• Patient unresponsive, not breathing normally with no signs of circulation
• Call resuscitation team dial 2222

• Maintain personal safety
• CPR 30:2
• Attach defibrillator/monitor
  • ensure high quality chest compressions
  • minimise interruptions to compressions
• Give oxygen
  • use waveform capnography
  • continuous compressions when advanced airway in place
• Secure vascular access (intravenous or intraosseous)
• Minimise interruptions
• Consider reversible causes of cardiac arrest

Treat reversible causes

• Hypoxia
• Hypovolaemia
• Hypo-/hyperkalaemia/metabolic
• Hypothermia
• Thrombosis - coronary or pulmonary
• Tension pneumothorax
• Tamponade - cardiac
• Toxins

Advanced Life support

Assessment (every 2 minutes)

• Review rhythm and assess clinically
• Keep record of time, number of shocks and drugs given

Shockable (VF/pulseless VT)

• Give one shock
• minimise interruptions
• Immediately resume CPR for 2 min
• minimise interruptions
• check if time to give adrenaline and/or amiodarone
• After 2 min, return to assessment

Non-shockable (PEA/Asystole)

• Immediately resume CPR for 2 min
• minimise interruptions
• check if appropriate loop of CPR to give adrenaline
• After 2 min, return to assessment

Return of spontaneous circulation

• Follow Post-arrest management below

Stop resuscitation

• Resuscitation team leader decides to stop resuscitation after discussion with the team

Consider

• Ultrasound imaging
• Mechanical chest compressions to facilitate transfer/treatment
• Coronary angiography and percutaneous coronary intervention
• Extracorporeal CPR

Defibrillation energies

• Vary by manufacturer
• Base shock energy for a particular defibrillator on manufacturer's guidance
  • if unsure, deliver highest available energy

Peripheral administration

• Drugs administered peripherally must be followed by a flush of at least 20 mL sodium chloride 0.9% to aid entry into central circulation or into a fast-running drip

Adrenaline

Shockable rhythm

• Give first dose of adrenaline 1:10,000 (100 microgram/mL) 1 mg (10 mL) by IV/IO injection after delivery of third shock
• Give subsequent doses of adrenaline after alternate 2-min loops of CPR (which equates to every 3–5 min) for as long as cardiac arrest persists

Non-shockable rhythm

• Give adrenaline 1 mg IV/IO as soon as intravascular or intraosseous access is achieved
• Give subsequent doses of adrenaline after alternate 2-min loops of CPR (which equates to every 3–5 min) for as long as cardiac arrest persists

Amiodarone

• Amiodarone 300 mg by IV/IO injection from a prefilled syringe or diluted in 20 mL glucose 5% to be given after third shock
• If VF/VT persists, or recurs, an additional dose of amiodarone 150 mg can be given by IV/IO injection after 5 defibrillation attempts

Immediate goals post-resuscitation

• Use ABCDE approach
• Provide cardiorespiratory support to optimise tissue perfusion, especially to brain
• Aim for SpO₂ of 94–98% and normal PaCO₂
• Targeted temperature management
• Attempt to identify and treat precipitating causes of arrest
• initiate measures to prevent recurrence (e.g. anti-arrhythmic therapy). See Cardiac arrhythmias
• Establish underlying cause of cardiac arrest and treat. If in doubt, seek advice from on-call medical SpR
• Transport patient to appropriately equipped critical care unit

Immediate post-arrest investigation

• Blood gases
• U&E, glucose
• Chest X-ray
• 12 lead ECG

• Consider patients with VT or VF occurring ≥48 hr after acute MI or with no obvious reversible factors for implantation of a cardioverter defibrillator (ICD)
• seek advice of cardiology team

Failure to resuscitate

• Inform relatives
• Start death procedures

• Dependent upon underlying cause