Principles of
Cardiac Arrest Management
Richard Lake 10/2003
Background Information
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40% of deaths under the age of 75yrs in Europe
are due to cardiovascular disease
One third of people who suffer a myocardial
infarction die before reaching hospital
Most die within an hour of the onset of acute
symptoms
The majority of these deaths the presenting
rhythm is Ventricular Fibrillation or pulseless
Ventricular Tachycardia, (VF/ pulseless VT)
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The only treatment for VF/ pulseless VT is
attempted defibrillation
With each minute’s delay the chance of a
successful outcome fall by 7-10%
Once in hospital the incidence of VF after
Myocardial Infraction is approximately 5%
Most likely presentation of in hospital
cardiac arrest is asystole or pulseless
electrical activity (PEA).
The Chain of Survival
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Early Access to emergency services or
cardiac arrest team
Out of hospital summon EMS
by dialling 999/112
In hospital call cardiac arrest
team ring 2222 (check
number when on placement)
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External chest compressions and
ventilation will slow down the
rate of deterioration of the brain
and heart
Basic Life Support should be
performed immediately
Basic Life Support
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Danger
Response
Shout for Help
Airway
Breathing
If no help arrived leave victim, go for help
Circulation
Danger
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Check for danger to:
Yourself
Bystanders
Victim
Even clinical areas can have dangers, so
ALWAYS CHECK
Response
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Check the victim for response
Ask a question, ‘hello are you
alright?’
Give a command, ‘open your
eyes!’
Give a painful stimulus; pinch the
shoulder
If no response shout for help
Checking for response
Airway
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Check the airway
Open the airway, place one hand on the
victims forehead and gently tilt head back
Remove any visible obstruction from the
victims mouth, including dislodged
dentures. Leave well fitting dentures in
place
DO NOT ATTEMPT ANY FINGER SWEEPS
Opening the airway
Jaw thrust technique may be
needed if C-spine injury
If available use airway adjuncts
Nasopharyngeal airway insertion
Oropharyngeal airway insertion
Breathing
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Keeping the airway open:
Look – for chest movements
Listen – at the victims mouth for breath sounds
Feel – for air on your cheek
Look, listen and feel for no more than 10
seconds to determine if the victim is not
breathing.
If not breathing
and no help has arrived
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Leave the victim and go to summon help
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Turn the victim onto his back if he is not already in
that position
Give 2 effective rescue breaths, each of which
should make the chest rise and fall
If you have difficulty achieving an effective breath:
Recheck the victims mouth and remove any
obstruction
Recheck there is head tilt and chin lift
Make up to 5 attempts to achieve 2 effective
breaths
Even if unsuccessful move onto check circulation
If available use a pocket mask
Bag valve mask device may be
used
Circulation
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Look, listen and feel for normal breathing,
coughing, swallowing, eye flickering, or
any movement by the victim
If you feel confident check for a carotid
pulse
You should take no more than 10 seconds
to do this
Always check pulse same side as
you
If no breathing
but signs of circulation
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Continue rescue breaths at a rate of 10
breaths per minute
After every 10 breaths (every 1 minute)
recheck for signs of circulation
This should take no longer than 10
seconds to check
If no breathing and
no signs of circulation
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Commence CPR at a ratio of
15 Compressions
to 2 ventilations
Ensure correct hand position
The Chain of Survival
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Out of hospital the aim is to
deliver a shock within
5 minutes of the EMS receiving
a call
In hospital the first healthcare
responder should be trained and
authorised to use a defibrillator
immediately
Automated External Defibrillator
AED hands off pads
Automated External Defibrillators
may be used
Manual Defibrillator
Manual Defibrillator Paddles
Defibrillation
Defibrillation should be performed
promptly
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Often defibrillation restores a
perfusing heart rhythm, this is
often inadequate to sustain
circulation and further
advanced life support is
required to improve the
chances of long term survival
Remember the chain of survival
The Universal Treatment
Algorithm
An important part of
Advanced Cardiac Life Support
Objectives
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Recognise the four cardiac arrest rhythms
Identify correctly the appropriate
algorithm for each of the rhythms
Discuss the potential reversible causes of
cardiac arrest
BLS Algorithm
if appropriate
Precordial Thump
Attach Monitor/Defib
Assess rhythm
+/- Pulse Check
NON VF/VT
VF / VT
DEFIB X 3
as necessary
During CPR Correct
reversible causes
CPR 1 MIN
Check electrode / paddle positions
Attempt/verify airway/02/IV access
Give adrenaline every 3 mins
? buffers/atropine/
pacing/antiarrhythmics
CPR 3 min
Re-assess one
minute after
defibrillation
BLS Algorithm
if appropriate
Precordial Thump
if appropriate
Attach Monitor/Defib
Assess rhythm
+/- Pulse Check
?
