CHAPTER

9
Cardiopulmonary Arrest
Belinda B. Hammond

C ardiopulmonary arrest is not an unusual occurrence

in the emergency department. Causes can range from
the expected terminal event of chronic or acute illnesses
cardiopulmonary arrest.1 The automatic external defibrilla-
tor (AED) is useful for early defibrillation in that no specific
rhythm interpretation is required by the operator. The AED
to sudden cardiac death. Hypoxemia secondary to severe will determine whether the rhythm is “shockable” or not.
respiratory insufficiency, intentional or accidental drug It is assumed that the reader is familiar with the prin-
overdose, or neurologic insult can also result in unexpected ciples of BLS and techniques of high-quality chest compres-
cardiopulmonary arrest. Traumatic cardiopulmonary arrest sions. Specific BLS guidelines and advanced cardiac life
is a less common and more difficult to manage cause support (ACLS) treatment algorithms can be found on the
of arrest. American Heart Association’s website. All emergency nurses
The goal of basic life support (BLS) is to restore effective should obtain and maintain certification in ACLS.
circulation and oxygenation and to maintain intact neuro-
logic function. Emphasis is placed on the immediate initia- • Open-access, multilingual websites that provide
tion of the following steps: straightforward explanations and demonstrations of
• Recognize sudden cardiac death by establishing unre- cardiopulmonary resuscitation (CPR) are available;
sponsiveness and absence of normal respiration see http://www.learncpr.org.
• Activate emergency response team (“calling a code” in • The American Heart Association has an application for smart
phones called “Pocket First Aid and CPR.”
the hospital setting)
• Perform high-quality chest compressions
• Begin rescue breathing MANAGEMENT OF
• Perform rapid defibrillation if appropriate CARDIOPULMONARY ARREST
Emphasize to all patients with a history of heart disease the impor- Chest Compressions
tance of calling 911 rather than having family members drive them One of four rhythms can cause cardiopulmonary arrest:
to the emergency department. • Ventricular fibrillation (VF)
• Pulseless ventricular tachycardia (VT)
The ABCs of BLS have been replaced by CAB— • Pulseless electrical activity (PEA)
compressions, airway, breathing—to reflect the growing • Ventricular asystole
evidence that chest compressions are the most important The 2010 American Heart Association Guidelines for Car-
aspect of early resuscitation efforts. In addition, airway diopulmonary Resuscitation and Emergency Cardiovascular
management takes time and can delay the initiation of Care Science1 emphasizes the need for quality chest com-
effective chest compressions.1 pressions as fundamental in managing cardiopulmonary
Most victims of cardiopulmonary arrest initially experi- arrest resulting from these four rhythms.
ence ventricular fibrillation. Chest compressions can main- The importance of high-quality chest compression
tain some level of cardiac output but will not convert this cannot be overemphasized.
life-threatening rhythm; defibrillation is the only definitive • Push hard, push fast—to the tune of “Stayin’ Alive”!
treatment. The interval from collapse to defibrillation is • Allow complete release of chest pressure between
one of the most important determinants of survival from compressions.

89
90 UNIT 2 Basic Clinical Issues
• Assess for femoral pulse during compressions to deter- • Consider intraosseous (IO) insertion if no venous access
mine the effectiveness of compressions. is available.
• Minimize interruptions of chest compressions. • Avoid central venous access via the subclavian approach
• In the absence of an advanced airway, synchronize com- during resuscitation efforts because of the need to stop
pressions to ventilations with a ratio of 30 : 2. Once an compressions and the potential for complications such
advanced airway has been placed, give continuous chest as pneumothorax.
compressions at a rate of at least 100 per minute; do not
pause for ventilations. Defibrillation
• High-quality chest compressions can quickly lead to • Other than high-quality CPR, the only rhythm-specific
provider fatigue. Rotate the chest compressor every 2 treatment shown to increase survival to hospital dis-
minutes. charge is defibrillation of VF or pulseless VT.1
• The main goal is to electrically terminate a shockable
Airway Control rhythm as quickly as possible; the earlier the defi-
During cardiopulmonary arrest, oxygen delivery to the vital brillation occurs, the better the chance of patient
organs is diminished because of low blood flow (perfusion) survival.
