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Adult Cardiopulmonary Arrest: Including Adult Advanced Life Support (ALS)

When attending a possible cardiac arrest situation, implement your (well practiced) basic and advanced life support training as follows:

Initial assessment (Basic life support and in-hospital resuscitation guideline)^1,2

1. Ensure personal safety ie patient, any bystanders, and yourself are safe.
2. If you witness a collapse or find a patient apparently unconscious; initially shout for help, then assess whether the patient is responsive by gently shaking his shoulders and asking loudly, "Are you all right?".

Heart Rhythm Assessment details from Advanced Life Support Guideline.³
Cyclically repeat the following 2 points, until successful or resuscitation is deemed unsuccessful.

1. Briefly interrupt CPR for assessment of heart rhythm and one defibrillation attempt each cycle if indicated:
   • VF or pulseless VT - defibrillation recommended - perform one shock (150-360J biphasic or 360J monophasic). Check rhythm immediately afterwards, if rhythm has improved check for pulse; if unsuccessful resume CPR immediately for a further 2 minute cycle before further attempt, (and correct any reversible causes). If there is doubt whether rhythm is fine VF or asystole, defibrillation not recommended.
   • Pulseless electrical activity (PEA) or asystole - defibrillation not recommended - give adrenaline ±atropine (see below), continue CPR and correct any reversible causes.
2. Complete 2 minutes of CPR before pausing again to assess rhythm and output. Whilst performing CPR consider:
   • Correcting reversible causes (4H's and 4T's):
     • Hypoxia, Hypovolaemia, Hypothermia or Hyperkalaemia (or hypokalaemia, hypocalcaemia, acidaemia, or other metabolic disorder)
     • Tension pneumothorax, Tamponade (cardiac), Toxins or Thromboembolism (coronary or pulmonary).
   • Check electrode position and contacts
   • Attempt or verify adequate IV access, airway and oxygenation.
   • Give uninterrupted compressions once airway secure.
   • Give adrenaline (1 mg IV) immediately if PEA or asystole, or after second shock if VT/VF. Repeat adrenaline every 3-5 min (ie every 2 cycles - suggested sequence drug-shock-CPR-rhythm check).
   • Consider: amiodarone, atropine, magnesium, calcium, thrombolytic drugs (give immediately if PE most likely).
     • Give bolus of amiodarone 300 mg if VF/VT persists after 3 shocks, immediately followed by a (4th) shock. A further dose of 150 mg may be given for recurrent or refractory VF/VT, followed by an infusion of 900 mg over 24 h.³ Use lidocaine if amiodarone not available.
     • Use atropine 3 mg IV (once only) if asystole, or PEA exists with bradycardia (rate <60/min).
     • Consider magnesium sulphate 8 mmol (4 ml of a 50% solution) for refractory VF/VT if hypomagnesaemia suspected (potassium-losing diuretics, Torsades de pointes, digoxin toxicity).
     • Consider calcium (10 ml 10% calcium chloride) in cases of PEA where there has been hyperkalaemia, hypocalcaemia, overdose of calcium-channel-blockers or magnesium (e.g. during treatment of pre-eclampsia).

Further Care Transfer to ITU, for monitoring of breathing, circulation and mechanical ventilation as appropriate. Consider need for sedation, and for therapeutic hypothermia for unconscious patients, particularly those who are resuscitated following a cardiac arrest outside hospital.³

Consider when NOT to resuscitate may be a valid decision:

• If a patient’s condition is such that resuscitation is unlikely to succeed.
• If a mentally competent patient has consistently stated or recorded the fact that he or she does not want to be resuscitated.
• If the patient has signed an advanced directive forbidding resuscitation.
• If resuscitation is not in a patient’s interest as it would lead to a poor quality of life (often a great imponderable!).

Ideally, involve patients and relatives in the decision before the emergency. When in doubt, resuscitate.

References Used

1. Resuscitation Council UK Resuscitation Guidelines (2005) based on
   2005 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations (CoSTR)
2. Resuscitation Council UK In-hospital Resuscitation Guideline (2005)
3. Resuscitation Council UK Advanced Life Support Guideline (2005)

Acknowledgements EMIS is grateful to Dr Huw Thomas for authoring of this article, based on the Resuscitation Council UK Guidelines 2005. The final copy has passed peer review of the independent Mentor GP authoring team. ©EMIS 2006.

Last issued 30 Aug 2006