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.
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.
- 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.
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.
- As per Primary Care guidelines
- 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).
- Fluid therapy as per CPG for hypovolemic cardiac arrest
- Work as a team, communicate well and establish a ‘hands-off’ overview position.
- As per Advanced Care guidelines
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. |
Standard basic and advanced life support as detailed above is appropriate for the vast majority of adult patients. There are some situations where modified or additional management is required, as detailed below. Clinical judgement should always apply
when using these guidelines.
Paramedic Witnessed Cardiac Arrest:
- The Australian Resuscitation Council recommends early application and defibrillation shock where appropriate.
- In line with the Defibrillation skill staff trained and authorised may consider a 3-stacked shock approach in witnessed cardiac arrests where:
- The patient was well-oxygenated and perfused prior to the arrest
- The patient is in a shockable rhythm
- The first shock can be delivered within 20-seconds of the cardiac arrest occurring
- Manual mode is available and charging / rhythm recognition can be less than 10 seconds
- If the patient does not have a return of spontaneous circulation within 10 seconds of the third shock CPR should be immediately commenced
- For the purpose of timing medications and other interventions, stacked shocks are counted as a single shock.
Persistent shockable rhythms (refractory VF/pVT)
Where Ventricular Fibrillation or pulseless Ventricular Tachycardia persists despite three defibrillation shocks:
- Ensure defibrillator is charging to correct energy setting (200J for adults) and pad placement is appropriate as per Defibrillation skill
- Administer Amiodarone - 300mg IV/IO after third shock
- Consider alternative (anterior-posterior) pad placement as per Defibrillation skill
- Consider further Amiodarone - 150mg IV/IO after two further shocks post first Amiodarone (minimum five shocks)
- Consider ECMO suitability if available
- Consider double sequential defibrillation if two manual defibrillators available and specifically trained and authorised clinician present (clinical exception required)
- Consider Lignocaine - 1mg/kg IV/IO after two further shocks post second Amiodarone (minimum seven shocks) (clinical exception required)
Single Responder Resuscitation
Where a single responder clinician is the first at the scene of a cardiac arrest:
- Attach cardiac monitor/defibrillator or AED immediately. It is acceptable to use a manual defibrillator in automatic mode until additional clinicians arrive
- Perform CPR with a focus on high quality chest compressions, utilising mechanical CPR if available or bystanders to help
- Interventions such as vascular access, medications or airway management are not a priority and should only occur prior to the arrival of further clinicians if they do not interrupt high quality CPR.
Mechanical CPR
Mechanical CPR does not usually have a role in immediate management of cardiac arrest as there is no evidence it routinely improves outcomes or is of better quality than high performance manual CPR. However it should be considered when:
- There is insufficient space or clinicians to perform manual resuscitation safely or effectively
- Clinicians are fatigued and prolonged resuscitation attempts are expected
- Extricating and transporting a patient with ongoing resuscitation attempts
Mechanical CPR should be applied in a manner that minimises pauses to chest compressions.
A trained and authorised clinician must be present to supervise the mechanical CPR device whenever in use.
Termination of Resuscitation
Cardiac arrest in special circumstances
CPR Induced Consciousness (CPRIC)
A patient may move or show other signs of life while in cardiac arrest if cerebral perfusion is maintained with high quality CPR. This situation may lead clinicians to believe the patient is not in cardiac arrest and lead to delayed defibrillation and/or inappropriate pauses in CPR.
If is patient movement or other signs of life in cardiac arrest:
- It is appropriate to briefly pause CPR to confirm whether the patient is still in cardiac arrest or whether ROSC has been achieved.
- If the patient remains in cardiac arrest, resuscitation attempts should be continued.
- If the patient's movement is significant enough to interfere with resuscitation, consider ASMA consult for discussion of sedation options.
Cardiac arrest in pregnancy:
- Manual Uterine Displacement to relieve aortocaval compression
- 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 rapid extrication and transport for resuscitative hystorotomy
- Consider transport to ECMO capable facility
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