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Cardiac arrest and cardiopulmonary resuscitation

Last updated: May 25, 2021

Summarytoggle arrow icon

Cardiac arrest is the sudden cessation of cardiac function, resulting in loss of circulation. In adults, the most common cause of cardiac arrest is an underlying cardiac condition (e.g., coronary artery disease, valvular heart disease). However, cardiac arrest can also be caused by noncardiac etiologies such as _Definitions"#Z2c4b7b192fbfa8d2679ddc134ed0e9c5" data-lxid="Ig0Y92">hypovolemia, hypothermia, or tension pneumothorax (e.g., the Hs and Ts). In children, the causes of cardiac arrest are varied but are more frequently caused by profound hypoxia (e.g., due to airway obstruction).Sudden cardiac arrest manifests as apnea, pulselessness, and sudden loss of consciousness.
Cardiopulmonary resuscitation (CPR) is a lifesaving procedure that maintains circulation in patients with sudden cardiac arrest until cardiac function can, ideally, be restored. There are two types of protocols for CPR: basic life support (BLS), for lay rescuers and medical professionals alike, and advanced cardiac life support (ACLS), solely for medical professionals. BLS involves checking the patient's responsiveness, calling for help, performing chest compressions and rescue breaths, and, if available, using an automated external defibrillator (AED). ACLS includes additional procedures such as drug therapy (especially epinephrine), securing the airways (e.g., endotracheal intubation), and finding and treating reversible causes of cardiac arrest. Immediate initiation of high-quality chest compressions is the most important factor in survival after cardiac arrest. Modifications to BLS and ACLS are required for children and neonates. After return of spontaneous circulation, postresuscitation care is essential for good neurological and functional outcomes. This involves neuroprotective measures, hemodynamic support, critical care unit admission, monitoring for organ dysfunction, and treatment of underlying causes and complications.

The resuscitative interventions and algorithms described in this article are consistent with the guidelines of the American Heart Association (AHA) and the International Liaison Committee on Resuscitation (ILCOR) Consensus on Science with Treatment Recommendations (CoSTR). Some details may vary in international healthcare settings, depending on the governing authorities and available resources. Local protocols should be consulted whenever possible.

Chain of survival in cardiac arrest [1][2]

The following are elements of standardized care that maximize survival in cardiac arrest.

Choice of approach in suspected cardiac arrest

General principles

  • Start with chest compressions in most patients with suspected cardiac arrest before delivering rescue breaths (circulation-airway-breathing (CAB) approach).
  • Minimize interruptions to CPR.
  • When in doubt as to whether a collapsed patient is in cardiac arrest, performing CPR is better than withholding it. [1]
  • Withholding CPR can be appropriate in the following limited situations. [3]
    • An advanced directive or valid DNR explicitly prohibiting CPR.
    • Situations in which CPR would expose the rescuer to serious risks, e.g., serious infectious or toxic exposures in the absence of adequate PPE
    • Signs of irreversible death, e.g., rigor mortis

CPR should be started if there is any uncertainty regarding an advanced directive or DNR (e.g., its validity or clarity), or regarding the irreversibility of death

Chest compression technique (in adults and postpubertal children/adolescents) [1]

High-quality chest compressions are associated with better survival rates. Chest compression techniques differ in children, infants, and neonates (see “CPR in infants and children” and “Chest compression technique in neonates” for details).

  • Key targets of high-quality chest compressions
    • Compression rate: 100–120 per minute
    • Compression depth: 5–6 cm (2–2.5 inches)
    • Full chest recoil is required between compressions.
  • Provider positioning
    • Kneel next to the patient.
    • Place hands on the middle of the sternum (on top of one another, fingers interlaced).
    • Keep the arms straight and do not bend the elbows; the shoulders should be directly above the hands.
    • Use full body weight to deliver rapid, firm compressions.
  • Patient positioning: supine on a firm surface

Rescue breathing [1]

  • Mouth-to-mouth
    • Open the airway using the head-tilt/chin-lift maneuver.
    • Pinch the patient's nose closed.
    • Form a tight seal over the patient's mouth.
    • Breathe slowly into the patient's mouth over ∼ 1 second; verify sufficient ventilation by checking for thoracic movement.
    • Move away from the mouth between breaths to allow air to escape and ensure the patient is still positioned correctly so the airway remains open.
  • BMV equipment and 100% O2 available: See “Bag-mask ventilation” for technique.

Continuous compression-only CPR is a reasonable alternative to mouth-to-mouth rescue breathing if the provider is uncomfortable administering rescue breaths or there is concern for infectious disease transmission.

