CARDIAC ARREST
Sudden cardiac arrest is different from a heart attack, which
occurs when blood flow to a portion of the heart is blocked.
However, a heart attack can sometimes trigger an electrical
disturbance that leads to sudden cardiac arrest. Sudden cardiac
arrest is a medical emergency. If not treated immediately, it
causes sudden cardiac death. With fast, appropriate medical
care, survival is possible. Administering cardiopulmonary
resuscitation (CPR) — or even just rapid compressions to the
chest — can improve the chances of survival until emergency
personnel arrive.
Definition
 Sudden cardiac arrest is the sudden, unexpected loss of
heart function, breathing and consciousness. Sudden
cardiac arrest usually results from an electrical disturbance
in heart that disrupts its pumping action, stopping blood
flow to the rest of the body.
 A cardiac arrest, also known as cardiopulmonary
arrest or circulatory arrest, is the abrupt cessation of normal
circulation of the blood due to failure of the heart to
contract effectively during systole.
Causes
Hs
 Hypovolemia caused by bleeding, anaphylaxis, or
pregnancy
 Hypoxia - A lack of oxygen delivery to the heart, brain and
other vital organs.
 Hydrogen ions (Acidosis) - An abnormal pH in the body as
a result of lactic acidosis which occurs in prolonged
hypoxia and in severe infection
 Hyperkalemia or Hypokalemia - Both excess and
inadequate potassium can be life-threatening.
 Hypothermia - A low core body temperature, defined
clinically as a temperature of less than 35 degrees Celsius
(95 degrees Fahrenheit).
 Hypoglycemia or Hyperglycemia - Low blood glucose
from overdose of oral hypoglycemics such as sulfonylureas,
or overdose of insulin.
Ts
 Tablets
or Toxins
Tricyclic
antidepressants,
phenothiazines, beta blockers, calcium channel blockers,
cocaine, digoxin, aspirin, acetominophen.
 Cardiac Tamponade - Blood or other fluids building up in
the pericardium can put pressure on the heart so that it is
not able to beat.
 Tension pneumothorax - The build-up of air into one of the
pleural cavities, which causes a mediastinal shift. When this
happens, the great vessels (particularly the superior vena
cava) become kinked, which limits blood return to the
heart.
 Thrombosis (Myocardial infarction)
 Thromboembolism
(Pulmonary
embolism)
hemodynamically significant pulmonary emboli are
generally massive and typically fatal.
Causes
 Respiratory
 Cardiac
 Respiratory failure
 CAD
 Neurovascular
 Myocardial infarction
disease
 Congestive heart failure,
 Pulmonary embolism,
etc
etc
 Drug
 Mechanical
 Poisonous drug
 Obstruction
 Anti depressant
 Drowning
 Relaxant
 Accident
 Cardiac drug
 Burn
 Drug toxicity
 Gas
and
smoke  Metabolic
and
inhalation
electrolyte
 Hypo/Hyper electrolyte
 Metabolic acidosis
 Hypo/Hyper glycaemia
Risk factors:
 Scarring from a prior heart attack or other causes
 Cardiomyopathy
 Cardiac medications
 Electrical abnormalities
 Blood vessel abnormalities
 Recreational drug use
Symptoms
Signs of cardiac arrest: It strikes suddenly and without
warning.
Sudden loss of responsiveness
No response to tapping on shoulders
Does nothing when you ask if he is okay

No normal breathing
The victim does not take a normal breath when
you tilt the head up
Check for at least five seconds
Signs and symptoms of Cardiac arrest
Late
Early
-Unresponsiveness
 Dilation of pupil
-Apnoea/gasping
 Cold and clammy skin
-No carotid pulse
 Cyanosis

If these signs of cardiac arrest are present:
 Call for emergency medical services

Get an automated external defibrillator (AED)

If one is available

Begin CPR immediately
 Continue until professional emergency medical services
arrive

Use the AED as soon as it arrives.
