Cardiac Arrest in Adults - simple and advanced existence guide (ACLS)

Emergency cardiac medicine teaches a familiar and simple approach: primary survey followed by secondary survey. This approach provides a wonderful conceptual tool for the acute cardiac life support provider to use when approaching cardiac emergencies.

THE PRIMARY SURVEY

First ABCD

In the primary survey, focus on basic CPR and defibrillation.

Airway

Open the airway

Breathing

Provide positive pressure ventilation

Circulation

Give chest compressions

Defibrillation

Shock VF/ pulseless VT

SECONDARY SURVEY

Second ABCD

Airway

Establish advanced airway control Perform endotracheal intubation

Breathing

Assess the adequacy of ventilation via endotracheal tube Provide positive pressure ventilations

Circulation

Obtain IV access to administer fluids and medications Continue CPR

Provide rhythm appropriate cardiovascular medication

Differential Diagnosis

Identify the possible reasons for the arrest. Construct a differential diagnosis to identify reversible causes requiring specific treatment.

 CARDIAC ARREST IN ADULTS

ASSESSMENT

Hazards?  - Ensure the safety of the rescuer and the victim.

Hello         - Check for responsiveness by tapping and talking to the victim. Help!     - If patient unresponsive, call for assistance

CARDIO - PULMONARY RESUSCITATION (CPR)

A.       Airway

Open the airway by lifting the bony part of the chin with the fingers of one hand, while placing the other hand on the patient's forehead and tilting the

head backwards (head tilt chin-lift manoeuvre). This will lift the jaw and the tongue off the posterior pharyngeal wall, opening the airway.

1.         Remove vomitus/foreign bodies from the mouth if present

2.         Remove dentures only if they cannot be managed into place

NB. Do not tilt the head backwards if a neck injury is suspected - instead place fingers behind the jaw on each side and pull the jaw forwards while opening the mouth with your thumbs (Jaw Thrust Manoeuvre).

B.       Breathing

1.        While keeping the airway open, assess if patient is breathing by placing your ear next to the patient's mouth and look, listen and feel for up to 10 seconds for evidence of movement. If the patient is breathing, place in the recovery position.

2.         If patient is not breathing, send for help (and for a defibrillator) and administer 2 effective breaths. Then assess for signs of circulation. Take up to 10 seconds to check for any movement, swallowing or carotid circulation. If a pulse is present, administer one effective breath every 5 seconds (12/min).

3.         For mouth to mouth ventilation, keep the airway open and pinch the nose closed using the hand which is on the patient's forehead. Ensure that the chest wall rises. If a mouth to mouth mask device is available, this should be used. Place the device between the patient's teeth. Lift the jaw forwards while keeping the nostrils closed and form a tight mouth to mouth seal over the device. Ensure that the chest rises with each breath given.

4.         Mouth to nose ventilation may be indicated in the presence of trismus, mouth injuries, or if firm mouth to mouth seal is difficult to obtain.

5.         If a face mask is being used for ventilation, a tight seal around the mouth and nose is mandatory while keeping the airway open with the jaw thrust manoeuvre. If the correct size oropharyngeal tube is available, this may be inserted.

C.       Circulation

1.        If a pulse is absent, start chest compressions before a defibrillator

becomes available.

2.         A single precordial thump is indicated if no pulse is detected in cardiac arrest, which is witnessed, before defibrillation.

3.         Until the defibrillator arrives, after giving 2 patient ventilations, compress the sternum using the heel of both hands (one on top of the other) placed 2 finger breaths above the ziphisternum. Keep your elbows straight, and shoulders directly above your hands. The patient must be on a firm surface.

4.         If alone, compress sternum 15 times to a depth of 4-5 cm at a rate of 100/min (about 2 compressions per second) then return to airway opening, giving 2 breaths, 15 compressions repeatedly.

5.         If 2 rescuers are present,, one rescuer compresses the chest, while the other rescuer gives 2 breaths after every 15 compressions. Pause for the ventilation unless the patient is intubated.

NB. Never interrupt CPR for more than 10 seconds (unless intubating or defibrillating).

A.       Defibrillation

1.         Ventricular fibrillation is the most common mechanism of acute cardiac arrest in adults. Therefor the sooner the patient is defibrillated, the greater the chance of successful resuscitation.

2.         The moment the defibrillator arrives, lubricate paddles with electrode paste, (or place special defibrillation pads on chest), stop CPR and place one paddle to the right of the sternum just below the right clavicle and the other paddle over the left lower ribs in the mid-axillary line. Look at ECG on monitor (quick look paddles).