Automated external defibrillator (AED)

  • Description: a portable electronic defibrillator designed for use by lay rescuers in out-of-hospital settings that independently identifies shockable rhythms and delivers a shock.
  • Applying pads
    • Dry the skin where the pads will be applied, if necessary.
    • Place one pad on the right chest (above the nipple) and the other on the left side of the thorax (below the nipple).
    • Alternatively, place one pad anteriorly on the chest and the other posteriorly on the back.
  • Rhythm analysis
    • CPR should be paused during this phase.
    • Analysis should be repeated every 2 minutes (5 cycles of CPR).
  • Delivering shocks
    • The AED will indicate if a shock is advised and may begin to charge.
    • Resume CPR while the AED is charging.
    • When advised by the AED, clear the surroundings , then deliver the shock.
    • Resume CPR immediately after a shock is delivered.

Extracorporeal membrane oxygenation (ECMO)

Algorithm

The following apply to trained healthcare personnel in both in-hospital and out-of-hospital settings. Recommendations vary for lay rescuers.

BLS algorithm [5][6]
Single rescuer Two rescuers
Step 1: Assess scene safety.
  • Assess risk of harmful exposures that may require a specialized response (e.g., fire, toxins).
  • Don appropriate PPE if necessary and available.
Step 2: Assess patient responsiveness.
  • Assess responsiveness verbally (e.g., shouting) or by shaking the shoulders.
  • If no response or only abnormal breathing (e.g., gasping), proceed to next step.
Step 3: Call for help.
  • Out-of-hospital setting: Do the following prior to starting CPR.
    • Activate an emergency response (e.g., shout for help; call 9-1-1).
    • Retrieve AED if close by and easily accessible.
  • In-hospital: Do the following prior to starting CPR.
    • Shout for help or activate resuscitation team (e.g., call a “code blue”).
    • Retrieve defibrillator (e.g., on the nearest crash cart).
    • Activate CPR mode on the bed if available. [6]
  • Special situations: Initiating CPR prior to calling for help is necessary in some cases. [7][8]
  • Direct second rescuer to do the following:
    • Out-of-hospital: Activate emergency response and retrieve AED if available.
    • In-hospital: Activate resuscitation team and retrieve defibrillator.
  • Proceed to next step and perform single-rescuer CPR (if indicated) until second rescuer returns.
Step 4: Assess for signs of life.
Step 5: Perform CPR and defibrillate as needed.
  • Single-rescuer CPR
    • Perform 30 chest compressions followed by two rescue breaths (30:2) per cycle
    • Compression-only CPR is reasonable if mouth-to-mouth breathing is deemed too risky and BMV equipment is unavailable.
  • AED available
Endpoints [1]
  • Continue BLS until:
    • ACLS-trained providers arrive
    • Rescuers are too fatigued to continue
    • The patient shows clear signs of life, such as coughing, breathing, and movement of the extremities

Minimizing interruptions and delays to initiation of high-quality CPR plus early defibrillation of shockable rhythms are the most important factors in improving patient survival and reducing long-term complications after cardiac arrest.

With a collapsed patient, remember the DRs ABCD: Check the environment for Danger, assess for a Response, Shout for help, open the Airway, check for Breathing, start CPR, attach the Defibrillator.

Precordial thump [5]

  • Indication: Consider before initiating CPR only if all of the following criteria are met.
    • Patient is on telemetry.
    • Rescuer-witnessed onset of unstable VT
    • A defibrillator is not immediately available.
  • Procedure [9]
    • Make a fist and, using the ulnar aspect, deliver a firm blow to the sternum from a height of 20 cm.
    • Initiate CPR immediately if there is no sign of conversion.

Alternative BLS techniques like the precordial thump should not delay high-quality CPR or retrieval of the defibrillator.

Overview [8]

Crisis resource management [8]

  • Assign a designated team leader prior to starting the resuscitation.
    • All communication about patient status and treatments delivered should go through the team leader.
    • Final decisions about which treatments to pursue and when to stop resuscitation should be made by the team leader after discussion with other team members.
  • Other suggested roles include:
    • At least 2 CPR performers: 1 for chest compressions and 1 for airway and ventilation
      • Providers of chest compressions should be swapped every 2 minutes to prevent fatigue.
      • Coordinate changeovers to minimize interruptions to CPR.
    • Provider(s) in charge of IV/IO access and medications
    • Provider(s) in charge of rhythm and pulse checks and defibrillation
    • Provider in charge of specific procedures (e.g., intubation, pericardiocentesis, point-of-care ultrasound)
    • Timekeeper and/or note-taker
  • Prior to each pause, ensure that team members are aware of their roles to minimize interruptions to CPR during the pause.

