Treatment of Cardiac Arrest in Primary Health Care

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

• 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.

Breathing

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.

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

• Ensuring airway patency in a child requires experience. Continue compression and bag-mask ventilation until further help is available.
• Proceed to pharmaceutical resuscitation only when there are more helpers present and airway patency has been ensured.
• Continue resuscitation according to the paediatric advanced life support algorithm (see Fig 4 in http://cprguidelines.eu/assets/guidelines/European-Resuscitation-Council-Guidelines-2021-Pa.pdf).