Resuscitation
A 61 year old man is brought to the Emergency Department by paramedics. His wife explains he complained of a "sharp pain in his chest when he was breathing". His only past medical history is a laparoscopic cholecystectomy 2 weeks ago. His initial observations are pulse 134, BP 76/54, RR 32 and SpO2 85% on air. Whilst examining the patient he becomes unresponsive. You cannot feel a central pulse and cannot see or feel any respiratory effort. A defibrillator is attached and shows a narrow complex tachycardia with a rate of 135. You begin CPR, intravenous access is achieved and the first dose of adrenaline administered. Assuming the patient remains in cardiac arrest when should further adrenaline be given and at what dose?
Answer:
If rhythm is non-shockable (pulseless electrical activity or asystole):- Restart chest compressions immediately for 2 minutes
- Give adrenaline 1 mg IV as soon as intravascular access is achieved
- Recheck rhythm after 2 minutes, if non-shockable rhythm persists, continue CPR for a further 2 minutes
- Continue this sequence if a non-shockable rhythm persists; give further adrenaline 1 mg IV every alternate 2 minute cycle (approx. every 3 - 5 mins)
Cardiorespiratory Arrest
Resuscitation
Last Updated: 28th February 2022
Sequence for collapsed/sick patient in hospital
- Ensure personal safety
- Shout for help
- Check patient for a response (shake and shout)
- If patient does not respond:
- Shout for help (if not done already)
- Turn patient onto back
- Open airway using head tilt and chin lift +/- jaw thrust
- Look, listen and feel for signs of life (< 10 secs)
- If there are no signs of life, start cardiopulmonary resuscitation (CPR)
Chest compressions
- Place hands over middle of lower half of sternum
- Depth 5 – 6 cm
- Rate 100 – 120 cpm
- Ratio 30 compressions: 2 breaths
- Change person giving chest compressions every 2 minutes if possible
- Minimise interruptions – pauses should be < 5 secs
Airway and ventilation
- Use whatever equipment is available immediately
- Use an inspiratory time of about 1 s and give enough volume to produce a visible rise of the chest wall
- Add supplemental oxygen as soon as possible
- Tracheal intubation should only be attempted by those who are experienced and can insert the tube with minimal interruption (< 5 s) to chest compressions
- Waveform capnography should be routinely used for confirming that a tracheal tube is in the airway and for subsequent monitoring during CPR (used to monitor quality of CPR, as an indicator of ROSC and as a prognostic indicator)
- Once an advanced airway is established, perform chest compressions uninterrupted at a rate of 100-120 cpm and ventilate the lungs at approx 10 breaths/min
Defibrillation
- Attach self-adhesive defibrillator pads as soon as possible while compressions are ongoing
- Place one pad to the right of the upper sternum below the clavicle and the other in the left midaxillary line in the 5th intercostal space
- Once pads are applied, pause briefly for a rapid rhythm check
- Deliver the first shock with energy of at least 150 J; it is reasonable to increase the energy for subsequent shocks
- If rhythm is shockable (ventricular fibrillation or pulseless ventricular tachycardia):
- Restart chest compressions while defibrillator is charging
- Once defibrillator is charged and the safety check completed, stop chest compressions, deliver the shock and restart chest compressions immediately for 2 minutes
- After 2 minutes, perform further rhythm check, if shockable rhythm persists, deliver a second shock
- After a further 2 minutes, perform further rhythm check, if shockable rhythm persists, deliver a third shock; give adrenaline 1 mg IV and amiodarone 300 mg IV while continuing a further 2 minutes of CPR
- Continue this sequence if a shockable rhythm persists; give further adrenaline 1 mg IV after alternative shocks (approx. every 3 - 5 mins) and give a further dose of 150 mg IV amiodarone after a total of five defibrillation attempts
- If rhythm is non-shockable (pulseless electrical activity or asystole):
- Restart chest compressions immediately for 2 minutes
- Give adrenaline 1 mg IV as soon as intravascular access is achieved
- Recheck rhythm after 2 minutes, if non-shockable rhythm persists, continue CPR for a further 2 minutes
- Continue this sequence if a non-shockable rhythm persists; give further adrenaline 1 mg IV every alternate 2 minute cycle (approx. every 3 - 5 mins)
Treat reversible causes
Potential causes or aggravating factors for which specific treatment exists must be considered during cardiac arrest.
- Hypoxia
- Hypovolaemia
- Hypo-/hyperkalaemia/metabolic (hypoglycaemia, hypocalcaemia, acidaemia)
- Hypothermia
- Thrombosis – coronary or pulmonary
- Tension pneumothorax
- Tamponade
- Toxins
Duration of resuscitation attempt
If attempts at obtaining return of a spontaneous circulation (ROSC) are unsuccessful, the resuscitation team leader should discuss stopping CPR with the team. The decision to stop CPR requires clinical judgement and a careful assessment of the likelihood of achieving ROSC. It should be based on the individual circumstances of the case.
If it was considered appropriate to start resuscitation, it is usually considered worthwhile continuing as long as a patient remains in VF/pVT, or there is a potentially reversible cause that can be treated. It is generally accepted that asystole in the absence of a reversible cause and with ongoing ALS constitutes reasonable grounds for stopping further resuscitation attempts, although a shorter or longer time could be appropriate depending on the circumstances of the arrest.
Return of spontaneous circulation (ROSC)
Immediate post cardiac arrest treatment:
- Use ABCDE approach
- Aim for SpO2 of 94 - 98%
- Aim for normal PaCO2
- 12-lead ECG
- Treat precipitating cause
- Targeted temperature management
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- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
