Fast Fact Study Guide: Cardiac Arrest Management
Just the Facts: The interventions that increase the odds of survival in out-of-hospital cardiac arrest are quality compressions and early defibrillation. Little else has shown promise in improving outcomes.
Identifying cardiac arrest – The two most important findings used to identify cardiac arrest are unresponsiveness and lack of breathing. Although a pulse check is performed while assessing breathing, this assessment has proven inherently unreliable and should not delay care.
Quick Tip: Beware agonal breathing. The autonomic gasping that occurs in some cardiac patients can easily be confused with breathing. When assessing for breathing look for predictable rise and fall of the chest. Irregular, unpredictable gasping should be considered agonal.
The Sequence of Advanced Cardiac Arrest Care
- Identify the need for CPR – assess responsiveness, breathing, and pulse.
- Call for help/ensure the presence of a defibrillator – defibrillation is an urgent need, but so is the presence of a well-prepared team.
- Begin chest compressions – remember success is measured as a byproduct of how often the chest is being compressed. Maximize compression fraction and minimize pauses. Consider using external feedback devices, such as ETCO2, to ensure quality. Change compressors at every rhythm check or sooner if needed.
- Connect defibrillator without interrupting compressions. Analyze rhythm and defibrillate if necessary – do not delay. Defibrillate as soon as the device is ready. Consider safety when delivering defibrillations.
- Prepare for two-minute sequences of chest compressions followed by rhythm analysis and defibrillation if needed. Keep time. If possible, use incident command to ensure quality.
- If not already completed, manage the airway per local protocol. Obtain IV or IO access.
- Once access is obtained, administer epinephrine. Consider early administration as there may be a survival benefit. Repeat every 3-5 minutes or per protocol.
- Assess the need for antidysrhythmic medications (such as lidocaine or amiodarone). Follow local protocol.
- Assess and treat correctable causes.
Quick Tip: Minimize movement of cardiac arrest patients. Typically movement delays or pauses chest compressions and decreases survival.
Quick Tip – When to Defibrillate: Although some experts would suggest delaying defibrillation in favor of chest compressions for patients with prolonged downtime, a large study performed by the Resuscitation Outcomes Consortium demonstrated no significant benefit. While compressions should certainly be started while the defibrillator is being attached, there is no demonstrated benefit of an artificial delay in defibrillation.
Quick Tip: Cardiac arrest is best treated as a team. Proper teamwork facilitates a number of important objectives being accomplished at the same time. It is key that everyone understands the global objectives (quality, uninterrupted compressions, and early defibrillation) and know their appointed jobs. This understanding allows for a shared mental model and leads to improved team performance. Team leadership, in the form of incident command and organized training before the event, is also key to success.
BLS Performance Points
Quick Tip: Although you may be an advanced provider, BLS care is most important in cardiac arrest patients.
- Maximize compression fraction – ensure that for as much time as possible, someone’s hands are on the chest performing compressions. High performing systems achieve the highest success when compressions occur 90% of the time that crews are with the patient.
- Compress at a depth of no less than 2 inches in adults or children (1.5 inches in infants) and no more than 2.4 inches. Use an external feedback device if available.
- Compress at a rate of no less than 100 compressions per minute and no more than 120 compressions per minute. Use external feedback device if available.
- Defibrillate as soon as possible. Consider escalating energy in refractory dysrhythmias. Manual mode will likely decrease pauses in compressions.
The Airway Question
There is a great deal of discussion surrounding airway and breathing in cardiac arrest management. More research is needed, but in the meantime, you may encounter a wide range of prescribed approaches.
Cardiocerebral resuscitation – This approach minimizes or delays ventilation in the immediate phases of management in favor of chest compressions. The research is promising, particularly in adults with sudden cardiac arrest. Areas of concern include asphyxia cardiac arrest and pediatrics. This approach has shown the greatest rewards in training and instructing untrained bystanders.
Advanced airway – It is hard to determine what the most appropriate airway management technique is in the setting of cardiac arrest management. Some experts say intubation, others say BLS airways. More research is needed. What remains true however is that no technique should ever delay or pause chest compressions. Practitioners should always assess a cost vs. benefit for any airway procedure and follow local protocols.
