151R. Chawla and S. Todi (eds.), ICU Protocols: A stepwise approach, DOI 10.1007/978-81-322-0535-7_19, © Springer India 2012

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

S. N. Myatra , M.D. (*) • A. T. Kothekar , M.D. • J. V. Divatia , M.D., F.I.S.C.C.M. Department of Anaesthesia, Critical Care and Pain , Tata Memorial Hospital , Mumbai , India e-mail: sheila150@hotmail.com

19 Cardiorespiratory Arrest

Sheila Nainan Myatra , Amol T. Kothekar , and Jigeeshu V. Divatia

Step 1: Early recognition of sudden cardiac arrest—check responsiveness and breathing

Check response—gently tap the patient on her shoulders and check for a • response. 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. Suspect cardiac arrest if there is no response and absent or agonal respiration. •

Step 2: Activate the emergency system Activate the emergency system if present in your hospital or just shout for help. • Get the de fi brillator or send someone to get it.

Step 3: Check the pulse There is a de-emphasis on pulse check. 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 compression.

152 S.N. Myatra et al.

Step 4: Start cardiopulmonary resuscitation (CPR)—initiate chest 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 directly above the hand. • 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 fi rst so that the hands are overlapped and parallel. Interlock fi ngers to avoid compression on the ribs.

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

Compressions rate—at least 100/min. • Depth of sternal compression—at least 2 in., i.e., 5 cm (one-third anteroposterior • diameter in children and infants). Compression ventilation ratio—the adult patient 30:2 (with one or more rescu-• ers) and 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 fi ve cycles (approximately 2 min) of compression and ventilation (ratio • 30:2). Switch the compressor every 2 min. • Give 2 min of uninterrupted CPR (limit interruptions 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/min—“one and two and three and ….” Every time you say a number, compress, and when you say “and,” you relax.

Ventilation After every 30 compressions, give two slow rescue breaths using the face mask • and the AMBU bag (using the reservoir bag) to deliver 100% oxygen. Before you start ventilation, open the airway using a jaw thrust or a head tilt/chin • lift maneuver (avoid this in trauma victims with suspected cervical spine injury). Give one breath over 1 s (rapid ventilation could cause gastric insuf fl ations and • increase the risk of aspiration, should be avoided). Give suf fi cient 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 fall of the tongue. The use of cricoid pressure during ventilation is generally not recommended. • Complete fi ve cycles of compression followed by ventilation (it will take approx-

imately 2 min if you give it at the correct rate).

15319 Cardiorespiratory Arrest

Step 5: Attach the de fi brillator (automated external de fi brillators [AED] or manual de fi brillators) and shock if indicated

As soon as an AED/manual de fi brillator is available, attach it and shock if indicated, • i.e., in ventricular fi brillation (VF) and pulseless ventricular tachycardia (VT). Prefer a biphasic de fi brillator; if unavailable, use a monophasic de fi brillator. • Ensure that no one is touching the patient before you shock. • Electrode placement should be in the anterior-lateral pad position (default). • Alternative positions are anterior-posterior, anterior-left infrascapular, and ante-rior-right infrascapular. 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 fi rst 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 de fi brillation; resume CPR immediately. • Reattach the de fi brillator 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 de fi brillator 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 de fi brillator 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 de fi brillator is not available. Electric pacing is not recommended for routine use in cardiac arrest. •

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, • vasopressin, and lidocaine may be administered through this route. (Use 2–2½ times the dose diluted in 5–10 mL of distilled water or saline.) Give a vasopressor soon after giving the shock. Epinephrine IV/IO dose should • be 1 mg every 3–5 min (vasopressin IV/IO dose—40 units can replace the fi rst or second dose of epinephrine and repeated again after 20 min). Amiodarone should be given when VF/VT is unresponsive to CPR, de fi brillation, • and vasopressor therapy. IV/IO fi rst 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 bene fi t.

154 S.N. Myatra et al.

Other drugs are not routinely used and should be considered only in speci fi c • situations:

Magnesium sulfate (1–2 g) for torsades de pointes associated with a long QT –interval. 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.

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. • Con fi rm the placement of advanced airway by the clinical method (chest expan-• sion and breath sound), and in addition, use the capnography to con fi rm and monitor the correct placement. Record the depth and secure the tube. Once advanced airway is in place, give 8–10 breaths per minute and do uninter-• rupted chest compressions.

Step 8: Treat reversible causes During each 2-min period of CPR, review the most frequent causes— fi ve H’s and fi ve 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. Use quantitative waveform capnography to monitor end tidal CO •

2 if available

(expressed as a partial pressure in mmHg—PetCO 2 ) in intubated patients. If

PetCO 2 is less than 10 mmHg, attempt to improve CPR quality.

