Cardiorespiratory Arrest	19

Sheila Nainan Myatra, Amol T. Kothekar,

and Jigeeshu V. Divatia

A 60-year-old female diabetic patient with ischemic heart disease was operated for a cholecystectomy. On the Þrst postoperative day in the ICU, she complained of sudden chest discomfort. While taking the history, the patient suddenly stopped speaking and fell back in the bed.

Step 1: Early recognition of sudden cardiac arrest—check responsiveness and breathing

¥Check responseÑgently tap the patient on her shoulders and check for a response.

¥Check breathingÑno breathing or no normal breathing (i.e., only gasping). Remember that short period of seizure-like activity or agonal gasps may occur in victims of cardiac arrest and often confuse the rescuer.

¥Suspect cardiac arrest if there is no response and absent or agonal respiration.

Step 2: Activate the emergency system

¥Activate the emergency system if present in your hospital or just shout for help. Get the deÞbrillator or send someone to get it.

Step 3: Check the pulse

¥There is a de-emphasis on pulse check. Check the pulse using a central pulse (carotid or femoral) for no more than 10 s. If pulse is not felt in 10 s or there is any doubt, start chest compression.

S.N. Myatra, M.D. (*) ¥ A.T. Kothekar, M.D. ¥ J.V. Divatia, M.D., F.I.S.C.C.M. Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Mumbai, India

e-mail: [e-mail]

R. Chawla and S. Todi (eds.), ICU Protocols: A stepwise approach,	151
DOI 10.1007/978-81-322-0535-7_19, © Springer India 2012

152	S.N. Myatra et al.

Step 4: Start cardiopulmonary resuscitation (CPR)—initiate chest compressions before giving rescue breaths (airway, breathing, and circulation [ABC] is now circulation, airway, and breathing [CAB])

Positioning

¥The victim should lie supine on a hard surface.

¥The rescuer should kneel beside the victimÕs thorax (either side).

¥Keep arms straight, elbows locked, and the shoulder directly above the hand.

¥Hand placement: Place the heel of the hand on the lower half of the victimÕs sternum in the center (middle) of the chest, between the nipples, and then place the heel of the second hand on top of the Þrst so that the hands are overlapped and parallel. Interlock Þngers to avoid compression on the ribs.

Technique

During CPR, remember to Òpush hard and push fastÓ (all you need is two hands):

¥Compressions rateÑat least 100/min.

¥Depth of sternal compressionÑat least 2 in., i.e., 5 cm (one-third anteroposterior diameter in children and infants).

¥Compression ventilation ratioÑthe adult patient 30:2 (with one or more rescuers) and the child or infant 30:2 (with one rescuer) and 15:2 (with more than one rescuer).

¥Compression relaxation ratioÑ1:1 (allow complete recoil of the chest).

¥Perform Þve cycles (approximately 2 min) of compression and ventilation (ratio 30:2).

¥Switch the compressor every 2 min.

¥Give 2 min of uninterrupted CPR (limit interruptions to <10 s and interrupt only during intubation and just when you are ready to deliver a shock).

To easily achieve the above, one could use simple counting at the speed of

approximately 100/minÑÒone and two and three and É.Ó Every time you say a number, compress, and when you say Òand,Ó you relax.

Ventilation

¥After every 30 compressions, give two slow rescue breaths using the face mask and the AMBU bag (using the reservoir bag) to deliver 100% oxygen.

¥Before you start ventilation, open the airway using a jaw thrust or a head tilt/chin lift maneuver (avoid this in trauma victims with suspected cervical spine injury).

¥Give one breath over 1 s (rapid ventilation could cause gastric insufßations and increase the risk of aspiration, should be avoided).

¥Give sufÞcient tidal volume to ensure visible chest rise.

¥Reposition mask if there is a leak and insert an oral or nasal airway if there is airway obstruction due to fall of the tongue.

¥The use of cricoid pressure during ventilation is generally not recommended. Complete Þve cycles of compression followed by ventilation (it will take approx-

imately 2 min if you give it at the correct rate).

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Step 5: Attach the defibrillator (automated external defibrillators [AED] or manual defibrillators) and shock if indicated

¥As soon as an AED/manual deÞbrillator is available, attach it and shock if indicated, i.e., in ventricular Þbrillation (VF) and pulseless ventricular tachycardia (VT).

¥Prefer a biphasic deÞbrillator; if unavailable, use a monophasic deÞbrillator.

¥Ensure that no one is touching the patient before you shock.

¥Electrode placement should be in the anterior-lateral pad position (default). Alternative positions are anterior-posterior, anterior-left infrascapular, and ante- rior-right infrascapular.

