Cardiac arrest in adults

I46.0/I46.9

DESCRIPTION

Described as the loss of a heart beat and a palpable pulse, irrespective of the electrical activity captured on ECG tracing. Irreversible brain damage can occur within 2–4 minutes.

Clinical features include:

  • sudden loss of consciousness, absent carotid pulses
  • loss of spontaneous respiration

EMERGENCY TREATMENT

  • Diagnose rapidly. After ensuring the safety of the scene, commence resuscitation as per acute adult cardiac arrest algorithm – as above
  • Make a note of the time of starting resuscitation.
  • Place the patient on a firm flat surface and commence resuscitation immediately.
  • Call for skilled help and an automated external defibrillator (AED) or defibrillator.
  • Initiate CAB (Circulation Airway Breathing) sequence of CPR (cardiopulmonary resuscitation).
  • Where a defibrillator is not immediately available, a single powerful precordial thump is recommended for witnessed cardiac arrest where a defibrillator is not immediately available.
  • Document medication and progress after the resuscitation.

Cardiopulmonary resuscitation (CPR)

Circulation

  • Check for carotid pulse for about 5 seconds.
  • If there is no pulse or you are not sure, start with chest compressions at a rate of 100-120 compressions per minute. Push hard and allow full recoil of chest with minimum interruptions.

Airway and breathing

  • To open the airway, lift the chin forward with the fingers of the one hand and tilt the head backwards with other hand on the forehead.
  • Note: Do not do this where a neck injury is suspected – refer below for management of suspected neck injury.
  • Do not do this where a neck injury is suspected – refer below for management of suspected neck injury
  • Ensure airway is open throughout resuscitation.
  • If there is no normal breathing, attempt 2 respirations with bag-valve-mask resuscitator and face mask.
  • The administered breaths must cause visible chest rising in patient. If not, reposition and try again once and proceed to next step.
  • Repeat the cycle of 30 compressions followed by 2 respirations for 5 cycles and then re-assess for a pulse.
  • If advanced airway is placed, administer 1 breath every 6 second. Avoid excessive ventilation.
  • Oxygenate with 100% oxygen.

Where neck injury is suspected:

  • To open the airway, place your fingers behind the jaw on each side.
  • Lift the jaw upwards while opening the mouth with your thumbs (jaw thrust).
  • To open the airway, place your fingers behind the jaw on each side.
  • Maintain in line cervical spine immobilisation.

Initiate fluids, IV/IO access

  • Sodium chloride 0.9%.

LoEI [1]

If pulseless with shockable rhythm (ventricular fibrillation/tachycardia)

  • Defibrillate, as indicated per algorithm.
  • Immediately resume CPR. Starting with chest compression.
  • Continue CPR for 2 minutes.
  • Administer adrenaline (epinephrine) as per algorithm.
  • Seek reversible cause of arrest.
  • Continue CPR until spontaneous breathing and/or heart beat returns.
  • For management of
  • ventricular fibrillation or pulseless ventricular tachycardia that is unresponsive to defibrillation:
  • Amiodarone, IV bolus, 300 mg, 2 minutes after adrenaline (epinephrine) dose.
    • Follow by a bolus of 10 mL sodium chloride 0.9%
    • Patient remains in a shockable rhythm following further 2 minutes of CPR, a defibrillation shock, another adrenaline (epinephrine) dose, and another 2 minutes of CPR (5 cycles of 30:2): Amiodarone, IV bolus, 150 mg.

LoEI [2]

If pulseless with non-shockable rhythm

  • Immediately resume CPR. Starting with chest compression.
  • Continue CPR for 2 minutes.
  • Administer adrenaline as per algorithm.
  • Seek reversible cause of arrest.
  • Continue CPR until spontaneous breathing and/or heart beat returns.

Immediate emergency medicine treatment

Adrenaline (epinephrine) is the mainstay of treatment and should be given immediately, IV or intra-osseous, when there is no response to initial resuscitation or defibrillation.

  • Adrenaline (epinephrine), 1:1 000, 1 mL, IV immediately, as a single dose. LoEI [3]
    • Flush with 5–10 mL IV of sterile water or sodium chloride, 0.9%.
    • Repeat every 3–5 minutes during resuscitation.

If no IV line is available:

  • Adrenaline (epinephrine), intra-osseous (IO), 1:1000, 1 mL, via IO line. LoEIII [4]
    • Flush with 5–10 mL of sterile water or sodium chloride 0.9%.
    • Repeat every 3–5 minutes during resuscitation.
  • Assess continuously until the patient shows signs of recovery.
  • Consider stopping resuscitation attempts and pronouncing death if:
    • further resuscitation is clearly clinically inappropriate, e.g. incurable underlying disease, all known reversible factors addressed or
    • no success after all the above procedures have been carried out for ≥ 30 minutes.
  • Consider carrying on for longer especially when:
    • hypothermia and drowning, particularly in younger patients
    • poisoning or drug overdose or carbon monoxide poisoning