rather than arterial oxygen content (ventilation), emphasiz- • Do not interrupt chest compressions while the defi-
ing again the need for immediate initiation of high-quality brillator is charging if charging takes more than 10
chest compressions. Still, 100% supplemental oxygen should seconds.
be initiated as soon as possible, without delaying or inter- • Follow each shock immediately with 2 minutes of high-
rupting compressions, during resuscitation from cardiopul- quality chest compressions to enhance coronary per-
monary arrest.1 fusion. Even if VF is terminated by the shock, almost all
• Open and maintain a patent airway using: patients will experience a period of nonperfusing rhythm.
• Head-tilt chin-lift CPR is needed to maintain circulation during this time.2
• Jaw lift without head extension if suspected head or • Do not stop to check for a pulse after delivering the
neck injury shock. Pulse checks may be performed if an organized
• Do not delay chest compressions or defibrillation to rhythm is evident on the monitor, but chest compres-
establish an invasive airway. sions should not be interrupted for longer than 10
• Refer to Chapter 8, Airway Management, for more seconds.2
information concerning airway management.

Breathing and Ventilation Resume chest compressions immediately after a shock is delivered
without checking for a pulse or rhythm.
• Assess rise and fall of chest for adequacy of ven-
tilation.
• If bag-mask ventilation is sufficient, invasive airway • Shocks can be delivered through paddles or self-adhesive
management may be deferred until return of spontane- disposable pads applied to anterior-posterior or anterior-
ous circulation (ROSC). anterior position.
• Monitor rate and depth of manual ventilation to prevent • Use of self-adhesive, hands-free monitor or defibril-
hyperventilation. Excessive ventilation can increase lator pads is recommended over paddles.
intrathoracic pressure, decreasing venous return to the • To maximize current flow through the myocardium,
heart. the recommended pad placement is sternal-apical.
• In the patient without an advanced airway, the rate of • Place the sternal pad to the right of the upper
ventilation is two ventilations after each cycle of 30 chest sternum below the clavicle.
compressions. Once an advanced airway is placed, ven- • Place the center of the apical pad in the left
tilations should be given at a rate of 8 to 10 per minute midaxillary line.
(one ventilation every 5–6 seconds) without a pause in • Place the apical pad beneath the female breast.
chest compressions. • Do not allow pads to touch one another.
• Do not place pads on top of a transdermal medi-
Obtaining Circulatory Access cation patch (nitroglycerine, nicotine, hormone
• Establish intravenous (IV) access. replacement). Remove the patch and wipe the
• Use a large-gauge catheter to access a large vein, prefer- skin clean before applying the pad.
ably in the antecubital space. Do not interrupt chest • American Heart Association guidelines note if there is
compressions while obtaining IV access. any evidence of an implantable cardioverter defibrillator
 CHAPTER 9 Cardiopulmonary Arrest 91
(ICD) or permanent pacemaker, defibrillation should
TABLE 9-1 THE H’S AND T’S:
not be delayed by pad or paddle placement. It is recom-
COMMON CAUSES OF
mended to avoid placing the pads or paddles over the
implanted device.1 CARDIOPULMONARY
• These devices do not need to be deactivated during ARREST
resuscitation efforts. H’S T’S
• Anterior-posterior placement of the pads is recom-
Hypoxia Toxins (including drug overdose)
mended to minimize damage to the device2 but pad
Hypovolemia Tamponade (cardiac)
placement should not delay defibrillation.
Hydrogen ion (acidosis) Tension pneumothorax
• The energy level for the initial shock with a biphasic Hypothermia Thrombosis (coronary and
defibrillator is 120 to 200 joules; if using a monophasic pulmonary)
defibrillator, use 360 joules. If unsure as to whether Hypokalemia, hyperkalemia
the defibrillator is biphasic or monophasic, deliver the
shock at 200 joules. Deliver subsequent shocks at the
energy level that was previously successful.
