Cardiac Arrest in General Practice: When Guidelines Meet Reality

Cardiorespiratory arrest is an absolute emergency in any general practice. Standardized guidelines provide medical staff with the knowledge required to deal with such situations. Unfortunately, when discussing the complex situations encountered in Advanced Life Support, they start from the assumption that the necessary equipment is also available. The reality of a general practice is most often completely different. This is why I thought it would be useful to adapt these guidelines to the environment and resources available to us as general practitioners and to offer pragmatic advice specifically for these situations.

One element I want to address from the beginning is that the majority of patients will not survive a cardiac arrest. In general, coronary artery disease is the most common cause of cardiac arrest, followed by non-ischemic cardiomyopathies. These events usually occur in people who appeared to be in good health. According to recent data, on average only 7.5% of patients in Europe survive, with a relatively wide range between 3.1% and 35%. These variations depend on regional medical infrastructure, road infrastructure and the ability of emergency services to reach the victim in time, but also on the awareness of people in the immediate vicinity of the victim and their decision whether or not to initiate Basic Life Support.

In general, bystanders' reluctance to initiate CPR is partly based on the traumatic experience of seeing someone dying in front of them. A physiological reaction is to want to block out this experience and move in the opposite direction. The fear of doing more harm than good, although medically unjustified, is another reason why the proportion of the population initiating CPR before the arrival of an ambulance varies so greatly between European countries.

The concept of the Chain of Survival was introduced approximately 20 years ago. Its purpose is not simply to identify each individual component of the rescue process, but rather to emphasize that all of them are critical to allowing the victim to survive. As presented throughout the guidelines, it consists of:

• recognition of cardiac arrest and activation of the emergency medical services;

• early CPR and defibrillation, with restoration of a cardiac rhythm;

• post-resuscitation care, with optimization of cerebral perfusion and cardiac function;

• recovery and restoration of quality of life.

  
  

Results obtained in recent years emphasize the importance of high-quality resuscitation. Performing each individual link smoothly, without interruption and to a high standard ultimately makes the difference in the patient's quality of life. In many situations, a delay of two or three minutes can make the difference between being able to walk to the shops independently and remaining bedridden. We can therefore see that having resources available and using them optimally are two different things.

The resources available in a general practice are almost nonexistent. Most practices are not technically equipped to treat such patients. Most of the staff working in them are not capable of managing a cardiac arrest. In France, for example, a large proportion of general practices are staffed only by general practitioners, without medical or auxiliary staff. A resuscitation situation as a one-man show therefore becomes even more challenging. So what is the role of a modern general practice in the effort to improve patient care for this particular group of patients?

The human factor and the general practitioner's medical training are two important pillars. The human factor also includes the physician's personality. A resuscitation situation is very often psychologically traumatic for those involved. There is nothing glorious about watching someone die in front of you, and the less accustomed you are to such situations, the more traumatic the experience becomes.

During my career as an anesthesiologist, I have frequently been involved in these situations. The fact that I can still remember some of these events even ten years later illustrates their traumatic nature.

In this context, any serious resuscitation course should also present real footage of resuscitation situations. Watching the dynamics of a situation that can sometimes become chaotic helps prepare future rescuers. Not only can they experience the traumatic nature of the event without being directly involved or carrying responsibility for the outcome, but they can also observe how teamwork functions.

Alongside these lessons comes the understanding that such a situation can occur anywhere and at any time, and that we, as healthcare professionals, must manage it as effectively as possible for our patients.

Basic Life Support and Advanced Life Support

Historically, patient resuscitation has been divided into Basic Life Support (BLS) and Advanced Life Support (ALS). ALS has several variations, such as Pediatric Advanced Life Support (PALS) and Advanced Trauma Life Support (ATLS), which, however, are mainly relevant to emergency medical services or the hospital setting.

The Chain of Survival must include rapid recognition → activation of emergency medical services → initiation of high-quality BLS → implementation of high-quality ALS → and finally post-resuscitation care.

In general, cardiac arrest should be suspected in any person who is unresponsive. Abnormal respiratory sounds, snoring or labored breathing should prompt assessment of the pulse and initiation of chest compressions after the emergency medical services have been called.

From the outset, I should mention that chest compressions, whether performed correctly or incorrectly, do not usually cause major injuries. Many resuscitation providers will still say that if no rib has been broken, the compressions were not deep enough.

Basic Life Support – Adults

The hands are placed one over the other on the lower half of the sternum, with the fingers interlocked to avoid additional pressure on the ribs and to increase efficiency. The elbows remain extended and should not flex. The rescuer's shoulders and head should be positioned directly perpendicular to the point of contact with the patient.

Compression should be brisk, reaching a depth of at least 5 cm, followed by complete recoil. The rate should be 100–120 compressions per minute. In recent years, the rhythm of Stayin' Alive has often been used to help maintain the correct compression rate.

After every compression, the chest should be allowed to return to its original position. The hands should not lose contact with the patient. Compressions are more effective when the patient is positioned on a hard surface. This may even require moving the patient down onto the floor. Pregnant patients should be resuscitated with a slight left lateral tilt in order to avoid aortocaval compression.

Adult BLS uses a 30:2 compression-to-ventilation ratio. Ventilation can be performed mouth-to-mouth or using ALS equipment such as a bag-valve-mask or supraglottic airway devices.

BLS is continued without interruption at a ratio of 30:2 until ALS becomes available, either in the form of additional equipment or through the arrival of emergency medical personnel.

Basic Life Support – Pediatric

Resuscitation in children begins with five rescue breaths, followed by chest compressions at a ratio of 15:2.

