Cardiac Arrest Treatment Following Open Heart Surgery

Initial Response Algorithm

External chest compressions should be performed immediately if emergency resternotomy is not immediately available 1
For witnessed VF/VT arrest, perform immediate defibrillation; if unsuccessful within 1 minute, initiate CPR 1
For asystolic or bradycardic arrest with pacer wires already in place, attempt immediate pacing; if unsuccessful within 1 minute, initiate CPR 1
Rapidly identify and correct potential causes of arrest including tamponade, pneumothorax, valve dysfunction, graft occlusion, or bleeding 2

Early resternotomy is reasonable in an appropriately staffed and equipped ICU (Class 2a recommendation) 1, 2
Open-chest CPR is useful if cardiac arrest develops during surgery when the chest is already open or in the early postoperative period 1, 4
Resternotomy should be performed by experienced providers, as good outcomes have been observed with rapid resternotomy protocols 2

For patients refractory to standard resuscitation procedures, mechanical circulatory support including ECMO or cardiopulmonary bypass may improve outcomes 1, 2
Consider mechanical circulatory support when the suspected etiology is potentially reversible during a limited period of mechanical support 5

Use lower tidal volumes, lower respiratory rates, and increased expiratory time to minimize risk of auto-PEEP and barotrauma 3, 6
Evaluate for tension pneumothorax, which can be a rare but life-threatening complication 3, 6
Brief disconnection from the ventilator or pause in bag-mask ventilation with thoracic compression may relieve hyperinflation if present 3

Cardiac arrest occurs in 1-8% of cardiac surgery cases, typically in highly monitored settings with trained staff available 1, 2
For patients with epicardial pacing wires, immediate pacing should be attempted before external cardiac massage in cases of asystole or extreme bradycardia 7

Failure to recognize mechanical causes of arrest (tamponade, bleeding, graft occlusion) that require surgical intervention 1