Cardiorespiratory Arrest

21
Sheila Nainan Myatra and Amol T. Kothekar

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

Basic Life Support (Fig. 21.1)

Step 0: Verify Scene Safety

Safe environment on the scene of an emergency should be ensured for the person
(provider) delivering cardio-pulmonary resuscitation (CPR). A quick look at the
patient’s location and surroundings helps to rule out imminent physical threats such
as toxic or electrical hazards. CPR should never be provided in situations unsafe for
providers.

 tep 1: Early Recognition of Sudden Cardiac

S
Arrest—Check Responsiveness

Check response: Gently tap the patient on his/her shoulders and check for a response.

S. N. Myatra (*) · A. T. Kothekar

Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha
National Institute, Mumbai, India

© Springer Nature Singapore Pte Ltd. 2020 207

R. Chawla, S. Todi (eds.), ICU Protocols, https://doi.org/10.1007/978-981-15-0898-1_21
208 S. N. Myatra and A. T. Kothekar

BLS Healthcare Provider Adult Cardiac Arrest Algorithm-2015 Update

verify scene safety.

Provide rescue
Victim is unresponsive.
breathing:
Shout for nearby help.
1 breath every 5-6
Activate emergency response system via
seconds, or about 10-12
mobile device (if appropriate).
breaths/min.
Get AED and emergency equipment
• Activate emergency
(or send someone to do so).
response system (if
Normal
No normal not already done)
breathing,
breathing, after 2 minutes.
has pulse Look for no breathing or only
Monitor until has pulse • Continue rescue
gasping and check pulse breathing; check
emergency
(simultaneously).Is pulse pulse about every 2
responders arrive.
definitely felt within 10 seconds? minutes. If no pulse,
being CPR (go to
"CPR" box).
No breathing or
• If possible opioid
only gasping,
overdose, administer
no pulse
naloxone if available
per protocol.

By this time in all scenarios,

CPR
Being cycles of
30 compressions and 2 breaths.
Use AED as soon as it is available.
emergency response system or backup
is activated, and AED and emergency
equipment are retrieved or someone is
retrieving them.

AED arrives.

Check rhythm.
Shockable rhythm?
Yes, No,
shockable nonshockable

Give 1 shock, Resume CPR immediately Resume CPR immediately for

for about 2 minutes (until prompted by about 2 minutes (until prompted by
AED to allow rhythm check). AED to allow rhythm check).
Continue until ALS providers take over Continue until ALS providers take
or victim starts to move. over or victim starts to move.

Fig. 21.1  AHA BLS Health Provider Adult Cardiac Arrest Algorithm-2015 update

 tep 2: Activate the Emergency System If Patient

S
Is Unresponsive

Activate the emergency system if present in your hospital or just shout for help. Get
the defibrillator or send someone to get it.
21  Cardiorespiratory Arrest 209

Step 3: Simultaneously Check the Breathing and Pulse

• Check breathing—no 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.
• Check pulse—Healthcare Providers should check the pulse simultaneously while
checking for breathing, to minimize delay in detection of cardiac arrest and ini-
tiation of CPR. 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 com-
pression. Lay rescuers need not check for a pulse.

 tep 4: Start Cardiopulmonary Resuscitation (CPR): Initiate Chest

S
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 victim’s thorax (either side).
• Keep arms straight, elbows locked, and the shoulder and the hands of the pro-
vider should be in vertical line.
• Hand placement: Place the heel of the hand on the lower half of the victim’s
sternum in the center (middle) of the chest, between the nipples, and then place
the heel of the second hand on top of the first so that the hands are overlapped
and parallel. Interlock fingers to avoid compression on the ribs.

Technique
During CPR, remember to “push hard and push fast” (all you need is two hands):

• Compressions rate—100–120/min.
• Depth of sternal compression—At least 2 inches i.e. 5  cm (at least one-third
anteroposterior diameter in children and infants). Avoid excessive chest com-
pression depths (greater than 6 cm). Avoid leaning on the chest between com-
pressions to allow full chest wall recoil
• Compression ventilation ratio—the adult patient 30:2 (with one or more rescu-
ers) and in the child or infant 30:2 (with one rescuer) and 15:2 (with more than
one rescuer).
• Compression relaxation ratio—1:1 (allow complete recoil of the chest).
• Perform five cycles (approximately 2 min) of compression and ventilation (ratio
30:2).
• In adult victim of cardiac arrest with an unprotected airway, perform CPR with
the goal of a chest compression fraction as high as possible, with a target of at
least 60%
210 S. N. Myatra and A. T. Kothekar

• Swap the person delivering chest compressions and bag—mask ventilation every
2 min.
• Give 2 min of uninterrupted CPR. Limit any interruption 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 100–120/min—“one and two and three and ….” Every time you say
a number, compress, and when you say “and,” you relax.