If intra-arterial pressure monitoring is present and diastolic pressure is less than • 20 mmHg, attempt to improve CPR quality. Return of spontaneous circulation (ROSC) can be con fi rmed by return of pulse • or blood pressure or abrupt sustained increase in PetCO

2 (typically ³ 40 mmHg)

or spontaneous arterial pressure waves with intra-arterial monitoring.

15519 Cardiorespiratory Arrest

Step 10: 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 • postcardiac arrest care. Optimize ventilation to minimize the lung injury. Do chest X-ray to con fi rm • airway position and to diagnose pneumonia / pulmonary edema. Use lung-pro-tective 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 (FiO •

2 ) should be adjusted

to the minimum concentration needed to achieve arterial oxyhemoglobin satura-tion of ³ 94%, with the goal of avoiding hyperoxia while ensuring adequate oxy-gen delivery. Treat hypotension (systolic blood pressure [SBP] < 90) with fl uid and vasopres-• sors and treat other reversible causes. Consider induced hypothermia. Adult patients with persistent coma after ROSC • should be cooled to 32–34°C for 12–24 h provided SBP is more than 90 mmHg or mean arterial pressure (MAP) is more than 70 with or without vasopressors. Patients comatose before cardiac arrest or another reason to be comatose (e.g., • drug overdose and status epilepticus) should be excluded. Avoid hypothermia in patients with coagulapathy/bleeding or refractory arrhythmias because hypo-thermia exaggerates these conditions. Cooling can be done using cold IV fl uid bolus of 30 mL/Kg, surface cooling (ice packs, mattresses), endovascular cool-ing, 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). Maintain glucose control—moderate glycemic control (144–180 mg/dL). • Use anticonvulsants if the patient is seizing (use EEG monitoring if available). • 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). Reduce the risk of multiorgan injury and support organ function if required. •

Step 11: Prognostication after cardiac arrest

In patients treated with therapeutic hypothermia: Clinical neurologic signs, electrophysiologic studies, biomarkers, and imaging • should be performed where available 3 days after cardiac arrest. Presently, there is limited evidence to guide decisions regarding limitation/with-• drawal of life support in these patients as favorable outcomes have been seen in those in whom studies predicted poor outcome. Use your best clinical judgment based on this testing to make a decision.

In patients who have not undergone therapeutic hypothermia, the following features are present:

Absence of pupillary response to light on the day 3 • Absence of motor response to pain by the day 3 •

156 S.N. Myatra et al.

Absence of bilateral cortical response to median nerve somatosensory evoked • potentials in those comatose for at least 72 h after a hypoxic-ischemic insult

Limitation/withdrawal of life support in this situation can be considered.

Step 12: Assist survivors from cardiac arrest who require rehabilitation services

Managing cardiac arrest (flow chart)

Unresponsive with no breathing or no normal breathing (only gasping)

Activate emergency response if present or shout for helpGet an AED/defibrillator or send someone to get it

Check pulse (no more than 10 seconds)Give one breath every 5–6 secondsRecheck pulse every 2 minutes

Start CPR cycles of 30 compressionsfollowed by two ventilations

CPR for 2 minutesIV/IO accessEpinephrine every 3–5 minutesAmiodarone for refractory VF/VT

As soon as the AED/defibrillatorarrives, attach

Resume CPR immediately for 2 minutesIV/IO accessEpinephrine every 3–5 minutes

Treat reversible causes

Deliver shock: Biphasic 120–200 JMonophasic 360 J

Consider advanced airwayQuantitative waveform capnography ifavailable

Consider advanced airwayQuantitative waveform capnographyif available

Monitor the quality of CPR at all times• Push hard (≥2 inches) and fast (≥100/min)

• Ensure complete chest recoil between compressions

• Minimize interruptions in compressions

• Avoid excess ventilation

• Rotate the compressor every 2 minutes

• If there is no advanced airway, continue compression to ventilation ratio at 30:2

• If PetCO2 <10 mm Hg, improve quality of CPR

• Monitor intra-arterial pressure if diastolic pressure is <20 mm Hg; improve CPR quality

Pulse

No Pulse

Nonshockable

(Asystole/pulseless electrical activity)

Shockable (VF/VT)

Reattach the AED/defibrillator after every 2 minutes of CPR

DeathROSC

Postcardiac arrest Care

Treat reversible causes

15719 Cardiorespiratory Arrest

Suggested Reading

1. Berg RA, Hemphill R, Abella BS, et al. Part 5: adult basic life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;2;122(18 Suppl 3):S685–705 .

Comprehensive guidelines for cardiopulmonary resuscitation. 2. Kilgannon JH, Jones AE, Shapiro NI, et al. Association between arterial hyperoxia following

resuscitation from cardiac arrest and in-hospital mortality. JAMA. 2010;303:2165–71. Among patients 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.

Websites

1. www.americanheart.org 2. www.aha.org