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CDHB

Cardiac Arrest

Commence basic life support unless the patient’s status is DNACPR. Use the ABCs of CPR. Call for the Clinical Emergency Team and resuscitation trolley. Consider precordial thump if monitored or witnessed and a defibrillator is not immediately available.

REMEMBER:

• External chest compression at 100/min.
• 30 compressions to 2 ventilations for both 1 and 2 person CPR. Minimize interruptions to chest compressions.
• Use oropharyngeal airway with ambu bag and face mask or supraglottic airway rather than intubate unless you are confident of success. If you insert an endotracheal tube, basic life support must not stop for more than 20 seconds. Give uninterrupted chest compressions at 100/min once intubated with a ventilation rate of 6-10/min.
• When the defibrillator arrives identify the rhythm utilizing the electrode pads.
• Position pads at right of upper sternum below the clavicle, and left of the left nipple in the anterior axillary line.
• Do not use dilated pupils as an indication to stop resuscitation.

Identify the Cardiac Rhythm

• Ventricular fibrillation (VF):
  1. Defibrillate immediately using initial setting of 200 joules. Give one shock.
  2. Perform CPR for 2 minutes.
  3. If still in VF give one shock at maximum setting (360 joules), then 2 minutes CPR.
  4. After second shock if still in VF give adrenaline 1 mg IV. Continue one shock / 2 minutes CPR sequence.
  5. After third shock if still in VF give amiodarone 300 mg IV bolus. Continue one shock / 2 minutes CPR.
  6. Repeat adrenaline every 3-5 minutes.
  7. If still in VF consult Cardiologist regarding the use of other agents. Consider metoprolol 1-2 mg IV.
• Pulseless Electrical Activity (Electromechanical dissociation), i.e., organized electrical activity on ECG but failure of effective myocardial contraction:
  1. Consider and treat possible causes including hypovolaemia, major electrolyte imbalance, tension pneumothorax, cardiac tamponade, pulmonary embolism, overdose, anaphylaxis. May occur transiently following VF/asystole. Urgent echocardiography may be useful.
  2. In absence of other specific therapy give adrenaline 1 mg IV. Repeat every 3-5 minutes.
• Ventricular asystole:

  Note: Exclude the possibility of monitor failure resulting in apparent asystole.

  1. Perform CPR. Briefly check rhythm every 2 minutes. Minimize interruptions to CPR.
  2. Give adrenaline 1 mg IV. Repeat adrenaline every 3-5 minutes.
  3. Consider an adrenaline infusion.
  4. Consider transcutaneous or transvenous pacing.
  5. Consider and treat possible causes including hypovolaemia, major electrolyte imbalance, tension pneumothorax, cardiac tamponade, pulmonary embolism, and overdose.
• Bradycardia and Heart Block:
  1. Percussion (fist) pacing. For patients in cardiac arrest, percussion (fist) pacing is not recommended. However it may be considered in haemodynamically unstable bradyarrhythmias until an electrical pacemaker (transcutaneous or transvenous) is available.
  2. Consider atropine 0.6 mg IV and repeat if necessary.
  3. Consider an adrenaline infusion.

Adult In-Hospital Resuscitation

Adult In-Hospital Resuscitation

Authorized by the CDHB Resuscitation Coordinator 2011.

Post-Arrest Management

• Maintain basic life support unless the patient has an adequate spontaneous circulation and respiration.
• Titrate inspired oxygen to achieve sat.O₂ of 94-98%.
• Monitor ECG and transfer when stable to CCU or ICU, depending upon level of consciousness and requirement for artificial ventilation.

Information for Doctors Regarding Resuscitation Decisions

Cardiopulmonary resuscitation (CPR) can be lifesaving, particularly in the hospital context where effective CPR can be commenced very quickly. Cardiac arrest may be due to an acute and potentially reversible event and CPR can be effective at restoring cardiorespiratory function and allowing recovery.

CPR is the default option within all health care facilities in New Zealand unless an advance decision is made that CPR should not be attempted.

More commonly however, cardiac arrest is the final event in the dying process and for many patients with advanced illness, CPR has virtually no prospect of success and may be either unsuccessful or leave the patient worse off.

DNACPR stands for "Do Not Attempt Cardiopulmonary Resuscitation" and is the medical order in the CDHB which indicates that CPR should be withheld, allowing the death of that patient from natural causes or inevitable progression of their illness.

DNACPR status must be clearly displayed in the patient's notes. If this order is not apparent then as indicated the default position is to carry out CPR.

For further details, see Cardiac Arrest.

Topic Code: 1335