ACLS algorithm [8]

The information is presented here in steps so that the priority of the interventions is clear. In clinical practice, these steps are performed simultaneously by multidisciplinary teams under a single provider's leadership and repeated depending on healthcare resources and the patient's condition.

ACLS algorithm
Priority 1: CPR
  • Follow recommendations for BLS.
  • Perform CPR for at least 2 minutes before the first rhythm check (see “Priority 2”).
  • Do not interrupt CPR, except for rhythm and pulse checks.
  • Consider advanced airway device placement only if necessary and feasible without major interruption of CPR.
  • See “Ensuring high-quality CPR” for details.
Priority 2: Rhythm and pulse check

Priority 3: Defibrillation

(shockable rhythms only)

Priority 4: Resuscitation medications
Priority 5: Hs and Ts
Endpoints

Evaluate and treat reversible causes of cardiac arrest (e.g., Hs and Ts) without stopping CPR, defibrillation, and administration of resuscitation medications.

Continue CPR and defibrillation attempts as long as the patient remains in a shockable rhythm.

Ensuring high-quality CPR

Rhythms in cardiac arrest

Rhythms in cardiac arrest
Rhythm Appearance Explanation Consequence
Shockable rhythms Ventricular fibrillation (VF)
  • Coarse or fine irregular waves of varying size, morphology, and rhythm
  • Arrhythmic and unsynchronized high-frequency contraction of the ventricles
Pulseless ventricular tachycardia (pulseless VT)
  • Rapid, regular broad complexes
  • Rapid, regular ventricular rate (along with pulselessness)
Nonshockable rhythms Pulseless electrical activity (PEA)
  • Variable; may resemble any regular electrical activity on the monitor
  • Rhythmic electrical activity (commonly low rate, wide, distorted QRS complexes) without a detectable central pulse
  • Myocardial contraction either:
    • Does not occur (true PEA, i.e., electromechanical dissociation)
    • Does not generate sufficient cardiac output for a pulse to be detectable (pseudo-PEA)
Asystole
  • Gently undulating line
  • No electrical activity
  • Lack of ventricular electrical and mechanical activity

Avoid pausing CPR longer than 10 seconds for rhythm and pulse checks.

Defibrillation

  • Timing
  • Procedure
    • Set cardioverter/defibrillator to unsynchronized mode.
    • Place paddles or electrode pads firmly on the thorax of the patient (anteroapical or anteroposterior position).
      • Direct and firm contact between the pads/paddles and the skin is essential.
      • Conducting gel may be required for paddles.
    • “Clear” the patient.
      • Ensure that all healthcare staff steps away from the patient.
      • Turn oxygen off or move flow away from the patient's chest.
    • Administer the shock.
      • Handheld paddles have shock buttons for each thumb and both need to be held down until fully charged to deliver the shock.
      • For devices with self-adhesive electrode pads, the shock button is located on the main device.
    • Resume CPR immediately after defibrillation for a full 2-minute cycle. [8]
  • Defibrillator dosage
    • Biphasic defibrillator (preferred; follow the manufacturer's instructions when available) [5][10]
      • First shock: 120–200 J
      • Additional shocks: 200–360 J
    • Monophasic defibrillator: 360 J for all shocks

Ensure the defibrillator is set to unsynchronized mode for treating cardiac arrest due to shockable rhythms.

Resume CPR immediately after each shock is delivered and continue for at least 2 minutes prior to the next rhythm and pulse check.

Resuscitation medications [5]

Obtain peripheral IV access or IO access for medications without interrupting CPR. All resuscitation medications should be administered while CPR is ongoing to ensure their circulation to the heart and brain.

The following applies to patients with VF or pulseless VT identified at rhythm and pulse check after at least 2 minutes of high-quality CPR (or earlier if cardiac monitoring was already in place at the time of cardiac arrest).

Precharge the defibrillator prior to the next rhythm and pulse check to minimize the time that CPR is interrupted for defibrillation.

The following applies to patients with PEA or asystole identified at the rhythm and pulse check.

There is no recommended duration of asystole at which resuscitation should cease. [5][11][12]

In most shockable rhythms, the cause of cardiac arrest may be effectively treated with defibrillation. In nonshockable rhythms and refractory shockable rhythms, the aim of CPR is to provide end-organ perfusion while the underlying cause of arrest is identified and treated.

