Cardiac arrest is defined as the abrupt loss of cardiac function and can result from ventricular fibrillation, pulseless ventricular tachycardia, asystole, or pulseless electrical activity. Management involves cardiopulmonary resuscitation (CPR) including chest compressions, ventilation, and defibrillation if indicated. The chain of survival links immediate recognition, early CPR, rapid defibrillation if needed, advanced life support, and post-cardiac arrest care. Basic life support involves chest compressions, airway management, rescue breathing, and public access defibrillation with an automated external defibrillator if available. Advanced life support adds establishment of intravenous access, rhythm monitoring/defibrillation, and administration

1. ‫الرحیم‬ ‫الرحمن‬ ‫هللا‬ ‫بسم‬

2. C A R D I A C A R R E S T
C A R D I A C A R R E S T A N D C P R

3. DEFINITION
• Cardiac arrest is defined as an abrupt loss of cardiac pump function which may be
reversible by a prompt intervention, but will lead to death in its absence.
• Cardiac arrest may result from one of the following four mechanisms:
• 1. Ventricular fibrillation (VF)
• 2. Pulseless ventricular tachycardia
• 3. Asystole
• 4. Pulseless electrical activity (PEA).

4. CAUSES
Ventricular fibrillation
• Myocardial ischemia or infarction
• Electrocution
• Other structural heart diseases
• Hypokalemia and hyperkaliemia
• Drugs
Ventricular asystole
• Localized failure of conducting tissue
• Massive myocardial infarction
Pulseless electrical activity (PEA)
• Cardiac rupture
• Massive pulmonary embolism
NOTE
1 . Initial rhythm of VT may degrade into PEA or asystole with passage of time
2. Reversible causes of refractory VTNF, asystole and PEA are 6 Hs and 6Ts, and have been listed later.

5. MANAGEMENT [CARDIOPULMONARY
RESUSCITATION (CPR)]
• Cardiopulmonary resuscitation provides artificial ventilation and perfusion to the vital
organs, particularly heart and brain until spontaneous cardiopulmonary function is
restored.
• It encompasses both basic life support (BLS) and advanced life support (ALS).
• Successful resuscitation following cardiac arrest requires an integrated set of
coordinated actions represented by the links in the "Chain of Survival".

6. LINKS IN THE CHAIN OF SURVIVAL
• Immediate recognition of cardiac arrest and activation of the emergency response system (ERS)
• Early CPR with an emphasis on chest compressions
• Rapid defibrillation
• Effective advanced life support (ALS)
• Integrated post-cardiac arrest care

7. BASIC LIFE SUPPORT
• Basic life support (BLS) indicates maneuvers which, without special equipment (except
automated external defibrillator and a protective shield), either prevent circulatory and
respiratory arrest or externally support the circulation and ventilation of a victim in arrest.
• The major goal of BLS is to provide adequate oxygen and perfusion to vital organs (brain
and heart) until advanced cardiac life support is available.
• Most out-of-hospital cardiac arrests occur following a myocardial injury and present initially
with VF or pulseless VT.
• The patient is therefore likely to be responsive to defibrillation that has become a part of
BLS.
• Immediate recognition and activation of ERS, early CPR and rapid defibrillation (when
appropriate) are the first three
• BLS links in the adult Chain of Survival.

8. BASIC LIFE SUPPORT
• Immediate Recognition and Activation of Emergency Response System (ERS)
• Early recognition that a cardiac arrest has occurred is the key to survival. For every minute a
patient is in cardiac arrest the chances of survival drop by roughly 10%. If a patient is
unresponsive, he/she is presumed to be in cardiac arrest.
• If a lone rescuer finds an unresponsive adult (i.e. no movement or response to stimulation)
or witnesses an adult who suddenly collapses, he/she should first ensure that the scene is
safe.
• Rescuer should then check for a response by tapping the victim on the shoulder and
shouting at the victim.
• If the victim also has absent or abnormal breathing (i.e. only gasping), the rescuer should
assume the victim is in cardiac arrest. The trained or untrained lay person should activate
the ERS.

9. PULSE CHECK
• Both lay rescuers and health-care providers have difficulty detecting a pulse. Further,
health-care providers also may
take too long to check for a pulse.
• Therefore, lay rescuer should not check for a pulse and should assume that cardiac
arrest is present if an adult suddenly collapses or an unresponsive victim is not
breathing normally.
• The health-care provider may palpate pulse (carotid artery) but should take no more
than 10 seconds to check for a pulse and, if the rescuer does not definitely feel a pulse
within that time period the rescuer should start chest compressions.

