Twitter icon
Facebook icon
Google icon
LinkedIn icon

Cardiac Arrest Management Top 10

Todd M. Cage MEd, NRP

Introduction

No event in medicine is quite as dramatic as the resuscitation of a patient in cardiopulmonary arrest. In order to achieve a successful outcome, skilled medical personnel must come together and function as a team.1 Protocols for resuscitation are generally based on American Heart Association (AHA) Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC). These guidelines are evidence-based and are updated every five years through an international consensus process.

The management of the cardiac arrest patient requires a variety of tasks and skills, some of which are very basic. Often the key to a successful resuscitation is attention to many small details. The next 10 items are what EMS providers should keep in mind when faced with a patient in cardiac arrest. The organized resuscitative efforts of the providers on scene could mean the difference between life and death.

 

1. High-Quality CPR

Perform high-quality CPR. Perfusion is the linchpin to the entire effort. Without perfusion of blood to the brain, outcomes will be sub-optimal in the event of return of spontaneous circulation (ROSC). High-quality CPR includes pushing hard and fast at the recommended depth of at least 2 inches, while allowing for full chest recoil.2 Based in part on data from the Resuscitation Outcomes Consortium (ROC) trial current guidelines indicate a compression rate between 100-120 compressions per minute is optimal.2,3 (Click here for more on the ROC trial.)

 

2. Early Defibrillation

Provide for early defibrillation. Decades of research indicates that the primary treatment for ventricular fibrillation is defibrillation. The speed at which the defibrillation is delivered is essential because the probability of successful defibrillation deteriorates over time.4 Communities most successful in reducing death from sudden cardiac arrest rely on early defibrillation by first responders and/or public access defibrillation.5

 

3. Take a Break.

Switch rescuers every two minutes. Rescuers tire quickly during the performance of high-quality CPR.2 The ability to deliver effective compressions compression ability declines before the rescuer realizes his fatigue.6 Leadership is an essential component in cardiac arrest to ensure rescuers rotate to minimize the impact of fatigue. A key leadership component in the management of cardiac arrest is to ensure rescuers rotate to minimize the impact of fatigue.

 

4. Ventilation

Avoid excessive rate and volume of ventilation. Although oxygenation is important, metabolic demands for oxygen are decreased in the cardiac arrest state. Studies of witnessed cardiac arrest indicate that residual oxygen that exists in the body can be used with high-quality chest compressions. This is the basis for teaching lay rescuers compressions-only CPR. It is unknown how long this residual oxygen lasts in the body, so it is expected that traditional CPR will begin shortly after the arrival of trained rescuers.7-11 The 2015 AHA Guidelines recommend a ventilation rate of less than 10 breaths per minute in CPR in the presence of an advanced airway.24 This is logical considering the patient receiving single-rescuer CPR from a healthcare provider would receive 10 breaths during the two-minute cycle of CPR. Positive pressure ventilation reduces cardiac perfusion pressure, thereby working against the effort created by chest compression. Therefore, when ventilation occurs, it should be done in a way that only produces visible chest rise.2

 

5. Team Approach

Use a team approach. Resuscitation is almost always the work of a group of rescuers coming together to share their skill sets for the purpose of saving the life of the patient. Since the 2000 release of To Err is Human, Building a Safety Health System by the Institutes of Medicine, healthcare organizations and researchers have been exploring methods of improving teamwork and team leadership in the healthcare environment.

 

6. Don’t Interrupt.

Minimize interruptions in chest compressions. Ensuring that the chest compression fraction (CCF) is greater than 80% is essential. CCF is the proportion of time that compressions are actively being performed.12 Ensuring that no more than 10 seconds elapses without chest compressions can optimize CCF. Methods to assist in this include continuing chest compressions during laryngoscopy, reducing the preshock pause by resuming compressions as the defibrillator charges and maintaining situational awareness. CCF should be assessed and tracked as part of a cardiac arrest quality assurance program.