 If two people are available to help, one should begin
CPR immediately while the other calls 9-1-1 and finds an
AED.
Cardiopulmonary resuscitation:
 Cardiopulmonary resuscitation (CPR) is a procedure to
support and maintain breathing and circulation for a person
who has stopped breathing (respiratory arrest) and/or whose
heart has stopped.
 It is a method which includes all measures that are applied
to revive patients who have stoped breathing suddenly or
unexpectedly either due to respiratory or cardiac failure
 Cardiopulmonary resuscitation (CPR) is an emergency
procedure which is performed in an effort to manually
preserve intact brain function until further measures are
taken to restore spontaneous blood circulation and
breathing in a person in cardiac arrest.
 CPR involves chest compressions at least 5 cm deep and at
a rate of at least 100 per minute in an effort to create
artificial circulation by manually pumping blood through
the heart.
Epidemiology:
The American Heart Association reports that, in the United
states, nearly 250,000 deaths each year are due to heart
attacks. Out of these 80% die outside the hospital setting and
do not received any medical treatment after suffering heart
attack.
If CPR is administered within first four minutes after the heart
attack, the chances for brain damage are virtually nonexistent.
If administered between 4 to 6 minutes the brain damage is
probable, 6 to 10 min brain damage is likely, and after 10 min
the chances of some type of brain damage are virtually
certain. So knowledge of CPR does not only save lives, but
also allows victims to recover without sustaining any
permanent damage.
Purpose:
-CPR is performed to restore and maintain breathing and
circulation and to provide oxygen and blood flow to the heart,
brain, and other vital organs
Indication of CPR:
There are three general symptoms that warrant immediate
administration of CPR:
 Victim is not Breathing
Victim has No Pulse
 Victim is
unconscious.
1. Cardiac arrest:
 Ventricular Fibrillation(VF)
 Ventricular tachycardia(VT)
 Asystole
 Pulse less electrical activity
2. Respiratory Arrest
 Drowning
 Stroke
 Foreign body in throat
 Smoke inhalation
 Drug overdose
 Epiglottis paralysis
 Suffocation
 Accident injury
 Coma
Principles of CPR:
 To restore effective circulation and ventilation
 To prevent irreversible cerebral damage due to anoxia.
When the heart fails to maintain the cerebral circulation for
approximately four minutes the brain may suffer
irreversible damage.
General Instructions For effective CPR:
1. CPR technique is used in persons whose respiration and
circulation of blood have suddenly and unexpectedly stopped.
2. There is no need of attempting CPR techniques in patients
in the last of an incurable illness and in persons whose heart
beat and respirations have been absent for more than six
minutes.
3. The immediate responsibilities of the resuscitator are:
o To recognize the signs of cardiac arrest
o Protect the patient’s brain from anoxia by immediately
starting
o Artificial ventilation of the lungs and external cardiac
massage.
o Call for help
4. The cardio-pulmonary resuscitation must be initiated within
three or four minutes in order to prevent permanent brain
damage.
o Strike the center of the chest sharply with of the clenched
first twice.
o Call for assistance
o Clear the airway of false teech, vomitus, food material
etc.
o Initiate ventilation and external cardiac massage without
wasting time.
5. The CPR techniques should not be discontinued for more
than five seconds before normal circulation and ventilation of
lungs are established except;
o When the patient’s is moved to a hard surface
o When endotracheal intubation is being carried out(
maximum time allowed for these two procedures is 15
second
o Before CPR is attempted in a patient, make sure that the
airway is clear. It may be obstructed due to many
reasons. So keep the patient’s neck hyper extended after
confirming that he is having any cervical injury.
Sequence of CPR:
CPR consists of three phases;
 Phase I
 Phase II
 Phase III
Phase I- Basic life support:
I. A-Airway:
 The first step on CPR is to establish patent airway for the
patient. Completely 30 compression and quickly maintain
airway.
 Give head tilt chin lift position (in case of neck injury use
jaw thrust position because it reduces neck and spine
movement.)
