The management of cardiac arrest involves following the guidelines provided by the Resuscitation Council UK, tailored for different levels of care: Basic Life Support (BLS), Immediate Life Support (ILS), and Advanced Life Support (ALS). Below is a comprehensive overview of the recommended actions for asystole, pulseless electrical activity (PEA), ventricular tachycardia (VT), and ventricular fibrillation (VF) in the ICU setting.
Basic Life Support (BLS)
BLS focuses on immediate, non-invasive interventions to maintain circulation and ventilation.
Key Steps:
- Safety: Ensure the scene is safe.
- Responsiveness: Check the patient for responsiveness.
- Help: Shout for help and call for emergency assistance within the ICU.
- Breathing and Circulation:
- Check for normal breathing and a carotid pulse for no more than 10 seconds.
- If the patient is not breathing normally and has no pulse, begin CPR immediately.
5. CPR (Cardiopulmonary Resuscitation):
- Perform chest compressions at a rate of 100-120 compressions per minute, depth of 5-6 cm.
- Use a ratio of 30 chest compressions to 2 rescue breaths.
- Ensure high-quality compressions with minimal interruptions.
6. AED (Automated External Defibrillator):
- Attach an AED as soon as it is available.
- Follow the AED prompts to deliver a shock if indicated (for shockable rhythms: VF/VT).
- Continue CPR until advanced care arrives.
Immediate Life Support (ILS)
ILS includes additional interventions and more advanced airway management, following the principles of BLS with additional capabilities.
Key Steps:
- BLS Continuation:
- Continue high-quality CPR and use an AED as per BLS guidelines.
2. Advanced Airway Management:
- Secure the airway using basic or advanced techniques (e.g., supraglottic airway devices, endotracheal intubation if trained).
3. Oxygen Delivery:
- Provide high-flow oxygen.
4. Medications:
- Prepare for the administration of emergency medications as directed by ALS protocols.
5. Rhythm Recognition:
- Recognise and differentiate between shockable and non-shockable rhythms using an AED or manual defibrillator.
Advanced Life Support (ALS)
ALS involves advanced interventions, including drug administration, defibrillation, and sophisticated airway management.
For Shockable Rhythms (VF/pulseless VT):
- Immediate Defibrillation:
- Deliver a shock at 150-200 joules (biphasic) or 360 joules (monophasic) as soon as the rhythm is identified.
- Resume CPR immediately after the shock, starting with chest compressions.
2. CPR:
- Perform high-quality CPR for 2 minutes (5 cycles of 30:2 or continuous compressions with advanced airway).
- Minimise interruptions in chest compressions.
3. Reassess Rhythm:
- After 2 minutes of CPR, reassess the rhythm.
- Deliver another shock if VF/VT persists.
4. Medications:
- Administer epinephrine 1 mg intravenously every 3-5 minutes (after the second shock and then every 3-5 minutes).
- Consider amiodarone 300 mg IV after the third shock, with an additional dose of 150 mg if VF/VT persists.
5. Advanced Airway and Monitoring:
- Secure the airway and provide continuous capnography to monitor end-tidal CO2.
6. Identify and Treat Reversible Causes:
- Consider potential reversible causes (Hs and Ts).
For Non-Shockable Rhythms (Asystole/PEA):
- CPR:
- Perform high-quality CPR immediately.
- Ensure minimal interruptions.
- Medications:
- Administer epinephrine 1 mg IV every 3-5 minutes as soon as possible.
- Reassess Rhythm:
- Reassess rhythm every 2 minutes.
- Continue CPR if asystole/PEA persists.
- Advanced Airway and Monitoring:
- Secure the airway and provide continuous capnography.
- Identify and Treat Reversible Causes:
- Consider potential reversible causes (Hs and Ts).
Summary Table for ICU Management
| Level of Care | Rhythm | Key Actions |
|---|---|---|
| BLS | All rhythms | – Ensure scene safety |
| – Check responsiveness, call for help | ||
| – Begin CPR if no breathing/pulse (30:2 compressions to breaths) | ||
| – Attach AED, follow prompts for shockable rhythms | ||
| ILS | All rhythms | – Continue BLS measures |
| – Secure advanced airway, provide high-flow oxygen | ||
| – Recognize rhythms and prepare for drug administration | ||
| ALS | Shockable (VF/pulseless VT) | – Immediate defibrillation (150-200 J biphasic or 360 J monophasic) |
| – Resume CPR immediately after shock | ||
| – Administer epinephrine every 3-5 minutes | ||
| – Consider amiodarone after third shock | ||
| – Secure airway, monitor end-tidal CO2 | ||
| – Identify and treat reversible causes (Hs and Ts) | ||
| Non-Shockable (Asystole/PEA) | – Immediate CPR | |
| – Administer epinephrine every 3-5 minutes | ||
| – Reassess rhythm every 2 minutes | ||
| – Secure airway, monitor end-tidal CO2 | ||
| – Identify and treat reversible causes (Hs and Ts) |
Hs and Ts (Reversible Causes)
- Hs:
- Hypoxia
- Hypovolemia
- Hypothermia
- Hypo-/Hyperkalemia
- Hydrogen ions (acidosis)
- Ts:
- Tension pneumothorax
- Tamponade (cardiac)
- Toxins
- Thrombosis (coronary or pulmonary)
Special Considerations for ICU
- Continuous Monitoring: Patients in the ICU are typically continuously monitored, allowing for rapid detection of cardiac arrest.
- Advanced Airway Management: Trained ICU staff should secure the airway using endotracheal intubation and ensure effective ventilation.
- Multidisciplinary Approach: Involve the ICU team, including physicians, nurses, and respiratory therapists, to provide comprehensive care.
- Post-Resuscitation Care: Following successful resuscitation, implement post-resuscitation care protocols, including targeted temperature management and hemodynamic support.
By adhering to these UK guidelines for BLS, ILS, and ALS in the ICU, healthcare providers can effectively manage cardiac arrest, improve patient outcomes, and reduce the risk of complications.