• Ensure that all personnel are “clear” of the patient, bed, • Follow bolus injections of drugs with a 20-mL bolus
and equipment before delivering shocks. of IV fluid; elevate the extremity for 10 to 20 seconds
following administration to facilitate delivery to the
Drugs central circulation.2
• The drugs most commonly used during resuscitation
from cardiopulmonary arrest are epinephrine, vasopres- Treat Reversible Causes
sin, and amiodarone. Although high-quality CPR and early defibrillation, when
• Epinephrine, 1 mg, either IV or IO, is given every 3 to 5 appropriate, are the cornerstones of successful resuscitation
minutes during cardiopulmonary arrest in the adult. from cardiopulmonary arrest, possible causes of the arrest
• Because of its vasoconstrictor effects, epinephrine must be considered early on. Reversible causes of arrest or
increases cerebral and coronary blood flow during factors that may impede resuscitative efforts are known as
CPR. the “H’s and T’s” and are listed in Table 9-1. A high index
• Studies have demonstrated no benefit to higher doses of suspicion and specific diagnostic measures are needed to
or increasing doses of epinephrine during cardiopul- identify and treat these conditions.
monary arrest.2
• Epinephrine may be administered via the endo-
tracheal tube if IV or IO access cannot be obtained.
THE TEAM APPROACH
However, drug absorption is unpredictable and this • One person, certified in ACLS, should assume the role
route is not recommended.2 of team leader and direct the resuscitation efforts.
• Vasopressin (Pitressin), 40 units, either IV or IO, can • Closed-loop communication is essential. Team members
replace either the first or the second dose of epinephrine. should repeat orders for medications (including the
• The effects and survival rates of vasopressin use dosage) and other interventions and announce the com-
have not been shown to differ from those of pletion of these orders.
epinephrine.2 • One team member is designated to document all aspects
• The recommended initial dose of amiodarone is 300 mg, of the resuscitation and to frequently review for the team
either intravenously or intraosseously; this may be fol- what interventions have been used and the time frame
lowed by a single 150-mg dose. of the resuscitation.
• Amiodarone (Cordarone) can be administered in • Table 9-2 lists the various roles of the resuscitation team
either of the following ways: and their responsibilities.
• Direct injection of undiluted drug followed by a
minimum 10 mL flush FAMILY PRESENCE DURING
• Minimally diluting two 150-mg doses in two
10 mL 0.9% sodium chloride–filled (“flush”)
RESUSCITATION
syringes3 The Emergency Nurses Association (ENA) has long advo-
• If amiodarone is unavailable, lidocaine can be given. cated offering family members the option of being present
However, there is no evidence demonstrating at the patient’s bedside during resuscitative efforts4; some
improved survival with lidocaine use.2 feel that nurses have a moral obligation to offer this
92 UNIT 2 Basic Clinical Issues

TABLE 9-2 ROLES AND RESPONSIBILITIES OF THE RESUSCITATION TEAM

Team Leader Recorder
• Directs assessment and interventions • Documents all steps of the resuscitation effort, including
• Observes team members for ability to fulfill assigned roles accurate times using the same clock
• Ensures closed-loop communications • Frequently reviews with the team what medications and
• Requests input from team members interventions have been completed
• Teaches and reinforces efforts of team members • Helps monitor compressor fatigue and calls for a change
• Advises team of patient’s medical history as it becomes
Airway Manager
known
• Maintains patent airway
• May communicate orders to others not directly involved in the
• Continually monitors respiratory and ventilator status of
resuscitation effort
patient
• Calls for portable chest radiograph, other interventions,
• Provides adequate ventilation via bag-mask or advanced
etc.
airway
• Participates in closed-loop communication
• Requests arterial blood gas studies when appropriate
• Monitors efficiency of chest compressions; reminds Traffic Controller
compressors to change to prevent fatigue • Clears the resuscitation room of unneeded observers.