Steps to perform head tilt chin lift position:
 Place one hand on the victim’s forehead and push with
your palm to tilt the head back.
 Place the finger of the other hand under the bony part of
the lower jaw near the chin.
 Lift the jaw to bring the chin forward.
Things to avoid with head tilt thin lift:
 Do not press deeply into the soft tissue under the chin
because this might block the airway.
 Do not use the thumb to lift the chin.
 Clear the airway if an obstruction is suspected, clear the
mouth and upper airway with finger or by suction.
 Establish an artificial airway if the patient does not breath
spontaneously with the positioning of the head and neck.
This is done by passing an endo tracheal tube of appropriate
size into the trachea.
II. B- Breathing: If the spontaneous breathing does not takes place after
establishing a patent airway the rescuer should try to
ventilate the lungs. This can be done by mouth to mouth
breathing bag and mask ventilation or mechanical
ventilation.
 Ventilate the lungs using mouth to mouth or mouth to nose
breathing. Keeps the head and neck in the hyper extended
position.
 Pinch the patient nose after taking a deep breath, open the
mouth widely and cover the patient mouth around the lips
completely to produce a tight seal. Deliver three or four full
breaths into patient mouth in quick succession.
 Look for chest wall to rise with each breath look, listen and
feel for patient exhaled breaths.
III. C- Circulation:- When cardiac arrest is suspected, verify
it by the absent carotid.
Steps to locate carotid artery:
1. Locate the trachea using 2 or 3 fingers.
2. Slide this 2 or 3 fingers into groove between the trachea
and the muscle at the side of the neck (sternocleido
muscle), where you can feel carotid pulse.
3. Feel for pulse for at least 5 sec but not more than 10 sec. If
no pulse start CPR with chest compression at a rate of 100/
mints (follow 30:2 compression and respiration).
4. The foundation of CPR is chest compression.
Steps to perorm chest compression:
1. Position yourself at the victim’s site.
2. Make sure the victim is lying face up as a firm, flat surface.
If the victim is lying face down, carefully roll him face up.
If you suspect the victim has head or neck injury try to keep
the head, neck and torso in a line when rolling the victim to
a face up position.
3. Draw imagery line between 2 nipples. Put the head of one
hand on the centre of the victim’s chest on the lower half of
the breast bone in between nipple).
4. Put the head of or other hard or top of the 1st hands.
5. Straighten your arms and position or shoulders directly over
your hands.
6. Push hard and fast: press down at least 2 inches (5 cm) with
each compression, deliver compression in smooth fashion
at a rate of at least 100/ mins.
7. At the end of each compression make sure you allow the
chest to recoil (re-expand) completely. Chest recoil allows
Blood to flow into the heart and is necessary for chest
compression to create blood flow.
8. Minimize interruption.
Phase II- Advanced Life Support
E. ECG: Connect The Patient To Monitor
 Watch for any abnormal rhythm
F- Fibrillation: If monitor shows ventricular tachycardia or ventricular
fibrillation, take a rhythm strip
 Select 200 joules deliver shock if no change again
deliver shock needed.
Phase-III Prolonged life support:G-Gauging: Identify the cause and treat
 Do hemodynamic monitoring ECG, cardiac monitoring,
vital signs
 Temporary pacing
 Intubation
H- Human mentation: Save the cerebral circulation initiate CPR within 4
minutes
 Monitor pupils reaction and changes

Check general responses.
I- Intensive care : Transfer to intensive care unit
 Monitor closely and continuously.
The American Heart Association guidelines:
The 2010 guidelines "strongly recommend" that untrained /
lay responders perform "compression-only" CPR, sometimes
known as CCR. However, medical professionals and trained
lay people are still urged to give the victim two "rescue
breaths" in between each series of 30 chest compressions.
Points to be remembered if performing Chest
Compressions only:
1. Chest compressions should be performed at 100 per
minute
2. Increase the depth of chest compressions to at least 2
inches for adults; children and infants 1.5 inches
3. Continue with chest compressions for as long as possible
or until help arrives
4. There has been a change in the recommended sequence
for the lone rescuer to initiate chest compressions before
giving rescue breaths (C-A-B rather than A-B-C).
