Chapter 9 Cardiopulmonary Arrest
• Recognize sudden cardiac death by establishing unresponsiveness and absence of normal respiration
• Activate emergency response team (“calling a code” in the hospital setting)
• Perform high-quality chest compressions
The ABCs of BLS have been replaced by CAB—compressions, airway, breathing—to reflect the growing evidence that chest compressions are the most important aspect of early resuscitation efforts. In addition, airway management takes time and can delay the initiation of effective chest compressions.1
Most victims of cardiopulmonary arrest initially experience ventricular fibrillation. Chest compressions can maintain some level of cardiac output but will not convert this life-threatening rhythm; defibrillation is the only definitive treatment. The interval from collapse to defibrillation is one of the most important determinants of survival from cardiopulmonary arrest.1 The automatic external defibrillator (AED) is useful for early defibrillation in that no specific rhythm interpretation is required by the operator. The AED will determine whether the rhythm is “shockable” or not.
Management of Cardiopulmonary Arrest
Chest Compressions
One of four rhythms can cause cardiopulmonary arrest:
• Ventricular fibrillation (VF)
• Pulseless ventricular tachycardia (VT)
• Pulseless electrical activity (PEA)
The 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science1 emphasizes the need for quality chest compressions as fundamental in managing cardiopulmonary arrest resulting from these four rhythms.
The importance of high-quality chest compression cannot be overemphasized.
• Push hard, push fast—to the tune of “Stayin’ Alive”!
• Allow complete release of chest pressure between compressions.
• Assess for femoral pulse during compressions to determine the effectiveness of compressions.
• Minimize interruptions of chest compressions.
• In the absence of an advanced airway, synchronize compressions to ventilations with a ratio of 30 : 2. Once an advanced airway has been placed, give continuous chest compressions at a rate of at least 100 per minute; do not pause for ventilations.
• High-quality chest compressions can quickly lead to provider fatigue. Rotate the chest compressor every 2 minutes.
Airway Control
During cardiopulmonary arrest, oxygen delivery to the vital organs is diminished because of low blood flow (perfusion) rather than arterial oxygen content (ventilation), emphasizing again the need for immediate initiation of high-quality chest compressions. Still, 100% supplemental oxygen should be initiated as soon as possible, without delaying or interrupting compressions, during resuscitation from cardiopulmonary arrest.1
• Open and maintain a patent airway using:
• Do not delay chest compressions or defibrillation to establish an invasive airway.
• Refer to Chapter 8, Airway Management, for more information concerning airway management.
Breathing and Ventilation
• Assess rise and fall of chest for adequacy of ventilation.
• If bag-mask ventilation is sufficient, invasive airway management may be deferred until return of spontaneous circulation (ROSC).
• Monitor rate and depth of manual ventilation to prevent hyperventilation. Excessive ventilation can increase intrathoracic pressure, decreasing venous return to the heart.
• In the patient without an advanced airway, the rate of ventilation is two ventilations after each cycle of 30 chest compressions. Once an advanced airway is placed, ventilations should be given at a rate of 8 to 10 per minute (one ventilation every 5–6 seconds) without a pause in chest compressions.
Obtaining Circulatory Access
• Establish intravenous (IV) access.
• Use a large-gauge catheter to access a large vein, preferably in the antecubital space. Do not interrupt chest compressions while obtaining IV access.
• Consider intraosseous (IO) insertion if no venous access is available.
• Avoid central venous access via the subclavian approach during resuscitation efforts because of the need to stop compressions and the potential for complications such as pneumothorax.
Defibrillation
• Other than high-quality CPR, the only rhythm-specific treatment shown to increase survival to hospital discharge is defibrillation of VF or pulseless VT.1
• The main goal is to electrically terminate a shockable rhythm as quickly as possible; the earlier the defibrillation occurs, the better the chance of patient survival.
• Do not interrupt chest compressions while the defibrillator is charging if charging takes more than 10 seconds.
• Follow each shock immediately with 2 minutes of high-quality chest compressions to enhance coronary perfusion. Even if VF is terminated by the shock, almost all patients will experience a period of nonperfusing rhythm. CPR is needed to maintain circulation during this time.2
• Do not stop to check for a pulse after delivering the shock. Pulse checks may be performed if an organized rhythm is evident on the monitor, but chest compressions should not be interrupted for longer than 10 seconds.2
• Shocks can be delivered through paddles or self-adhesive disposable pads applied to anterior-posterior or anterior-anterior position.
• American Heart Association guidelines note if there is any evidence of an implantable cardioverter defibrillator (ICD) or permanent pacemaker, defibrillation should not be delayed by pad or paddle placement. It is recommended to avoid placing the pads or paddles over the implanted device.1
• The energy level for the initial shock with a biphasic defibrillator is 120 to 200 joules; if using a monophasic defibrillator, use 360 joules. If unsure as to whether the defibrillator is biphasic or monophasic, deliver the shock at 200 joules. Deliver subsequent shocks at the energy level that was previously successful.
• Ensure that all personnel are “clear” of the patient, bed, and equipment before delivering shocks.
Drugs
• The drugs most commonly used during resuscitation from cardiopulmonary arrest are epinephrine, vasopressin, and amiodarone.
• Epinephrine, 1 mg, either IV or IO, is given every 3 to 5 minutes during cardiopulmonary arrest in the adult.
• Vasopressin (Pitressin), 40 units, either IV or IO, can replace either the first or the second dose of epinephrine.
• The recommended initial dose of amiodarone is 300 mg, either intravenously or intraosseously; this may be followed by a single 150-mg dose.
• Follow bolus injections of drugs with a 20-mL bolus of IV fluid; elevate the extremity for 10 to 20 seconds following administration to facilitate delivery to the central circulation.2
Treat Reversible Causes
Although high-quality CPR and early defibrillation, when appropriate, are the cornerstones of successful resuscitation from cardiopulmonary arrest, possible causes of the arrest must be considered early on. Reversible causes of arrest or factors that may impede resuscitative efforts are known as the “H’s and T’s” and are listed in Table 9-1. A high index of suspicion and specific diagnostic measures are needed to identify and treat these conditions.
TABLE 9-1 THE H’s AND T’s: COMMON CAUSES OF CARDIOPULMONARY ARREST
| H’s | T’s |
|---|---|
| Hypoxia | Toxins (including drug overdose) |
| Hypovolemia | Tamponade (cardiac) |
| Hydrogen ion (acidosis) | Tension pneumothorax |
| Hypothermia | Thrombosis (coronary and pulmonary) |
| Hypokalemia, hyperkalemia |
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