• Participates in closed-loop communications • Provides for patient privacy by keeping doors and curtains
closed and limiting noise, extraneous conversations, and other
Chest Compressors
distractions
• Perform high-quality, uninterrupted CPR
• Remain aware of fatigue and are willing to rotate with other Family Advocate or Liaison
team members • If family chooses to be present during resuscitation efforts:
• Participate in closed-loop communications • Stays with family to offer support and information
• Removes disruptive family members if necessary
Treatment Nurse
• If family chooses not to be present:
• Establishes and maintains IV access
• Provides family with private waiting area with telephone,
• Operates defibrillator, including ensuring all are “clear” before
tissues, and beverages
discharge
• Maintains contact with resuscitation team and provides
• Monitors for femoral pulse during chest compressions
frequent updates to family
• Administers IV or IO medications
• Stays with family members as needed
• Assesses vital signs as appropriate
• Offers to contact hospital chaplain or family’s preferred
• Participates in closed-loop communications
spiritual adviser
• Accompanies family to bedside when resuscitation efforts
have been completed
• Informs family of “what happens next” depending on
outcome of resuscitation

CPR, Cardiopulmonary resuscitation; IO, intraosseous; IV, intravenous.

Adapted from Neumar, R. W., Otto, C. W., Link, M. S., Kronick, S. L., Shuster, M., Callaway, C. W., … Morrison, L. J. (2010). Part 8: Adult advanced
cardiovascular life support: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation,
122(18 suppl 3), S729–S767; Zimmerman, J. L. (2007). Fundamental critical care support (4th ed.). Mount Prospect, IL: Society of Critical Care Medicine.

opportunity.5 In order for family presence at the bedside to Table 9-3 summarizes some of the concerns and benefits of
be successful, one health care team member (a nurse or family presence during resuscitation.
knowledgeable chaplain or social worker) should be
assigned to care solely for the family members. SPECIFIC CAUSES OF CARDIAC ARREST
• Remain physically at the family member’s side.
• Explain in simple terms what is happening and why. Pulseless Ventricular Tachycardia/
• Inform team members involved in the resuscitation that Ventricular Fibrillation
a family member is present. • Defibrillation is the treatment of choice for pulseless VT
• If at all possible, allow the family member to hold the or VF.
patient’s hand and speak to the patient during the resus- • Epinephrine, 1 mg IV or IO, is repeated every 3 to 5
citation efforts.5 minutes and makes VF more responsive to defibrillation.
 CHAPTER 9 Cardiopulmonary Arrest 93
• Support circulation with high quality CPR while consid-
TABLE 9-3 BENEFITS AND
ering the cause. Treating possible reversible causes of
CONCERNS RELATED
cardiac arrest is discussed below.
TO FAMILY PRESENCE • Although no randomized, controlled trials have shown
DURING RESUSCITATION improved survival from asystole or PEA following drug
EFFORTS administration, the ACLS algorithm recommends epi-
nephrine, 1 mg IV or IO every 3 to 5 minutes, once IV
POTENTIAL BENEFITS POSSIBLE CONCERNS
access has been obtained.
Families understand the Family members may • Defibrillation and pacing are not recommended for
seriousness of the patient’s interfere with the
managing asystole or PEA.
illness or injury and see resuscitation efforts.
• Do not interrupt CPR for longer than 10 seconds to
that all possible
check for a pulse.
interventions were
performed to save their
• If asystole is observed on the monitor, check leads
loved one’s life. and cable connections, assess height of gain on the
Families are able to begin the Family members may monitor and confirm rhythm in at least two different
grieving process; closure misinterpret resuscitation leads.
and healing may be activities in a way that
facilitated. increases the potential for Symptomatic Bradycardia
litigation. • Bradycardia may be “absolute” (rate <60 bpm) or “rela-
Family members can provide Events and procedures may tive” (a heart rate that is less than expected given the
additional information be too traumatic for the patient’s clinical condition).
concerning the patient’s family members. • Bradycardia is considered “symptomatic” if indications
medical history and of poor perfusion are present and are due to the slow
possible events leading to heart rate.
the cardiopulmonary arrest. • Chest pain
Family members are given a Safety of family members • Shortness of breath
chance to say “good-bye.” may be compromised; • Decreased level of consciousness
members may faint or be • Lightheadedness, dizziness, syncope
accidentally exposed to • Hypotension
blood or body fluids. • If bradycardia is symptomatic:
Family fear and anxiety may be Family’s response to grief
• Assess airway and breathing; support as needed
reduced and their feelings may be anger or violence.