10. EARLY CARDIOPULMONARY
RESUSCITATION (CPR)
• CPR includes four sequential steps:
1. Circulation
2. Airway
3. Breathing (CAB)
4. Defibrillation
• Previously, the sequence used to be Airway, Breathing and Circulation (ABC).

11. CIRCULATION
• Circulation is achieved by chest compressions.
• Chest compressions consist of forceful rhythmic applications of pressure over the lower-half of the sternum.
These
compressions create blood flow by increasing intrathoracic pressure and directly compressing the heart. This
generates
blood flow and oxygen delivery to the myocardium and brain.
• Effective chest compressions are essential for providing blood flow during CPR. For this reason all patients in
cardiac
arrest should receive chest compressions.
• For cardiac compression the patient should be in a supine position on a firm surface.
• The rescuer should place the heel of one hand on the center (middle) of the victim's chest (i.e. lower-half of
the sternum) and the heel of other hand on top of the first so that the hands are overlapped and parallel to
each other.

12. • Chest compression is performed at a rate of 100/minute with the compression phase occupying at least 50%
of the
whole cycle of compression-relaxation ("duty cycle"). The compression depth should be at least 2 inches (5 cm).
• Rescuers should allow complete recoil of the chest after each compression to allow the heart to fill
completely before
the next compression.
• The rate of compression refers to the speed of compressions, not the actual number of compressions
delivered per
minute. The actual number of chest compressions delivered per minute is determined by the rate of chest
compressions
and the number and duration of interruptions (e.g. to open the airway, deliver rescue breaths and allow AED
analysis).
• The rescuer should "push hard, push fast", and allow the chest to recoil after each compression

13. • If other rescuers are present, the first rescuer should direct them to activate the ERS and get the automated
external
defibrillator (AED); the first rescuer should start CPR immediately.
• If the rescuer is not trained in recognizing abnormal breathing, the lay rescuer should phone the ERS once the
rescuer finds that the victim is unresponsive; the dispatcher at ERS should be able to guide the lay rescuer to
check
for breathing and the steps of CPR.
• The health-care provider can check for response and look for no breathing or no normal breathing (i.e. only
gasping)
before activating the ERS.
• After activation of the ERS, all rescuers should immediately begin CPR for adult victims who are unresponsive
with no
breathing or no normal breathing (only gasping). The rescuer should treat the victim who has occasional gasps
as if he
or she is not breathing.

14. • A health-care provider can tailor the sequence of rescue actions to the most likely
cause of arrest. For example, if a lone health-care provider sees an adolescent suddenly
collapse, the provider may assume that the victim has suffered a sudden cardiac arrest;
he/she activates ERS immediately to get an AED, and then returns to the victim to
provide CPR. If a lone health-care provider finds an adult drowning victim or a victim
of foreign body airway obstruction who becomes unconscious, the health-care
provider may give about 5 cycles (approximately 2 minutes) of CPR before activating
ERS.

15. • In both single-rescuer and two-rescuers CPR, 30 compressions are delivered followed by 2 breaths. However,
only "hands-on" CPR is also recommended for lay person who is reluctant to give mouth-to-mouth
respiration or is not trained in that.
• The rescuer should interrupt chest compression as infrequently as possible and should limit interruptions to
no more
than 10 seconds at a time.
• When more than one rescuer is present, rescuers should change roles after every 2 minutes or five cycles of
CPR.
Consider switching rescuers during any intervention associated with appropriate interruptions in chest
compressions
(e.g. when an AED is delivering a shock). Every effort should be made to accomplish this switch in <5 seconds.
• Pre-cordial thump: There is only anecdotal evidence that the electric current produced by pre-cordial thump
may terminate VF. On the other hand, there is evidence that one thump may convert VT into VF or asystole.
Therefore, a thump should not be attempted in unwitnessed cardiac arrests.