In newborns and infants, the ratio is 3:1. Depending on the size of the child, either the two-finger technique over the sternum or a single-hand technique is used. In infants, chest compressions are initiated if the heart rate falls below 60 beats per minute.

Advanced Life Support

ALS requires advanced knowledge and skills, such as intravenous or intraosseous access and management, as well as identification and treatment of reversible causes contributing to the cardiac arrest.

Ventilation and Airway Management

During resuscitation, ventilation can be performed using a mask or a supraglottic airway device such as a laryngeal tube. Orotracheal intubation should only be performed by experienced practitioners with a high success rate. When securing the airway, chest compressions should be interrupted for no more than five seconds.

Capnometry should be used both for endotracheal intubation and supraglottic airway devices. The use of capnometry provides feedback regarding the quality of chest compressions and can provide early evidence of ROSC.

Ideal parameters are a tidal volume of 6–8 ml/kg body weight, a respiratory rate of 10/minute, an inspiratory time of 1–2 seconds, and a PEEP between 0 and 5 cm H₂O.

These parameters are relevant mainly to ambulance personnel or retired anesthesiologists like myself, because in a general practice they have virtually no practical significance. Nobody has a ventilator readily available.

Defibrillation

Patients should be defibrillated as quickly as possible once a defibrillator becomes available. An AED that is already being used should not be replaced by a manual defibrillator, because changing devices would waste valuable time. CPR is continued immediately before and after defibrillation. High-quality CPR increases the likelihood of successful defibrillation. Chest compressions should be interrupted for less than five seconds for defibrillation.

During defibrillation, any contact with the patient must be avoided. Wearing gloves is not sufficient to prevent rescuers from receiving an electrical shock.

Handheld paddles on manual defibrillators are considered obsolete. Adhesive pads are recommended because they minimize interruptions and maintain better contact with the skin, thereby reducing skin burns and increasing the effectiveness of delivered shocks. In adults, the pads are positioned anterolaterally along the mid-axillary line, but repositioning them to an anteroposterior position is recommended after the third failed shock.

When operating the defibrillator, all oxygen sources should be moved at least one meter away from the pads. This includes oxygen being administered to the patient. Pads should also be placed at least 8 cm away from pacemakers or implantable defibrillators.

The first shock delivered should have an energy of at least 150 J. If the shock is unsuccessful, increasing the energy for subsequent shocks is recommended. Defibrillation in children is performed using 4 J/kg body weight.

Subcutaneous identification of implanted devices such as pacemakers and implantable cardioverter-defibrillators remains important. Implantable defibrillators can automatically deliver shocks during resuscitation, and these shocks may be felt by rescuing personnel. If the implanted defibrillator is unable to convert a shockable rhythm, the use of an external defibrillator is recommended. Rescuers can be protected by positioning a sufficiently powerful magnet directly over the device; most implantable defibrillators can be deactivated in this way. It may be necessary to protect rescuers from the implanted defibrillator because, under resuscitation conditions, the cardiac rhythm may be interpreted incorrectly and the device may deliver an inappropriate shock.

Some general practices in Germany, for example, are equipped with defibrillators, although this tends to be the exception rather than the rule. The high acquisition costs and subsequent expenses associated with technical recertification make ownership economically unattractive. This financial reality ultimately comes at the expense of patients.

Medication During Resuscitation

Medications should be administered intravenously or intraosseously. The techniques for establishing intravenous or intraosseous access will not be explained here due to space limitations.

Adrenaline 1 mg should be administered as soon as possible when there is no shockable rhythm (ventricular fibrillation, ventricular tachycardia). When the rhythm is shockable, 1 mg adrenaline is administered after the third shock. Administration is repeated every 3–5 minutes.

After the third unsuccessful shock, 300 mg amiodarone IV is administered in ventricular fibrillation. After another two unsuccessful defibrillation attempts, an additional single dose of 150 mg amiodarone IV is administered in adults. Alternatively, 100 mg lidocaine IV can be administered after the third shock, followed by another 50 mg after the fifth shock.

If pulmonary embolism is suspected, administration of a thrombolytic agent should be considered. Following its administration, CPR/ALS should be continued for 60–90 minutes.

Most general practices in Germany are equipped with IV cannulas and the equipment necessary to establish intravenous access. In France, these are often unavailable because most general practitioners do not routinely administer intravenous infusions or IV medications to their patients. The low acquisition and storage costs are one reason why all general practices should be equipped with such materials.

Sedation of Patients During ALS

CPR and ALS can result in situations in which patients become conscious, at which point sedation using substances such as fentanyl, ketamine or midazolam may be recommended.

This discussion remains primarily relevant to emergency medical services because such drugs are generally not available in general practices. What I want to emphasize here is simply that optimally performed cardiac massage can result in the patient “waking up.” Having experienced this many times, I can confirm that it is quite bizarre to see the people you are resuscitating open their eyes and look at you, only to lose consciousness again when you stop. This is therefore a sign that what you are doing is effective.

Ultrasound During CPR and Other Advanced Techniques

Most of these advanced techniques are not appropriate considerations for the role of the general practitioner in this particular context.

Ultrasound during CPR may be performed by appropriately trained personnel to identify conditions such as cardiac tamponade or pneumothorax, but only if interruptions can be kept to a minimum and the examination does not interfere with the overall resuscitation effort.

Right ventricular dilatation during CPR is not sufficient to diagnose pulmonary embolism.

REBOA – Resuscitative Endovascular Balloon Occlusion of the Aorta – is not routinely recommended unless performed as part of a clinical study.

Intra-arrest cooling is not recommended except in cases of severe hyperthermia.

ECPR / ECMO-CPR may be performed when conventional CPR fails to restore effective circulation.

Sources: [1]

Last updated: September 20, 2026