Ventilation
• Untrained lay rescuers should not attempt ventilation and should provide
“Compression-­only CPR”.
• Healthcare Providers and Trained Lay Rescuers can provide rescue breaths in a
ratio of 30 compressions to 2 breaths. After every 30 chest compressions, two
slow rescue breaths (each breath over 1 s) can be given using the face mask and
the AMBU bag (with a reservoir bag) to deliver 100% oxygen.
• Before you start ventilation, open the airway using a jaw thrust or a head tilt/chin
lift maneuver. If cervical spine injury is suspected, airway should be opened
using a jaw thrust without head extension (head tilt/chin lift)). Manual spinal
motion restriction by placing 1 hand on either side of the patient’s head is pre-
ferred over immobilization devices.
• Give one breath over 1 s. Rapid ventilation should be avoided as it can lead to
gastric insufflations with increase in the risk of aspiration.
• Give sufficient 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 tongue fall.
• The use of cricoid pressure during ventilation is generally not recommended.

Complete five cycles of compression followed by ventilation (this will take

approximately 2 min, provided you are delivering it at the correct rate).

 tep 5: Attach the Defibrillator (Automated External Defibrillators

S
[AED] or Manual Defibrillators) and Shock
If Indicated

• As soon as an AED/manual defibrillator is available, attach it, check rhythm and

deliver shock if indicated, i.e., in ventricular fibrillation (VF) and pulseless ven-
tricular tachycardia (VT).
• Always prefer a biphasic defibrillator; if biphasic defibrillator is unavailable,
monophonic defibrillator can be used.
• Ensure that no one is touching the patient before you deliver the shock.
• Electrode placement should be in the anterior-lateral pad position (default).
Alternative positions are anterior-posterior, anterior-left infrascapular, and
anterior-­right infrascapular.
21  Cardiorespiratory Arrest 211

• Shock energy—(a) Biphasic: Use the manufacturer’s recommendation (120–

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 2–4 J/Kg first 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 defibrillation; resume CPR immediately.
• Reattach the defibrillator 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 per-
formed while the defibrillator 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 defibrillator 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 defibrillator is not available.
• Electric pacing is not recommended for routine use in cardiac arrest.
• If it is not a shockable rhythm, resume CPR for 2  min and then re attach the
defibrillator

Extracorporal CPR can be considered in select patients who have not responded
to initial conventional CPR, if it can be rapidly implemented.

Advanced Cardiac Life Support

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,
naloxone and lidocaine may be administered through this route. (Use 2–2½ times
the dose diluted in 5–10 mL of distilled water or saline for the tracheal route)
• Give a vasopressor soon after giving the shock. Epinephrine IV/IO dose should
be 1 mg every 3–5 min.
• Amiodarone should be given when VF/VT is unresponsive to CPR, defibrillation,
and vasopressor therapy. IV/IO first dose should be 300 mg bolus, and the second
dose should be 150 mg (after 3–5 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 benefit.
• Other drugs are not routinely used and should be considered only in specific
situations:
212 S. N. Myatra and A. T. Kothekar

–– Magnesium sulphate (1–2 g) for torsades de pointes associated with a long

QT interval or if there is hypomagnesemia.
–– Sodium 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.
–– Calcium—Hyperkalemia, hypocalcemia or calcium channel blocker toxicity
–– Naloxone—In opioid overdose, administer naloxone if available
–– Steroids—There may be some benefit with the use during in hospital cardiac
arrest, but the evidence is weak

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 tube—Combitube, or laryn-
geal tube).
• Continue bag mask ventilation if advanced airway is not placed.
• Confirm the placement of advanced airway by the clinical method (chest expansion
and breath sound), and in addition, use the Continuous waveform capnography to
confirm and monitor the correct placement. Record the depth and secure the tube.
• Once advanced airway is in place, give 10 breaths per minute and deliver uninter-
rupted chest compressions at 100–120/min (No need for synchrony between
chest compression and ventilation).

Step 8: Treat Reversible Causes

During each 2-min period of CPR, review the most frequent causes—five H’s and
five T’s—to identify factors that may have caused the arrest or may be complicating
the resuscitation.

Five H’s Five T’s

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 compres-
sions, minimizing interruptions in compressions, avoiding excessive ventilation,
and rotating the compressor every 2 min.
21  Cardiorespiratory Arrest 213

• Use quantitative waveform capnography to monitor end tidal CO2 if available

(expressed as a partial pressure in mmHg—PetCO2) in intubated patients. If
PetCO2 is less than 10 mmHg, attempt to improve CPR quality.
• If intra-arterial pressure monitoring is already present and the diastolic pressure
is less than 20 mmHg, attempt should be made to improve quality of CPR.