16. AIRWAY
• The trained lay rescuer who feels confident that he/she can perform both compressions and
ventilations should open the airway using a head tilt-chin lift maneuver.
• A health-care provider should use the head tilt-chin lift maneuver to open airway of a victim with no
evidence of head or neck trauma.
• For victims with suspected spinal injury, rescuers should initially use manual spinal motion restriction
(e.g. placing one hand on either side of victim's head to hold it still) while performing compressions. If
health-care providers suspect a cervical spine injury, they should open the airway using jaw thrust
method. However, if he/she fails to open the airway using jaw thrust, head tilt-chin lift maneuver should
be done.
• In head tilt-chin lift method the chin is moved forward with the index and middle fingers of one hand
while the other hand is placed over the forehead so as to flex the neck in relation to the chest and extend
the head in relation to the neck.
•In jaw-thrust method the angles of mandible are grasped with both hands and the mandible is lifted
forward

17. BREATHING
• After opening the airway, mouth-to-mouth or mouth-to-nose or mouth-to-mask or bag-mask breathing is
started with compression: ventilation ratio of 30:2 (i.e. at a rate of 8-10/minute).
• To provide mouth-to-mouth rescuer breaths, open the victim's airway, pinch the victim's nose and create an
airtight mouth to- mouth seal. Give one breath over one second, taking normal (and not deep) breath. Each
rescue breath is delivered over l second. If the victim's chest does not rise with the first rescue breath,
reposition the head by performing the head tilt-chin lift again and then give the second rescue breath.
Volume of each rescue breath should produce visible chest rise. Bag-mask ventilation is not the
recommended method of ventilation for a lone rescuer during CPR. It is most effective when provided by two
trained and experienced rescuers. One rescuer opens the airway and seals the mask to the face while the
other squeezes the bag.
• When an advanced airway (i.e. endotracheal tube, Combi tube or laryngeal mask airway) is in place during
CPR, give 1 breath every 6 to 8 seconds without attempting to synchronize breaths between compressions;
this will result in delivery of 8 to 10 breaths/minute. There should be no pause in chest compressions for
delivery of ventilations after advanced airway in place. Tidal volume per breath should be 6-7 mL/kg (about
600 mL in adults). Excessive ventilation is unnecessary and can cause gastric inflation and its resultant
complications, such as regurgitation and aspiration. More important, excessive ventilation can be harmful
because it increases intrathoracic pressure, decreases venous return to the heart and diminishes cardiac
output and survival.

18. EARLY DEFIBRILLATION
• The importance of early cardiac defibrillation in patients of cardiac arrest has led to the
development of AEDs. Since VF and pulseless VT are the major causes of cardiac arrest in
adults, application of early defibrillation in field setting by the paramedics is important.
• Defibrillator should be used as soon as it is available and is not to be used only after CAB
have been completed.
• AEDs are capable of analyzing cardiac rhythm and if appropriate, advise/deliver an electric
counter shock. The operator merely places two self-adhesive electrode pads onto the
patients and administers a shock when advised, standing clear when the AED is ready to
discharge.
• If a shockable rhythm is detected, one shock at 360 J (monophasic defibrillators) or 150-200
J (biphasic defibrillators) is given.
• CPR should be started immediately following one shock and continued for five cycles of
30:2 compression-to-ventilation ratio before re-checking the rhythm.

19. ADVANCED LIFE SUPPORT
• Advanced life support (ALS) consists of BLS (CAB and early defibrillation) followed by use of special
equipment and drugs for establishing and maintaining effective ventilation and circulation (ABCD) where D
stands for defibrillation and for differential diagnoses which include treatable causes of cardiac arrest.
Advanced Airway
• It includes the use of oral and nasal airways, bag mask, orotracheal and naso-tracheal endotracheal tubes for
intubations, esophageal-tracheal combi tube, laryngeal mask airway, and surgical procedures like crico-
thyrotomy and tracheostomy.
Advanced Breathing
• Confirmation of endotracheal tube placement using both clinical assessment (tube seen passing through
vocal cords; five-point auscultation-over epigastrium, left and right anterior chest, and left and right mid-
axillary parts of chest; condensation of water vapor inside the tube) and use of a device (e.g. exhaled carbon
dioxide detector or end-tidal CO2 capnograph, esophageal detector device). End-tidal carbon dioxide is the
gold standard to confirm position of tube in trachea.
• Securing the endotracheal tube using tube holders (which are better than using tape or bandage to hold the
tube).
• Ventilate at a tidal volume of 6-7 mL/kg and at a rate of 8-10 breaths/minute.
• Confirm effective ventilation and oxygenation by end-tidal CO2 monitor and oxygen saturation monitor.

