Cardiac arrest and cardiopulmonary resuscitation

Last updated: August 12, 2022

Summarytoggle arrow icon

Cardiac arrest is the sudden cessation of cardiac function and blood circulation, manifesting as apnea, pulselessness, and loss of consciousness. In adults, cardiac arrest is most commonly caused by cardiac conditions (e.g., coronary artery disease), but it can also have noncardiac etiologies (e.g., hypothermia), whereas in children, etiologies are more varied and more frequently related to profound hypoxia (e.g., due to airway obstruction). Cardiopulmonary resuscitation (CPR) is a lifesaving procedure that artificially maintains circulation and ventilation until cardiac function is hopefully restored. Immediate initiation of high-quality chest compressions is the most important factor for survival after cardiac arrest.

There are two clinical algorithms to provide 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 responsiveness, calling for help, performing chest compressions and rescue breaths, and, if available, using an automated external defibrillator (AED). ACLS includes additional measures (e.g., resuscitation medications, airway management) and identifying and treating reversible causes of cardiac arrest (e.g., Hs and Ts). Modifications to BLS and ACLS are required for children and neonates.

After the return of spontaneous circulation (ROSC), comprehensive postresuscitation care is essential for good neurological and functional outcomes. This involves neuroprotective measures, hemodynamic support, critical care admission, monitoring for organ dysfunction, and treatment of underlying causes and complications.

Recommendations in this article are consistent with the 2020 American Heart Association (AHA) and the International Liaison Committee on Resuscitation (ILCOR) guidelines and consensus statements. Practice may vary according to regional authorities and resources. Consult local protocols whenever possible. [1]

Chain of survival [2][3][4]

The initial approach to cardiac arrest is influenced by the rescuers (e.g., number of rescuers, training received), patient factors (e.g., age, pregnancy), and location (i.e., in-hospital vs. out-of-hospital).

Algorithms

Overview of life support algorithms
Key components

BLS algorithm

ACLS algorithm

Special patient groups
Postresuscitation care

Approach

Chest compressions [2]

Chest compression technique differs in children, infants, and neonates; see “Basic life support in infants and children” and “Neonatal life support.”

  • Key targets for high-quality chest compressions
    • Compression rate: 100–120 per minute
    • Compression depth for adults: 5–6 cm (2–2.5 inches)
    • Allow full chest recoil between compressions.
  • Provider positioning and technique (adults and children; excluding infants)
    • Kneel or stand next to the patient depending on whether they are on the ground or in a bed, respectively.
    • Center the hands (one on top of the other, fingers interlaced) over the sternum.
    • Keep the arms straight (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
  • Minimizing interruptions

High-quality chest compressions are associated with better survival rates.

Mechanical CPR devices [5]

Rescue breathing [2]

  • Mouth-to-mouth
    1. Open the airway using the head-tilt/chin-lift maneuver.
    2. Pinch the patient's nose closed.
    3. Form a tight seal over the patient's mouth.
    4. Breathe slowly into the patient's mouth for ∼ 1 second; check for chest rise to confirm sufficient ventilation.
    5. Move away from the patient's mouth between breaths to allow air to escape, ensuring the patient's airway remains open.
  • If equipment is available: Ventilate with 100% O2; select a modality based on patient factors and provider expertise. [8]

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.

Withholding CPR

Only consider allowing natural death in limited situations, e.g.: [9]

Initiate CPR if there is any uncertainty regarding the validity of a DNR or the irreversibility of death.

The BLS algorithm allows appropriately trained individuals to recognize cardiac arrest, provide high-quality chest compressions, deliver ventilations, and utilize an AED.

BLS algorithm [1][10]

The optimal sequence of some BLS steps varies between single-rescuer BLS and two-rescuer BLS.

  • Assess scene safety: e.g., check for fire and other hazards, don PPE for infectious or toxic exposures
  • Assess patient responsiveness : Proceed with BLS if no response or only abnormal breathing (e.g., gasping).
  • Call for help: Shout for assistance and/or activate the emergency response.
  • Retrieve an AED or defibrillator: e.g., from the nearest crash cart
  • Assess for signs of life: Check pulse and respiration simultaneously.
  • Perform high-quality CPR.
  • Defibrillate as needed.
    • Use an AED or defibrillator as soon as it is available.
    • Perform 5 cycles (2 minutes) of CPR between each rhythm analysis and/or shock.
  • Endpoints [2]
    • The patient shows clear signs of life: e.g., coughing, breathing, movement of the extremities
    • Rescuers are too fatigued to continue
    • ACLS-trained providers arrive

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

For 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, and attach the Defibrillator.

Single rescuer vs. two rescuers

Differences between single- and two-rescuer BLS [1][10]
Single-rescuer BLS Two-rescuer BLS
Calling for help
Once AED is available
CPR technique

Automated external defibrillator (AED)

  • Description: a portable electronic defibrillator that independently identifies shockable rhythms and delivers a shock; designed to be used by lay rescuers in out-of-hospital settings
  • Applying pads
    • Dry the skin where the pads will be applied, if necessary.
    • Anterior-lateral placement: Place one pad on the right chest (above the nipple) and the other on the left side of the thorax (below the nipple).
    • Anterior-posterior placement: Place one pad anteriorly on the chest and the other posteriorly on the back.
  • Rhythm analysis
    • Pause CPR during rhythm analysis.
    • Repeat analysis 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 shock delivery: Perform for 2 minutes (5 cycles) prior to the next rhythm analysis.