Step 10: Return of Spontaneous Circulation ROSC

• Return of spontaneous circulation (ROSC) can be confirmed by return of pulse

or blood pressure or abrupt sustained increase in PetCO2 (typically ≥40 mmHg)
or spontaneous arterial pressure waves with intra-arterial monitoring.

Step 11: 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
post-cardiac arrest care.
• Optimize ventilation to minimize the lung injury. Do chest X-ray to confirm
airway position and to diagnose pneumonia/pulmonary edema. Use lung-­
protective 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 oxyhemoglo-
bin saturation of ≥94%, with the goal of avoiding hyperoxia while ensuring
adequate oxygen delivery. PaCO2 can be maintained within a normal physiologi-
cal range, taking into account any temperature correction.
• Treat hypotension (systolic blood pressure [SBP] < 90) with fluid and vasopres-
sors and treat other reversible causes.
• Consider targeted temperature management (TTM) in adult patients with persis-
tent coma after ROSC. It is recommended to select and maintain a constant tem-
perature between 32 and 36  °C and to actively prevent fever. TTM should be
maintained for at least 24 h after achieving target temperature.
• The wide range of TTM between 32 °C and 36 °C practically removes contrain-
dications of hypothermia. All patients in whom intensive care is continued are
eligible for TTM. The patients in whom, lower temperature conveys some risk
like bleeding, can be offered higher temperature up to 36 °C. Lower temperatures
might be preferred when patients have clinical conditions like seizures, cerebral
edema that can be worsened at higher temperatures. Patients who present at the
lower end of the TTM range can be maintained at that lower temperature without
warming them to a higher target.
• Cooling can be done using cold IV fluid 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).
214 S. N. Myatra and A. T. Kothekar

• Maintain glucose control as done for other critically ill patients. No specific tar-
get range of blood glucose levels are recommended
• In patients who are comatose after ROSC, an EEG for the diagnosis of seizure
should be promptly performed and interpreted. Such patients should be moni-
tored frequently or continuously with EEG.
• Identify and treat acute coronary syndrome (ACS). Patients with suspected ACS
should be sent to a facility with coronary angiography and interventional reper-
fusion facility (primary percutaneous coronary intervention). If coronary angiog-
raphy is indicated, it is reasonable to do it regardless of whether the patient is
comatose or awake. In other words, coronary angiography should not be denied
in comatose patients in whom it is indicated.
• Though routine use of beta blocker is not recommended, its initiation or continu-
ation of may be considered early after cardiac arrest due to VF/VT.
• Reduce the risk of multiorgan injury and support organ function if required.

Step 11: Prognostication After Cardiac Arrest (Table 21.1)

One of the most fearful complications after cardiac arrest (CA) is poor neurologic
recovery leading to persisting vegetative state due to Hypoxic–ischemic brain injury
(HIBI). Neurological outcome after CA is commonly measured by Cerebral
Performance Categories scale (CPCs). CPC 1–2 is considered as good neurological
outcome And CPC 3–5 is considered as poor neurological outcome. Alternatively
modified Rankin Scale (mRS) or Glasgow Outcome Scale (GOSE) can be used.
Poor neurological outcome justifies withdrawal of life-sustaining treatment. It is
vital to have high certainty while predicting poor outcome as there are isolated
reports of improvement in neurological status up to 6 months of cardiac arrest in
initially comatose cardiac arrest survivors. For this reason, the diagnostic tests used
for predicting poor outcome should have false-positive rates (FPRs) close to 0%,
with narrow 95% confidence intervals (CIs; 0%–10%). A test with such accuracy
will provide confidence to the treating physician to take an end of life care decision,
in the form of limitation or withdrawal of life support, including evaluation for
organ donation.

 eneral Principles of Neuro-Prognostication After Cardiac Arrest

G
Clinical neurologic signs, electrophysiologic studies, biomarkers, and imaging
should be performed where available three days after cardiac arrest. In patients
treated with TTM, where sedation or paralysis could be a confounder, the earliest
time for prognostication using clinical examination may be 72 h after return to nor-
mothermia. Few useful exams are bilaterally absent pupillary light reflex 72 to
108 h after cardiac arrest, Persistent absence of EEG reactivity to external stimuli at
72 h after cardiac arrest, and persistent burst suppression on EEG after rewarming.
Presence of myoclonus (not status myoclonus) should not be used to predict poor
neurologic outcomes because of the high FPR.
21  Cardiorespiratory Arrest 215

