Cardiac arrest and cardiopulmonary resuscitation

Cardiopulmonary resuscitation is an Emergency lifesaving procedure performed when there is sudden cessation of heart beats. It involves the combination of chest compressions and artificial ventilation to preserve blood flow to the organs including the brain function. Early initiation of CPR can double or triple the chances of survival after cardiac arrest.

Note: High quality CPR

Compressions

• Infant: 2 finger compression (if alone) or thumb encircling technique (if you have assistance)

• Child: 1 or 2 hand

• Adult: Two hands

CPR quality parameters

• Compression rate: 100–120/min

• Compression depth: approximately 1/3 antero-posterior diameter of the chest

• Compression/ventilation ratio:

  • Adults and children: 30:2

  • If alone: 30:2

  • If you have assistance: 15:2

• Allow chest recoil

• Minimize interruptions

• Adequate ventilation

Clinical presentation

• Unresponsiveness (sudden loss of consciousness)

• Absence of central pulse (carotid pulse/femoral pulse or brachial pulse in infants)

• Loss of spontaneous respiration

Investigations

While continuing with CPR, point of care (POC) tests are conducted while looking for the reversible causes of the cardiac arrest (Hypovolemia, hypoxia, hypo/hyperkalemia, acidosis, hypothermia, hypoglycemia, tension pneumothorax, toxins, thrombi, cardiac tamponade).

These includes:

• POC Blood gases

• POC Bicarbonates

• POC Electrolytes – Potassium, sodium, Calcium, Chloride

• POC Creatinine, POC urea

• POC RBG

• Bedside ultrasound – looking for pneumothorax, cardiac tamponade or thrombi

• POC Toxicology screens (If available)

• POC ECG (if there is return of spontaneous circulation)

• POC lactate

• POC Troponin

Management

• HAZARDS – ensure safety and use of PPEs.

• HELLO – Check for responsiveness, Carotid pulse (not more than 10 seconds) and breathing.

• CPR starts with early recognition (unresponsiveness, loss of spontaneous breathing and absence of carotid pulse). In infant’s CPR is initiated when the heart rate is below 60 beats/min.

• Call for HELP and immediately start chest compression. As more members arrives to help assign different roles including airway and breathing management, time recording, documentation, AED/monitor, medications.

• Open the airway by performing chin lift or jaw thrust (if suspecting C spine injury). Use airway adjuncts to open the airway.

• Give 2 breaths using bag valve mask connected to oxygen source and observe for chest rise.

• Establish IV access for administration of fluids and medications, if failed perform Intraosseous access.

• After FIVE cycles of compressions/ventilation (2 minutes), check for pulse and use AED/Defibrillator to analyze rhythm if there is a need to deliver shock.

• If no need for shocking continue with CPR for another 2 minutes (FIVE cycles).

Pharmacological treatment

A: Adrenaline (IV)

• Adult: 1 mg

• Pediatrics: 0.01 mg/kg

• Repeat every 3–5 minutes

AND

A: 0.9% Sodium chloride (IV)

• Adult: 2000 mls

• Pediatrics: 20 mls/kg

If suspecting hypovolemia as a cause of the arrest.

AND

A: Dextrose 5% (IV)

If needed to correct hypoglycemia.

OR

C: Dextrose 10%, 25% or 50% (IV)

If needed to correct hypoglycemia.

AND

C: Sodium bicarbonate 1 mmol/kg (IV) push

If needed to correct acidosis.

Additional medications maybe required depending on cause of the cardiac arrest (the reversible cause).

Disposition

Upon achieving return of spontaneous circulation (ROSC), definitive airway is achieved by performing endotracheal intubation for mechanical ventilation and patient must be admitted to the ICU or transferred to a facility with an ICU capacity.