VF / VT
Non VF / VT
BLS Algorithm
if appropriate
Precordial Thump
Attach Monitor/Defib
Assess rhythm
+/- Pulse Check
VF / VT
DEFIB X 3
as necessary
CPR 1 MIN
During CPR Correct
reversible causes
Check electrode / paddle positions
Attempt/verify airway/02/IV access
Give adrenaline every 3 mins
? buffers/atropine/
pacing/antiarrhythmics
BLS Algorithm
if appropriate
Precordial Thump
Attach Monitor/Defib
Assess rhythm
+/- Pulse Check
NON VF/VT
During CPR Correct
reversible causes
Check electrode / paddle positions
Attempt/verify airway/02/IV access
Give adrenaline every 3 mins
? buffers/atropine/
pacing/antiarrhythmics
CPR 3 min
Re-assess one
minute after
defibrillation
Potentially Reversible Causes
Hypoxia
Hypovolemia
Hyper/ Hypokalemia and metabolic disturbances
Hypothermia
Tension pneumothorax
Tamponade
Toxic/ therapeutic disturbances
Thrombo-embolic/ mechanical obstruction
BLS Algorithm
if appropriate
Precordial Thump
Attach Monitor/Defib
Assess rhythm
+/- Pulse Check
NON VF/VT
VF / VT
DEFIB X 3
as necessary
During CPR Correct
reversible causes
CPR 1 MIN
Check electrode / paddle positions
Attempt/verify airway/02/IV access
Give adrenaline every 3 mins
? buffers/atropine/
pacing/antiarrhythmics
CPR 3 min
Re-assess one
minute after
defibrillation
Drugs used commonly
during resuscitation
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Epinephrine (Adrenaline)
Atropine
Amiodarone
Magnesium Sulphate
Lidocaine (Lignocaine)
Sodium Bicarbonate
Calcium
Epinephrine (Adrenaline)
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First line cardiac arrest drug, given after
every 3 minutes of CPR
Dose 1mg (10ml of 1 in 10,000) IV
Causes vasoconstriction, increased
systemic vascular resistance increasing
cerebral and coronary perfusion
Increases myocardial excitability, when the
myocardium is hypoxic or ischaemic
Atropine
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Given for asystole or pulseless electrical
activity with a rate less than 60 beats per
minute
3mg is given as a single intravenous dose
It blocks the activity of the vagus nerve on
the SA and AV nodes, increasing sinus
automaticity and facilitating AV node
conduction
Amiodarone
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For Refractory VF/VT; haemodynamically stable VT and
other resistant tachyarrhythmias
If VF or pulseless VT persists after the first 3 shocks
then Amiodarone 300mg is considered.
If not pre-diluted, must be diluted in 5% dextrose to
20ml. (Will crystallise is mixed with saline)
Should be given centrally but in an emergency can be
given peripherally
Increases the duration of the action potential in the atrial
and ventricular myocardium
Magnesium Sulphate
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For refractory VF when hypomagnesaemia
is possible; ventricular tachyarrhythmias
when hypomagnesaemia is possible
In refractory VF – 1 to 2g (2-4ml of 50%
magnesium sulphate) peripherally over 1
to 2 minutes.
Other circumstances 2.5g (5ml of 50%
magnesium sulphate) over 30 minutes
Lidocaine (Lignocaine)
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For Refractory VF/ pulseless VT (when
Amiodarone is unavailable
100mg for VF/ pulseless VT that persists
after three shocks. Another 50mg can be
given if necessary
Sodium Bicarbonate
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Given for severe metabolic acidosis and
Hyperkalaemia
50mmol (50ml of 8.4% solution), where
there is an acidosis or cardiac arrest
associated with Hyperkalaemia
Calcium
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Administered when pulseless electrical
activity caused by:
Hyperkalaemia
Hypocalcaemia
Overdose of Calcium channel blocking
drugs
Dose 10ml of 10% calcium chloride
repeated according to blood results
Summary
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Cardiac arrest can
have a variety of
causes
The chain of survival
is essential to improve
outcome from cardiac
arrest
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Awareness of the universal treatment
algorithm is important
A knowledge of the drugs used in cardiac
arrest, their routes and dilution is also
essential
Questions
References
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Resuscitation Council (UK). (2000) Advanced Life
Support Provider Course Manual . 4th Edition.
Resuscitation Council (UK).:London
Resuscitation Council (UK). (2002) Immediate Life
Support Course Manual . 1st Edition. Resuscitation
Council (UK).:London