 

7. Time Medication Administration

Administer medications at the start of the two-minute compression cycle. When drugs are administered, a certain amount of time is required for the medication to reach the central circulation. In cardiac arrest, the peak effect of an intravenous vasopressor is at least 1 to 2 minutes after administration.13

 

8. Use Capnography.

Assess perfusion with end-tidal capnography. Aside from being a recommended measure of verifying the placement of an advanced airway, end tidal capnography (EtCO2) is gaining acceptance as a tool to determine perfusion status.12 Studies indicate that monitoring EtCO2 trends during CPR can guide rescuers’ compression depth and rate, detect fatigue and ROSC.14-17 There is also growing evidence to suggest that EtCO2 values that are persistently <10 mmHg indicate that ROSC is unlikely.18-22

 

9. Reversible Causes

Begin the search for reversible causes early. It is important for the provider to try to determine the reason the patient is in cardiac arrest. These reasons may indicate why the arrest occurred or why the resuscitation is not progressing. The Hs and Ts model advocated by the AHA is the most well-known tool to assess for reversible causes, however, other options may be available.12 Good history taking and a physical exam are keys to working through the differential diagnosis to determine the cause of the cardiac arrest.

 

10. After ROSC

There’s a pulse, now what? The patient has experienced ROSC, which means a pulse is present and the patient may have spontaneous breathing. Once ROSC is obtained; the big key is to ensure that the patient ends up in the best place to continue their care. Ideally, this is a facility equipped to deliver reperfusion therapy and hypothermia.23

After gaining ROSC, assess vital signs including blood pressure and respiratory function, and obtain a 12-lead ECG. Then transport to a tertiary care center capable of percutaneous coronary intervention (PCI) and therapeutic hypothermia.

 

Conclusion

The act of resuscitation is a high-risk, low-frequency skill. This means that healthcare workers should practice frequently to ensure their skills stay fresh.

 

