A.

Definitions

1. Cardiopulmonary arrest is defined as the sudden cessation of cardiac and respiratory

function

2. Resuscitation is the revival of a patient from potential cr apparent death. Clinically, death is
defined by the loss of heartbeat, respirations, and cerebral function. The limiting factor in
resuscitation is the ability to perfuse the brain and myocardium with oxygenated blood.

3. ABCS. Successful resuscitation must.restore ventilatory and circulatory function while

maintaining cerebral viability. The overall hierarchy of management during resuscitation is
directed toward restoring or preventing.loss of the physiologic systems most

immediately responsible for supporting cerebral function. Preventing anoxic brain damage and
death requires function of airway patency, breathing, and circulation.

a. Airway. A patent airway is necessary for gas exchange

b. Breathing. Airway patency alone does not assure adequate ventilation. Breathing
(ventilation) allows oxygenation of the blood and elimination of carbon dioxide.

(1) Normal ventilatory control is mediated by the:

(a) Central and peripheral chemoreceptors, wh.ich detect changes in the pH and arterial
oxygen tension (PO), respectively

(b) Respiratory control center (brain stem-integrating and motor neurons)

(c) Respiration effectors

(i) Neuromuscular (spinal cord, nerves, muscles)

(ii) Ventilatory (chest wall, pleura, airways, lung parenchyma)

(2) Hypoventilation may occur if any aspect of normal ventilatory control is disrupted. The
chemoreceptors, brain stem, and effector neurons are sensitive to prolonged hypoxia and
acidosis. The spinal column, chest wall, and lung parenchyma may all be affected by ischemia,
acidosis, or traumatic injury
c. Circulation. Circulatory function is necessary to distribute oxygen to, and remove carbon
dioxide from, distal end organs. Circulatory failure typically represents either inadequate blood
volume or inadequate pump function.

Prognosis. The general outcome of cardiac arrest is poor. Factors influencing outcome include
the time between arrest and the institution of therapy, the type of cardiac arrest, and the
underlying cause. Irreversible hypoxic brain damage is noted after 4 minutes of

cardiac arrest

1. Predictors of outcome. Studies of comatose survivors o cardiac arrest suggest that a

definitive prognosis of p0or outcome can be made on the basis of the neurologic examination
72 hours after the hypoxic-ischemic event. The lack of motor response to pain is the best
predictor of poor outcome at 72 hours.

2. Termination of resuscitation attempts. Resuscitation attempts may be terminated following

adequate trial of advanced cardiac life support (ACLS) protocols if no reversible causes of
arrest are identified and arrest persists despite resuscitative efforts.

3. Do not attempt resuscitation (DNAR) situations. Cardiopulmonary resuscitation (CPR) and

ACLS protocols should be withheld under the following circumstances:

a. A valid DNAR order has been established prior to arrest.

b. Successful resuscitation is deemed impossible given the patient's underlying medical

condition.

APPROACH TO THE PATIENT

A. Primary survey of the patient includes a rapid (10-second) assessment of the ABCS.

1. Airway and breathing are assessed by visualizing spontarneous respirations while

hearing or feeling expired air from the patient's airway. Head-tilt and chin-lift
procedures may be performed for patients without risk of cervical spine injury. If
sportaneous respirations are not present, ventilation should be assisted by mouth-to-
maskor bag-valve-mask breathing.

2. Circulation is assessed by palpating either a carotid or femoral pulse. If no pulse is

palpable, chest compressions should be performed to promote blood flow until a
defibrillator is available. Cardiac rhythm should be assessed immediately with the
defibrillator paddles to identify ventricular fibrillation or another rhythm responsive to
cardioversion. Early defibrillation (direct current (DC) cardioversion] is the most
impartant interventicn for successful resuscitation during known ventricular fibrillation
cardiac arrest and should take precedent over intravenous line placement and
intubation.

B. Secondary survey of the patient is directed toward more definitive management of

the ABCS and investigating the underlying cause.

1. Airway management. The decision to perform endotracheal intubation or use other

airway adjuncts to maintain and protect the airway must be made.

