Cardiac Arrest & Resuscitation Guide

🚨 Recognising Cardiac Arrest

        Cardiac Arrest = Unresponsive + Not Breathing Normally

        Agonal gasping (occasional, irregular, noisy breaths) counts as NOT breathing normally — treat as cardiac arrest.

Assessment — 10 seconds maximum

Unresponsive: No response to voice or sternal rub
Not breathing normally: Absent breathing or agonal gasps only
No pulse check: Guidelines do not recommend pulse check by lay rescuers; healthcare providers may simultaneously check carotid pulse ≤10 seconds — if in doubt, start CPR

        Remember: Agonal breathing is a sign of cardiac arrest, NOT a sign that the patient is breathing. Do NOT delay CPR for agonal breathing.
      

📞 In-Hospital Cardiac Arrest Sequence

Shout for help and press the emergency call bell immediately
Note the exact time of collapse (critical for documentation)
Call Code Blue (dial 555 or hospital-specific number) — announce your exact location clearly and calmly
Start CPR immediately — do not wait for the crash team to arrive
Attach AED or defibrillator as soon as it becomes available

        Code Blue announcement example: "Code Blue, Ward 3B, Room 312, we have a cardiac arrest. Code Blue, Ward 3B, Room 312."
      

👥 Code Blue Team Roles

Every resuscitation should have clearly assigned roles from the moment the team arrives.

★ Team Leader

Senior doctor / intensivist. Leads all resuscitation decisions, assesses rhythm, directs team, calls time of ROSC or cessation.

▶ Compressor

Usually a nurse. Delivers high-quality chest compressions. Rotates every 2 minutes to maintain quality — fatigue degrades compression depth rapidly.

🐴 Airway Manager

Anaesthetist or intensivist. Manages BVM ventilation, intubation. Confirms ETT placement by waveform capnography.

💉 Vascular Access / Drugs

Nurse or doctor. Establishes IV/IO access, draws up and administers drugs (adrenaline, amiodarone) as directed.

📋 Recorder

Nurse with clipboard / tablet. Documents timeline, rhythm at each 2-minute check, all drugs (dose, route, time), shocks delivered.

⏳ Timekeeper

Calls 2-minute CPR cycle transitions, drug timing, and elapsed resuscitation time aloud.

📦 Circulator

Fetches additional equipment, medications, documentation forms, communicates with ward staff, manages family.

⚡ Your Role Before the Team Arrives

        Two priorities only:
        Start CPR — 30:2, hard and fast, good chest recoil
Attach AED and follow voice prompts the moment it arrives

      

Every minute without CPR reduces survival by 10%. Every minute to first shock in VF reduces survival by 7-10%. You are the most important person in the first minutes.

♥ BLS Algorithm Overview

Unresponsive + Not Breathing Normally ↓ Call for Help + Start CPR (30:2) ↓ Attach AED → Assess Rhythm ↓ Shockable? → Shock + Resume CPR OR Non-Shockable? → Continue CPR

          Adult — Single rescuer or before advanced airway:
30 compressions : 2 breaths
        

          Paediatric — 2 healthcare providers:
15 compressions : 2 breaths
        

💪 Compression Quality Standards

Parameter	Standard	Why it matters
Rate	100–120 compressions/min	Too slow = inadequate perfusion; too fast = inadequate filling
Depth (adult)	5–6 cm (at least 5 cm, no more than 6 cm)	Too shallow = no perfusion; too deep = rib fractures, lacerations
Recoil	Full chest recoil — do not lean on chest	Incomplete recoil raises intrathoracic pressure, reduces venous return
Interruptions	<10 seconds for any pause	Every 10 sec off CPR worsens outcome — hands-on CPR fraction >80%
Hand position	Heel of hand, lower half of sternum, interlocked fingers, arms straight	Correct position = effective compression & minimises rib fractures
Rescuer rotation	Every 2 minutes exactly	Fatigue begins at 90 sec — rotate to maintain quality even if not tired

        Memory tip for rate: Compress to the beat of "Stayin' Alive" by the Bee Gees — 103 beats/min. Available on most cardiac arrest apps as a metronome.
      

💌 Ventilation

BVM oxygen flow: 10–15 L/min, reservoir bag attached for near-100% O2
Breath duration: 1 second per breath — deliver over 1 second, not a rapid pop
Visible chest rise: Only give enough to see gentle chest rise
Avoid over-ventilation: Excessive ventilation increases intrathoracic pressure, reduces cardiac output, causes gastric distension and aspiration risk
Two-person BVM technique preferred: One person holds mask with two-handed E-C technique, second person squeezes bag

        After advanced airway (ETT or LMA) is placed: Switch to asynchronous CPR — 10 breaths/minute (one breath every 6 seconds) + continuous compressions without pausing for breaths.
      