Special situations [1][10][11]

The ACLS algorithm adds the following to the BLS algorithm: rhythm recognition in cardiac arrest, resuscitation medications, treatment of reversible causes of cardiac arrest, and advanced airway management. Maximizing high-quality CPR and early defibrillation remain the most important factors for survival and good neurological outcome. [12]

ACLS algorithm [10][12]

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

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

Rhythm recognition in cardiac arrest

Rhythms in cardiac arrest
Rhythm Appearance Pathophysiology Classic etiologies
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
  • Result: no cardiac output
Pulseless ventricular tachycardia (pulseless VT)
Nonshockable rhythms Pulseless electrical activity (PEA)
  • Variable
  • May resemble any regular electrical activity on the monitor
Asystole
  • Gently undulating line

In prolonged cardiac arrest, rhythms frequently degenerate into asystole; check with emergency providers if another rhythm was detected prior to admission.

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

Defibrillation

Defibrillate as soon as possible once a shockable rhythm is recognized to maximize survival.

Procedure

  1. Set the defibrillator to unsynchronized mode.
  2. Place the paddles or pads firmly on the patient's thorax.
  3. Set energy dosage and press the charge button.
    • Biphasic defibrillator (preferred) [10][13]
      • First shock: 120–200 J
      • Additional shocks: 200–360 J
    • Monophasic defibrillator : 360 J for all shocks
  4. Resume CPR while the defibrillator is charging.
  5. When fully charged, “clear” the patient, i.e., ensure no other personnel and equipment are in contact with the patient or pads.
  6. Administer the shock.
    • Paddles: Simultaneously hold down both shock buttons located under each thumb.
    • Pads: Press the shock button on the defibrillator.
  7. Resume CPR immediately after defibrillation for a full 2-minute cycle. [12]

Ensure the defibrillator is set to unsynchronized mode when treating cardiac arrest with a shockable rhythm.

Pitfalls and troubleshooting

  • Provide interval CPR if there is a delay between rhythm recognition and shock delivery.
  • Conducting gel may be required for paddles.
  • Direct, firm contact between the pads or paddles and the skin is essential.
  • Consider shaving the patient's chest if there is a lot of hair.
  • Turn oxygen off or divert the flow away from the patient.

Resuscitation medications [10]

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

Crisis resource management [12]

Effective teamwork is essential to the success of resuscitative efforts. The following roles, responsibilities, and communication strategies are recommended during ACLS:

  • Assign a designated team leader prior to starting 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:
  • Prior to each pause, ensure team members are aware of their roles to minimize interruptions to CPR.

Apply the following for patients with Vfib or pulseless VT identified at any time during cardiac arrest. Simultaneously evaluate for and treat reversible causes of cardiac arrest, e.g., Hs and Ts.

1st defibrillation attempt

2nd attempt

  • Shock administered after clearing patient
  • CPR resumed until the next rhythm and pulse check (2 minutes or 5 cycles of CPR).
  • First dose of epinephrine given

3rd attempt

4th attempt

  • Shock administered after clearing patient
  • CPR resumed until the next rhythm and pulse check (2 minutes or 5 cycles of CPR).
  • Repeat dose of epinephrine given

5th attempt

  • Shock administered after clearing patient
  • CPR resumed until the next rhythm and pulse check (2 minutes or 5 cycles of CPR).
  • Second dose (half of the first dose) given of:

Endpoints

Precharge the defibrillator prior to the next rhythm and pulse check to minimize interruption of CPR.

The following applies to patients with PEA or asystole identified at any time during cardiac arrest. Simultaneously evaluate for and treat reversible causes of cardiac arrest, e.g., Hs and Ts.

First identification of nonshockable rhythm

  • CPR started and continued until next rhythm and pulse check (2 minutes or 5 cycles of CPR).
  • First dose of epinephrine given as soon as possible

Subsequent identification of nonshockable rhythm

  • CPR resumed until next rhythm and pulse check (2 minutes or 5 cycles of CPR).
  • Repeat dose of epinephrine given at 3–5 minute intervals.

Endpoints

Only consider pausing CPR if a lifesaving procedure requiring access to the chest must be performed, e.g., pericardiocentesis.