• Administer supplemental oxygen
of isolation minimized.
• Obtain IV access and a 12-lead ECG
Adapted from Fell, O. P. (2009). Family presence during resuscitation • Prepare for transcutaneous pacing (see below)
efforts. Nursing Forum, 44(2), 144–150; Laskowski-Jones, L. (2007). • Atropine is the drug of choice for acute symptomatic
Should families be present during resuscitation? Nursing, 37 (5), 44–47; bradycardia. An initial dose of 0.5 mg can be repeated
and Tomlinson, K. R., Golden, I. J., Mallory, J. L., & Comer, L. (2010). Family every 3 to 5 minutes for a maximum dose of
presence during adult resuscitation: A survey of emergency department 3 mg.
registered nurses and staff attitudes. Advanced Emergency Nursing • In patients who have undergone heart transplantation,
Journal, 32 (1), 45–58.
isoproterenol (Isuprel) is the drug of choice for symp-
tomatic bradycardia. Following transplantation, the
• Vaspressin, 40 units IV or IO, can be substituted for the vagus nerve is not intact and atropine administration
first or second dose of epinephrine. will be ineffective.
• Amiodarone is the preferred treatment for shock- • If transcutaneous pacing is not available once the
refractory VF. maximum dose of atropine has been given, a continuous
IV infusion of epinephrine and/or dopamine may be
Asystole or Pulseless Electrical Activity considered.
• Ventricular asystole is often an end-stage rhythm in • Transcutaneous pacemaking
which there is a total absence of ventricular contraction. • Apply pacing electrodes as indicated on the pacing
PEA refers to a heterogeneous group of organized elec- device or the electrode package; placement may be
trical rhythms that fail to produce effective contraction anterior/posterior or anterior/anterior.
and a palpable pulse.2 • Set pacemaker rate at 70 bpm.
94 UNIT 2 Basic Clinical Issues
• Slowly increase the milliamperes (mA) until electri- • There has been short scene and transport time
cal capture (see below) occurs. Use the lowest level • Objective signs of life (pupillary response, spontane-
possible that maintains capture. ous breathing, palpable carotid pulse, and cardiac
• Assess pacing activity electrical activity) were present when the patient
• Electrical capture: Observe the monitor for arrived at the emergency department.7
electrical pacing spikes each followed by a wide • Emergency thoracotomy may be helpful in controlling
QRS complex. massive intrathoracic hemorrhage leading to pulseless
• Mechanical capture: Present when each pacing electrical activity (PEA), managing cardiac tamponade,
spike/QRS complex grouping produces a palpable or initiating internal cardiac massage.7
femoral pulse.
• Do not use carotid pulse to assess circulation in CARDIOPULMONARY ARREST IN
patient being externally paced as the electrical
activity of the pacemaker also causes generalized
THE PREGNANT WOMAN
muscle contraction. Care of the pregnant woman involves two patients: the
• Once electrical and mechanical capture have mother and her fetus. The best chance for fetal survival is
been obtained, assess the patient’s hemodynamic maternal survival, particularly if the mother experiences
response to pacing. The pacemaker rate may need cardiopulmonary arrest. Management of cardiopulmonary
to be increased to maintain an adequate cardiac arrest in the pregnant woman should follow the BLS and
output. ACLS treatment algorithms with the additional consider-
• Sedate the patient if possible due to the pain of con- ations listed below8:
current muscle contractions and electrical shock • Administer 100% oxygen and anticipate difficult airway
with each paced beat. management.
