1. Principles of Cardiac Arrest Management
Richard Lake 10/2003

2. Background Information
40% of deaths under the age of 75yrs in Europe are due to cardiovascular disease
One third of people who suffer a myocardial infarction die before reaching hospital
Most die within an hour of the onset of acute symptoms
The majority of these deaths the presenting rhythm is Ventricular Fibrillation or pulseless Ventricular Tachycardia, (VF/ pulseless VT)

3. The only treatment for VF/ pulseless VT is attempted defibrillation
With each minute’s delay the chance of a successful outcome fall by 7-10%
Once in hospital the incidence of VF after Myocardial Infraction is approximately 5%
Most likely presentation of in hospital cardiac arrest is asystole or pulseless electrical activity (PEA).

4. The Chain of Survival

5. Early Access to emergency services or cardiac arrest team
Out of hospital summon EMS
by dialling 999/112
In hospital call cardiac arrest
team ring 2222 (check
number when on placement)

6. External chest compressions and
ventilation will slow down the
rate of deterioration of the brain
and heart
Basic Life Support should be
performed immediately

7. Basic Life Support Danger Response Shout for Help Airway Breathing
If no help arrived leave victim, go for help
Circulation

8. Danger Check for danger to: Yourself Bystanders Victim
Even clinical areas can have dangers, so ALWAYS CHECK

9. Response Check the victim for response
Ask a question, ‘hello are you alright?’
Give a command, ‘open your eyes!’
Give a painful stimulus; pinch the shoulder
If no response shout for help

10. Checking for response

11. Airway Check the airway
Open the airway, place one hand on the victims forehead and gently tilt head back
Remove any visible obstruction from the victims mouth, including dislodged dentures. Leave well fitting dentures in place
DO NOT ATTEMPT ANY FINGER SWEEPS

12. Opening the airway

13. Jaw thrust technique may be needed if C-spine injury

15. If available use airway adjuncts

16. Nasopharyngeal airway insertion

19. Oropharyngeal airway insertion

20. Breathing Keeping the airway open: Look – for chest movements
Listen – at the victims mouth for breath sounds
Feel – for air on your cheek
Look, listen and feel for no more than 10 seconds to determine if the victim is not breathing.

21. If not breathing and no help has arrived
Leave the victim and go to summon help

22. Turn the victim onto his back if he is not already in that position
Give 2 effective rescue breaths, each of which should make the chest rise and fall
If you have difficulty achieving an effective breath:
Recheck the victims mouth and remove any obstruction
Recheck there is head tilt and chin lift
Make up to 5 attempts to achieve 2 effective breaths
Even if unsuccessful move onto check circulation

24. If available use a pocket mask

26. Bag valve mask device may be used

28. Circulation
Look, listen and feel for normal breathing, coughing, swallowing, eye flickering, or any movement by the victim
If you feel confident check for a carotid pulse
You should take no more than 10 seconds to do this

29. Always check pulse same side as you

30. If no breathing but signs of circulation
Continue rescue breaths at a rate of 10 breaths per minute
After every 10 breaths (every 1 minute) recheck for signs of circulation
This should take no longer than 10 seconds to check

31. If no breathing and no signs of circulation
Commence CPR at a ratio of
15 Compressions
to 2 ventilations

32. Ensure correct hand position

34. The Chain of Survival

35. Out of hospital the aim is to
deliver a shock within
5 minutes of the EMS receiving
a call
In hospital the first healthcare
responder should be trained and
authorised to use a defibrillator
immediately

36. Automated External Defibrillator

37. AED hands off pads

38. Automated External Defibrillators may be used

40. Manual Defibrillator

41. Manual Defibrillator Paddles

42. Defibrillation

43. Defibrillation should be performed promptly

44. Often defibrillation restores a
perfusing heart rhythm, this is
often inadequate to sustain
circulation and further
advanced life support is
required to improve the
chances of long term survival

45. Remember the chain of survival

46. The Universal Treatment Algorithm
An important part of
Advanced Cardiac Life Support

47. Objectives Recognise the four cardiac arrest rhythms
Identify correctly the appropriate algorithm for each of the rhythms
Discuss the potential reversible causes of cardiac arrest

48. Re-assess one minute after defibrillation
BLS Algorithm
if appropriate
Precordial Thump
Attach Monitor/Defib
Assess rhythm
+/- Pulse Check
VF / VT
NON VF/VT
DEFIB X 3 as necessary
During CPR Correct reversible causes
CPR 3 min
Re-assess one minute after defibrillation
CPR 1 MIN
Check electrode / paddle positions Attempt/verify airway/02/IV access Give adrenaline every 3 mins ? buffers/atropine/ pacing/antiarrhythmics