2. Breathing manageiment entails the administration of oxygen and assessment of the

need for ventilat minations shoul support with positive pressure. Arterial blood gas
(ABG) determinations be considered to guide ventilatory management

3. Circulatory management

a. Intravenous access should be obtained for the delivery of fluids and medications
required for resuscitation. Standard intravenous access for resuscitation is two 14- to
16-gauge peripheral intravenous catheters. Central venous access may be obtained.

b. Electrocardiographic monitoring should be instituted, and the cardiac rhythm

identified and treated using ACTS guidelines. The underlying cause of the arrest should
be identified and treated if possible.

4. Other interventions

a. Laboratory studies, including creatine kinase levels, electrolytes, and serum and
urine toxin screens should be considered.

b. Bladder catheterization with a Foley catheter should be considered to assist in fluid

management.

c. Nasogastric tube placement should be considered for patients who are being
mechanically ventilated (to decrease aspiration risk). Nasogastric tube placement
should also be considered for patients suspected of drug overdose (to allow
administration of decontamination agents).

Reassessment. The patient should be reassessed frequently using both the primary
and secondary surveys until the patient has been stabilized.

III. AIRWAY

A. Assessment. The most important part of airway management is assessing

immediate airway patency as well as determining future risk of airway
compromise. Tasks to protect
the airway, such as endotracheal intubation, are often easier to perform than making a
decision about future airway risk.

1. Airway patency

a. The airway should be assessed for patency first by looking, listening, and feeling for air
exchange. The patient without spontaneous respirations requires an attempt at ventilation to
assess airway patency.

b. The most common cause of airway obstruction is prolapse of the tongue into the posterior
oropharynx, causing obstruction of airflow. Physical examination may also reveal foreign
bodies or facial, mandibular, or tracheal-laryngeal fractures

that may result in airway obstruction.

2. Airway protection

a. Testing the gag reflex is one way to assess airway protection. This method predominantly
assesses the sensory afferent component of cranial nerves IX and X

b. A superior alternative is to assess the posterior oropharynx for pooled secretions and, time
permitting to observe the patient for the ability to swallow. Swalloving is the natural means of
protecting the airway and cearing secretions; a patient with pooled oral secretions requires
definitive airway management. Intact swallowing requires coordinated function of the sensory
and motor components of cranial nerves V2, V3, IX, and X.

B. Interventions

1. General guidelines

a. Protection of the cervical spine. All trauma victims should be placed in a protective cervical
spine collar (this step is often performcd in the prehospital setting).

However, intubation is best performed with the collar off and experienced hands maintaining
spinal immobilization.

b. Prevention of aspiration. Vomiting and aspiration are common events associated with
resuscitation. Immediate suctioning of the lower pharynx and oropharynx with a Yankauer
device is mandatory for proper airvway management. A vomiting patient should be rolled to
the left lateral decubitus position while properly protecting the entire spine so that the airway
can be cleared.

2. Simple maneuvers and airway adjunct devices

a. Head tilt/chin lift. This maneuver is performed by simultaneously lifting the chin forward
while applying pressure to the forehead and is contraindicated if neck trauma is suspected.

b. Jaw thrust. Applying pressure behind the angles of the mandible to thrust the entire
mandible forward simultaneously lifts the tongue and epiglottis forward. The jaw thrust
maneuver is the preferred method for patients with possible cervical spine injury.
Oropharyngeal airway (OPA). An OPA is a curved, hollow plastic device that is placed over the
top of the tongue. Its curved shape allows the distal portion of

the device to fit behind the base of the tongue, lifting it for

obstruction.

(1) Indications for use are an obstructed airway in ah obtunded individual. Cor-scious patients
will not tolerate an OPA.

(2) Sizing. The device is sized by comparing its length to the distance between the corner of the
mouth and the angle of the mandible externally

d. Nasopharyngeal airway (NPA, nasal trumpet). An NPA is a soft rubber tube 15-20 cm long,
which is lubricated and passed through an open nasal passage so that the distal tip lies behind
the tongue.

(1) Indications. Conscious and semiconscious patients can tolerate an NPA. The trumpet is
indicated when oral trauma precludes OPA usage or when an OPA may not be tolerated by a
semiconscious or conscious patient requiringlimited airway management.

(2) Complications include nasal trauma (sustained during placement) and laryngospasm and
vomiting in a conscious patient with a sensitive oropharynx.

e. Laryngeal mask airway (LMA). The LMA is a new device comprised of a mask