Treatment of cardiac arrest

Cardiac arrest is a sudden stop in effective blood flow due to the failure of
the heart to contract effectively.

Loss of effective cardiac activity is generally due to the spontaneous initiation

of a non-perfusing arrhythmia, sometimes referred to as a malignant arrhythmia.
The most common non-perfusing arrhythmias include the following:
1) Ventricular fibrillation (VF)
2) Pulseless ventricular tachycardia (VT)
3) Pulseless electrical activity (PEA)
4) Asystole
5) Pulseless bradycardia

Basic life support

1) Make sure the scene is save, then tap the patient on the shoulder and shout “are
you OK?”
2) Ask for help.
3) Open the airway. With the patient lying on his or her back, tilt the head back
slightly to lift the chin.
4) Diagnose cardiac arrest by checking the patient's response to sound and touch,
absent respirations and impalpable carotid or femoral pulses.
5) If the arrest is witnessed, consider giving one or two precordial thumps.
6) If the precordial thumps didn't restore the pulse and breathing, begin
cardiopulmonary resuscitation immediately.

Cardio pulmonary resuscitation (CPR)

It is an emergency procedure performed to cardiac arrested patients, chest
compression done often with artificial ventilation in an effort to manually preserve
intact brain function until further measures are taken to restore spontaneous blood
circulation and breathing.

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 CPR alone is unlikely to restart the heart; It’s main purpose is to restore partial
flow of oxygenated blood to the brain and heart. The objective is to delay tissue
death and to extend the brief window of opportunity for a successful resuscitation
without permanent brain damage. Administration of a direct current electric shock
to the patient's heart, termed “defibrillation”, is effective only for certain heart
rhythms, namely ventricular fibrillation or pulseless ventricular tachycardia, rather
than asystole or pulseless electrical activity. CPR may succeed in inducing a heart
rhythm that may be shockable. In general, CPR is continued until the person has
a return of spontaneous circulation or is declared dead.

CPR should be continued while the defibrillator is being applied and charged.
Additionally, CPR should be resumed immediately after a defibrillatory shock until
a pulsatile state is established.

Positioning for CPR:

1) CPR is most easily and effectively performed by laying the patient supine on a
relatively hard surface, which allows effective compression of the sternum.
2) Delivery of CPR on a mattress or other soft material is generally less effective.
3) The person giving compressions should be positioned high enough above the
patient to achieve sufficient effect, so that he or she can use body weight to
adequately compress the chest.

For an unconscious adult, CPR is initiates as follow:

1) Give 30 chest compressions
2) Perform the head-tilt chin-lift maneuver to open the airway and determine if the
patient is breathing
3) Before beginning ventilations, look in the patient’s mouth for a foreign body
blocking the airway
Chest compression:
The provider should do the following:
1) Place the heel of one hand on the patient’s sternum and the other hand on top of
the first, you may tangle the fingures.
2) Extend the elbows and the provider leans directly over the patient.
3) Press down on the heart near the sternum, compressing the chest at least 2
inches (about 5 cm).
4) Release the chest and allow it to recoil completely

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5) The compression depth for adults should be at least 2 inches (about 5 cm); for
young children 1/2; and for babies 1/3 of the depth and use two or one hand.
6) The compression rate should be at least 100/min.
7) The key phrase for chest compression is, “Push hard and fast”
8) After 30 compressions, 2 breaths are given; if at least 2 trained rescuers are
present a ratio of 15:2 is preferred. In newborns a rate of 3:1 is recommended
unless a cardiac cause is known in which case a 15:2 ratio is reasonable, however,
an intubated patient should receive continuous compressions while ventilations are
given 8-10 times per minute.
9) This entire process is repeated until a pulse returns or the patient is transferred to
definitive care.
10) To prevent provider fatigue or injury, new providers should intervene every 2-
3 minutes (ie, providers should swap out, giving the chest compressor a rest while
another rescuer continues CPR.