Overview of causes [10][11][13][16]

Hs and Ts [13]
5 Hs 5 Ts

Bedside diagnostic studies

Hs

Hs [10][11][13][16]
Supporting studies and findings Management
Hypovolemia
Hypoxia
Hyperkalemia/hypokalemia [17]
Hydrogen ions (severe acidosis)
Hypothermia
  • Temperature [11]
    • Severe: < 30°C (86°F)
    • Moderate: 30–34°C (86–93°F)
    • Mild: > 34°C (93°F)

Ts

Ts [10][11][13][16]
Supporting studies and findings Management
Tension pneumothorax
Tamponade
(cardiac)
Toxins
Thrombosis (pulmonary)
Thrombosis (coronary)

Other reversible causes of cardiac arrest [10][11][13][16]

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

Supporting studies and findings Management

Trauma

Hypoglycemia [10][23][24]
  • Blood glucose < 70 mg/dL (< 3.9 mmol)
Other electrolyte abnormalities [11]
Asthma
  • Clinical suspicion and/or known history of asthma
Anaphylaxis
  • Clinical suspicion, e.g., known allergen exposure

Avoid routine dextrose administration for cardiac arrest (e.g., in potentially normoglycemic or hyperglycemic patients) as it can worsen survival and neurological outcomes. [26]

Return of spontaneous circulation (ROSC) [13]

Termination of resuscitation (TOR) [29]

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 advance directive prohibiting resuscitation is discovered.
  • Experience of the provider and resuscitation team
  • Factors associated with poor outcomes [14]
    • Patient factors: older age, poor functional status, terminal malignancy, organ failure
    • Resuscitation factors: delay to onset of CPR, delay to defibrillation

Important considerations

Evidence does not support using 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. [10][30]
  • Shockable rhythms: Resuscitation should typically continue as long as the patient remains in a shockable rhythm. [10][14]
  • Nonshockable rhythms: There is no recommended duration of asystole at which resuscitation should cease. [15]
  • Prolonged resuscitation is typically appropriate in the following circumstances: [10][14]
    • Hypothermia: Continue until adequately rewarmed (e.g., core temperature > 35°C/95°F).
    • Toxicity (e.g., local anesthetic toxicity): Prolonged resuscitation may allow toxins to be metabolized and excreted.
    • Pulmonary embolism: Continue resuscitation for at least 60–90 minutes after administration of thrombolytic agents.

The post-ROSC phase of cardiac arrest focuses on optimizing hemodynamic support, identifying and treating the underlying cause of arrest, and minimizing secondary brain injury through neuroprotective measures.

Initial postresuscitation stabilization [10]

Additional management and urgent interventions [10]

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 performed. Talk to the Family, Give thanks to the team, consider initiation of Hypothermia, and admit to ICU.

Neuroprognostication [10]

Organ donation [4][9]

Complications of CPR

Complications of cardiac arrest

Anoxic-ischemic encephalopathy [31][32][33][34]

We list the most important complications. The selection is not exhaustive.

Cardiac arrest in pregnancy

Modifications to BLS and ACLS [11][37]

Perimortem cesarean delivery (PMCD) [37]

Traumatic cardiac arrest [38]

BLS in infants and children

Technique modifications [23]

  • Compression rate: 100–120/minute
  • Compression-to-breath ratio
    • Single rescuer: 30:2
    • Two rescuers: 15:2
  • Postpubertal children/adolescents: Same CPR technique as for adults
  • Children ≥ 1 year of age until puberty
  • Infants < 1 year old [39]
    • Compression depth: 4 cm
    • Rescue breaths: Form a seal over both the nose and mouth.
  • Defibrillation
    • Children 1–8 years old: If available, use an AED with pediatric attenuation (if no other device is available, use an adult AED).
    • Infants < 1 year old: If available, use a manual defibrillator (if no other device is available, use an adult AED). [39]

Greater emphasis is placed on ventilation compared to CPR in adults, as hypoxia is a more common cause of cardiac arrest in infants and children.

Algorithm modifications [10][23][40]

For simplification, similar algorithms are recommended for adults and children in North America, despite their physiological differences. [41][42]

  • Initial steps (identical to BLS algorithm for adults): Assess scene safety and patient responsiveness, and call for help.
  • Check for signs of life
    • Pulse present, no breathing
    • No pulse, gasping, or no breathing: Start CPR.
  • Single rescuer sequence
    • Perform 2 minutes of CPR (30:2 with a compression 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.
  • Two-rescuer sequence
    • Direct the second rescuer to call for help and retrieve a defibrillator.
    • Start CPR at a ratio 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. [23]
  • Rhythm assessment and defibrillation
  • Endpoints: identical to BLS algorithm for adults.

Pediatric modifications to advanced life support [23]

Advanced life support for children requires different drug and defibrillator dosages. The same algorithm for ACLS in adults should be followed for pediatric patients.

Use the Broselow tape in pediatric patients to rapidly determine medication dosages, equipment sizing, and defibrillator shock dosages.

Neonatal life support [23]

See “The newborn infant" for a more complete neonatal resuscitation algorithm. The most important differences in CPR technique in neonates compared to in infants and children are as follows:

  • Compression rate: 100–120/minute
  • Compression-to-breath ratio: 3:1 (as hypoxia is the most common cause of arrest in neonates).
  • 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 changes between compressions and delivering breaths if only a single provider is present
    • Two rescuers: two-thumb-encircling hands technique

Extracorporeal membrane oxygenation (ECMO)

Interested in the newest medical research, distilled down to just one minute? Sign up for the One-Minute Telegram in “Tips and links” below.

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