3.         If ventricular fibrillation is present and there are no signs of circulation, immediately administer a 200 joule unsynchronized shock (ensure that the " synch" button, if present, is switched OFF). If ventricular fibrillation persists, immediately repeat with another 200 J shock. If ventricular fibrillation persists, repeat with 360 J (i.e. 3 shocks are administered rapidly and consecutively, checking monitor screen for persistent ventricular fibrillation before each shock).

4.         If no pulse returns after 3 shocks, continue or start CPR, intubate, set up a large bore IV line and administer drugs as described below. Look for and correct reversible causes of cardiac arrest.

5.         Defibrillate (3 shocks of 360) after every minute of CPR if venticular fibrillation persists.

B.       Endotracheal intubation and initial drug therapy

1.         Intubate the trachea as soon as possible if competent to do so.

2.         Always oxygenate lungs well before intubating.

3.         Intubate using a 7.0 or 8.0 endotracheal tube in adults.

4.         If more than one attempt required, oxygenate and ventilate patient adequately between attempts. (do not take more than 30 seconds per attempt).

5.         Adrenaline, is indicated in all cardiac arrests not responding to initial resuscitation/defibrillation. Give 1 ml of 1:1000 solution IV stat (or 2ml of 1:1000 solution via ET tube if no IV line available yet - dilute 2ml of 1:1000 solution with 8ml of sterile saline). Repeat every 3 minutes during resuscitation.

C.       Further Management according to ECG response

1.         Ventricular fibrillation (and pulseless ventricular tachycardia)

Defibrillate     - immediately (200 -200-360J) if no sign of circulation. If no pulse returns, do 1 min of CPR, and repeat 3 shocks at 360J after every minute of CPR if ventricular fibrillation/pulseless VT persists.

Adrenaline      - if initial 3 defibrillation shocks unsuccessful, repeat using 1mg every 3 minutes during CPR.

Amiodarone    - 300mg bolus followed with 20ml dextrose water flush (not normal saline), given after the first IV dose of adrenaline following the second set of shocks if VF/VT persists.

An additional dose of 150mg may be given after 3-5 mins if VF/VT persists.

After return of spontaneous circulation, a loading dose of 360mg may be administered over 6 hours at a rate of 1 mg/min.

Thereafter, a maintenance infusion of 540mg is administered over 18 hours at a rate of 0.5mg/min (maximum dose - 2.2g/24 hours).

Lignocaine      - 1 mg/kg stat only if Amiodarone is not available. Repeat every 3-5 min if necessary (maximum total dose 3mg/kg).

Magnesium    - 1-2g stat if above unsuccessful or if hypomagnesaemia or torsades de pointes is suspected.

Bicarbonate    - 1ml/kg of 8.5% solution IV after 20 minutes, or sooner if hyperkalaemia or metabolic acidosis is present.

Always look for and correct reversible causes of cardiac arrest.

1.         Non VF/VT ( Pulseless electrical activity and Asystole)

(QRS complexes or straight line on ECG and no pulses detectable)

¤       Continue CPR

¤       Look for and correct reversible causes, especially hypoxia, hypovolaemia, hypothermia, acidosis, tension pneumothorax, cardiac tamponade, pulmonary embolism, toxins and drug overdoses.

¤       Check that the electrode and/or paddle positions and contact is optimal

¤       Give Adrenaline          -1mg every 3 minutes during CPR

¤       Give Atropine             -1mg IV every 3 min if bradycardia or

asystole - up to 3 mg

¤       Consider Bicarbonate  -1ml/kg of 8,5% IV if indicated (eg

hyperkalaemia/metabolic acidosis)

¤       Consider Pacing if the arrest was witnessed and there is evidence of some electrical activity.

B.       General Comments

1.         The best success rates are achieved when CPR commences within 4 minutes of arrest, and advanced life support is started within 8 min of arrest.

2.         Defibrillate as soon as a defibrillator becomes available. Check for the absence of pulse before defibrillating.

3.         Adrenaline can be administered via the ET tube until an IV line is available

- inject twice the normal IV dose (dilute 2ml with 8ml normal saline).

4.         Avoid intracardiac adrenaline if possible (except as a last resort)

Dilated pupils may be due to drugs, hypothermia, snakebite etc, and therefore does not necessarily indicate brain damage.