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Ovid: Oxford Handbook of Clinical Medicine

Editors: Longmore, Murray; Wilkinson, Ian B; Turmezei, Tom; Cheung, Chee Kay Title: Oxford Handbook of Clinical Medicine, 7th Edition Copyright ©2007 Oxford University Press > Back of Book > ▶▶Cardiorespiratory arrest ▶▶Cardiorespiratory arrest Ensure safety of patient and yourself. Confirm diagnosis (unconscious, apnoeic, absent carotid pulse). Causes MI; PE; trauma; tension pneumothorax, electrocution; shock; hypoxia; hypercapnia; hypothermia; U&E imbalance; drugs, eg digoxin. Basic life support Shout for help. Ask someone to call the arrest team and bring the defibrillator. Note the time. Begin CPR as follows (ABC): Airway: Head tilt (if no spine injury) + chin lift/jaw thrust. Clear the mouth. Breathing: Check breathing then give 2 breaths after 1st set of compressions, each inflation ~1s long. Use specialized bag and mask system (eg Ambu® system) if available and 2 resuscitators present. Otherwise, mouth-to-mouth breathing. Chest compressions: Give 30 compressions to 2 breaths (30 : 2). CPR should not be interrupted except to give shocks or to intubate. Use the heel of hand with straight elbows. Centre over the lower 1/3 of the sternum; aim for 4cm compression at 100/min. Advanced life support For algorithm and details, see over. Notes: Place defibrillator paddles on chest as soon as possible and set monitor to read through the paddles if delay in attaching leads. Assess rhythm: is this VF/pulseless VT? The following assumes monophasic defibrillator.

  • In VF/VT, defibrillation must occur without delay: 360J (150-360J biphasic).
  • Asystole and electromechanical dissociation (synonymous with pulseless electrical activity) are rhythms with a poorer prognosis than VF/VT, but potentially remediable (see box next page). Treatment may be life-saving.
  • Obtain IV access and intubation if possible.
  • Look for reversible causes of cardiac arrest, and treat accordingly.
  • Check for pulse if ECG rhythm compatible with a cardiac output.
  • Reassess ECG rhythm. Repeat defibrillation if still VF/VT. All shocks are 360J.
  • Send someone to find the patient’s notes and the patient’s usual doctor. These may give clues as to the cause of the arrest.
  • If IV access fails, adrenaline, atropine, and lidocaine may be given down the tracheal tube but absorption is unpredictable. Give 2-3 times the IV dose diluted in ≥10mL 0.9% saline followed by 5 ventilations to assist absorption. Intracardiac injection is not recommended.

When to stop resuscitation No general rule, as survival is influenced by the rhythm and the cause of the arrest. In patients without myocardial disease, do not stop until core temperature is >33°C and pH and potassium are normal. Consider stopping resuscitation after 20min if there is refractory asystole or electromechanical dissociation. After successful resuscitation:

  • 12-lead ECG; CXR, U&Es, glucose, blood gases, FBC, CK/troponin.
  • Transfer to coronary care unit/ITU.
  • Monitor vital signs.
  • Whatever the outcome, explain to relatives what has happened.

When ‘do not resuscitate’ may be a valid decision (UK DoH guidelines)

  • If a patient’s condition is such that resuscitation is unlikely to succeed.
  • If a mentally competent patient has consistently stated or recorded the fact that he or she does not want to be resuscitated.
  • If the patient has signed an advanced directive forbidding resuscitation.
  • If resuscitation is not in a patient’s interest as it would lead to a poor quality of life (often a great imponderable!). ▶Ideally, involve patients and relatives in the decision before the emergency. When in doubt, resuscitate.

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