🔬 Mechanical CPR & Feedback Devices

LUCAS Device

Mechanical piston device providing consistent compressions
Indicated: prolonged resuscitation, transport, angiography suite
Ensure correct sternal notch placement before activation
Pause compressions only during placement (<10 sec)

CPR Feedback

Accelerometer-based devices (ResQCPR, Zoll CPR-D padz) give real-time depth/rate feedback
Waveform capnography: ETCO2 >10 mmHg indicates adequate CPR; sudden rise suggests ROSC
Target ETCO2 >20 mmHg during CPR where possible

⚡ ALS 2-Minute Cycle Algorithm

Start / Continue CPR (30:2) ↓ Attach Defibrillator → Minimise pause → Assess Rhythm ↓

SHOCKABLE
VF / Pulseless VT Shock 150–200 J biphasic Resume CPR immediately — do NOT check pulse first After 3rd shock: Adrenaline 1mg IV + Amiodarone 300mg IV

NON-SHOCKABLE
PEA / Asystole Continue CPR without interruption Adrenaline 1mg IV as soon as access obtained, then every 3–5 min Search for reversible causes (H's & T's)

↓ Signs of ROSC? → Post-ROSC care (Tab 4)

💊 Drug Reference

Drug	Dose & Route	Timing	Notes
Adrenaline (Epinephrine)	1 mg IV/IO (10 mL of 1:10,000 solution)	PEA/Asystole: as soon as IV access; VF/pVT: after 3rd shock — then every 3–5 min	Flush with 20 mL 0.9% NaCl after each dose. Peripheral > central (less delay).
Amiodarone	1st dose: 300 mg IV bolus; 2nd dose: 150 mg IV	After 3rd shock in refractory VF/pVT; 2nd dose after 5th shock	Give in 5% dextrose if possible. May cause hypotension post-ROSC.
Lidocaine (alternative)	1–1.5 mg/kg IV bolus	Alternative to amiodarone if not available	Less evidence than amiodarone for VF.
Sodium Bicarbonate	50 mmol IV (50 mL of 8.4%)	Only if documented severe acidosis (pH <7.1), hyperkalaemia, or TCA overdose	Not routine. Excess worsens intracellular acidosis.
Calcium Gluconate	10 mL of 10% IV (6.8 mmol)	Hyperkalaemia, hypocalcaemia, calcium channel blocker OD	Repeat every 10 min. Monitor ECG.
Atropine	3 mg IV (single dose)	Vagally-mediated bradycardia pre-arrest — NOT recommended for asystole during arrest	Removed from ALS algorithm for asystole/PEA.

🔍 Reversible Causes — 4 H's & 4 T's

Select a rhythm category to prioritise your search:

H1 — Hypoxia

Clue: cyanosis, low SpO2 pre-arrest, airway obstruction, PE

Action: 100% O2, BVM, confirm ETT placement, suction airway

H2 — Hypovolaemia

Clue: trauma, GI bleed, ectopic pregnancy, flat neck veins

Action: IV fluid bolus 500 mL–1L 0.9% NaCl; identify and control bleeding source

H3 — Hypo/Hyperkalaemia & Metabolic

Clue: renal failure, peaked T waves/wide QRS (hyperkalaemia), flat T waves (hypokalaemia), ABG result

Action: IV calcium gluconate (hyperkalaemia), potassium replacement, correct pH

H4 — Hypothermia

Clue: cold environment, low temperature reading, near-drowning, Osborn J waves on ECG

Action: Warm IV fluids, external warming; "not dead until warm and dead" — continue CPR until ≥30–32°C

T1 — Tension Pneumothorax

Clue: absent breath sounds unilaterally, tracheal deviation, raised JVP, recent central line/trauma/mechanical ventilation

Action: Needle decompression (2nd ICS MCL or 4th ICS AAL) → chest drain

T2 — Tamponade (Cardiac)

Clue: recent cardiac surgery/trauma/pericarditis, Beck's triad (muffled sounds, raised JVP, hypotension), point-of-care echo

Action: Emergency pericardiocentesis; surgical drainage if traumatic

T3 — Toxins (Poisoning)