Diagnostic studies

The patient's history may provide clues as to the cause of arrest. However, in the absence of a clear cause in the history, assessment of the rhythm, point of care ultrasound, and a blood gas analysis may yield further information.

Blood studies

Point of care ultrasound (POCUS) [13]

POCUS should not prolong the rhythm/pulse check.

Evaluate cardiac rhythm to identify potential etiology

Reversible causes of cardiac arrest [7][10][15]

The Hs and Ts are used to help remember the most common reversible causes of cardiac arrest. [10]

Hs

Hs
Supporting test Treatment
_Definitions"#Z2c4b7b192fbfa8d2679ddc134ed0e9c5" data-lxid="Ig0Y92">Hypovolemia
Hypoxia
Hyperkalemia/hypokalemia [16]
Hydrogen ions (severe acidosis)
Hypothermia
  • Temperature
    • Severe: < 30°C (86°F)
    • Moderate: 30–34°C (86–93°F)
    • Mild: > 34°C (93°F)

Ts

Ts
Supporting test and findings Treatment
Tension pneumothorax
Tamponade
(cardiac)
Toxins
Thrombus (pulmonary)
Thrombus (coronary)
Trauma

Other reversible causes of cardiac arrest

Several other reversible causes of cardiac arrest exist and may be screened for and treated during cardiac arrest.

Supporting feature Treatment
Hypoglycemia
  • VBG/ABG: Blood glucose < 70 mg/dL (< 3.9 mmol)
Other electrolyte abnormalities [7]
Carbon monoxide poisoning
Asthma
  • Clinical suspicion
Anaphylaxis

The use of dextrose in cardiac arrest is associated with lower survival rates and poor neurological outcomes. It should not be given to normoglycemic or hyperglycemic patients. [21]

Return of spontaneous circulation (ROSC) [10]

  • Indications of ROSC
    • Clear signs of life, e.g., breathing, coughing or movement
    • Return of palpable pulse and blood pressure or presence of arterial waveform with intraarterial monitoring
    • An abrupt and sustained increase in expiratory CO2 measured with capnography
  • Further management: Tailor supportive care to minimize end-organ damage and increase the likelihood of survival with good neurological recovery (see “Postresuscitative care”).

Termination of resuscitation (TOR) [22]

Indications for TOR (in-hospital cardiac arrests)

No clear guidance exists on when to terminate CPR in hospitals. Decisions should take into account the following factors:

  • The patient's wishes: Terminate resuscitation efforts if a valid DNR or an advanced directive prohibiting resuscitation is discovered.
  • Experience of the provider and resuscitation team
  • Factors associated with poor outcomes [11]
    • Patient factors: older age, cognitive impairment, terminal malignancy, organ failure
    • Resuscitation factors: delay to onset of CPR, delay to defibrillation.

Important considerations

Evidence does not support the use of any single clinical decision rule to guide in-hospital TOR. See also “Tips and Links” below for AHA guidelines on the ethics of withholding CPR and terminating resuscitative efforts.

  • End-tidal CO2: The AHA suggests that an end-tidal CO2 < 10 mm Hg after 20 minutes of resuscitation may be considered alongside other factors in the decision to terminate resuscitation; it should not be used alone to determine TOR. [5][23]
  • Shockable rhythms: Resuscitation should typically continue as long as the patient remains in a shockable rhythm. [5][11]
  • Nonshockable rhythms: There is no recommended duration of asystole at which resuscitation should cease. [12]
  • Prolonged resuscitation is typically appropriate in the following circumstances: [5][11]
    • Hypothermia: Continue until adequately rewarmed (e.g., core temperature > 35°C/95°F).
    • Poisoning (e.g., local anesthetic toxicity): Prolonged resuscitation can allow toxins to be metabolized and excreted.
    • Pulmonary embolism: Continue for ≥ 60–90 minutes after administration of thrombolytic agents.

Goals of postresuscitation care [24]

Goal-directed postresuscitation care provides patients with the best chance of neurologically intact survival.

Management [5][24][25][26]

All postarrest patients should be admitted to a critical care unit.

Postresuscitation management [5][24][25][26]
Diagnostic studies Interventions Targets and monitoring
Airway and breathing
  • ABG
  • Chest x-ray to confirm ETT tube placement (and any central lines)
  • Consider CT angiogram of the thorax if PE is suspected or the cause of the arrest is unknown.
Circulation
Disability


Don't forget the ABCs of postresuscitation care: Obtain an ABG, BP, and Chest x-ray, Draw blood for laboratory studies, and ensure an ECG is done. Talk to the Family, Give thanks to the team, consider initiation of Hypothermia, and admit to ICU.

