Cardiac Arrest

Epidemiology, Etiology
1. Originates most commonly from an arrhythmia or can be due to non-cardiac origins (trauma, overdose, etc.)
a. Asystole is most common presenting rhythm over ventricular fibrillation (VF) and pulseless ventricular
tachycardia (PVT)
2. Most common clinical finding is CAD, accounting for 75% of sudden cardiac arrests

Pathophysiology
1. Primary cardiac arrest: arterial blood is fully oxygenated at the time of arrest. As forward blood flow ceases,
arterial blood oxygenation remains normal for about 10 minutes and subsequently declines due to the lack of
ventilation
2. Respiratory failure can lead to severe hypoxemia, hypotension, and secondary cardiac arrest
3. Presentation - Anxiety, chest pain, N/V, Diaphoresis, Apnea, Hypotension, Cold or clammy extremities

Desired Outcome
1. The global goals of resuscitation are to preserve life, restore health, relieve suffering, limit disability, and respect
the individual's decisions, rights, and privacy
a. Good neurological function should be primary treatment outcome
2. Respect the individual's decisions: allows patients to communicate their wishes and preferences regarding medical
care and may lead to a “do not attempt resuscitation” order

Cardiopulmonary resuscitation (CPR)

1. High quality CPR continues to be emphasized in the latest guidelines published by the AHA.
a. Provides critical blood flow to the heart and brain, prolongs the time of VF, and increases the likelihood
that a shock will terminate VF
b. For every minute that elapses before successful defibrillation can be administered, survival rates decrease
by 7% to 10% if CPR is not provided. Immediate CPR, the survival rates decline gradually (3%–4% per
minute)
2. Proper technique: rate and depth of compressions, allowing full chest recoil after each compression, avoiding
excessive ventilation, and minimizing interruptions
3. CPR is frequently suboptimal, particularly when rescuers become fatigued. Mechanical devices developed for this
concern.
4. Basic CPR alone is not likely to terminate VF and lead to return of spontaneous circulation (ROSC)

Advanced Life Support2

1. Once EMS or other ACLS certified providers arrive, additional therapy may be given other than CPR. a. Bag
mask device or an advanced airway
b. One provider can deliver 1 breath every 6 seconds while continuous chest compressions are being
performed by a second provider.
2. VF or PVT: One shock should be administered with the immediate resumption of chest compressions.
a. If there is still a shockable rhythm, then an additional shock should be delivered every 2 minutes. b. After
2 cycles, epinephrine is indicated.
c. This cycle is repeated until either a pulse is obtained with effective circulation, the rhythm changes, or the
patient expires.
3. Asystole or PEA : If the cardiac rhythm is not deemed to be shockable
a. Consider reversible causes.
b. CPR should be performed with epinephrine administration every 3 to 5 minutes

Ventricular Fibrillation/ Pulseless Ventricular Tachycardia3

1. Non-pharm
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a. Electrical defibrillation is the only effective method of restoring a cardiac rhythm
b. Witnessed adult cardiac arrest or AED is immediately available: use defibrillator ASAP
c. Arrest not witnessed or AED is not immediately available: CPR initiated while the defibrillator is being
retrieved and defibrillation attempted as soon as the device is ready for use
d. In hospital: if AED is available, CPR should begin while the AED is being placed
e. Not necessary to check pulse after defibrillation due to poor perfusion. Check after 2 min and if still
VF/PVT, pharmacological therapy should be started with repeated attempts of defibrillation
2. Pharm4
a. Sympathomimetics first agents to be administered with goal of augmenting low coronary and cerebral
perfusion pressure present during CPR
i. Epinephrine – VF, PVT, Asystole, PEA
1. Alpha- and beta- receptor agonist, increasing the rate and
forcefulness of hert contractions
2. 1 mg IV or IO every 3 to 5 minutes ii. Vasopressin - VF, PVT,
Asystole, PEA
1. ADH, non-adrenergic, Increases BP and vascular
resistance through V1 receptors
2. 40 U IV or IO to replace epinephrine iii. Amiodarone –
VF, PVT
1. Classified as a class III antiarrhythmic (K channel blocker) but possesses
electrophysiologic characteristics of all four Vaughn Williams classifications
2. AE: Hypotension, Bradycardia due to formulation
3. ARREST and ALIVE Trial
4. First dose 300 mg IV or IO bolus then second dose 150 mg iv. Lidocaine – VF, PVT
1. Alternative to Amiodarone
2. First dose 1-1.5 mg/kg IV or IO then second dose 0.5-0.75 mg/kg
v. Magnesium – Clinical improvement noted an improvement in ROSC in patients with arrests
associated with torsades de pointes
vi. Thrombolysis: Only if caused by PE

Pulseless Electrical Activity and Asystole3

1. Pulseless electrical activity is defined as the absence of a detectable pulse and the presence of some type of
electrical activity other than VF or PVT
2. Asystole occurs when there is a lack of electrical activity in the heart and appears as a flat line on the ECG
3. Treatment
a. Depends on condition in addition to primary pharmacologic agent
b. The algorithm for treating PEA and asystole are the same. Both conditions require CPR, airway control,
and IV access
c. Defibrillation should be avoided in patients with asystole
4. Non-pharm
a. Hypovolemia – IV fluids, Hypothermia – Rewarming, Thrombosis – PCI, MONA, Heparin, etc.
5. Pharm
a. Primary pharmacologic agent used in the treatment of asystole or PEA is epinephrine; Vasopressin and
Atropine is no longer recommended

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References
1. Ewy GA. Cardiocerebral and cardiopulmonary resuscitation - 2017 update. Acute Med Surg. 2017;4(3):227-234.
Published 2017 May 26. doi:10.1002/ams2.281
2. Chamberlain D, Frenneaux M, Fletcher D. The primacy of basics in advanced life support. Curr Opin Crit Care.
2009;15(3):198-202. doi:10.1097/MCC.0b013e3283293138
3. Merchant RM, Topjian AA, Panchal AR, et al. Part 1: Executive summary: 2020 American Heart Association
guidelines for Cardiopulmonary Resuscitation and emergency cardiovascular care. Circulation.
2020;142(16_suppl_2). doi:10.1161/cir.0000000000000918
4. Ong ME, Pellis T, Link MS. The use of antiarrhythmic drugs for adult cardiac arrest: a systemic review.
Resuscitation. 2011;82(6):665-670.doi:10.1016/j.resuscitaion.2011.02.033

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