Cardiac Arrest Management

Initial Response

• The American Heart Association recommends immediately beginning high-quality chest compressions at a rate of 100-120 compressions per minute with a depth of 5-6 cm, ensuring complete chest recoil between compressions, while simultaneously activating the emergency response system and retrieving the defibrillator 1, 2
• Verify scene safety first before approaching the patient to avoid becoming a second victim 2
• Check for responsiveness by shouting and tapping the victim 1, 2, 3
• Activate the emergency response system immediately and retrieve the AED/defibrillator 1, 2, 3
• Simultaneously assess breathing and pulse within 10 seconds, looking for no breathing or only gasping while checking for a pulse 1, 2, 3

High-Quality CPR Technique

• Chest compressions are the priority and should be started immediately by healthcare providers rather than beginning with ventilation 3
• The recommended compression depth is 5-6 cm in adults 1, 2
• The recommended compression rate is 100-120 compressions per minute 1, 2
• The hand position should be at the center of the chest on a firm surface 1, 4
• Complete chest recoil is necessary, allowing full recoil between compressions to prevent cardiac refilling errors 1, 2
• Minimize interruptions, keeping pauses less than 10 seconds 1, 2
• Use a 30:2 compression-to-ventilation ratio for single rescuer and 30:2 ratio for two healthcare providers in adults 1, 2, 3

Early Defibrillation

• Use the AED/defibrillator as soon as it becomes available, without delaying CPR to retrieve it, but apply it immediately once present 1, 2
• Check rhythm to determine if shockable (ventricular fibrillation or pulseless ventricular tachycardia) 1, 2
• If shockable rhythm, deliver one shock immediately and resume CPR for 2 minutes before reassessing rhythm 1, 2
• If non-shockable rhythm, resume CPR immediately for 2 minutes 1, 4

Advanced Life Support Interventions

• Establish IV/IO access as soon as feasible without interrupting compressions 1
• Administer epinephrine every 3-5 minutes for all cardiac arrest rhythms 1, 2
• Consider amiodarone or lidocaine for refractory ventricular fibrillation or pulseless ventricular tachycardia 1, 2
• Manage the airway appropriately, administering 100% oxygen at 15 L/min and using bag-mask ventilation initially 3, 5

Special Populations

• For pediatric patients, start CPR if heart rate <60/min with signs of poor perfusion 4, 6, 7, 8
• For pediatric patients, use a 30:2 ratio for single rescuer and 15:2 ratio for two or more rescuers 4, 6, 7, 8
• For pregnant patients, perform left uterine displacement during CPR and use a firm backboard with patient supine 5
• For suspected opioid overdose, administer naloxone if available while continuing CPR 1, 2

Critical Pitfalls to Avoid

• Do not delay CPR to obtain a detailed history, as the priority is immediate chest compressions 2
• Do not perform prolonged pulse checks, starting CPR if uncertain after 10 seconds 2
• Do not provide inadequate compression depth or rate, as compressions must be hard and fast to be effective 1, 2
• Do not lean on the chest between compressions, preventing adequate cardiac refilling 1, 2
• Do not interrupt compressions for prolonged periods, keeping pauses less than 10 seconds 1, 2

Immediate Initiation of CPR Based on Unresponsiveness and Breathing Assessment

Recognition Algorithm for Healthcare Providers

• Simultaneous assessment of responsiveness, breathing, and pulse should be completed within 10 seconds; if a pulse cannot be confirmed within this time, CPR must be started immediately. 9
• Absence of normal breathing (including agonal gasping) is considered a sign of cardiac arrest and triggers immediate chest compressions. 9

Decision Points After Initial Assessment

No Pulse (or Uncertain) + No Normal Breathing

• Initiate chest‑compression‑first CPR without delay. 9

Definite Pulse + No Normal Breathing

• Provide rescue breathing only (≈1 breath every 6 seconds in adults, 1 breath every 2–3 seconds in children) and re‑evaluate the pulse every 2 minutes. 9

Pediatric Threshold for CPR

• Begin CPR when the heart rate is < 60 beats/minute and signs of poor perfusion (e.g., mottled skin, weak pulses, altered mental status) are present; otherwise, give rescue breaths and monitor closely. 9

Critical Timing Considerations

• Healthcare providers detect pulses correctly only about 78 % of the time; prolonged pulse checks (average ≈ 20 seconds) significantly postpone life‑saving compressions. Therefore, pulse assessment must not exceed 10 seconds. 9
• Initiating CPR within ≈ 1.9 minutes of collapse doubles to triples survival compared with initiation at ≈ 5.7 minutes; the greatest benefit occurs within a 4–6‑minute window after collapse. 9

Guidance for Lay Rescuers

• Lay rescuers should start CPR on any unresponsive victim who is not breathing normally, without attempting a pulse check. 9
• Pulse‑check accuracy for untrained individuals is low (≈ 47 % at 5 seconds), making the combination of unresponsiveness + abnormal breathing sufficient to trigger CPR. 9

Common Pitfalls to Avoid

• Do not extend pulse checks beyond 10 seconds; if uncertainty remains, commence compressions immediately. 9
• Do not mistake agonal gasping for normal breathing—gasping indicates cardiac arrest and requires immediate CPR. 10
• Do not delay chest compressions to obtain a medical history or establish intravenous access; compressions are the priority. 9
• In pediatric bradycardia with adequate perfusion (heart rate < 60 bpm but good color and strong pulses), CPR should not be started; instead, provide rescue breathing and reassess frequently. 9