Cardiopulmonary Resuscitation

1. Put the person's back on a firm surface to allow for efficient chest compressions.

3. Immediate chest compressions

4. Defibrillate right away if an automatic external defibrillator is available.

The first shock is delivered at 360 or 200 J with a monophasic defibrillator or biphasic defibrillator, respectively.

Defibrillation is for life-threatening arrhythmias

Ventricular fibrillation

Ventricular tachycardia

5. Precordial thump if immediate defibrillation not available

6. CPR is immediately resumed after the first shock.²

 

When to determine that further CPR is futile.

Determining when CPR is futile depends on several factors, including clinical context, duration of resuscitation, underlying health status, and response to interventions. Here are key considerations:

General Indicators of CPR Futility

1. Prolonged CPR with No Response

   • If there is no return of spontaneous circulation (ROSC) after 20–30 minutes of high-quality CPR with advanced life support, the chances of meaningful survival decline significantly.

2. Asystole for a Prolonged Period

   • If a patient remains in asystole (flatline) despite all resuscitative efforts and correctable causes have been addressed, CPR is unlikely to succeed.

3. Severe Underlying Conditions

   • CPR is often considered futile if the patient has a terminal illness (e.g., end-stage cancer, multi-organ failure) or conditions like severe neurological injury incompatible with meaningful recovery.

4. No Detectable Signs of Life

   • Absence of pulse, no breathing efforts, fixed and dilated pupils, and no cardiac activity on ultrasound suggest a poor prognosis.

Ethical and Legal Considerations

• Do Not Resuscitate (DNR) orders or advance directives should always be honored if in place.

• Family discussions may be necessary when discontinuing CPR in cases with unclear prognosis.

Exceptions (When to Continue CPR)

Some scenarios warrant prolonged resuscitation efforts:

• Hypothermia (patients with very low body temperatures may survive with extended CPR)

• Drowning victims (especially young individuals in cold water)

• Toxicological overdoses (certain drug overdoses are reversible with prolonged support)

Final Decision

Ultimately, the decision to terminate CPR should be made by the resuscitation team, considering medical evidence, patient wishes, and ethical factors.

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Absent Present - Post resuscitative care)

 

Establish Airway

Head tilt, chin lift; jaw thrust if trauma

In an unwitnessed arrest, provide five cycles of CPR ((30 compressions: 2 breathes = One cycle) prior to defibrillation.

This will increase myocardial oxygen and energy substrates, increasing the likelihood of a restoration of spontaneous circulation to the myocardium following defibrillation.¹

Begin compressions²

Minimize the preshock pause (the time taken from the last compression to the delivery of shock).¹

Compressions: 100/min, 2 inches depth, allow recoil, minimize interruptions. Do not lean hands on the chest between compressions, to allow complete recoil between compressions.

To perform chest compressions, identify the lower sternuym in the center of the chest, between the nipples. The heel of the hand should be in this position, and place the second hand over the first so that they are overlapped and parallel. Compressions should depress the sternum at least 2 in (5 cm) for the average adult, and then allow the chest to return to normal position. Chest recoil allows venous return to the heart.

Breathing: For single rescuer provide chest compression only CPR. This stems from research showing no survival advantage from ventilations during bystander-provided CPR compared to chest compressions only.

Additionally, without interruptions to chest compressions, more blood flow is delivered to vital organs, and mouth-to-mouth resuscitation is thought to be one of the major psychological obstacles to would-be rescuers during a bystander-witnessed arrest.

If second trained rescuer available, 30:2 ratio; with advanced airway, 8–10 breaths per minute

 

This results in minimal interruption of compressions and blood flow.

Every 2 minutes, reassess, rotate compressors, and resume compressions promptly

Circulation is assessed by palpation of the carotid pulse.

If a pulse is present, rescue breathing can continue with one breath every 5–6 seconds.

If a pulse is absent, re-start chest compressions.

Intravenous Access

Administer: Epinephrine 1 mg iv every 3-5 minutes

 

Amiodorone for refractory: Dose

Initial dose: 1000 mg over the first 24 hours of therapy, delivered by the following infusion regimen:
-Loading infusions: 150 mg over the first 10 minutes (15 mg/min), followed by 360 mg over the next 6 hours (1 mg/min)
-Maintenance infusion: 540 mg over the remaining 18 hours (0.5 mg/min)

Maintenance dose: After the first 24 hours, continue the maintenance infusion rate of 0.5 mg/min; may increase infusion rate to achieve effective arrhythmia suppression.
-Supplemental infusions: 150 mg over 10 minutes (15 mg/min) for breakthrough episodes of ventricular fibrillation (VF) or hemodynamically unstable ventricular tachycardia (VT)

Maximum dose: Initial infusion rate: 30 mg/min

Duration of therapy: Until ventricular arrhythmias stabilize (most patients require 48 to 96 hours); maintenance infusion of up to 0.5 mg/min can be continued for up to 3 weeks.

Comments: Mean daily doses greater than 2100 mg for the first 24 hours were associated with increased risk of hypotension.

Use: Initiation of treatment and prophylaxis of frequently recurring VF and hemodynamically unstable VT in patients refractory to other therapy.

 

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