49. ? VF / VT Non VF / VT BLS Algorithm Precordial Thump
if appropriate
Precordial Thump
if appropriate
Attach Monitor/Defib
Assess rhythm
+/- Pulse Check ?
VF / VT
Non VF / VT

50. During CPR Correct reversible causes
BLS Algorithm
if appropriate
Precordial Thump
Attach Monitor/Defib
Assess rhythm
+/- Pulse Check
VF / VT
During CPR Correct reversible causes
DEFIB X 3 as necessary
Check electrode / paddle positions Attempt/verify airway/02/IV access Give adrenaline every 3 mins ? buffers/atropine/ pacing/antiarrhythmics
CPR 1 MIN

51. During CPR Correct reversible causes
BLS Algorithm
if appropriate
Precordial Thump
Attach Monitor/Defib
Assess rhythm
+/- Pulse Check
NON VF/VT
During CPR Correct reversible causes
CPR 3 min
Re-assess one minute after defibrillation
Check electrode / paddle positions Attempt/verify airway/02/IV access Give adrenaline every 3 mins ? buffers/atropine/ pacing/antiarrhythmics

52. Potentially Reversible Causes
Hypoxia
Hypovolemia
Hyper/ Hypokalemia and metabolic disturbances
Hypothermia
Tension pneumothorax
Tamponade
Toxic/ therapeutic disturbances
Thrombo-embolic/ mechanical obstruction

53. Re-assess one minute after defibrillation
BLS Algorithm
if appropriate
Precordial Thump
Attach Monitor/Defib
Assess rhythm
+/- Pulse Check
VF / VT
NON VF/VT
DEFIB X 3 as necessary
During CPR Correct reversible causes
CPR 3 min
Re-assess one minute after defibrillation
CPR 1 MIN
Check electrode / paddle positions Attempt/verify airway/02/IV access Give adrenaline every 3 mins ? buffers/atropine/ pacing/antiarrhythmics

58. Drugs used commonly during resuscitation
Epinephrine (Adrenaline)
Atropine
Amiodarone
Magnesium Sulphate
Lidocaine (Lignocaine)
Sodium Bicarbonate
Calcium

59. Epinephrine (Adrenaline)
First line cardiac arrest drug, given after every 3 minutes of CPR
Dose 1mg (10ml of 1 in 10,000) IV
Causes vasoconstriction, increased systemic vascular resistance increasing cerebral and coronary perfusion
Increases myocardial excitability, when the myocardium is hypoxic or ischaemic

60. Atropine
Given for asystole or pulseless electrical activity with a rate less than 60 beats per minute
3mg is given as a single intravenous dose
It blocks the activity of the vagus nerve on the SA and AV nodes, increasing sinus automaticity and facilitating AV node conduction

61. Amiodarone
For Refractory VF/VT; haemodynamically stable VT and other resistant tachyarrhythmias
If VF or pulseless VT persists after the first 3 shocks then Amiodarone 300mg is considered.
If not pre-diluted, must be diluted in 5% dextrose to 20ml. (Will crystallise is mixed with saline)
Should be given centrally but in an emergency can be given peripherally
Increases the duration of the action potential in the atrial and ventricular myocardium

62. Magnesium Sulphate
For refractory VF when hypomagnesaemia is possible; ventricular tachyarrhythmias when hypomagnesaemia is possible
In refractory VF – 1 to 2g (2-4ml of 50% magnesium sulphate) peripherally over 1 to 2 minutes.
Other circumstances 2.5g (5ml of 50% magnesium sulphate) over 30 minutes

63. Lidocaine (Lignocaine)
For Refractory VF/ pulseless VT (when Amiodarone is unavailable
100mg for VF/ pulseless VT that persists after three shocks. Another 50mg can be given if necessary

64. Sodium Bicarbonate
Given for severe metabolic acidosis and Hyperkalaemia
50mmol (50ml of 8.4% solution), where there is an acidosis or cardiac arrest associated with Hyperkalaemia

65. Calcium Administered when pulseless electrical activity caused by:
Hyperkalaemia
Hypocalcaemia
Overdose of Calcium channel blocking
drugs
Dose 10ml of 10% calcium chloride repeated according to blood results

66. Summary Cardiac arrest can have a variety of causes
The chain of survival is essential to improve outcome from cardiac arrest

67. Awareness of the universal treatment algorithm is important
A knowledge of the drugs used in cardiac arrest, their routes and dilution is also essential

68. Questions

69. References
Resuscitation Council (UK). (2000) Advanced Life Support Provider Course Manual . 4th Edition. Resuscitation Council (UK).:London
Resuscitation Council (UK). (2002) Immediate Life Support Course Manual . 1st Edition. Resuscitation Council (UK).:London