• The presence of hypoxemia and acidosis may prevent • Perform chest compressions slightly higher on the chest
the heart from responding to pacemaker stimulation. because of the elevated diaphragm and abdominal
If unable to “capture,” assess for and treat these contents.
conditions. • To prevent compression of the inferior vena cava
and decreased blood return to the heart by the gravid
uterus, manually displace the uterus to the left. If this
TRAUMATIC CARDIOPULMONARY ARREST manual maneuver is unsuccessful, place a firm wedge
• Survival rates from traumatic cardiopulmonary arrest under the patient’s pelvis and chest for a 30-degree left-
resulting from both blunt and penetrating injuries are lateral tilt.
poor (0% to 3.7%) and some consider resuscitation of • Obtain IV access above the diaphragm.
these patients to be futile.6 • Administer defibrillation and ACLS drugs as usual,
• In trauma patients presenting with VF, consider that without changes in joules or dosage.
this rhythm may be the cause and not the result of • Remove internal or external fetal monitoring devices
trauma. before defibrillation.
• Trauma patients experiencing cardiopulmonary arrest • Search for and treat contributing factors based on the
should be managed using the ABCDEs of trauma assess- BEAU-CHOPS mnemonic:
ment and care as described in Chapter 35, Stabilization • Bleeding or disseminated intravascular coagulo-
of the Trauma Patient. pathy
• Injuries leading to traumatic arrest are generally exten- • Embolism: coronary, pulmonary, amniotic fluid
sive and often include thoracic trauma such as tension • Anesthetic complications
pneumothorax, aortic or ventricular rupture, penetrat- • Uterine atony
ing chest trauma, or cardiac tamponade. • Cardiac disease: myocardial infarction (MI), isch-
• Patients with massive hypovolemia, as is often the case emia, aortic dissection, cardiomyopathy
in traumatic cardiopulmonary arrest, rarely survive.6 • Hypertension, preeclampsia, eclampsia
• Emergency thoracotomy, particularly in patients with • Others: consider the H’s and T’s
blunt chest trauma, carries an extremely high mortality • Placental abruption, placenta previa
rate. The American College of Surgeons Committee on • Sepsis
Trauma recommends considering emergency depart- • If ROSC does not occur within 4 minutes of resuscita-
ment thoracotomy only for patients experiencing car- tion efforts, consider immediate emergency cesarean
diopulmonary arrest from penetrating injury if: section.
 CHAPTER 9 Cardiopulmonary Arrest 95

PATIENT MANAGEMENT FOLLOWING • The patient’s core temperature must be continuously

monitored using an esophageal or bladder catheter
SUCCESSFUL RESUSCITATION thermometer.
A major concern is management of the patient once there • Axillary, oral, and tympanic temperature monitoring
is ROSC after successful resuscitation from cardiopulmo- is not appropriate or reliable in these patients.
nary arrest. The goals of care during this time are to mini- • Controlling shivering is a priority when caring for a
mize postarrest brain injury, myocardial dysfunction, and patient undergoing therapeutic hypothermia. Sedation,
the systemic reperfusion response and to resolve the under- analgesia, and neuromuscular blockers are given and the
lying problem that caused the cardiopulmonary arrest in patient is intubated and mechanically ventilated.
the first place.9 Early goal-directed therapy bundles are • Because electrolyte shifts and hyperglycemia are
being developed to improve survival and to promote func- common during the cooling time, baseline laboratory
tional recovery.10 Two specific interventions that can be values are obtained. Blood glucose levels are monitored
initiated in the emergency department are treating the on an hourly basis.
underlying cause of cardiopulmonary arrest through early • “Cold diuresis” occurs so an indwelling urinary catheter
percutaneous coronary intervention and the induction of is needed.
hypothermia. • Once cooling has started, do not interrupt it for diag-
nostic examinations (computed tomography scan) or
Early Percutaneous Coronary Intervention other interventions (PCI).
