Immediate Management of Post-Appendectomy Cardiac Arrest
Initiate high-quality CPR immediately with chest compressions at 100-120/minute and depth of at least 2 inches while simultaneously identifying and treating reversible causes specific to the post-surgical setting—hypovolemia from bleeding, tension pneumothorax, cardiac tamponade, or medication-related causes. 1
Initial Resuscitation Protocol
Begin chest compressions without delay if the patient is unresponsive with no pulse or only gasping respirations, maintaining compression rate of 100-120/minute with depth of at least 2 inches and allowing complete chest recoil between compressions 1, 2
Minimize interruptions in chest compressions, as any pause reduces coronary perfusion pressure and decreases likelihood of return of spontaneous circulation (ROSC) 2
Use 30:2 compression-to-ventilation ratio if two rescuers are present, and switch compressors every 2 minutes to prevent fatigue 2
Activate emergency response and call for immediate assistance, as perioperative cardiac arrest requires rapid identification of reversible causes 3
Identify and Treat Reversible Surgical Causes
The perioperative setting has a different spectrum of causes compared to standard cardiac arrest, requiring modification of traditional algorithms 3:
Perform immediate needle decompression if tension pneumothorax is clinically suspected (rare but possible complication), by inserting a 14-gauge needle at 2nd intercostal space, mid-clavicular line on affected side 2
Administer IV/IO crystalloid boluses aggressively to treat hypovolemia from surgical bleeding or third-spacing, which is a common cause of perioperative arrest 2, 4
Give epinephrine 1 mg IV/IO as soon as feasible, and repeat every 3-5 minutes during cardiac arrest to increase myocardial and cerebral blood flow during CPR 1, 2
Rapidly assess for intra-abdominal bleeding, though this is less common with appendectomy than with more extensive abdominal procedures 3
Defibrillation and Rhythm Management
Perform immediate defibrillation if ventricular fibrillation or pulseless ventricular tachycardia is identified, as early defibrillation with concurrent high-quality CPR is critical to survival 1
Continue CPR immediately after shock delivery while minimizing interruptions 1
Advanced Airway and Ventilation
Place advanced airway (endotracheal intubation) if not already present, as this is more critical in pulseless electrical activity (PEA) arrests which are common in the perioperative setting 2
Use lower tidal volumes, lower respiratory rates, and increased expiratory time to minimize auto-PEEP and barotrauma risk 2, 5
Target arterial oxygen saturation ≥94% but avoid hyperoxia 2
Post-ROSC Care
Once return of spontaneous circulation is achieved:
Optimize oxygenation by titrating FiO2 to maintain oxygen saturation 94-99%, avoiding both hypoxemia and hyperoxia 2, 6
Avoid hyperventilation—target normocapnia with PETCO2 35-40 mmHg, as hypocapnia reduces cerebral blood flow 2, 7
Treat hypotension aggressively by maintaining adequate perfusion pressure to prevent secondary brain injury, addressing underlying cause with volume resuscitation or inotropic support 2, 8
Consider targeted temperature management (32-36°C) if patient remains comatose after ROSC 2, 6
Perform immediate focused assessment to determine reversible causes and prevent additional end organ damage 6
Critical Pitfalls to Avoid
Do not delay CPR while searching for causes—begin compressions immediately and investigate simultaneously 1, 3
Do not assume standard medical causes—perioperative arrests have unique etiologies including hypovolemia, medication effects, and surgical complications that require directed intervention 3, 4
Do not hyperventilate during or after resuscitation, as this decreases cerebral perfusion 2
Be cautious with epinephrine dosing in the post-surgical setting due to potential for rebound hypertension and bleeding, though standard ACLS dosing should still be followed 1, 9