Initial Management of Cardiac Arrest

Immediate Assessment and Airway Management

• The American Heart Association recommends immediately assessing responsiveness, activating emergency response, checking for breathing and pulse simultaneously within 10 seconds, and if no pulse is detected, beginning high-quality CPR at 100-120 compressions per minute with a depth of at least 2 inches while preparing for defibrillation 1
• Ensure scene safety first, then immediately shout for nearby help and activate the emergency response system 1
• If the patient has no pulse or is only gasping, proceed directly to CPR without delay 1
• If the patient is not breathing but has a pulse, provide rescue breathing at 1 breath every 6 seconds (10 breaths per minute) 1
• Administer supplemental oxygen immediately to maintain oxygen saturation >95% 2

High-Quality CPR Protocol

• Begin CPR immediately with cycles of 30 compressions and 2 breaths 1
• Push hard: at least 2 inches (5 cm) depth 4
• Push fast: 100-120 compressions per minute 4
• Allow complete chest recoil between compressions 4
• Minimize interruptions in compressions 4
• Avoid excessive ventilation 4
• Change compressor every 2 minutes or sooner if fatigued 4

Rhythm Assessment and Defibrillation

• Use the AED as soon as it is available and check the rhythm 1
• For shockable rhythms (VF/pulseless VT), deliver one shock immediately 1
• For non-shockable rhythms (PEA/Asystole), resume CPR immediately for 2 minutes 1
• Focus on identifying and treating reversible causes (H's and T's) 5

Vascular Access and Medication Administration

• Establish IV or IO access as soon as possible during resuscitation 1
• Administer epinephrine 1 mg IV/IO every 3-5 minutes during cardiac arrest 1
• For refractory VF/pulseless VT, administer amiodarone or lidocaine 1, 3, 4

Advanced Airway Management

• Once an advanced airway (endotracheal tube or supraglottic airway) is placed, provide 1 breath every 6 seconds (10 breaths per minute) with continuous chest compressions 1
• Use waveform capnography to confirm and monitor ET tube placement 1
• Persistently low PETCO2 values (<10 mm Hg) during CPR indicate poor CPR quality or low likelihood of ROSC 5

Identifying and Treating Reversible Causes (H's and T's)

• During each 2-minute CPR cycle, systematically consider reversible causes 1
• H's: hypovolemia, hypoxia, hydrogen ion (acidosis), hypo-/hyperkalemia, hypothermia 2, 4
• T's: tension pneumothorax, tamponade (cardiac), toxins, thrombosis (pulmonary), thrombosis (coronary) 2, 4, 5, 6

Management of Hypotension Without Cardiac Arrest

• For the crashing patient with hypotension but a pulse, immediately establish IV access and begin fluid resuscitation 2
• If cardiogenic shock is suspected, administer dopamine, dobutamine, or norepinephrine 7

Recognition of Return of Spontaneous Circulation (ROSC)

• Signs of ROSC include palpable pulse and measurable blood pressure, abrupt sustained increase in PETCO2 (typically ≥40 mm Hg), and spontaneous arterial pressure waves with intra-arterial monitoring 1, 4
• Once ROSC is achieved, immediately initiate post-cardiac arrest care, including treatment of hypoxemia and hypotension 5

Critical Pitfalls to Avoid

• Do not delay CPR to establish vascular access or administer medications 1
• Do not administer atropine during PEA or asystole—it has been removed from cardiac arrest algorithms due to lack of benefit 5
• For suspected opioid overdose, standard resuscitation measures take priority over naloxone administration 1, 6
• Avoid excessive ventilation during CPR, as this impairs venous return and cardiac output 1, 3, 4