¥Shock energyÑ(a) Biphasic: Use the manufacturerÕs recommendation (120Ð 200 J); if unknown, use maximum available. Second and subsequent doses should be equivalent, and higher doses may be considered if available. (b) Monophasic: 360 J (in children and infants, use 2Ð4 J/Kg Þrst and 4 J/Kg for subsequent shocks; higher energy may be considered but not to exceed 10 J/Kg).

¥No pulse check is recommended after deÞbrillation; resume CPR immediately.

¥Reattach the deÞbrillator after every 2 min of CPR.

¥Reduce time between the last compression and shock delivery and the time between shock delivery and resumption of compressions. CPR should be performed while the deÞbrillator is readied.

¥There is no upper limit to the number of shocks you give. Remember that the shockable rhythms are the ones with the better prognosis, so never give up on a VF or pulseless VT.

¥AEDs can now be used even in infants with a pediatric dose attenuator if the manual deÞbrillator is not available. If neither is available, the AED without the pediatric dose attenuator can be used. (All AEDs are biphasic.)

¥The precordial thump may be considered in witnessed, monitored, and unstable ventricular tachyarrhythmias only when a deÞbrillator is not available.

¥Electric pacing is not recommended for routine use in cardiac arrest.

Step 6: Drug therapy

¥Use intravenous (IV) or intraosseous (IO) route for bolus delivery of drugs. For IV use, give the bolus drug followed by a 20-mL saline push and raise the extremity.

¥If both IV and IO are unavailable, then tracheal route may be used. Epinephrine, vasopressin, and lidocaine may be administered through this route. (Use 2Ð2½ times the dose diluted in 5Ð10 mL of distilled water or saline.)

¥Give a vasopressor soon after giving the shock. Epinephrine IV/IO dose should be 1 mg every 3Ð5 min (vasopressin IV/IO doseÑ40 units can replace the Þrst or second dose of epinephrine and repeated again after 20 min).

¥Amiodarone should be given when VF/VT is unresponsive to CPR, deÞbrillation, and vasopressor therapy. IV/IO Þrst dose should be 300 mg bolus, and the second dose should be 150 mg (after 3Ð5 min if VF/VT recurs or persists). This may be followed by a 24-h infusion. (Use lidocaine only if amiodarone is unavailable.)

¥Atropine should not be used during pulseless electrical activity or asystole as it is unlikely to have a therapeutic beneÞt.

154	S.N. Myatra et al.

¥Other drugs are not routinely used and should be considered only in speciÞc situations:

ÐMagnesium sulfate (1Ð2 g) for torsades de pointes associated with a long QT interval.

ÐSodium bicarbonate (initial dose is 1 mEq/Kg) should be used only if there is hyperkalemia, bicarbonate-responsive acidosis, or tricyclic antidepressant overdose. It is harmful in hypercarbic acidosis.

Step 7: Advanced airway

¥Weigh the need for minimally interrupted compressions against the need for insertion of an advanced airway, i.e., the endotracheal tube or the supraglottic airway (laryngeal mask airway, esophageal tracheal tubeÑCombitube, or laryngeal tube).

¥Continue bag mask ventilation if advanced airway is not placed.

¥ConÞrm the placement of advanced airway by the clinical method (chest expansion and breath sound), and in addition, use the capnography to conÞrm and monitor the correct placement. Record the depth and secure the tube.

¥Once advanced airway is in place, give 8Ð10 breaths per minute and do uninterrupted chest compressions.

Step 8: Treat reversible causes

During each 2-min period of CPR, review the most frequent causesÑÞve HÕs and Þve TÕsÑto identify factors that may have caused the arrest or may be complicating the resuscitation:

Five HÕs	Five TÕs
Hypovolemia	Tension pneumothorax
Hypoxia	Tamponade, cardiac
Hydrogen ion (acidosis)	Toxins
Hypo-/hyperkalemia	Thrombosis, pulmonary
Hypothermia	Thrombosis, coronary

Step 9: Monitor the CPR quality throughout resuscitation

¥Give emphasis on delivering high-quality CPR. This means giving compressions of adequate rate and depth, allowing complete chest recoil between compressions, minimizing interruptions in compressions, avoiding excessive ventilation, and rotating the compressor every 2 min.

¥Use quantitative waveform capnography to monitor end tidal CO2 if available (expressed as a partial pressure in mmHgÑPetCO2) in intubated patients. If PetCO2 is less than 10 mmHg, attempt to improve CPR quality.

¥If intra-arterial pressure monitoring is present and diastolic pressure is less than 20 mmHg, attempt to improve CPR quality.

¥Return of spontaneous circulation (ROSC) can be conÞrmed by return of pulse

or blood pressure or abrupt sustained increase in PetCO2 (typically ³40 mmHg) or spontaneous arterial pressure waves with intra-arterial monitoring.