20. HIGH QUALITY CPR
• Push hard ≥2 inches or 5 cm) and fast (≥100/minute)
• Allow chest wall to recoil back completely in between two compressions
• Minimize interruptions during chest compressions
• Rotate chest compressor every 2 minutes
• Avoid excessive ventilation
• 30:2 chest compression : ventilation ratio if advanced airway not in place
• If end tidal CO2 <10 mm Hg by quantitative waveform capnography, improve CPR quality
• If intra-arterial relaxation phase pressure <20 mmHg, improve CPR quality

21. ADVANCED CIRCULATION
• It includes continuation of chest compression along with establishing an intravenous access, attaching a
cardiac monitor/defibrillator and assessing the rhythm, defibrillation and administering drugs appropriate for
rhythm and condition.
• With advanced airway in place, rescuers no longer provide cycles of compression with pauses for ventilation.
The
compression is done continuously at the rate of 100/minute and ventilation is provided at 8-10 breaths/minute
(1 breath
every 6-8 seconds).
• Basic rhythms commonly seen in patients with cardiac arrest include ventricular fibrillation (VF), pulseless VT,
asystole
and PEA. Of these, VT and fibrillation are the most common rhythm and are most amenable to therapy.
• Rhythm checks should be done only after 2 minutes of CPR and not immediately following a defibrillation
attempt.
• Pulse check should be performed only after 2 minutes of CPR if the monitor shows a change in rhythm from
previous
one or it shows an organised rhythm.

22. VENTRICULAR FIBRILLATION
• Also known as Pulseless Ventricular Tachycardia (VT) (Shockable Rhythms)
• As soon as a defibrillator is available, it should be used for early conversion of the fibrillating heart to
normally contracting heart. One shock at 360 J (monophasic defibrillators) or 150-200 J (biphasic
defibrillators) is given that is followed by CPR immediately without checking the rhythm or the pulse.
• Continue CPR for 2 minutes, then pause briefly to check the monitor for rhythm. If VT/VF persists:
• Give second shock of same energy, resume CPR immediately and continue for 2 minutes, and repeat
this cycle.
• Immediately following second shock give adrenaline (epinephrine) intravenously in a dose of 1 mg (1
mL of
1: 1000 solution) as an IV bolus followed by a rapid bolus of 20 mL of saline and elevating the arm up. If
IV access
is not available, intraosseous (IO) route should be accessed

23. • lf VTNF persists, continue giving shock every 2 minutes.
• Repeat adrenaline every 3-5 minutes if VTNF persists.
• One dose of vasopressin, 40 U, may replace either the first or the second dose of adrenaline.
• If after two doses of adrenaline VT/VF persists, administer amiodarone 300 mg IV followed by 150 mg after
3-5 minutes if VT/VF persists; start amiodarone infusion (maximum cumulative dose: 2.2. g over 24 hours).
• If amiodarone is not available or is not effective, give lidocaine. The initial dose of lidocaine is 1 to 1.5 mg/kg
• IV bolus. If VF or pulseless VT persists, additional doses of 0.5 to 0.75 mg/kg IV push may be administered at
• 5 to 10 minute intervals to a maximum dose of 3 mg/kg.
• • Look for reversible causes if VTNF persists.
• • If organised electrical activity is seen during brief pause in compressions every 2 minutes, check for pulse.
• • If a pulse is present, start post-resuscitation care.
• • If a pulse is not present, continue CPR and switch to non-shockable rhythm sequence if VT or VF disappear.

24. PULSELESS ELECTRICAL ACTIVITY (PEA)
AND ASYSTOLE
• (Non-Shockable Rhythms)
• PEA is defined as cardiac electrical activity in the absence of any palpable pulse. These
patients often have some
mechanical myocardial contractions but they are too weak to produce a detectable pulse.
Asystole is commonly seen in patients of unwitnessed sudden cardiac arrest outside the
hospital and in critically-ill patients, and is nearly always fatal.
• Both are non-shockable rhythms.
• If the rhythm is PEA or asystole:
• If cardiac monitor/defibrillator monitor shows PEA or asystole, start CPR, beginning with
chest compressions, and should continue for 2 minutes before the rhythm check is
repeated.

