Cardiac Arrest in Adults
Description Covid-19 considerations Emergency treatment Additional guidance ICD-10 code: I46.0/I46.9 DESCRIPTION Described as the loss of a heart beat and a palpable pulse, irrespective of the electrical activity captured on ECG tracing. Irreversible brain damage can occur within 2–4 minutes. Clinical features include: sudden loss of consciousness absent carotid and all other pulses loss o
ICD-10 code: I46.0/I46.9
DESCRIPTION
Described as the loss of a heart beat and a palpable pulse, irrespective of the electrical activity captured on ECG tracing. Irreversible brain damage can occur within 2–4 minutes.
Clinical features include:
- sudden loss of consciousness absent carotid and all other pulses
- loss of spontaneous respiration
COVID-19 CONSIDERATIONS
- The infection risk that CPR poses to providers due to aerosolization of coronavirus particles is not negligible.
- This potential risk should be weighed against the probability of achieving spontaneous return of circulation to inform the decision to initiate or stop CPR.
- For in-hospital cardiac arrest in patients with suspected COVID-19, CPR has been shown to not be beneficial unless an immediate reversible cause is suspected, e.g., dislodgement of ET tube, etc. and is therefore not recommended.
- For out of hospital cardiac arrest in patients with suspected COVID-19, it is recommended to not start conventional CPR in unwitnessed cardiac arrest as it will likely not be beneficial.
- Appropriate PPE should be worn by all staff before initiating CPR: FFP3 mask, visor, gloves and gown.
EMERGENCY TREATMENT
- Diagnose rapidly. After ensuring the safety of the scene, commence resuscitation as per the appropriate acute adult cardiac arrest algorithm – Fig 20.1 or 20.2 above.
- Make a note of the time of starting resuscitation.
- Place the patient on a firm flat surface and commence resuscitation immediately.
- Call for skilled help and an automated external defibrillator (AED) or defibrillator.
- Initiate CAB (Circulation Airway Breathing) sequence of CPR (cardiopulmonary resuscitation).
- Check the rhythm as soon as defibrillator or AED is available and defibrillate if a shockable rhythm is identified.
- Document medication and progress after the resuscitation.
Cardiopulmonary resuscitation (CPR)
Circulation
- Check for carotid pulse for about 5 seconds.
- If there is no pulse or you are not sure, start with chest compressions at a rate of 100-120 compressions per minute to a depth of +/- 5cm. Push hard and allow full recoil of chest with minimum interruptions.
Airway and breathing
- To open the airway, lift the chin forward with the fingers of the one hand and tilt the head backwards with other hand on the forehead.
Note:
Do not do this where a neck injury is suspected – refer below for management of suspected neck injury.
- Ensure airway is open throughout resuscitation.
- If there is no normal breathing, attempt 2 respirations with bag-valve-mask resuscitator and face mask.
- The administered breaths must cause visible chest rising in patient. If not, reposition and try again once and proceed to next step.
- Repeat the cycle of 30 compressions followed by 2 respirations for 5 cycles and then re-assess for a pulse.
- If advanced airway is placed, administer 1 breath every 6 seconds without interrupting chest compressions. Avoid excessive ventilation.
- Oxygenate with 100% oxygen.
- Where neck injury is suspected:
- Do not perform a chin lift or head tilt manoeuvre if a neck injury is suspected
- To open the airway, place your fingers behind the jaw on each side.
- Lift the jaw upwards while opening the mouth with your thumbs (jaw thrust).
- Maintain in line cervical spine immobilisation.
Initiate fluids, IV/IO access
- Sodium chloride 0.9%, IV
- Administer a bolus of 1 litre during CPR if an increase in preload may benefit the patient, e.g., hypovolaemic shock, distributive shock, haemorrhagic shock.
- Administer fluid cautiously during CPR if an increase in the preload could be detrimental, e.g., massive pulmonary embolism or cardiac tamponade.
If pulseless with shockable rhythm (ventricular fibrillation/tachycardia)
- Defibrillate, as indicated per algorithm.
- Immediately resume CPR, starting with chest compression.
- Continue CPR for 2 minutes.
- Administer adrenaline (epinephrine) as per algorithm and directions below (Immediate emergency medicine treatment).
- Seek reversible cause of arrest.
- Continue CPR until spontaneous breathing and/or pulse returns.
- For management of ventricular fibrillation or pulseless ventricular tachycardia that is unresponsive to defibrillation:
- Amiodarone, IV bolus, 300 mg, 2 minutes after adrenaline (epinephrine) dose.
- Follow by a bolus of 10 mL sterile water or sodium chloride 0.9%.
- Patient remains in a shockable rhythm following further 2 minutes of CPR, a defibrillation shock, another adrenaline (epinephrine) dose, and another 2 minutes of CPR (5 cycles of 30:2): Amiodarone, IV bolus, 150 mg.
If pulseless with non-shockable rhythm
- Immediately resume CPR. Starting with chest compression.
- Continue CPR for 2 minutes.
- Administer adrenaline as per algorithm.
- Seek reversible cause of arrest.
- Continue CPR until spontaneous breathing and/or pulse returns.
Immediate emergency medicine treatment
Adrenaline (epinephrine) is the mainstay of treatment and should be given immediately, IV or intra-osseous, when there is no response to initial resuscitation or defibrillation.
- Adrenaline (epinephrine), 1:1 000, 1 mL, IV immediately, as a single dose.
- Flush with 5–10 mL IV of sterile water or sodium chloride 0.9%.
- Repeat every 3–5 minutes during resuscitation.
If no IV line is available:
- Adrenaline (epinephrine), intra-osseous (IO), 1:1000, 1 mL, via IO line.
- Flush with 5–10 mL of sterile water or sodium chloride 0.9%.
- Repeat every 3–5 minutes during resuscitation.
ADDITIONAL GUIDANCE
Continue CPR until spontaneous breathing and/or heart beat returns. Assess continuously (every 2 minutes) until the patient shows signs of recovery.
Termination of resuscitation:
- The decision to stop CPR attempts depends on the specifics of the individual patient and should be based on clinical judgement.
- Consider stopping resuscitation attempts and pronouncing death if there is incurable underlying disease, or if asystole > 20 minutes (in the absence of the factors below).
Consider carrying on for longer especially with:
- hypothermia and drowning
- poisoning or medicine overdose
- neurotoxic envenomation (e.g. black and green mamba or Cape cobra snakebite) – see: Snakebites
This decision should take into consideration the potential risk that CPR poses to the rescuer e.g. infectious diseases.
Click here for the Supporting NEMLC report and reviews_(2020-4 review cycle).
Standard Treatment Guidelines And Essential Medicines List For South Africa, Adult Hospital level, 2020-4_Version 1_June 2024
Chapter 20: Emergencies and Injuries