Ventilation:
If the patient is not breathing, 2 ventilations are given via the provider’s mouth or
a bag-valve-mask (BVM or ambu-bag). If available, a barrier device (pocket mask
or face shield) should be used.
To perform the BVM or invasive airway technique, the provider does the
following:
1) Ensure a tight seal between the mask and the patient’s face

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2) Squeeze the bag with one hand for approximately 1 second, forcing at least 500
mL of air into the patient’s lungs
To perform the mouth-to-mouth technique, the provider does the following:
1) Pinch the patient’s nostrils closed to assist with an airtight seal
2) Put the mouth completely over the patient’s mouth
3) After 30 chest compression, give 2 breaths (the 30:2 cycle of CPR)
4) Give each breath for approximately 1 second with enough force to make the
patient’s chest rise
5) Failure to observe chest rise indicates an inadequate mouth seal or airway
occlusion
6) After giving the 2 breaths, resume the CPR cycle

Complications:
Complications of CPR include the following:
1) Fractures of ribs or the sternum from chest compression (widely considered
uncommon)
2) Gastric insufflation from artificial respiration using noninvasive ventilation
methods (eg, mouth-to-mouth, BVM); this can lead to vomiting, with further
airway compromise or aspiration; insertion of an invasive airway (eg, endotracheal
tube) prevents this problem.

Advanced cardiac life support (ACLS)

1) Endotracheal intubation and ventilation of the lungs.

2) Early 'blind' electrical defibrillation. Direct current (DC) cardioversion

improves outcomes when cardiac arrest is due to ventricular fibrillation
(VF). It should be performed as soon as the diagnosis of VF is confirmed. In
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 cardiac arrest where the rhythm is in doubt, two or three DC shocks (200,
200 then 360 joules) should be tried 'blind'. The interval between each shock
should be less than one minute with a check of rhythm being made after
each shock and continue of CPR.
3) Drugs (in VF) are secondary to electrical defibrillation and have limited
efficacy.
4) All drugs should be given as boluses, with lidocaine being tried first. Other
drugs may be considered subsequently. There should be cycles of at least a
further 3 DC shocks (of 360 joules) and continued CPR for one minute
(approximately 10 sequences of 5:1 compression-ventilation) before each
new drug is given. The anterior electrode is placed on the right, below the
clavicle. The apex electrode is applied to the left side of the patient, just
below and to the left of the pectoral muscle. This scheme works well for
defibrillation and cardioversion, as well as for monitoring an ECG.

One paddle up (sternum) and the other down (apex)

5) Intravenous fluids:
An intravenous line should be established at the antecubital fossa (not at the
hand or wrist) and 1000 mL of normal saline infused rapidly. Central venous
cannulation is not mandatory, but may be required if other venous access cannot
be gained. Volume loading is necessary to maintain an adequate venous return
to the heart. Colloid solutions containing gelatine such as polygeline
(Haemaccel) are not usually required. Dextrose solutions are contraindicated as
they do not adequately expand the circulation and glucose may be toxic to
hypoxic brain cells

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Routes of drug administration:

All drugs should be given via the intravenous line with normal saline running.
There is no role for intracardiac administration. If there is delay in gaining
intravenous access, some drugs, including adrenaline, lidocaine and atropine,
may be administered via the endotracheal tube at twice the intravenous dose. In
young children, the intraosseous route can be used for both fluid and drug
delivery and is comparable to intravenous administration.
Adrenaline: In adults, current recommendations are for intravenous adrenaline 1
mg (10-15 microgram/kg) to be given immediately and repeated every 3-5
minutes.
Atropine: (1-2 mg) is often given, but probably has little or no effect in cardiac
arrest. The dose is not repeated.

Lidocaine: There is little (if any) evidence that lidocaine terminates VF and
theoretically it may adversely raise the threshold for successful electrical
defibrillation. The major effective use for lidocaine is to suppress ectopic
ventricular activity once spontaneous circulation has returned. The initial dose
is 1.5 mg/kg followed by an infusion of 2-8 mg/minute.

Notes:
1) Before defibrillation, ensure the patient and the area is not wet, the
patient’s body should be dried and the wet area should be abandoned to a
dry place.
2) The staff must not touch the bed during electrical defibrillation, to avoid
electrification.

3) Resuscitation should be continued till spontaneous heart beats and cardiac

output start or death confirmed.

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