Before proceeding with CPR:
 Make sure rescuer is not in any danger
 Make sure that victim is not in danger
 -Avoid moving the victim unless there is in immediate
danger or preparing for CPR
 Assess the surroundings for any people who can help
 Determine if the victim is conscious or unconscious by
positioning yourself next to the victim, tapping him/her on
the shoulder and shouting "Are you OK? Are you OK""
several times
 If no response, immediately ask someone to call 911 and
then have the person report back to you. If no one is
available call 911 yourself prior to beginning CPR
Basics of CPR:
To perform CPR, remember the basic steps of CPR
administration called CAB
o C for circulation
o A for airway
o B for breathing
C – COMPRESSIONS: External chest compressions provide
artificial circulation when rescuer apply rhythmic pressure on
the lower half of the victim's breastbone, it force the heart to
pump blood.
A - CLEAR AIRWAY
 Place the victim on his/her back on a firm surface. Kneel
next to the victim's neck and shoulders.
 To open the airway, place palm on the forehead to carefully
tilt the head back and lift the chin forward with other hand.
 Then check for signs of life for no longer than 10 second.
Place ear over the mouth of the victim, and while counting
from 10 to 0 listen if the victim is breathing.
 There are no signs of life, proceed to B.
B – BREATHING : Breathing - refers to rescue breathing, where
one person is breathing into other or also commonly referred
to as mouth to mouth technique
 Using the thumb and forefinger of rescuer hand that's on the
victim's forehead, pinch the person's nose shut.
 Keep the heel of rescuer hand in place so the person's head
remains tilted. Keep rescuer other hand under the person's
chin, lifting it up.
 As rescuer keep an airtight seal with his mouth, give first
breath and watch the victim's chest rise. If rises, give
second breath. If not, start from the beginning. Goal is for
the victim to receive two full mouth to mouth breaths, 1
second each.
CPR Guidelines for the health care provider:
A. Chest compressions:
 Push hard and push fast
 Compress chest at rate of 100/mt
 Allow complete chest recoil after each compressions
 Minimize interruptions in chest compressions
B. Compression-to-ventilation ratio: 30:2 for single rescuer
for all clients except newborns
C.1-second breath:
 Each rescue breath should be given over 1 second
 Chest should rise with each breath
 Avoid delivering too many breaths or breath too large
and/ too forceful
D. Attemp defibrillation:
 Deliver one shock followed by immediate CPR
beginning with chest compressions
 Check rhythm after 5 cycles of CPR
Basic Life Support: Basic life support is an emergency
procedure that consists of recognizing an arrest and initiating
proper CPR techniques to maintain life until the victim either
or its transported to a medical facility where advanced life
support measures are available.
CHECK RESPOSIVENESS
Shake and Shout
OPEN AIRWAY
Head tilt-chin lift/jaw thrust
CHECK BREATHING
Look, listen and feel
IF BREATHING
Put in recovery position
IF NO BREATHING
Provide 2 effective breaths and assess for
Signs of circulation 10seconds only
NO CIRCULATION
Compress chest 100/minute in ratio of 30 compression to 2
breaths
CIRCULATION PRESENT
Continue rescue breathing
Check circulation every minute
Steps of CPR:
Safe implementation of CPR involves the five steps
STEP I: Assess level of consciousness: Person who appears
to be unconscious may be asleep, deaf, or possibly
intoxicated. Unconsciousness is confirmed by shaking the
victim’s shoulder and shouting “ Are you Ok? If the person
does not responding, the emergency response system is
activated Immediately and the victim is cautiously placed in
the supine position on a firm surface, remembering the
potential for head injury.