Table 21.1  Neuro-prognostication after cardiac arrest

Patients Patients not
treated with treated with
TTM TTM
Optimum time FPR Optimum FPR
Test window rate CI time window rate CI
Bilaterally absent 72 to 108 h 1% 0%–3% 72 h after 0% 0%–8%
pupillary light reflex after cardiac cardiac arrest
arrest
Bilaterally absent 72 to 120 h 2% 0%–7% 48 h after 7% 2%–20%
corneal reflexes after cardiac cardiac arrest
arrest
Extensor posturing or 36 to 108 h 10% 7%– 72 h after 15% 5%–31%
no motor response to after cardiac 15% cardiac arrest
pain arrest
Status myoclonus First 72 h after 0% 0%–4% On admission 0%; 0%–5%
cardiac arrest
at 24 h after 0% 0%–7%
cardiac arrest
within 72 h 0% 0%–14%
of cardiac
arrest
Persistent absence of 72 h/ 0% 0%–3%;
EEG reactivity to rewarming
external stimuli at 72 h
after cardiac arrest, and
persistent burst
suppression on EEG
after rewarming,
Presence of burst See above 72 h or more 0% 0%–11%;
suppression on EEG after cardiac
arrest
Bilateral absence of the 24 to 72 h 1%; 0%–3%; Same as Same Same as
N20 SSEP wave after cardiac TTM as TTM
arrest or after TTM
rewarming
Marked reduction of the within 2 h 0% to –
gray-white ratio (GWR) after cardiac 8%
on brain CT arrest
TTM: Therapeutic temperature management
FPR rate: False positive rate (Desirable: close to 0%)
CI: 95% confidence intervals (Desirable: 0%–10%)

Performance of various tests for neuro-prognostication after cardiac arrest have

been described in Table 21.1. Electrophysiological predictors of good outcome are
as follows:

1 . Presence of a continuous or nearly continuous EEG within 12 h from ROSC.

2. Presence of early EEG reactivity.
3. Improvement of auditory discrimination from the first to the second day after
ROSC.
216 S. N. Myatra and A. T. Kothekar

 tep 12: Assist Survivors from Cardiac Arrest Who Require

S
Rehabilitation Services

The ultimate goal of resuscitation should be restoring the pre-arrest health-related

quality of life (HRQOL). HRQOL should be assessed at a minimum of 3 months.
Patients who get successfully discharged alive from the hospital after cardiac arrest
often report cognitive impairment, restricted mobility, depression, and restricted
societal participation. Further studies in this area are warranted.
If patients resuscitated after cardiac arrest, subsequently die or have brain death,
do not achieve ROSC or have resuscitation terminated, they should be evaluated as
potential organ donors.

Suggested Reading
Callaway CW, Donnino MW, Fink EL, et  al. Part 8: Post-Cardiac Arrest Care: 2015 American
Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency
Cardiovascular Care. Circulation. 2015;132(18 Suppl 2):S465–82. An American Heart
Association update on the guidelines for Post cardiac arrest care
Kilgannon JH, Jones AE, Shapiro NI, et al. Association between arterial hyperoxia following resus-
citation from cardiac arrest and in-hospital mortality. JAMA. 2010;303:2165–71. Patients who
are admitted to the ICU following resuscitation from cardiac arrest, arterial hyperoxia was
independently associated with increased in-hospital mortality compared with either hypoxia
or normoxia
Kleinman ME, Brennan EE, Goldberger ZD, Swor RA, Terry M, Bobrow BJ, Gazmuri RJ, Travers
AH, Rea T. Part 5: adult basic life support and cardiopulmonary resuscitation quality: 2015
American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and
Emergency Cardiovascular Care. Circulation. 2015;132(suppl 2):S414–35. An update on the
guidelines for cardiopulmonary resuscitation and emergency cardiovascular care quality
Nolan JP, Soar J, Cariou A, Cronberg T, Moulaert VR, Deakin CD, Bottiger BW, Friberg H, Sunde
K, Sandroni C.  European Resuscitation Council and European Society of Intensive Care
Medicine Guidelines for Postresuscitation Care 2015: Section 5 of the European Resuscitation
Council Guidelines for Resuscitation 2015. Resuscitation. 2015;95:202–22. A comprehensive
review on guidelines for Postresuscitation Care
Sandroni C, D’Arrigo S, Nolan JP. Prognostication after cardiac arrest. Crit Care. 2018;22:150. A
multimodal approach combining multiple prognostication tests is recommended so that the risk
of a falsely pessimistic prediction is minimised

Websites

https://eccguidelines.heart.org/wp-content/uploads/2015/10/2015-AHA-Guidelines-Highlights-
English.pdf