25. • Give adrenaline 1 mg IV as soon as feasible.
• Re-check rhythm after 2 minutes of CPR.
• If PEA or asystole persists, continue CPR, re-check rhythm every 2 minutes and give adrenaline every 3-5
minutes.
• Vasopressin can replace first or second dose of adrenaline. Atropine is no longer recommended in PEA or
asystole.
• If rhythm check shows change in rhythm, check for pulse. If pulse is present, start post-resuscitation care. If
pulse
is absent, continue CPR with rhythm check every 2 minutes and adrenaline every 3-5 minutes.
• In case of asystole check that the leads are connected properly and the gain on monitor is set at maximum.
• If at any time the rhythm develops into VFNT, defibrillate the patient.
• Look for reversible causes (see differential diagnoses below) that can produce PEA.

26. • CPR can be stopped if:
VF:VT eliminated.
• Advanced airway device placed and position confirmed.
• Proper oxygenation and ventilation ensured using oxygen saturation monitor and end-
tidal CO2 monitor.
• All rhythm-appropriate drugs administered.
• All potentially reversible causes excluded.
• CPR performed for 10 minutes after the rhythm confirmed to be PEA/asystole.

27. DIFFERENTIAL DIAGNOSES
• Try to search for reversible causes producing cardiac arrest rhythm and treat them.
These causes have been listed as "6 Hs and 6 Ts".
• Reversible Causes of Cardiac Arrest
Six Hs Six Ts
• Hypoxia
• Hypovolemia
• Hypothermia
• Hydrogen ions (acidosis)
• Hypokalemia/ hyperkaliemia
• Hypoglycemia
• Tamponade, cardiac
• Tension pneumothorax
• Toxins/tablets
• Thrombosis, coronary (myocardial
infarction)
• Thrombosis, pulmonary embolism
• Trauma

28. • Sodium bicarbonate was widely used in patients with cardiopulmonary arrest with the objective of
managing academia
in these patients. However, no benefit has been shown when it is administered early during the CPR. In
fact, bicarbonate
may be detrimental to the patient. It may be used in patients with cardiac arrest related to hyperkaliemia
or tricyclic
antidepressant poisoning.
• Calcium had been used commonly in patients with asystole and EMD. However, because of the
potential role of intracellular calcium accumulation in irreversible ischemic cell injury, calcium is now
recommended only if there is some evidence to suggest hypocalcaemia, hyperkaliemia or calcium-
channel blocker overdose.
• Fibrinolytic therapy (e.g. streptokinase, tenecteplase, etc.) should not be routinely used in cardiac
arrest. When pulmonary embolism is presumed or known to be the cause of cardiac arrest empirical
fibrinolytic therapy can be considered.

29. POST-RESUSCITATION CARE
• Ensure an adequate airway and support breathing. Hyperventilation should be avoided
for routine care. Start at ventilation of 10-12/minute and ensure end-tidal CO2 of 35-
40 mmHg. Although 100% oxygen may have been used during initial resuscitation,
titrate inspired oxygen to the lowest level required to achieve an arterial oxygen
saturation of 94%, so as to avoid potential oxygen toxicity.
• Continuous cardiac monitoring.
• Use vasoactive medications and fluids to support circulation. Drugs include
norepinephrine, dobutamine and epinephrine.
• Epinephrine-0.1--0.5 μg/kg/minute
• Doparnine-5-10 μg/kg/rninute

30. • Norepinephrine-0.1--0.5 μg/kg/minute
• Avoid hyperthermia.
• Hypothermia (32-34°C) for 12-24 hours may be considered for any patient who is unable to follow verbal
commands
after resuscitation from cardiac arrest. One of the techniques recommended is to infuse 1-2 liters of ice-cold
isotonic
saline or Ringer's lactate. Clinicians should continuously monitor the patient's core temperature using an
esophageal
thermometer, bladder catheter in non-anuric patients or pulmonary artery catheter if one is placed for other
indications.
• Avoid hyperglycemia; maintain blood sugar <200 mg/dL.
• Overall the most common cause of cardiac arrest is cardiovascular disease and coronary ischaemia.
Therefore, ECG
should be obtained as soon as possible to detect ST elevation or new or presumably new left bundle branch
block.
• Attention should be directed to treating the precipitating cause of cardiac arrest ("Hs" and "Ts").