STEP II: Open the Airway: The tongue is a common cause
of airway obstruction in the unconscious person. The head tilt
chin lift method and the jaw thrust are the two recommended
methods for opening and maintaining the airway. Jaw thrust (
without head tilt) is the safest approach to use with a victim
with a suspected neck injury. The head must be carefully
supported to avoid turning or tilting it backward. While
maintaining an open airway, the rescuer takes 3 to 5 seconds
to look, listen and feel for spontaneous breathing.
STEP III: Initiate Artificial Ventilation
Give mouth to mouth breathing:
1. Hold the victim’s airway open with the head tilt chin lift.
2. Pinch the nose close with your thumb and index finger
(using the hand on the forehead).
3. Take a regular (not deep) breath and seal your lip around
the victim’s mouth creating an air tight seal.
4. Give one breath (blow for about 1 sec).
5. Watch for the chest to rise as you give the breath.
6. Give a second breathe blow for about 1 sec. Watch for
the chest to rise.
7. If you are unable to ventilate the victim after two
attempts, promptly return to chest compression.
OR
Give mouth to mask breathing:
1. Position yourself at the victim side.
2. Place the mask in the victim face using the bridge of the
nose as a guide for correct position.
3. Seal the mask against the face : Using the hand that is closer to the top of the victim’s
head, place your index finger and thumb along the edge
of the mask.
 Place the thumb of your second hand along the bottom
edge of the mask.
4. Place the remaining finger of your second hand along the
bony margin of the jaw and lift the jaw. Perform a head tilt
chin lift to open the airway.
5. While you lift the jaw, press firmly and completely around
the outside edge of the mask to seal the mask against the
face.
6. Deliver air over 1 sec to make the victim’s chest rise.
Steps to perform bag mask ventilation:
Positive pressure ventilation during CPR with bag mask
device:1. Position your self directly at the head side off the victim.
2. Place the mask on the victim face using the –bridge of
the nose as guide for correct position.
3. Use the ec clamp technique to hold the mask in place
while you lift the jaw to hold the airway open:
 Perform a head tilt.
 Place the mask on the face with narrow portion at the
bridge of the nose.
 Use the thumb and index finger of one hand to make a
“C” on the side of the mask.
 Use the remaining finger to lift the angle of the jaw
(3fingers from an “E”). Open the airway and press the
face to the mask.
4. Squeeze the bag to give breath (1 sec each).
STEP IV: Check for signs of circulation
 After you have given the first two breaths, check the
victim’s for signs of circulation to see if the heart is
beating
 .If the victim has no signs of circulation, CPR must be
started immediately.
 If the victim’s has signs of circulation but is not
breathing, continue rescue breathing at arate of one
breath every five seconds, or 12 per minute.
Post resuscitation measures:
After care of patient who has suffered cardiac arrest is crucial
to survival. Typical orders and their rationale are as follows: If not already in the ICU or CCU the patient is admitted
there because of the need for constant observation,
monitoring equipment, defibrillation and so forth.
 Monitoring of ECG, CVP, and blood pressure is instituted.
 Temperature is taken every hours for high temperature.
High temperature usually indicates cerebral damage or
edema.
 A hypothermia blanket is used if temperature is over 1010f
or 38.50f. Hypothermia helps to lessen cerebral edema
 e)Blood gas and pH determination are done to detect
metabolic acidosis which may have developed owing to
poor oxygenation during arrest
 A chest x-ray film to be obtained using portable equipment,
ribs often are accidently fractured during cardiac massage
 Insert endotracheal tube if not already in place. This
maintain as open airway for the unconscious patient who do
not clear secretion by coughing
 Give oxygen continuously for 48hours following
resuscitation by endotracheal tube or mask
 Insert foley’s catheter to measure urine output.