Clue: known OD, clinical context, toxidrome signs, family history, medication history (TCAs, digoxin, beta-blockers)

Action: Specific antidotes (naloxone, lipid emulsion, atropine), contact Poison Control, supportive care

T4 — Thrombosis (PE or Coronary)

Clue: PE — DVT risk factors, previous PE, sudden collapse; AMI — chest pain, STEMI prior to arrest, risk factors

Action: PE — consider IV alteplase 50mg (CPR for 60–90 min post-thrombolysis); STEMI — primary PCI if ROSC or ongoing arrest with ECMO

🕑 Rhythm Check & Decision Points

        Rhythm checks every 2 minutes exactly. Keep pause <5 seconds. Resume CPR immediately after analysis — do NOT feel for pulse after a shock; re-check pulse at the next 2-minute cycle only if organised rhythm appears on monitor.
      

When to Consider Stopping Resuscitation

Clinical decision by team leader — not a unilateral nursing decision
Asystole persisting >20 minutes with no reversible cause identified and CPR ongoing
No ROSC despite optimal CPR + correct treatment of all reversible causes
Traumatic arrest with obvious non-survivable injury
Pre-existing DNAR/DNR order confirmed and verified

        Never stop resuscitation for hypothermic arrest until core temperature is ≥32°C or rewarming is deemed unsuccessful.
      

✅ Recognising ROSC

        ROSC (Return of Spontaneous Circulation): Palpable pulse + measurable blood pressure + organised cardiac rhythm on monitor. May also see: sudden rise in ETCO2 (>40 mmHg), spontaneous breathing, eye opening, movement.
      

Do not interpret a single organised-looking beat or artefact as ROSC. Confirm palpable central pulse AND blood pressure measurement. Continue to monitor closely — re-arrest is common in the first minutes after ROSC.

💉 Immediate Post-ROSC Management — ABCDE

          A — Airway: Intubate if patient cannot protect airway or GCS <8. Confirm ETT position (waveform capnography gold standard). Secure tube, note depth at teeth.
        

          B — Breathing: Target SpO2 94–98% (titrate FiO2 — avoid hyperoxia, which worsens neurological outcome). Target PaCO2 35–45 mmHg (normocapnia — avoid hypocapnia which causes cerebral vasoconstriction). Get CXR to confirm ETT position and assess for pneumothorax.
        

          C — Circulation: Target MAP ≥65 mmHg. 12-lead ECG immediately — if STEMI or new LBBB present, activate cath lab for primary PCI. IV fluid bolus for hypotension. Start noradrenaline infusion if MAP <65 mmHg despite fluid. Insert arterial line for continuous monitoring.
        

          D — Disability: If comatose (GCS ≤8, no purposeful command-following), initiate Targeted Temperature Management (TTM) — see below. Avoid hyperthermia (>37.5°C is harmful). Blood glucose target 6–10 mmol/L — treat hypo and hyperglycaemia.
        

          E — Exposure: Check electrolytes (K⁺, Mg²⁺, Ca²⁺), lactate, ABG, FBC, coagulation. Identify and treat any precipitating cause (ACS, PE, sepsis). Trending lactate clearance indicates adequacy of resuscitation.
        

❄ Targeted Temperature Management (TTM)

        Indication: Comatose adult survivor of cardiac arrest (strongest evidence for out-of-hospital arrest with shockable initial rhythm, but current guidelines recommend for all comatose post-arrest patients regardless of initial rhythm or arrest location).
      

Target Temperature

32–36°C for 24 hours

Initiation

Begin as soon as possible after ROSC

Methods

Arctic Sun, ice packs, IV cold saline, cooling blankets

Rewarming Rate

0.25–0.5°C per hour (slow controlled rewarming)

Duration

24 h at target, then 24 h normothermia maintenance

Monitoring

Continuous core temp (oesophageal/bladder probe)

TTM Complications — Monitor For:

Shivering: Treat with buspirone, magnesium sulphate, propofol, meperidine
Bradycardia: Usually well tolerated if MAP adequate — avoid unnecessary atropine

Coagulopathy: Cooling impairs platelet function — monitor INR, fibrinogen
Electrolyte shifts: Rewarming causes K⁺ to shift extracellularly — monitor closely every 2 h

        Avoid hyperthermia (>37.5°C) for at least 72 hours post-arrest in all survivors, including those not meeting TTM criteria.
      

