Adult Cardiopulmonary Arrest

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

• Ensure personal safety, i.e. patient, any bystanders and yourself are safe.
• 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 their shoulders and asking loudly, "Are you all right?".

Responsive

• Leave them in the position in which you find them, provided there is no further danger.
• Try to find out what caused the collapse and get help if needed.
• Reassess them regularly.

Unresponsive³

Call resuscitation team (or go for help, dial 999, 222 or appropriate emergency number) unless patient has previously expressed a wish not to be resuscitated.⁴

It is most important that a single responder ensures that help is on its way. If other staff are at hand, several actions can occur simultaneously (e.g. attach monitoring leads or obtain venous access).
While awaiting this team, assess the patient using the ABCD approach:

1. A = Airway
   Turn the victim on to his back and then open the airway using head tilt and chin lift:
   • Place your hand on their forehead and gently tilt their head back.
   • With your fingertips under the point of the victim's chin, lift the chin to open the airway.
2. B = Breathing
   • Keeping the airway open, look for chest movement and signs of breathing (for maximum of 10 seconds).
   • Ignore any agonal breathing (occasional gasps, slow, laboured, or noisy breathing) which is common in the early stages of cardiac arrest - it should not be taken as a sign of life.
3. C = Circulation
   Clinicians may also check for presence of carotid pulse simultaneously with checking for breathing or after the breathing check. If the pulse is not clearly felt - assume it is absent.
   • If breathing - put patient into recovery position, check help is on its way and reassess regularly.
   • If the patient is not breathing but definitely has a pulse (respiratory arrest), ventilate the patient's lungs at about 10 breaths per minute and recheck pulse every minute.
   • If not clearly breathing and no definite pulse, begin CPR (30:2): repeated cycles of 30 chest compressions (aim for rate of 100/min) then 2 rescue breaths.
     • Rescue breaths can be delivered via ventilation bag and mask with oxygen supply, pocket mask, or mouth-to-mouth or mouth-to-nose technique.
     • Use simple airway adjuncts (oropharyngeal or nasopharyngeal airways) when available (but ensure chest compressions are interrupted for as little time as possible).
   • If rescue breaths do not cause the chest to rise:
     • Check the victim's mouth and remove any visible obstruction.
     • Recheck that there is adequate head tilt and chin lift.
   • Don't attempt more than 2 breaths each time before returning to chest compressions.
   • Give uninterrupted compressions once airway secure.
4. D = Defibrillation
   • When the defibrillator arrives, apply the electrodes to the patient and analyse the rhythm. The use of adhesive electrode pads or the "quicklook" paddles technique will enable rapid assessment of heart rhythm compared with attaching ECG electrodes.
   • If using an automated external defibrillator (AED), follow the voice prompts; if using a manual defibrillator follow the heart rhythm assessment algorithm below.
   • Always complete 2 minutes of CPR between each single defibrillation attempt.
   • Continue resuscitation until the resuscitation team arrives or the patient shows signs of life.

Cyclically repeat the following 2 points, until successful or resuscitation is deemed unsuccessful.

1. Momentarily interrupt CPR for assessment of heart rhythm on monitor and 1 defibrillation attempt each cycle if indicated:
   • VF or pulseless VT: defibrillation recommended - perform one shock (150-360 J biphasic or 360 J monophasic). Immediately resume chest compressions (30:2) without reassessing the rhythm or feeling for a pulse for a further 2-minute cycle before further assessment. 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 (4Hs and 4Ts):
     • 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 (i.e. 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 sulfate 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).

• 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.¹

Consider when NOT to resuscitate may be a valid decision:⁴

• 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 advance 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.