Cardiac Arrest Management

Initial Resuscitation

• Secure the airway with endotracheal intubation if not already in place, and avoid excessive ventilation by targeting 10-12 breaths/minute, and initially use the highest available oxygen concentration, then titrate FiO₂ to maintain SpO₂ 94-98% (avoid 100% saturation), as recommended by the American Heart Association 1, 2, 3
• Establish IV/IO access if not already in place, and provide initial fluid resuscitation with 1-2 L normal saline or lactated Ringer's, and consider 4°C fluid if initiating therapeutic hypothermia, as recommended by the American Heart Association 2
• Target mean arterial pressure (MAP) at ≥65 mmHg (preferably >80 mmHg), and initiate vasopressors such as dopamine or epinephrine for hypotension (SBP <90 mmHg), as recommended by the American Heart Association 1, 2
• Use continuous cardiac monitoring, pulse oximetry, quantitative capnography, arterial line for continuous blood pressure monitoring, and core temperature monitoring (esophageal, bladder, or rectal), as recommended by the American Heart Association 4

Post-Cardiac Arrest Care

• Actively prevent fever in all post-cardiac arrest patients, as recommended by the American Heart Association 1
• Perform EEG promptly for diagnosis of seizures in comatose patients, and consider continuous EEG monitoring, and treat seizures with standard anticonvulsant regimens, as recommended by the American College of Cardiology 1
• Avoid early neurological prognostication (wait at least 72 hours after normothermia), as recommended by the American Heart Association 1
• Maintain PaCO₂ within normal physiological range (35-45 mmHg), and avoid hyperoxia and hyperventilation, as recommended by the American College of Cardiology 1
• Monitor blood glucose levels regularly, and avoid both hyperglycemia and hypoglycemia, though specific target range is uncertain, as recommended by the American Diabetes Association 1

Advanced Support

• Consider mechanical circulatory support for patients refractory to standard resuscitation, as recommended by the American College of Cardiology 5
• Consider emergency coronary angiography for patients with STEMI on ECG, high suspicion of cardiac etiology, or initial rhythm of VF/pulseless VT, as recommended by the American Heart Association 1, 6, 7, 2

Identification and Management of Reversible Causes

• Use bedside cardiac ultrasound (BCU) to identify signs of reversible causes, such as hypothermia, cardiac tamponade, and pulmonary thrombosis, with minimal interruption to chest compressions (≤10 seconds), as recommended by the Society of Critical Care Medicine 8
• Identify and manage reversible causes, including:
  • Hypovolemia: using BCU findings of a small, hyperdynamic left ventricle, and collapsed IVC, and managed with rapid IV/IO crystalloid administration and blood transfusion for hemorrhage 8, 9
  • Hypoxia: using low SpO2 and low PETCO2 despite adequate CPR, and managed by ensuring proper airway management and ventilation with 100% oxygen 9
  • Acidosis: using arterial blood gas showing pH <7.2, and managed by treating the underlying cause and ensuring adequate ventilation 9
  • Electrolyte imbalances (hyperkalemia/hypokalemia): using ECG findings and serum potassium levels, and managed using calcium, insulin/glucose, and sodium bicarbonate for hyperkalemia, and potassium replacement for hypokalemia 9
  • Cardiac tamponade: using BCU findings of pericardial effusion with right atrial/ventricular diastolic collapse, and managed using pericardiocentesis (echocardiography-guided if available) 8, 10
  • Tension pneumothorax: using BCU/chest ultrasound findings of absence of lung sliding, absence of B-lines, and lung point sign, and managed using immediate needle decompression followed by chest tube placement 8, 9
  • Pulmonary thrombosis: using BCU findings of right ventricular dilation and dysfunction, and McConnell's sign, and managed using fibrinolytic therapy when pulmonary embolism is suspected 8, 10

Common Pitfalls

• Inadequate temperature management can worsen outcomes, with both hyperthermia and excessive cooling being harmful, as noted by the American Heart Association 1
• Failure to recognize and treat seizures can worsen outcomes, with EEG recommended for prompt diagnosis in comatose patients, as recommended by the American College of Cardiology 1
• Excessive ventilation can increase intrathoracic pressure and decrease venous return, worsening hemodynamics, as noted by the American Thoracic Society 1
• Premature prognostication should be delayed at least 72 hours after cardiac arrest or normothermia, as recommended by the American Heart Association 1