Prognostication [5]

Organ donation [3][27]

Cardiac arrest in pregnancy

Modifications to BLS and ACLS [7][28]

Perimortem cesarean delivery (PMCD) [28]

Traumatic cardiac arrest [29]

Basic life support in infants and children

Modifications to CPR technique in infants and children
Compression rate
  • 100–120/min
Compression-to-ventilation ratio
  • Single rescuer: 30:2
  • Two rescuer: 15:2
CPR technique Postpubertal children/adolescents
Children ≥ 1 year of age until puberty
  • Chest compressions: Deliver with one hand in smaller children.
  • Compression depth: 5 cm [30]
  • Children < 8 years old: If available, use an AED with pediatric attenuation (if no other device is available, use an adult AED). [30]
Infants < 1 year [31]
  • Compression depth: 4 cm [30]
  • Rescue breaths: Form a seal over both the nose and mouth.
  • If available, use a manual defibrillator (if no other device is available, use an adult AED). [30]

Modifications to BLS algorithm for infants and children

For simplicity's sake, similar algorithms are recommended for adults and children in North America, despite their physiological differences (see BLS algorithm). [32][33]

Hypoxia is a more common cause of cardiac arrest in neonates and children than in other groups. For this reason, greater emphasis is placed on ventilation. [32]

Modifications to BLS for pediatric patients [5][32][34]
Initial steps
  • Initial steps (identical to BLS algorithm for adults)
    • Assess scene safety.
    • Assess patient responsiveness/signs of life.
    • Call for help.
  • Pulse present; no breathing
    • Administer rescue breaths: 1 breath every 3–5 seconds (12–20 breaths/min)
    • If HR ≤ 60 beats/min: Start CPR.
  • No pulse; gasping/no breathing: Start CPR.
Single rescuer CPR Two rescuers CPR
  • Perform 2 minutes of CPR (30:2 at a rate of 100–120/minute) before calling for help or retrieving an AED (if it requires leaving the patient's side)
  • If a cell phone is available, make an immediate emergency call and perform CPR with the phone on speaker.
  • Direct second rescuer to call for help and retrieve defibrillator.
  • Start CPR at a rate of 30:2, changing to 15:2 when both rescuers are able to provide CPR.
  • If an advanced airway is in place, consider ventilating at a rate of 20–30/minute. [30]
Further management

Neonatal life support [30]

The details of neonatal resuscitation are covered in detail separately. The most important differences in CPR techniques compared to infants and older children are as follows.

  • Compression rate: 100–120/min
  • Compression-to-ventilation ratio: 3:1 (as hypoxia is the most common cause of arrest).
  • Chest compression technique in neonates
    • Single rescuer: two finger technique
      • Perform chest compressions using two fingers (the index and middle fingers) on the lower half of the sternum, just below the intermammary line.
      • Allows for faster alternations between compressions and delivering breaths for the single health care provider.
    • Two rescuers: two thumb-encircling hands technique
      • One rescuer performs chest compressions, while the other delivers breaths.
      • Use both hands to encircle the chest with the thumbs are placed over the lower third of the sternum.
      • Compress the lower sternum with both thumbs.
      • Results in more effective compressions and higher coronary artery perfusion than the two finger technique.

Ventilation is more important in children and newborns than in adults, as hypoxia is a common cause of cardiac arrest in children!

Pediatric modifications to ACLS algorithms [30]

Advanced life support for children requires different doses of drugs and different defibrillation energies. The same algorithm for advanced life support in adults should be followed for pediatric patients.

  • Defibrillator dosage: If using a manual defibrillator, the energy should be set as follows.
    • First shock: 2 J/kg
    • Second shock: 4 J/kg
    • Subsequent shocks ≥ 4–10 J/kg or until adult level is reached
  • Resuscitation medications: Drug doses should be adapted as follows.
    • Epinephrine 0.01 mg/kg (0.1 mL/kg of 1:10,000 concentration) IV/IO every 3–5 minutes (maximum dose 1 mg)
    • Lidocaine 1 mg/kg IV once, followed by 20–50 mcg/kg/minute IV infusion [35]
    • Amiodarone 5 mg/kg IV bolus; may be repeated to a maximum of 3 doses in shockable rhythms
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