Medical Cardiac Arrest

 

History:

 

  • Past medical history
  • Medications
  • Events leading to arrest
  • End stage renal disease
  • Estimated downtime
  • Suspected hypothermia
  • Suspected overdose
  • DNR form or living will

 

Significant Findings:

 

  • Unresponsive
  • Pulseless
  • Apneic
  • No electrical activity on EKG
  • Ventricular fibrillation/ventricular tachycardia
  • No auscultated heart tones

 

Differential:

 

  • Medical/trauma
  • Hypoxia/pulmonary
  • Potassium (hypo/hyper)
  • Drug overdose
  • Acidosis
  • Hypothermia
  • Device error/artifact

 

Criteria for Death/DNR

 

  • Yes

 

Withhold Resuscitation:

 

  • See COG 1.4 for criteria for death/withholding resuscitation
    • Contact Medical Control or Coroner

 

Criteria for Death/DNR?

 

  • No
    • Cardiac monitor / AED
    • Treat correctable causes early
    • Place BIAD and provide 8-10 breaths per minutes
    • Initiate IV/IO

 

V-Fib/Pulseless V-Tach?

 

  • Yes
    • Defibrillate 200, 300,360 joules
    • All subsequent shocks at 360 joules
    • Epinephrine 1 mg IV/IO repeat every 3-5 mins.
    • Amiodarone (cardarone) 300 mg IV/IO repeat once at 150 mg.
    • Place 2nd VI/IO when feasible

 

Asystole / PEA?

 

  • Yes
    • Place 2nd IV/IO if necessary

 

Return of spontaneous circulation?

 

  • YES

 

 

  • NO

 

 

PEARLS:

 

  • Epinephrine given every 3-5 minutes, max 4 doses. Contact medical control to request more doses.
  • CPR 100-120 compressions per minute and at a depth of no less than 2 inches with interruptions less than 5 seconds.
  • Monitor in paddles mode with metronome on.
  • Consider Calcium Gluconate (Kalcinate) 10-20 mL IV, followed by Normal Saline 100 mL IV and Sodium Bicarbonate 1 mEq/kg IV in hemodialysis patient early in the resuscitation.
  • If patient is receiving shocks from an automated internal cardiac defibrillator (AICD), wait 30-60 seconds after the internal shock to analyze the rhythm and then treat the patient as if the AICD was not present. Placement of the difibrillator pads should be approximately 3 inches away from the device if possible. Posterior/anterior placement is acceptable.
  • If patient has signs/symptoms of CPR-induced consciousness, consider Ketamine 1 mg/kg IV/IO (Max single dose 100 mg)
  • If patient is in persistent v-fib/v-tach, administer Lidocaine 1 mg/kg IV/IO after max Amiodarone dose.
  • If patient is in torsades de pointes or persistent v-fib/v-tach, administer Magnesium Sulfate 2 grams/4 mL slow IV push over 2 minutes.
  • Always confirm asystole in more than one lead.
  • Only move the patient enough to make adequate room to work.
  • All resuscitations initiated at the jail must be transported.
  • Transport patients with persistent V-fib/V-tach.
  • Assign a team resuscitation leader and utilize checklist.
  • Reassess and document endotracheal tube placement and EtCO2 frequently, after every move, and at transfer of care.