🧠 Neuroprognostication & Family Support

Neuroprognostication

Do not prognosticate until at least 72 hours post-arrest and after normothermia is re-established (sedation cleared)
Use multimodal approach: CT brain, EEG, SSEP (somatosensory evoked potentials), NSE serum biomarker (>60 ng/mL at 48–72 h = poor prognosis)
No single test reliably predicts outcome — combine clinical, EEG, and imaging data
Absent pupillary reflexes + absent corneal reflexes at 72 h = poor prognostic sign

Family Communication & Support

Honest, compassionate communication — explain what happened and current status
Offer chaplain and social worker support immediately
Family presence during resuscitation: consider allowing — evidence shows no harm and may help with grief
Bereavement support if patient does not survive: written information, follow-up contact
Staff support: hot debrief for team psychological wellbeing

📋 Cardiac Arrest Documentation Requirements

        The recorder role is critical. Accurate documentation supports audit, quality improvement, Utstein reporting, and medicolegal requirements.
      

Mandatory Data Points

Time collapse noted / time patient last seen normal
Time CPR initiated (who started)
Time defibrillator/AED attached
Time and energy of each shock delivered
Rhythm at each 2-minute check (document actual rhythm, not just "checked")
Time and team composition of Code Blue team arrival

All drugs given: name, dose, route, exact time
Airway interventions: time of intubation, tube size, depth
IV/IO access: site, time of insertion
Total CPR duration (hands-on time)
Time of ROSC — confirmed by whom
Time resuscitation ceased (if no ROSC) — decision by whom

Utstein Template

The Utstein style provides a standardised international template for in-hospital cardiac arrest reporting. Used for benchmarking, research, and JCI compliance. Submit to hospital quality/risk management department after every cardiac arrest event.

🗣 Debriefing

          Hot Debrief (2–5 minutes)

          Immediately after event. Led by team leader. What went well? What could be improved? Acknowledge team effort. No blame — systems focus. Helps process acute stress response.

          Cold Debrief (within 24–72 hours)

          Structured review of documentation. Timeline analysis. Drug and rhythm review. Identify learning points for training. Address psychological impact on team members. Involve clinical educator.

Cardiac arrest responses are psychologically demanding. Team members who show signs of distress should be offered occupational health and Employee Assistance Programme (EAP) support.

🛍 Crash Cart Quick Reference (GCC Context)

GCC hospitals following JCI accreditation standards perform daily crash cart seal checks and document compliance. Report any broken seal or missing item immediately to charge nurse.

⚡

Defibrillator

Charged, pads attached, self-test passed

💊

Adrenaline 1:10,000

10 x 10 mL ampoules

💊

Amiodarone 150mg

2 ampoules minimum

💊

Atropine, Adenosine

Per formulary stock list

💊

Calcium Gluconate, Glucose 50%, NaHCO3

As per hospital formulary

💌

BVM (Adult & Paediatric)

With reservoir bag, mask sizes 3–5

💌

Laryngoscope

Mac 3 & 4, working light confirmed

💌

ETTs (sizes 7.0–8.5)

+ stylette, 10 mL syringe

💌

LMA (sizes 3, 4, 5)

Supraglottic airway backup

💉

IV Access

14G, 16G, 18G cannulas; IO drill

📈

Monitoring

SpO2 probe, ETCO2 adaptor, BP cuff

📋

Code Blue Forms

Utstein template, Recorder sheet

💬 Knowledge Check — 10 MCQs

Test your understanding of cardiac arrest management. Select an answer and click Check.

ALS Quick Reference — Algorithm Summary Card

Phase	Action	Key Numbers
Compression	Hard, fast, full recoil, minimal pauses	Rate 100–120/min, Depth 5–6 cm
Ventilation (before ETT)	30:2 ratio, 1 sec/breath	10–15 L/min O2
Ventilation (after ETT)	Asynchronous, continuous compressions	10 breaths/min
Defibrillation (VF/pVT)	Shock → immediate CPR, no pulse check	150–200 J biphasic
Adrenaline — VF/pVT	After 3rd shock, then every 3–5 min	1 mg IV/IO
Adrenaline — PEA/Asystole	As soon as IV/IO access, every 3–5 min	1 mg IV/IO
Amiodarone (VF/pVT)	After 3rd shock	300 mg IV; 2nd dose 150 mg
Rhythm checks	Every 2 minutes exactly	<5 sec pause
Post-ROSC SpO2	Titrate FiO2 to target	94–98%
Post-ROSC MAP	Fluid + vasopressors as needed	≥65 mmHg
TTM target (comatose)	Cool for 24 h, then slow rewarming	32–36°C