Synchronous vs. asynchronous ventilations – Current American Heart Association Guidelines endorse a 30:2 compression to ventilation ratio for adults (and a 15:2 ratio for two rescuers managing a pediatric patient). Some systems have successfully adopted 10:1 asynchronous ventilations that utilize slightly lower volumes and do not interrupt compressions. Although initial results are promising, more research is needed. Follow local protocols.
Cardiac Arrest Rhythms
Ventricular fibrillation – This is the most common arrest dysrhythmia and is caused by uncoordinated, chaotic depolarizations of the ventricles resulting in a quivering of the muscle. It is characterized on the ECG as an irregularly, irregular series of complexes with no discernable P waves or pattern. Key treatment is early defibrillation. Epinephrine has shown some survival benefit although the research has not been unanimous. Limited evidence would also suggest the use of antidysrhythmics such as lidocaine or amiodarone.
Ventricular tachycardia – With ventricular fibrillation, it accounts for over 85% of all cardiac arrest dysrhythmias. It is caused by ventricular re-entry and/or increased ventricular automaticity, causing exceptionally fast contraction of the ventricles, leading to minimal filling and subsequent output. It is characterized by regular, fast wide complexes on an ECG without P waves (although retrograde P waves and capture beats may be present). Key treatment is defibrillation. Current recommendations also call for epinephrine and antidysrhythmics including lidocaine or amiodarone, however, research is limited.
Asystole – This is caused by an absence of electrical activity in the heart and is characterized by a flat line of the ECG. Key treatment is CPR. Defibrillation is not effective in this rhythm and therefore not indicated. Epinephrine is indicated, however, antidysrhythmics are not. As treatment options are limited, always consider correctable causes.
Pulseless electrical activity – This is caused when the cardiac muscle has no response to otherwise organized and normal cardiac conduction. It is characterized by a normal cardiac rhythm on an ECG (it can be any rhythm), but no corresponding pulse. Together with asystole, this accounts for roughly 15% of cardiac arrest dysrhythmias. Key treatment is CPR. Defibrillation is not effective in this rhythm and therefore not indicated. Epinephrine is indicated, however, antidysrhythmics are not. As treatment options are limited, always consider correctable causes.
Model Organization of a Cardiac Arrest Team
Position 1 – Patient’s right side – Compressor #1 – Can be any EMS level. Responsible for compressions and will alternate with position 2.
Position 2 – Patient’s left side – Compressor #2/AED – Can be any EMS level. Responsible for alternative compressions with position 1. If capable, this position can control the AED or defibrillator.
Position 3 – Airway – If an advanced airway will be used, this position should be staffed by a paramedic (however, an advanced airway is not always necessary). This position can be used to rotate in as a compressor if necessary.
Note: Positions 1, 2 and 3 are considered the “triangle of life” as they perform the most meaningful skills leading to survival. These positions should always be filled first.
Position 4 – Outside the triangle at the patient’s head – Team Leader – Ensures quality and keeps time. This position can be staffed by any level. Best served by utilizing a cardiac arrest checklist.
Position 5 – Outside the triangle at the patient’s right foot – Access and Medications. This position is staffed by a paramedic. He or she obtains IV/IO access and administers medications.
Position 6 – Outside the triangle at patient’s left foot – Defibrillation – This position is staffed by a level qualified to perform manual defibrillation. At proper intervals, this provider will perform the rhythm check and defibrillate as needed. This provider is also responsible for safety when using electrical therapy.
- Beware of re-arrest. Leave the pads in place.
- Prevent hypoxia – manage the airway with high priority. Assess the need for advanced airway.
- Assume the presence of a myocardial infarction – Obtain a 12 lead ECG, initiate transport to an appropriate destination. Follow local protocol.
- Prevent hypoperfusion – obtain blood pressure. Treat any hypotension immediately. Consider fluids first and quickly move to pressors if hypotension is unresolved.
- Treat seizures immediately.
- Monitor closely for the potential of re-arrest.
Quick Reference Chart
Team Leader Cardiac Arrest Checklist