Complication of CPR:
 Trauma ,fractured ribs and sternum
 Pneumothorax
 Rupted spleen
 Skin burns
 Cervical neck injury
 Oral, tracheal and larygea; damage
 Congestive heart failure
 Anoxic encephalopathy
.Surgical management:
ͽ Coronary angioplasty
ͽ Coronary bypass surgery
ͽ Corrective heart surgery
ͽ Heart transplantation
ͽ Radiofrequency catheter ablation
Medications used in CPR
Agent
and Indications
Action
Oxygen—
Administered to
improves tissue all patients with
oxygenation and acute cardiac
corrects
ischemia or
hypoxemia
suspected
hypoxemia,
including those
with COPD
Epinephrine—
Given to patients
increases
in cardiac arrest,
systemic
especially caused
vascular
by a systole or
resistance
and pulse less
BP;
improves electrical activity;
coronary
and may be caused by
cerebral
ventricular
perfusion
and tachycardia or
myocardial
ventricular
contractility
fibrillation
Vasopressin
(Pitressin)
increases
systemic
vascular
resistance and
BP
An alternative to
epinephrine
Nursing consideration
 Use 100% FiO2 during
resuscitation.
 Recognize that lung
damage is unlikely when
used for short time.
 Monitor dose by pulse
oximeter.
 Administer 1 mg every
3–5 minutes by IV push
or through endotracheal
tube.
 Avoid adding to IV lines
that contain alkaline
solution (bicarbonate).
 Give 40 U IV one time
only
Atropine—
blocks
parasympathetic
action; increases
SA node
automaticity and
AV conduction
Given to patients  Give rapidly as 0.5 mg
with symptomatic
IV push; may repeat the
bradycardia
dose of 3 mg
(hemodynamicall  Be aware that less than
y unstable,
0.5 mg in adult can
frequent
cause heart rate to
premature
decrease to a worse
ventricular
bradycardia.
contractions, and  Monitor patient for
symptoms of
reflexive tachycardia
ischemia)
Sodium
bicarbonate
(NaHCO3)—
corrects
metabolic
acidosis
Given to correct
metabolic
acidosis
 Administer initial dose
of 1 mEq/kg IV; then
administer dose based on
base deficit calculated
from arterial blood gas
values.
 Recognize that to
prevent development of
rebound metabolic
alkalosis, complete
correction of acidosis is
not indicated.
Magnesium—
Given to patients  May give 1–2 g diluted
promotes
with
abnormal
in 10 mL D5W over 5–
adequate
rhythm
20 minutes.
functioning of
 Monitor for hypotension,
cellular sodium–
asystole, bradycardia,
potassium pump
and respiratory paralysis
Follow-up interventions:
Diagnostic tests are often made during and after resuscitation
to determine precipitating causes, evaluate the effectiveness of
resuscitation, and detect complications. Test commonly
performed are;
1. Chest radiograph
2. ECG available, apply it and follow the prompts.
3. Hemodynamic monitoring
4. Laboratory studies including arterial blood gas analysis
Nursing Consideration of CPR:
 Clients who survive cardiopulmonary arrest are admitted to
a critical care unit, where they receive continuous cardiac
monitoring and have vital signs taken every 15 minutes
until stable. Nurse who works in the critical care setting
should assess for any type of ECG changes in the monitor,
if noted should inform immediately and emergency
interventions should be done.
 Post-resuscitation
assessment
provides
important
information regarding the effectiveness of the resuscitation.
Common disorders include recurrent dysrhythmias, coma,
other neurologic disorders, and renal failure.
 After the client regains consciousness, profound anxiety
often appears. The nurse should remember that clients need
psychological support when they have undergone such as
catastrophic physiologic event.
 Many clients have a very clear recall if the events
surrounding the resuscitation, including the verbal
communication that occurred. For this reason, members of
the resuscitation team should careful about what they say
 The nurse should take time to assess the client’s coping
mechanisms.
 The nurse should encourage expression of such feelings and
concerns, not only by the client but by significant others
who are equally stressed by the sudden, serious nature of
the disorder.
 Clear explanations and clarifications of misconceptions
about what has happenedhelp move client forward to
optimal physiologic and psychological recovery.
Prognosis
o If done well, CPR saves life
o Normaly is restored in rescued person
o CPR can also be ineffective, causing death
o In some cases, causes injuries