establish vascular access:

• Obtain IV or intraosseous (IO) access as soon as feasible without interrupting compressions 1, 2

Medication administration:

• Epinephrine 1 mg IV/IO every 3-5 minutes for all cardiac arrest rhythms 1, 2, 4, 3
• For refractory VF/pulseless VT: Consider amiodarone 300 mg IV/IO bolus (second dose 150 mg) OR lidocaine 1-1.5 mg/kg IV/IO (second dose 0.5-0.75 mg/kg) 1, 2, 4

Airway management:

• Initially use bag-mask ventilation with 100% oxygen at 15 L/min 2
• Consider advanced airway (endotracheal intubation or supraglottic airway) 1
• Once advanced airway is placed: Give 1 breath every 6 seconds (10 breaths/minute) with continuous chest compressions—do not pause compressions for breaths 1, 2
• Use waveform capnography to confirm and monitor ET tube placement 1

Critical pitfall for ventilation: If the patient is on a mechanical ventilator when arrest occurs, disconnect from the ventilator immediately and use manual ventilation with a self-inflating bag, as modern ventilators erroneously sense chest compressions as spontaneous breaths and deliver excessive respiratory rates, which decreases venous return and cardiac output. 5

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

Systematically address reversible causes during resuscitation: 1

The H's:

• Hypovolemia
• Hypoxia
• Hydrogen ion (acidosis)
• Hypo-/hyperkalemia
• Hypothermia

The T's:

• Tension pneumothorax
• Tamponade (cardiac)
• Toxins
• Thrombosis (pulmonary)
• Thrombosis (coronary)

Monitoring for Return of Spontaneous Circulation (ROSC)

Signs of ROSC: 1

• Palpable pulse and blood pressure
• Abrupt sustained increase in PETCO₂ (typically ≥40 mmHg)
• Spontaneous arterial pressure waves on intra-arterial monitoring

When ROSC is achieved: Initiate post-cardiac arrest care immediately. 1

Special Populations

Pediatric patients:

• Start CPR if heart rate <60/min with signs of poor perfusion 1, 2
• Use 30:2 ratio for single rescuer and 15:2 ratio for two or more rescuers 1, 2, 3
• Compression depth: at least one-third of anterior-posterior chest diameter 3

Suspected opioid overdose:

• Administer naloxone if available while continuing CPR 1, 2, 3

Critical Pitfalls to Avoid

• Do not delay CPR to obtain history, attach monitors, or establish IV access—compressions are the priority 2, 3
• Do not perform prolonged pulse checks—if uncertain after 10 seconds, start CPR 4, 3
• Do not provide inadequate compression depth or rate—compressions must be hard (5-6 cm) and fast (100-120/min) 2, 3
• Do not interrupt compressions for prolonged periods—keep pauses <10 seconds 1, 2
• Do not provide excessive ventilation—this decreases venous return and cardiac output 1, 5
• Do not lean on the chest between compressions—this prevents cardiac refilling 2, 3

Team Coordination

Effective resuscitation requires clear leadership and role allocation: 6

• Designate a team leader to coordinate efforts
• Assign specific roles: compressor, airway manager, medication administrator, recorder
• Communicate clearly and frequently
• Recent training and experience facilitate better performance 6