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Introduction

Cardiac Arrest is a time critical condition requiring immediate action and intervention.

The ARC ALS algorithm provides a simple flow of needs for the cardiac arrest patient and provides the core components of an improved performance and CPR team resuscitation model - IMPACT (SJAWA version of high-performance CPR).

IMPACT is designed around a set of principles intended to make sure the quality of care is at its best and is being delivered by a high-functioning group of personnel who communicate well, interact well and prioritise actions as appropriate with task focus.

The main objectives of IMPACT are to ALWAYS:

  • Provide consistent high-quality resuscitation with a focus on defibrillation, oxygenation and excellent compressions that are minimally interrupted
  • Create conditions to optimise a shockable rhythm being successfully reverted.
  • Have the mindset that achieving Return of Spontaneous Circulation (ROSC) as early as possible to influence survival with good neurological outcomes.
Clinical Presentation

As soon as Cardiac Arrest is established, commence resuscitation unless the Determination of Death criteria are obvious. If in doubt, start resuscitative efforts until facts are established.

If circulation is restored, refer to Return of Spontaneous Circulation (ROSC) CPG.

Exclusion Criteria
Exclusion Criteria
Risk Assessment
  • If trauma is the cause, follow the Traumatic Cardiac Arrest CPG
  • “Sudden Cardiac Arrest” is defined as an unexpected and abrupt event in somebody who has been well up to the point of collapse or a very short time before that. Must be witnessed, heard or have a very short credible down-time.
  • Take over compressions from bystanders on arrival.
  • Early application of LUCAS (where available) is de-emphasised and should only be considered when a patient is being moved or transported.
  • 30:2 is best regarded as 30 compressions to 2 seconds pause (to facilitate ventilation). Recommence CPR at 2-3 seconds regardless and do not wait for 2 breaths to be completed.
  • Early preparation for transport is de-emphasised in most cases, except where there are compelling circumstances.
Management
Primary Care

Commence High Quality, Task Focused, Minimally Interrupted Chest Compressions.

  • CPR Feedback Devices are mandatory where available.
  • Assess and defibrillate “Shockable” Rhythms every 2 minutes safely with a minimal peri-shock pause OR follow AED prompts.
  • Oxygenate patients early:
    • Passively via a high flow oxygen mask for 4 minutes in select patients OR
    • Via controlled BVM ventilation as soon as practicable for all other patients (see circular diagram)

    All passively oxygenated patients MUST be ventilated at approximately 4 minutes.

Intermediate Care (EMT / Level 2)
  • As per Primary Care guidelines
Advanced Care (AP)
  • An i-gel® should be considered the first line adjunct in MOST cases.
  • Do not attempt endotracheal intubation where a supraglottic device is adequate.
  • Gain vascular access when possible to do so.
  • Adrenaline as per CPG after 2nd shock (or ASAP after IV access has been established) and thereafter every 2nd loop.
  • Amiodarone after a total of 3 shocks have been given (including AED shocks delivered prior to ambulance arrival).
  • Work as a team, communicate well and establish a ‘hands-off’ overview position.
Critical & Extended Care (CCP, PSO)
  • As per Advanced Care (AP) guidelines
IMPACT CPR

The treatment for Cardiac Arrest patients revolves around core requirements; excellent quality chest compressions that are never interrupted unnecessarily, timely defibrillation and oxygenation.

Traditionally, these care needs have been approached in a regimental manner, and often some skills are prioritised at the expense and quality of others. Prioritising the core elements is essential and apply each of the other principles around that as necessary – as soon as it is possible to do so.

There is no prescribed order for this; it is dynamic and circumstance dependant as reflected in the Circular Diagram below.

Working space Good resuscitation cannot generally be delivered in poor environments. A rapid and dynamic risk assessment should be done to either create space or move the patient.
Standardised equipment placement The right equipment in the right place as often as possible.
High quality compressions Focused compressions (attention to quality) that are minimally interrupted. The use of CPR Quality Feedback Devices (where available) is mandatory.
Swap compressor EVERY 2 MINUTES A fatigued compressor delivers poor quality compressions. Prioritising paramedic skills over a swap of compressor in resource poor cases should not routinely occur unless it is critical to do so.
Create overview Scene leadership should be established as soon as practicable. This person should NOT be delivering skills, and ideally be standing away.
Maintain a calm, coordinated scene Encourage a calm and controlled scene with closed loop communication between the team, using functional language.
Ventilation The use of a BVM should be viewed as an important task in providing controlled ventilation. Aim for correct rate without excessive volumes under pressure.
Additional Information

Cardiac Arrest Secondary to Hypothermia:

  • Hypothermia as a cause of cardiac arrest is extremely rare in WA, and mostly accidental e.g. locked in a cool room. If you suspect that the cardiac arrest was secondary to hypothermia, record a temperature, continue high-performance CPR and transport (opt for ECMO centre if in close proximity).

Cardiac Arrest secondary to Hypoglycaemia:

  • Hypoglycaemia as a cause of sudden cardiac arrest is rare, especially in non-diabetic patients. If you suspect that the cardiac arrest was secondary to hypoglycaemia, consider Glucose, otherwise focus on continuing high-performance CPR resuscitation. BGL readings in cardiac arrest are unreliable due to hypoperfusion and should not be routine.

Pregnancy – Relieve Aortocaval Compression:

  • Manual Uterine Displacement; if this is not possible, place padding, such as a towel, under the right hip to tilt the patient’s hips approximately 15-30° (consider ECMO early if in vicinity).

Determination of Death: Recognition of Life Extinct and Termination of Resuscitation


References
References

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