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Cardiac Arrest, Emergency Medicine

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

- Echocardiogram: - Pericardial effusion - Wall motion abnormality - Valvular dysfunction

- 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

  • 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 compressionsEmphasis on postcardiac arrest care, particularly implementation of targeted temperature managementRemoval of atropine from PEA/asystole ACLS algorithms

Description

  • Sudden cardiac arrest is characterized by:UnresponsivenessPulselessnessLittle to no respiratory effort
  • Factors affecting survival:Initial rhythmTotal down timeTime 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 chestFor 2 rescuer CPR, a 15:2 compression to ventilation rate is recommendedDrug 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 painDyspneaPalpitationsSeizure activity
  • Immediately prior to arrest:Shock or hypotensionImpaired 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 positionPneumothoraxPulmonary etiology of arrest
  • Echocardiogram:Pericardial effusionWall motion abnormalityValvular dysfunction
  • Head CT scan (postresuscitation):Rule out bleed/neurologic source

Diagnostic Procedures/Surgery

  • Suspected cardiac etiology:Cardiac catheterization labPossible 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 arrest12-lead EKGMonitor vital signsFluid 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 carePediatric 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 monophasicIf 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:AmiodaroneLidocaineMagnesium for torsade de pointes
  • Asystole:Confirm in ≥2 leadsEpinephrineMay substitute vasopressin to replace 1st or 2nd dose of epinephrine
  • Pulseless electrical activity:EpinephrineTreat 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 STEMIConsider catheterization for suspected cardiac etiology without STEMIVentilatory supportCorrect electrolyte abnormalitiesInitiate volume resuscitation and provide vasopressors/inotropic support as neededTargeted temperature management for eligible patientsContinuous 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)