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JouniKurola

Treatment of Cardiac Arrest in Primary Health Care

Essentials

  • If the patient is unresponsive and is not breathing normally, start resuscitation.
  • The quality of compression-only cardiopulmonary resuscitation (CPR) is the most significant factor affecting the prognosis. In the light of research evidence, ensuring airway patency and pharmacological resuscitation are less significant. Such advanced life support measures must not disturb uninterrupted compression-only CPR of a high quality.
  • Any delay in the defibrillation of patients with ventricular fibrillation or ventricular tachycardia must be minimized. Defibrillators that advise the user can safely be used even without training.
  • In health care facilities, cardiac arrest can be prevented by NEWS scoring http://www.rcplondon.ac.uk/projects/outputs/national-early-warning-score-news-2http://www.mdcalc.com/national-early-warning-score-news identifying critically ill patients requiring immediate intensification of treatment.
  • The treatment of cardiac arrest should be practised regularly in health care institutions, so that the following can be ensured also in the absence of a physician:
    • high-quality CPR
    • defibrillation without delay.
  • Treatment and care units in primary health care must make sure that treatment plans are made for long-term and chronically ill patients, including plans for acute exacerbations and cardiac arrest.
  • For natural death, the health care personnel should have a unit-specific procedure to comply with locally relevant policies, e.g. to avoid making an unnecessary emergency call (112).
  • In children, cardiac arrest is most commonly due to oxygen deficiency, and its treatment with bag-mask ventilation is essential.

Immediate assessment and treatment of adults with suspected cardiac arrest

  • Making sure the patient is lifeless
    • The patient cannot be woken up.
    • The patient is not breathing normally.
  • Begin CPR (30:2), unless the patient has an advance care directive and the decision has been made to allow natural death (DNR = do not resuscitate, DNAR = do not attempt resuscitation, AND = allow natural death).
    • Emergency transfer to hard ground, as necessary, with sufficient space around
  • Assess the rhythm and defibrillate immediately, as necessary, as soon as a defibrillator is available.
  • Make sure that further help is called either within the the hospital/health care unit (2222 or other locally relevant internal emergency number) or by calling the emergency number (112) according to local instructions.
    • Instructions for calling further help must be given locally.

Treatment of cardiac arrest in an adult

Withholding or terminating resuscitation

  • Resuscitation should be withheld or terminated if
    • the helper's life is endangered during resuscitation
    • the patient has an evidently fatal injury or irreversible signs of death
    • the patient has expressed his/her wish not to be resuscitated or has an advance care directive including such a request.
  • Withholding or terminating resuscitation should be considered if
    • the patient is in asystole after advanced pharmaceutical life support for 20 minutes without a clearly treatable cause
      • Based on patient-specific assessment by a physician, the decision can be made to terminate resuscitation earlier particularly if the delay to emergency care was long.
    • the patient was found lifeless, the initial rhythm was non-shockable, and due to severe underlying diseases and poor quality of life known to the staff the harm from resuscitation would probably be more significant for the patient than the obtainable benefit.

Witnessed collapse

Breathing

  • Ensure airway patency primarily by insertion of a supraglottic device (see Airway Management and Assisted Ventilation in an Emergency).
    • Intubation can be used as the primary method of airway management if there is an experienced intubator present with a high probability of success.
    • A high probability of success can be defined as a more than 95% probability of success after two attempts.
  • When the airway device has been inserted, continue chest compressions uninterrupted at a rate of 100-120/minute Continuous Versus Interrupted Chestcompression for Cardiopulmonary Resuscitation of Nonasphyxialout-of-Hospital Cardiac Arrest.
    • Ventilate the patient at a rate of 10 breaths/minute.
    • If, when using a supraglottic airway device, air leaks during uninterrupted compressions, use a 30:2 ratio of compressions to ventilation, with a break for ventilation.
  • Make sure that breath sounds are heard, and start capnography.
    • etCO2 levels may be low during resuscitation. Suddenly elevated levels may be a sign of restored circulation.

Intravenous accessAdrenaline for Cardiac Arrest

History

  • Once resuscitation has been started, take the history.
  • Was the patient witnessed to collapse or found lifeless?
  • If found lifeless, when was the patient last certainly seen awake?
  • What did the patient complain of before becoming lifeless?
  • Underlying diseases
  • Functional capacity

Treatment after restored circulation

Breathing

  • Continue assisted ventilation even if the patient breathes spontaneously.
  • Ensure that the airway device is properly secured and effective.
  • Ensure that ventilation is effective and that the supplemental oxygen source is attached to the ventilation bag.
    • Continue manual ventilation to reach an etCO2 level of about 4.5-6.0 kPa.

Circulation

  • Feel for the carotid pulse (record the time).
    • Palpate; do not trust complexes seen on the monitor as signs of circulation.
  • Measure blood pressure, heart rate and peripheral temperature every 2-3 minutes, at first.
  • Take a 12-lead ECG and assess the need for cardiac reperfusion.
  • Aim for a systolic blood pressure > 100 mmHg.
    • Start fluid administration.
    • Start administering a vasopressor or an inotrope, as necessary.
  • If the patient starts to react, give 3-5 mg oxycodone i.v.

Special features of children with cardiac arrest

Detecting lifelessness and starting resuscitation

  • In a child, cardiac arrest is usually due to oxygen deficiency.
  • If the child's general condition has become drastically worse and the level of consciousness is impaired, do not hesitate to start assisted ventilation with a bag-mask with a supplemental oxygen source.
  • If the child cannot be woken and his/her breathing is not normal, start CPR at a ratio of 15:2.
  • Make sure that further help has been called (112), and concentrate carefully on ventilation to ensure that the child's chest rises with each breath.
  • Once a defibrillator is available, assess the rhythm.
    • In a child, the initial rhythm is usually either pulseless electrical activity (PEA) or asystole.
    • Defibrillate ventricular fibrillation or pulseless ventricular tachycardia with 4 J/kg.

Advanced life support