19 Cardiorespiratory Arrest	155

Step 10: Postcardiac arrest care after ROSC

¥The goal should be to optimize cardiopulmonary function and vital organ perfusion.

¥Transfer the patient to an appropriate hospital or ICU with facility to deliver postcardiac arrest care.

¥Optimize ventilation to minimize the lung injury. Do chest X-ray to conÞrm airway position and to diagnose pneumonia / pulmonary edema. Use lung-pro- tective ventilation if there is pulmonary dysfunction; adjust settings using blood gas values. Avoid excessive ventilation and hyperoxia.

¥Once ROSC is achieved, the fraction of inspired oxygen (FiO2) should be adjusted to the minimum concentration needed to achieve arterial oxyhemoglobin saturation of ³94%, with the goal of avoiding hyperoxia while ensuring adequate oxygen delivery.

¥Treat hypotension (systolic blood pressure [SBP] < 90) with ßuid and vasopressors and treat other reversible causes.

¥Consider induced hypothermia. Adult patients with persistent coma after ROSC should be cooled to 32Ð34¡C for 12Ð24 h provided SBP is more than 90 mmHg or mean arterial pressure (MAP) is more than 70 with or without vasopressors.

¥Patients comatose before cardiac arrest or another reason to be comatose (e.g., drug overdose and status epilepticus) should be excluded. Avoid hypothermia in patients with coagulapathy/bleeding or refractory arrhythmias because hypothermia exaggerates these conditions. Cooling can be done using cold IV ßuid bolus of 30 mL/Kg, surface cooling (ice packs, mattresses), endovascular cooling, etc. Sedation/muscle relaxants may be used to control shivering, agitation, or ventilator dyssynchrony as needed. After 24 h, start slow rewarming at 0.25¡C/h. Prevent hyperpyrexia (>37.7¡C).

¥Maintain glucose controlÑmoderate glycemic control (144Ð180 mg/dL).

¥Use anticonvulsants if the patient is seizing (use EEG monitoring if available).

¥Identify and treat acute coronary syndrome (ACS). Patients with suspected ACS should be sent to a facility with coronary angiography and interventional reperfusion facility (primary percutaneous coronary intervention).

¥Reduce the risk of multiorgan injury and support organ function if required.

Step 11: Prognostication after cardiac arrest

In patients treated with therapeutic hypothermia:

¥Clinical neurologic signs, electrophysiologic studies, biomarkers, and imaging should be performed where available 3 days after cardiac arrest.

¥Presently, there is limited evidence to guide decisions regarding limitation/withdrawal of life support in these patients as favorable outcomes have been seen in those in whom studies predicted poor outcome. Use your best clinical judgment based on this testing to make a decision.

In patients who have not undergone therapeutic hypothermia, the following features are present:

¥Absence of pupillary response to light on the day 3

¥Absence of motor response to pain by the day 3

156	S.N. Myatra et al.

¥Absence of bilateral cortical response to median nerve somatosensory evoked potentials in those comatose for at least 72 h after a hypoxic-ischemic insult

Limitation/withdrawal of life support in this situation can be considered.

Step 12: Assist survivors from cardiac arrest who require rehabilitation services

Managing cardiac arrest (flow chart)

Unresponsive with no breathing or no normal breathing (only gasping)

Activate emergency response if present or shout for help

Get an AED/defibrillator or send someone to get it

		Pulse	Give one breath every 5–6 seconds
	Check pulse (no more than 10 seconds)
			Recheck pulse every 2 minutes

No Pulse

Start CPR cycles of 30 compressions followed by two ventilations

As soon as the AED/defibrillator arrives, attach

Shockable (VF/VT)

Deliver shock: Biphasic 120–200 J Monophasic 360 J

CPR for 2 minutes IV/IO access

Epinephrine every 3–5 minutes Amiodarone for refractory VF/VT

Consider advanced airway Quantitative waveform capnography if available

Treat reversible causes

Resume CPR immediately for 2 minutes

Nonshockable IV/IO access

Epinephrine every 3–5 minutes

(Asystole/pulseless electrical activity)

Consider advanced airway Quantitative waveform capnography if available

Treat reversible causes

Reattach the AED/defibrillator after every 2 minutes of CPR

ROSC Death

Postcardiac arrest Care

Monitor the quality of CPR at all times

•Push hard (≥2 inches) and fast (≥100/min)

•Ensure complete chest recoil between compressions

•Minimize interruptions in compressions

•Avoid excess ventilation

•Rotate the compressor every 2 minutes

•If there is no advanced airway, continue compression to ventilation ratio at 30:2

•If PetCO2 <10 mm Hg, improve quality of CPR

•Monitor intra-arterial pressure if diastolic pressure is <20 mm Hg; improve CPR quality