Basics
- NOTE: The following information is based on 2010 Advanced Cardiac Life Support (ACLS) Guidelines. Any revisions made by the American Heart Association since then are not available at time of publication.
- Major ACLS Changes for the 2010 revision include:
- Change in the BLS sequence of treatment from A-B-C (airway, breathing, circulation) to C-A-B (circulation, airway, breathing) to emphasize early chest compressions
- Emphasis on postcardiac arrest care, particularly implementation of targeted temperature management
- Removal of atropine from PEA/asystole ACLS algorithms
Description
- Sudden cardiac arrest is characterized by:
- Unresponsiveness
- Pulselessness
- Little to no respiratory effort
- Factors affecting survival:
- Initial rhythm
- Total down time
- Time to successful defibrillation (as indicated)
- Time to basic life-support interventions
Etiology
Contributing factors to cardiac arrest are outlined by the American Heart Association as: á
- Hypovolemia
- Hypoxia
- Hydrogen ion (acidosis)
- Hypo-/hyperkalemia
- Hypothermia
- Toxins
- Tamponade, cardiac
- Tension pneumothorax
- Thrombosis
- Trauma
- Sudden cardiac arrest in children is often of a respiratory rather than cardiac etiology
- Follow current ACLS guidelines for pediatric cardiac arrest. Major differences between adult and pediatric cardiac arrest management include:
- Depth of compressions for pediatric populations should be ~1/3 to 1/2 the depth of the chest
- For 2 rescuer CPR, a 15:2 compression to ventilation rate is recommended
- Drug dosage differences: See "Medications"Ł section
Follow current ACLS guidelines for management of the pregnant cardiac arrest patient: á
- Awareness that airway may be difficult
- Compressions should be performed at a higher location than conventional CPR, slightly above the center of the sternum
- Follow Adult ACLS guidelines for defibrillation
- Pre- or postcardiac arrest pregnant patients should be placed in the left lateral recumbent position; during arrest, perform manual left uterine displacement
- To ensure a best possible outcome for the fetus, all efforts must be geared toward maternal survival
- In the event of a failed maternal resuscitation, an emergent cesarean delivery may be considered
Diagnosis
Signs and Symptoms
- Unresponsiveness
- Pulselessness
- Shallow, gasping respirations may persist for a few minutes
- Occasionally preceded by:
- Chest pain
- Dyspnea
- Palpitations
- Seizure activity
- Immediately prior to arrest:
- Shock or hypotension
- Impaired mentation
Essential Workup
- Assess circulation, airway, breathing
- Determine shockable vs. nonshockable rhythm and treat accordingly, per ACLS guidelines
Diagnosis Tests & Interpretation
Lab
Indicated only when successful return of spontaneous circulation (ROSC) is achieved: á
- Electrolytes
- BUN/creatinine
- Creatinine kinase with isoenzymes, cardiac troponin
- ABG
- CBC
- Therapeutic drug levels
- Toxicologic testing
- Lactic acid levels
Imaging
- EKG:
- Evaluate for STEMI or ACS
- CXR:
- Endotracheal tube position
- Pneumothorax
- Pulmonary etiology of arrest
- Echocardiogram:
- Pericardial effusion
- Wall motion abnormality
- Valvular dysfunction
- Head CT scan (postresuscitation):
- Rule out bleed/neurologic source
Diagnostic Procedures/Surgery
- Suspected cardiac etiology:
- Cardiac catheterization lab
- Possible cardiac output augmentation device placement
- EEG (postresuscitation)
- Identify and treat seizures
Differential Diagnosis
Sudden loss of consciousness with a palpable pulse: á
- Syncope
- Seizure
- Acute stroke
- Hypoglycemia
- Acute airway obstruction
- Head trauma
- Toxins
Treatment
Pre-Hospital
- Prompt initiation of standard CPR
- Confirm underlying rhythm
- Early defibrillation of pulseless ventricular tachycardia (VT) or ventricular fibrillation (VF)
- Secure airway and provide adequate respirations. Advanced airway should be deferred if placement interrupts BLS measures
- Postresuscitation care:
- Identify cause of arrest
