START

❶ Prepare the cardiac arrest trolley for any further events.

❷ Use positive pressure ventilation, aiming for:

• SpO₂ > 94% and < 98%.
• PCO₂ > 4.5 kPa and < 5.5 kPa.

❸ Give sedation and neuromuscular blocking drugs to reduce thermogenesis from shivering.

❹ Insert intra-arterial blood pressure monitoring. Consider vasopressor/inotrope to maintain systolic blood pressure, target SBP > 100 mmHg.

❺ Obtain 12-lead ECG and discuss with cardiology if percutaneous coronary intervention is possible or appropriate.

❻ Check blood glucose. Start glycaemic control therapies if above 10 mmol.l^-1.

❼ Check core temperature. Target temperature is a constant temperature in the range of 32 – 36°C (precise target determined by local policy):

• Temperature usually decreases without intervention in the immediate post-arrest period.
• Start cooling strategies if indicated (Box A).
• Avoid hyperthermia > 37.5°

❽ Give antiepileptic drugs if seizures develop (Box B).

❾ Plan further management in critical care area. Call for extra help as necessary.

Box A: COOLING STRATEGIES

Intravenous fluid bolus: if not contraindicated give 30 ml.kg^-1 of cold (4°C) non glucose-containing solutions  

External: simple ice packs and/or wet towels; cooling blankets or pads; water or air circulating blankets; water circulating gel-coated pads  

Internal: intravascular heat exchanger; cardiopulmonary bypass  

Box B: DRUGS TO CONTROL/PREVENT SEIZURES

• Benzodiazepines or propofol are likely to be closest to hand in the operating theatre.  
• Sodium valproate, levetiracetam, phenytoin or a barbiturate can also be used. 

Box C: CRITICAL CHANGES

Cardiac arrest → 2-1