References

  1. Schiebel N, Cage TM. Hospital emergency response team training course manual, fourth edition. Rochester, Minn.: Mayo Clinic; 2008:1.
  2. Kleinman ME, Brennan EE, Goldberger ZD, Swor RA, Terry M, Bobrow BJ, Gazmuri RJ, Travers AH, Rea T. Part 5: Adult Basic Life Support and Cardiopulmonary Resuscitation Quality: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015;132:S414-35. doi: 10.1161/CIR.0000000000000259.
  3. Idris AH, Guffey D, Aufderheide TP, Brown S, Morrison LJ, Nichols P, et al. Relationship between chest compression rates and outcomes from cardiac arrest. Circulation. 2012;125:3004-12.
  4. Larsen MP, Eisenberg MS, Cummins RO, Hallstrom AP. Predicting survival from out-of-hospital cardiac arrest: A graphic model. Ann Emerg Med. 1993;22:1652-58.
  5. White RD, Asplin BR, Bugliosi TF, Hankins DG. High discharge survival rate after out-of-hospital ventricular fibrillation with rapid defibrillation by police and paramedics. Ann Emerg Med. 1996;28(5):480-485.
  6. Manders S, Geijsel FE. Alternating providers during continuous chest compressions for cardiac arrest: Every minute or every two minutes? Resuscitation. 2009;80(9):1015-18.
  7. Hallstrom A, Cobb L, Johnson E, Copass M. Cardiopulmonary resuscitation by chest compression alone or with mouth-to-mouth ventilation. N Engl J Med. 2000;342:1546-53.
  8. Van Hoeyweghen RJ, Bossaert LL, Mullie A, Calle P, Martens P, Buylaert WA, et al. Quality and efficiency of bystander CPR. Belgian Cerebral Resuscitation Study Group. Resuscitation. 1993;26(1):47-52.
  9. Bobrow BJ, Clark LL, Ewy GA, Chikani V, Sanders AB, Berg RA. et al. Minimally interrupted cardiac resuscitation by emergency medical services for out-of-hospital cardiac arrest. JAMA. 2008;299(10):1158-65.
  10. Dorph E, Wik L, Stromme TA, Eriksen M, Steen PA. Oxygen delivery and return of spontaneous circulation with ventilation:compression ratio 2:30 versus chest compressions only CPR in pigs. Resuscitation. 2004;60(3):309-18.
  11. Sayre MR, Berg RA, Cave DM, Page RL, Potts J, White RD. Hands-only (compression-only) cardiopulmonary resuscitation: A call to action for bystander response to adults who experience out-of-hospital sudden cardiac arrest: A science advisory for the public from the American Heart Association Emergency Cardiovascular Care Committee. Circulation. 2008;117(16):2162-7.
  12. Meaney PA, Bobrow BJ, Mancini ME, et al. Cardiopulmonary resuscitation quality: [corrected] improving cardiac resuscitation outcomes both inside and outside the hospital: A consensus statement from the American Heart Association. Circulation. 2013;128(4):417-35. Epub 2013 Jun 25. Erratum in: Circulation. 2013;128(20):e408. Circulation. 2013;128(8):e120.
  13. Neumar RW, Otto CW, Link MS, Kronick SL, Shuster M, Callaway CW, et al. Part 8: Adult advanced cardiovascular life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122(10 Suppl 3):S729-67.
  14. Pokorna M, Necas E, Kratochvil J, Skripsky R, Andrlik M, Franek O. A sudden increase in partial pressure end-tidal carbon dioxide (P(ET)CO(2)) at the moment of return of spontaneous circulation. J Emerg Med. 2010;38(5):614-21.
  15. Sehra R, Underwood K, Checchia P. End tidal CO2 is a quantitative measure of cardiac arrest. Pacing Clin Electrophysiol. 2003;26(1 Pt 2):515-17.
  16. Bhende MS, Karasic DG, Karasic RB. End-tidal carbon dioxide changes during cardiopulmonary resuscitation after experimental asphyxial cardiac arrest. Am J Emerg Med. 1996;14(4):349-50.
  17. Falk JL, Rackow EC, Weil MH. End-tidal carbon dioxide concentration during cardiopulmonary resuscitation. N Engl J Med. 1988;318(10):607-11.
  18. Grmec S, Kupnik D. Does the Mainz Emergency Evaluation Scoring (MEES) in combination with capnometry (MEESc) help in the prognosis of outcome from cardiopulmonary resuscitation in a prehospital setting? Resuscitation. 2003;58(1):89-96.
  19. Grmec S, Klemen P. Does the end-tidal carbon dioxide (EtCO2) concentration have prognostic value during out-of-hospital cardiac arrest? Eur J Emerg Med. 2001;8:263-269.
  20. Kolar M, Krizmaric M, Klemen P, Grmec S. Partial pressure of end-tidal carbon dioxide successful predicts cardiopulmonary resuscitation in the field: A prospective observational study. Crit Care. 2008;12(15):R115.
  21. Ahrens T, Schallom L, Bettorf K, Ellner S, Hurt G, O'Mara V, et al. End-tidal carbon dioxide measurements as a prognostic indicator of outcome in cardiac arrest. Am J Crit Care. 2001;10(6):391-8.
  22. Touma O, Davies M. The prognostic value of end tidal carbon dioxide during cardiac arrest: A systematic review. Resuscitation. 2013;84(11):1470-9.
  23. Peberdy MA, Callaway CW, Neumar RW, Geocadin RG, Zimmerman JL, Donnino M, et al. Part 9: Post-cardiac arrest care: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122(18 Suppl 3):S768-86. Erratums: Circulation. 2011;123(6):e237. Circulation. 2011;124(15):e403.
  24. Link MS, Berkow LC, Kudenchuk PJ, Halperin HR, Hess EP, Moitra VK, Neumar RW, O'Neil BJ, Paxton JH, Silvers SM, White RD, Yannopoulos D, Donnino MW. Part 7: Adult Advanced Cardiovascular Life Support: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015;132:S444-64. doi: 10.1161/CIR.0000000000000261.

 

The EMS Reference is a community project, and we encourage your suggestions. Give us your feedback.

Published: August 13, 2014
Revised: November 27, 2015