- 12-lead EKG
- Monitor vital signs
- Fluid bolus and/or vasopressors for hypotension
- Transport to the closest facility that is capable of handling postarrest patients:
- Consider transport to center equipped for interventional cardiac care and those specializing in postarrest care
- Pediatric critical care center for children
Initial Stabilization/Therapy
- Initiate ACLS
- Perform standard CPR as long as no pulse is palpable:
- Stop CPR only briefly to check pulse, cardiac rhythm, or defibrillate
- Secure the airway
- Obtain IV/IO access
- Cardiac monitor
- Therapy is based on the underlying rhythm, according to ACLS protocols
Ed Treatment/Procedures
- Pulseless VT or VF:
- Immediate defibrillation with 1 countershock:
- Energy selection based on type of defibrillator for biphasic (if unknown use 200 J) or 360 J monophasic
- If defibrillation is unsuccessful, continue CPR for 2 min and re-evaluate rhythm. When IV/IO access is established, and after second rhythm check then consider:
- If refractory to defibrillation and epinephrine, consider:
- Amiodarone
- Lidocaine
- Magnesium for torsade de pointes
- Asystole:
- Confirm in ≥2 leads
- Epinephrine
- May substitute vasopressin to replace 1st or 2nd dose of epinephrine
- Pulseless electrical activity:
- Epinephrine
- Treat for reversible cause of pulseless electrical activity/asystole
- Postresuscitation:
- Treat the underlying cause of the arrest.
- EKG to establish presence of acute coronary syndrome:
- Immediate catheterization for STEMI
- Consider catheterization for suspected cardiac etiology without STEMI
- Ventilatory support
- Correct electrolyte abnormalities
- Initiate volume resuscitation and provide vasopressors/inotropic support as needed
- Targeted temperature management for eligible patients
- Continuous EEG to rule out seizures
Medication
Medication administration should never interrupt CPR: á
- Amiodarone: 300 mg (peds: 5 mg/kg to max. 15 mg/kg) IVP
- Epinephrine: 1 mg (peds: 0.01 mg/kg) IVP q3-5min
- Lidocaine: 1-1.5 mg/kg 1st dose (peds 1 mg/kg) IVP, then 0.5-0.75 mg/kg (peds: 20-50 ╬╝g/min) IV, up to 3 mg/kg
- Magnesium: 1-2 g (peds: 25-50 mg/kg max. of 2 g) slow IV
- Vasopressin: 40 U IVP (as replacement for dose 1 or 2 of epinephrine in adult arrest)
- Sodium bicarbonate: 1 mEq/kg (peds: 1 mEq/kg) slow
Follow-Up
Disposition
Admission Criteria
ROSC: á
- Intensive care unit
- Postresuscitation care
- Treatment of underlying cause of arrest
Discharge Criteria
None á
Issues for Referral
May consider referral to regional cardiac arrest center á
Followup Recommendations
Admission to ICU á
Pearls and Pitfalls
- Provide targeted temperature management in comatose post arrest patients.
- Expect recurrent cardiac arrest and provide close monitoring and appropriate postresuscitative treatment, which may consist of fluids and vasopressors.
- Get a cardiology consultation to determine if patient is candidate for cardiac catheterization.
Additional Reading
- Field áJM, Hazinski áMF, Vanden Hoek áTL, et al. 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science. Circulation. 2010; 122:S640-S656.
- Hallstrom áAP, Ornato áJP, Weisfeldt áM, et al. Public-access defibrillation and survival after out-of-hospital cardiac arrest. N Engl J Med. 2004;351:637-646.
- Neumar áRW, Otto áCW, Link áMS, et al. Part 8: Adult advanced cardiovascular life support: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2010;122:S729-S767.
- Peberdy áMA, Callaway áCW, Neumar áRW, et al. Part 9: Post-Cardiac Arrest Care: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascula care. Circulation. 2010;122:S768-S786.
- Wik áL, Hansen áTB, Fylling áF, et al. Delaying defibrillation to give basic cardiopulmonary resuscitation to patients with out-of-hospital ventricular fibrillation: A randomized trial. JAMA. 2003;289:1389-1395.
Codes
ICD9
427.5 Cardiac arrest á
ICD10
I46.9 Cardiac arrest, cause unspecified á
SNOMED
- 410429000 cardiac arrest (disorder)
- 422970001 Cardiac arrest due to trauma (disorder)