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Cardiac arrest 

Cardiac arrest

Chapter:
Cardiac arrest
Author(s):

Jasmeet Soar

, Jerry P. Nolan

, and David A. Gabbott

DOI:
10.1093/med/9780199204854.003.1701_update_002

July 30, 2015: This chapter has been re-evaluated and remains up-to-date. No changes have been necessary.

Update:

Technique of cardiopulmonary resuscitation (CPR)—modified recommendation for chest compressions.

Airway and ventilation—waveform capnography should be used to confirm correct placement of a tracheal tube and also provides an indication of the quality of CPR.

Treatment of shockable rhythms and of asystole—algorithms updated.

Monitored and witnessed VF/VT cardiac arrest should be treated with defibrillation attempts before chest compressions are commenced in some situations.

Updated on 30 May 2013. The previous version of this content can be found here.
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date: 30 March 2017

Cardiovascular disease is the most common cause of sudden cardiac arrest, which causes over 60% of adult coronary heart disease deaths. In Europe, the annual incidence of out-of-hospital cardiopulmonary arrests treated by emergency medical systems is 38 per 100 000.

Survival from cardiac arrest depends on a sequence of interventions—the Chain of Survival—comprising (1) early recognition and call for help, (2) early cardiopulmonary resuscitation (CPR), (3) early defibrillation, and (4) postresuscitation care. The division between basic life support and advanced life support (ALS) is arbitrary—the resuscitation process is a continuum.

Starting CPR

1 Check the patient for a response—and if they do not respond 2 Turn the patient on their back, open the airway, and check for breathing and circulation—and if the patient has no signs of life, no pulse, or if there is any doubt. 3 Start CPR immediately.

Initial resuscitation

1 The compression to ventilation ratio is 30:2, with a chest compression rate of 100 to 120/min and depth for compression of 5 to 6cm. 2 Use whatever equipment is available immediately for airway and ventilation. 3 Do continuous chest compressions with no pause for ventilations once the trachea is intubated—good quality chest compressions with minimal interruption for other procedures improves outcome. 4 When the defibrillator arrives, apply the electrodes to the patient and analyse the rhythm.

Advanced life support

Continue CPR and proceed to: 1 Treat shockable cardiac arrest rhythms (ventricular fibrillation/pulseless ventricular tachycardia—VF/VT) with attempted defibrillation. 2 Treat nonshockable rhythms (asystole and pulseless electrical activity, PEA) by treating the underlying cause. 3 Identify and treat reversible causes—hypoxia, hypovolaemia, electrolyte (hyperkalaemia, hypokalaemia, hypocalcaemia) or metabolic disorders (acidaemia), hypothermia, tension pneumothorax, tamponade, toxic substances, thromboembolism (pulmonary embolism or coronary thrombosis). 4 Minimizing interruptions to chest compressions will improve patient survival.

Postresuscitation care

The quality of postresuscitation care determines the patient’s final outcome if resuscitation is successful. Consider therapeutic hypothermia and early percutaneous coronary intervention (PCI) in comatose survivors of cardiac arrest to improve neurological outcome and survival.

Do not attempt cardiopulmonary resuscitation (DNACPR)

Do not attempt cardiopulmonary resuscitation decisions should be used to prevent CPR in patients who will not benefit from it or do not wish to have it. The most senior doctor available should enter a DNACPR decision and the reasons for it in the medical records, the decision should be communicated effectively to all members of the team involved in the patient’s care, and it should be reviewed regularly in the light of changes in the patient’s condition.

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