• The most common cause of cardiopulmonary arrest is
cardiovascular disease and coronary ischemia.10
• According to the American Heart Association, patients REFERENCES
with ROSC following cardiopulmonary arrest should
undergo immediate coronary angiography and percuta- 1. Neumar, R. W., Otto, C. W., Link, M. S., Kronick, S. L., Shuster,
neous coronary intervention (PCI) if electrocardiogram M., Callaway, C. W., … Morrison, L. J. (2010). Part 8: Adult
criteria for ST elevation myocardial infarction (STEMI) advanced cardiovascular life support: 2010 American Heart
are present or if the presence of acute coronary syn- Association guidelines for cardiopulmonary resuscitation and
emergency cardiovascular care. Circulation, 122(18 suppl 3),
drome is likely.9
S729–S767.
• If PCI is unavailable, thrombolytic therapy is appropri- 2. Field, J. M. (Ed.). (2008). ACLS resource text for instructors
ate for STEMI management in these patients.9 and experienced providers. Dallas, TX: American Heart
• Emergent PCI can be performed in conjunction with Association.
therapeutic hypothermia. 3. Turner, M., & Hankins, J. (2010). Pharmacology. In M.
Alexander, A. Corrigan, L. Gorski, J. Hankins, & R. Perucca
Therapeutic Hypothermia (Eds.), Infusion nursing: An evidence-based approach (3rd ed.,
• The main goal of therapeutic hypothermia is to preserve pp. 263–298). St. Louis, MO: Saunders/Elsevier.
neurologic functioning in patients following cardiopul- 4. Zimmerman, J. L. (2007). Fundamental critical care support
monary arrest with ROSC. Therapeutic hypothermia is (4th ed.). Mount Prospect, IL: Society of Critical Care
Medicine.
the only therapy that has been shown to improve neu-
5. Emergency Nurses Association. (2010, September). Family
rologic recovery in patients following cardiopulmonary presence during invasive procedures and resuscitation in the
arrest.10 emergency department [position statement]. Retrieved from
• Cooling should begin immediately after ROSC in http://www.ena.org/SiteCollectionDocuments/Position%20
patients who remain comatose. Statements/FamilyPresence.pdf
• Cooling can be initiated in the prehospital setting 6. Lockey, D., Crewdson, K., & Davies, G. (2006). Traumatic
with an IV infusion of iced saline. cardiac arrest: Who are the survivors? Annals of Emergency
• Other methods of inducing mild hypothermia Medicine, 48(3), 240–244.
include ice packs to the groin, axilla, neck, and head 7. Chalkias, A. (2009). Prehospital thoracotomy: When to do it?
and cooling blankets. Journal of Emergency Primary Health Care, 7(4). Retrieved from
http://www.jephc.com/full_article.cfm?content_id=548
• Commercial devices are available for therapeutic
8. Vanden Hoek, T. L., Morrison, L. J., Shuster, M., Donnino, M.,
hypothermia and involve either external surface Sinz, E., Lavonas, E. J., … Gabrielli, A. (2010). Part 12:
cooling or intravascular methods. Cardiac arrest in special situations: 2010 American Heart
• The temperature and time goals for therapeutic hypo- Association guidelines for cardiopulmonary arrest and
thermia are 32° C to 34° C (89.6–93.2° F) for 12 or 24 emergency cardiovascular care. Circulation, 122(18 suppl 3),
hours. S829–S861.
96 UNIT 2 Basic Clinical Issues
9. Neumar, R. W., Nolan, J. P., Adrie, C., Aibiki, M., Berg, R. A., on Cardiovascular Surgery and Anesthesia; the Council on
Böttiger, B. W., … van den Hoek, T. (2008). Post-cardiac Cardiopulmonary, Perioperative, and Critical Care; the
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Heart Association, Australian and New Zealand Council R. G., Zimmerman, J. L., Donnino, M., … Kronick, S. L.
on Resuscitation, European Resuscitation Council, Heart (2010). Part 9: Post-cardiac arrest care: 2010 American Heart
and Stroke Foundation of Canada, InterAmerican Heart Foun- Association guidelines for cardiopulmonary resuscitation and
dation, Resuscitation Council of Asia, and the Resuscitation emergency cardiovascular care. Circulation, 122(180 suppl 3),
Council of Southern Africa); the American Heart Association S768–S786.
Emergency Cardiovascular Care Committee; the Council