CPR – PROCEDURE

• Patient unresponsive and not breathing normally
• Call resuscitation team

• CPR 30:2
• ensure high quality chest compressions
• minimise interruptions to compressions
• use waveform capnography
• continuous compressions when advanced airway in place
• Secure airway
• Give oxygen
• Secure vascular access (intravenous or intraosseous)
• Attach defibrillator/monitor
• minimise interruptions

Advanced Life support

Assessment

• Review rhythm and assess clinically
• Keep record of time, number of shocks and drugs given 

Shockable (VF/pulseless VT)

• Give one shock
• minimise interruptions
• Immediately resume CPR for 2 min
• minimise interruptions
• check if appropriate loop of CPR to give adrenaline and amiodarone
• After 2 min, return to assessment

Non-shockable (PEA/Asystole)

• Immediately resume CPR for 2 min
• minimise interruptions
• check if appropriate loop of CPR to give adrenaline
• After 2 min, return to assessment

Return of spontaneous circulation

• Follow Post-arrest management below

Stop resuscitation

• Senior (consultant/SpR) decides to stop resuscitation

Treat reversible causes

• Hypoxia
• Hypovolaemia
• Hypo-/hyperkalaemia/metabolic
• Hypothermia
• Thrombosis – coronary or pulmonary
• Tension pneumothorax
• Tamponade – cardiac
• Toxins

Imaging

• Consider:
• Ultrasound imaging
• Mechanical chest compressions to facilitate transfer/treatment
• Coronary angiography and percutaneous coronary intervention
• Extracorporeal CPR

Defibrillation energies

• Deliver the first shock with an energy of at least 150J
• Shock energy for a particular defibrillator should be based on manufacturer’s guidance

Peripheral administration

• Drugs administered peripherally must be followed by a flush of at least 20 mL sodium chloride 0.9% to aid entry into central circulation

Adrenaline

Shockable rhythm

• Give first dose of adrenaline 1:10,000 (100 microgram/mL) 1 mg (10 mL) by IV/IO injection after delivery of third shock
• Give subsequent doses of adrenaline after alternate 2-min loops of CPR (which equates to every 3–5 min) for as long as cardiac arrest persists

Non-shockable rhythm

• Give adrenaline 1 mg IV/IO as soon as intravascular or intraosseous access is achieved
• Give subsequent doses of adrenaline after alternate 2-min loops of CPR (which equates to every 3–5 min) for as long as cardiac arrest persists

Amiodarone

• Amiodarone 300 mg by IV/IO injection from a prefilled syringe or diluted in 20 mL glucose 5% to be given after third shock
• If VF/VT persists, or recurs, an additional dose of amiodarone 150 mg can be given by IV/IO injection after 5 defibrillation attempts

Immediate goals post-resuscitation

• Use ABCDE approach
• Provide cardiorespiratory support to optimise tissue perfusion, especially to brain
• Aim for SpO₂ of 94–98% and normal PaCO₂
• Targeted temperature management
• Attempt to identify and treat precipitating causes of arrest
• initiate measures to prevent recurrence (e.g. anti-arrhythmic therapy). See Cardiac arrhythmias guideline
• Establish underlying cause of cardiac arrest and treat. If in doubt, seek advice from on-call medical SpR
• Transport patient to appropriately equipped critical care unit

Immediate post-arrest investigation

• Blood gases
• U&E, glucose
• Chest X-ray
• 12 lead ECG

• Consider patients with VT or VF occurring ≥48 hr after acute MI or with no obvious reversible factors for implantation of a cardioverter defibrillator (ICD)
• seek advice of cardiology team

Failure to resuscitate

• Inform relatives
• Start death procedures

• Dependent upon underlying cause