• SCA = Sudden Cardiac Arrest
  • sudden cessation of organized cardiac activity with hemodynamic collapse
• ALS = BLS + invasive techniques
• including: Defib and Drugs (IV therapy)
• apply advanced life support interventions
• look for potential causes of arrest

• Special cases
  • Maternal = left lateral + early intubation + perimortem delivery
  • LAST = prolonged CPR
  • CO2 embolus = head down + aspirate
• Electricity and chest compressions will save the patient
• COACHED person can also be the timer
• put patient on ventilator
  • 4-6 per minute
  • beware hyperventilation and unsurvivable accumulation of PEEP
  • modern OT ventilators can deliver volumes during CPR

• highest priorities in resuscitation from sudden cardiac arrest:
  1. Chest compressions = Good quality CPR
  • minimise interruptions to CPR during any ALS intervention at ALL times
  • immediate CPR
  2. Electricity = Early defibrillation
  • minimise the time to defibrillation = within 5 minutes
  • the chance of successful defibrillation decreases over time
• there are interventions that are indicated in ALL causes of cardiac arrest
• continue until
  • ROSC = responsiveness / normal breathing
  • consensus to stop

• as soon as defibrillator is available
• attach pads + charge + assess rhythm
• if NON-SHOCKABLE:
  • if rhythm compatible with spontaneous circulation
    • disarm defib + check pulse
  • continue CPR
• if SHOCKABLE:
  • single shock and continue CPR after delivery
  • do NOT stop to re-assess rhythm

1. VF
2. pVT

• types:
  1. Asystole
  2. PEA
• prognosis is much less favourable
• defibrillation is not indicated
• emphasis is on CPR and other ALS interventions (IV access, advanced airway, drugs, pacing)

• monophasic = 360 J
• biphasic = 200 J
• Lifepak 20E is biphasic
• if 1st shock is unsuccessful, increase energy to maximum (360 J) for subsequent shocks

• after defibrillation, immediate CPR
• this helps
  • maintain myocardial and cerebral viability
  • improve the likelihood of subsequent shock success

• vasopressor (adrenaline)
  • after 2nd failed defib = during 3rd cycle
  • increase ROSC
  • no evidence that use increases survival to hospital discharge
• anti-arrhythmic (amiodarone)
  • after 3rd failed defib = during 4th cycle
  • no evidence that any anti-arrhythimc use increases survival to hospital discharge
  • amiodarone improves short-term outcome of shock-refactory VF
• other drugs
  • no evidence that routine administration of otherdrugs improves survival to hospital discharge

• there are a group of potentially reversible conditions that (if unrecognised or left untreated) may prevent successful resuscitation
• 4H's and 4T's
  • THROw TEN TOXIc TAMPONs
  • https://twitter.com/drbenlovell/status/1376639156860882950?lang=en
  • Thrombosis / Tension PTX / Toxins / Tamponade

PRE ── Hypovolaemia = does pt look dry? ┌─ Hypoxaemia = cyanosis? IN ├─ Hyper/hypokalaemia + metabolic disorders = await bloods └─ Hypo/hyperthermia = check temp

IN ┌─ Toxins / poisons / drugs = general inspection └─ Thrombosis = pulmonary / coronary = ECG +/- CTPA POST ┌─ Tension pneumothorax = auscultate └─ Tamponade = TTE

• insufficient evidence for routine IVF
• infuse if:
  • hypovolaemia suspected
• at least 20 mL/kg = 1.5 L for adults

• Indications = VF / pVT
• Consider = Prophylaxis recurrent VF/VT
• ADR = hypotension, ⬇HR, CHB
• Dose = 300 mg, consider further 150 mg, then infusion 15 mg/kg over 24 hours

• Indication = ⬆K, ⬇Ca, overdose CCB
• ADR = ⬆myocardial and cerebral injury
  • tissue necrosis with extravasation

• Indication = VF/pVT as alternative to amiodarone
• ADR = reduced LOC, seizures, ⬇BP, ⬇HR

• not recommended to routinely administer
• consider fibrinolysis when:
  • adult with PE (proven / suspected)

• indications
  • torsades de pointes
  • cardiac arrest + digoxin toxicity
  • refractory VF / pVT
  • hypoMg
  • hypoK
• dose
  • 5 mmol bolus
• toxicity
  • areflexia
  • respiratory depression
  • oliguria (< 100 mL over 4 hours)

• indications
  • hyperK
  • metabolic acidosis
  • TCA overdose
  • prolonged arrest > 15 mins
• dose
  • 1 mmol/kg over 2 minutes

• Guedel's / NPA
• SGA / ETT
  • ETT indications
    • airway swelling (anaphylaxis)
    • soiled AW / vomiting
    • pregnancy (reduced FRC and ventilation)
• minimal interruption to CPR (20 seconds)
• after securing advanced airway, ventilate at RR 6-10
  • do NOT pause during chest compressions to deliver ventilations

• safe and effective non-invasive indicator of cardiac output during CPR
• may be an early indicator of ROSC in intubated patients

• CPP > 20 mmHg = coronary perfusion pressure
  • CPP = Aortic diastolic pressure - LV EDP
• DBP > 25 mmHg
• ETCO2 > 20 mmHg
• SBP > 100 mmHg during CPR have better outcomes...
• https://myemresidency.wordpress.com/2019/10/23/goal-directed-cpr/

