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Cardiac arrest - out of hospital care - Management
How do I manage someone with a non-shockable rhythm (asystole/PEA)?

For pulseless electrical activity (PEA):

  • Start cardiopulmonary resuscitation (CPR) at a ratio of 30 compressions to two rescue breaths.
    • Without stopping CPR, gain venous access as soon as possible.
  • Give adrenaline 1 mg intravenously (IV) as soon as venous access is achieved.
  • Continue CPR (with a 30:2 ratio of compressions to rescue breaths) until the airway is secured by a supraglottic airway device (such as laryngeal mask airway [LMA]), or a tracheal tube for those who have experience in tracheal intubation.
    • Once the airway is secured, ventilate the lungs at a rate of about 10 breaths per minute and continue chest compressions without pausing during ventilation.
      • The lungs may also be ventilated by means of a pocket mask or bag-valve-mask device (BVMD) with or without an oropharyngeal airway (OPA), but it should be noted that this method does not secure the airway against the aspiration of regurgitated gastric contents.
    • If an oropharyngeal airway (Guedel airway) or nasopharyngeal device is used, continue CPR with a 30:2 ratio of compressions to rescue breaths.
  • Recheck the rhythm after 2 minutes.
    • If there is no change in the ECG appearance on the defibrillator monitor:
      • Continue CPR.
      • Recheck the rhythm after 2 minutes.
      • If there is no change in the ECG appearance, give adrenaline 1 mg IV.
      • Continue giving CPR, checking the rhythm every 2 minutes and giving further adrenaline 1 mg IV every 3–5 minutes (alternate loops).
    • If the ECG changes and organized electrical activity is seen, check for a pulse:
      • If no pulse is present, continue CPR. Recheck the rhythm after 2 minutes and proceed accordingly; give further adrenaline 1 mg IV every 3–5 minutes (alternate loops).

For asystole and slow PEA (rate less than 60/minute):

  • Start cardiopulmonary resuscitation (CPR) at a ratio of 30 compressions to two rescue breaths.
    • Without stopping CPR, gain venous access as soon as possible.
  • Give adrenaline 1 mg IV as soon as venous access is achieved.
  • Continue CPR (with a 30:2 ratio of compressions to rescue breaths) until the airway is secured (for example, by tracheal intubation [should only be performed by those who have undergone extensive training and who practice the skills regularly] or alternative airway device).
    • Once an airway device has been inserted, ventilate the lungs at a rate of about 10 breaths per minute and continue chest compressions without pausing during ventilation.
  • Recheck the rhythm after 2 minutes:
    • If there is no change in the ECG appearance on the defibrillator monitor:
      • Continue giving CPR, checking the rhythm every 2 minutes and giving further adrenaline 1 mg IV every 3–5 minutes (alternate loops).
    • If ventricular fibrillation or ventricular tachycardia recurs, manage as for shockable rhythm.
    • If organized electrical activity is seen, check for a pulse or other signs of life (such as movement).
      • If no pulse or other sign of life is present, continue CPR. Recheck the rhythm after 2 minutes and proceed accordingly. Give further adrenaline 1 mg IV every 3–5 minutes (alternate loops).

Identify any potentially reversible causes of cardiac arrest and manage as appropriate.

© NHS Institute for Innovation and Improvement