• provides an estimation of
  • the degree of hypoxaemia
  • the adequacy of ventilation during CPR
• not a reliable indicator of the extent of tissue acidosis

• CPP = aortic diastolic pressure - right atrial pressure
• 15+ mmHg is predictive of ROSC
• ICU, where arterial and CVP already being monitored

• definition = not breathing, but has pulse
• ventilate RR 6-10
• check for pulse every 10 breaths (every minute)
• if doubt about pulse, start ECC
• all respiratory arrests will develop cardiac arrest if ventilation is delayed

• conditions
  • monitored and witnessed
  • usually in critical care areas (ED, ICU, OT, CCU, cath lab)
  • in well oxygenated patient
  • defibrillator is rapidly available (< 20 seconds)
• precordial thump whilst waiting for defibrillator
  • ONLY if pulseless VT = monitored pulseless VT arrest
  • NOT effective for VF
• if initial rhythm is VF/pVT:
  • 3 successive (stacked) shocks = without commencing ECC
  • after each shock, rapidly check (5 seconds) for rhythm change +/- pulse +/ ROSC
• start ECC if:
  • 3rd shock unsuccessful, or
  • asysole, or
  • PEA

• cardioversion
  • needs to be synchronised ("synced")
    • deliver at the R-wave
    • and NOT the T-wave (relative refractory period, where VF can be induced) = R-on-T phenomenon
  • usually in conscious patient
  • less electricity = 0.5 J/kg = 50 Joules
  • increase to 2 J/kg = 200 Joules (same as defib)

• Beware equipment failure, eg:
  • connecting hypoxic gases
  • error assembling bag valve devices
• unexplained hypoxia?
  • change gas supply
  • change circuits
  • remove patient from ventilator and gas supply, using self-inflating bag + RA
  • use O2 analyzer

• definition
  • organised rhythm
  • pulse
  • signs of life

• Targeted Temperature Management = 32-36° for 24= hours

• after ROSC (return of spontaneous circulation), post-resuscitation care commences
• re-evaluate patient (ABCDE approach)
• 12 lead ECG
• CXR
• assess adequacy of perfusion
• consider reperfusion therapy (thrombolytics / PCI)
• confirm + maintain adequacy of oxygenation and ventilation
  • may need advanced airway
• Targeted Temperature Management
  • if indicated
  • maintain constant target temperature between 32 and 36 for 24+ hours
• reversible causes = further investigation + treatment
• avoid hypoxia and hyperoxia

5. Post resus care

• Confirm ROSC
  • Central pulse
  • signs of life
• Immediate post-resuscitation care = ABCDE
• Investigations (ECG, CXR)
• Consider intubation
• Complete documentation
• Inform NOK
• Transfer patient

1. Airway
2. CPR
3. Defibrillator
4. Drugs
5. Scribe

• definition
  • asynchronous chaotic ventricular activity
  • that produces no cardiac output
• VF is the primary rhythm in sudden cardiac arrest
• the vast majority of survivors come from this group
• VF amplitude and waveform deteriorate over time
  • due to depletion of high energy phosphate stores in myocardium
  • effective BLS can slow or reverse this depletion

• definition
  • wide complex regular tachycardia
  • associated with no clinically detectable cardiac output

• definition
  • absence of any cardiac electrical activity
• there will never be cardiac output without electrical activity
  • sometimes no cardiac output despite electrical activity

• also, EMD (Electromechanical dissociation)

• presence of a coordinated electrical rhythm without a detectable cardiac output

• D = patient is Dry

• O = don't place pads over objects, like PPM / jewellery

• O = remove O2 from patient

• R = recheck that no-one is touching patient before applying shock

• Continue chest compressions
• O2 away
  • LMA/ETT is a closed circuit
  • however, may be safer to disconnect in case the weight of the unattended self-inflating bag pulls the airway out
• All others clear
• Charge (also do early all others clear check here: top clear, middle clear, bottom clear)
• Hands off
  • close the loop = "I'm safe"
  • a good time to change ECC operator
• Evaluate rhythm (< 5 seconds)
• Defib / Dump
  • can use "Shock" (so it sounds different to "Defib")
  • can use "Disarm" or "Dump"

1. Initial + 1st round = CPR + Attach defib + COACHED

• Check for Danger and patient Response

• Sends for help

• Opens Airway and checks Breathing

• Confirms arrest

• Commence CPR

• when help arrives,

1. attach Defibrillator
2. allocate roles
3. COACHED (shock 200 J)

2. 2nd round = CPR + IV access + COACHED

• recommence CPR
• obtain IV/IO access
• send bloods (VBG + full panel)
• information gathering = notes, medications, nurse
• assess for reversible causes
• at 2 minutes, COACHED (shock 200 J)

3. 3rd round = CPR + Adrenaline + COACHED

• recommence CPR
• Adrenaline 1mg + flush
• at 2 minutes, COACHED (shock 200 J)

4. 4th round = CPR + Amiodarone + COACHED

• recommence CPR
• Amiodarone 300 mg + flush
• at 2 minutes, COACHED (SR + disarm)

ANZCOR Guideline 11.2 (Protocols for Adult ALS)

Synchronized Electrical Cardioversion

ANZCOR Guideline 11.5 – Medications in Adult Cardiac Arrest