Medical Cardiac Arrest

Assessment

Pediatric Pearls: Signs & Symptoms: Differential: 
□ Treating patients on scene for 20 minutes can have improved ROSC rates and survival
□ Avoid intubation of the pediatric patient when possible. OPA/NPA is preferred. 
□ Children compensate well initially but decompensate quickly with little warning. 
□ Most pediatric cardiac arrests are due to respiratory compromise/hypoxia
□ Transport pediatric arrests to a level 1 pediatric center		□ STEMI
□ Syncope
□ Seizure
□ Decreased in ETCO2		□ Hypovolemia
□ Hypoxia
□ Acidosis
□ Hypoglycemia
□ Hyperkalemia
□ Hypothermia
□ Tension pneumothorax
□ Tamponade
□ Toxins
□ Thrombosis (PE, STEMI)

Clinical Management Options

EMT-B
• Assess for unresponsiveness, absence of normal breathing, and pulselessness 
• Assess for obvious death criteria 
• Begin Pit Crew CPR procedure with Engine until relieved by CHEMS arrival. 
• BLS Airway Management and BVM with Oxygen as available 
• Passive oxygenation with nasal cannula at 25 LPM 
• Consider airway management with I-gel
• For sustained Vtach/Vfib arrest (after the third shock), add a second set of pads to the patient to change the vector of defibrillation
• Do not let the pads touch as it can cause damage to the machines
Paramedic
• Vascular access 
• Epinephrine for three doses
• Fluid bolus with Isotonic Crystalloid as needed 
• Monitor ETCO2 & ECG 
• Narrow PEA QRS < 0.12 seconds: 
• Consider mechanical causes – Cardiac tamponade, Tension pneumo, Mechanical hyperinflation, PE, Hypovolemia, Acute MI, heart failure 
• Wide PEA QRS > 0.12 seconds or Asystole: 
• Consider metabolic causes – Tricyclic OD, Severe hyperkalemia, Acidosis, Calcium Channel Blocker OD, Acute MI, heart failure. 
• If awake/awareness during CPR, treat per RASS score.
• Consider transport to an ECMO center for sustained Vtach/Vfib and the patient meets criteria.
Consult Online Medical Control as Needed

Pearls

  • To be successful in adult or pediatric arrests, a cause must be identified and corrected. 
  • Respiratory arrest is a common cause of pediatric cardiac arrest. Unlike adults, early oxygenation and ventilation is critical.
    • Assess for airway obstruction if difficult to ventilate
  • Patients who are greater than 20 weeks pregnant should be transported immediately for consideration of perimortem C-section
  • In most cases, manage pediatric airways by basic interventions. 
  • Effective CPR is critical: 1) Push hard and fast at appropriate rate 2) Ensure full chest recoil 3) Minimize interruptions in CPR. Pause CPR< 10 seconds only. 
  • Effective CPR and prompt Defibrillation are the keys to successful resuscitation. 
  • Prolonged cardiac arrests may lead to tired providers and decreased compression quality. Ensure compressor rotation, summon additional resources as needed, and ensure provider “rest and rehab” during and post-event. 
  • For pediatrics use volume control device for Dextrose and Fluid infusions 
  • Always quickly confirm asystole in more than one lead. 
  • Trouble shoot for Equipment settings/ problems 
  • Reassess and document airway continuously after every move and at transfer of patient care. 
  • Initiate continuous ETCO2 as soon as practicable. 
  • Calcium and sodium bicarbonate should be given early if hyperkalemia is suspected (renal failure, dialysis). There is no indication for these medications in most cardiac arrests without suspected hyperkalemia or overdose. 
  • Adult treatment priorities: uninterrupted compressions, defibrillation, ventilation, then IV/IO and airway management if needed. 
  • Polymorphic VT (Torsades) may benefit from Magnesium Sulfate. 
  • Prior to any external shocks, providers should verify that defibrillation pads are well adhered to the patient and that they do not touch. 
  • Both lidocaine and amiodarone can be effective for Vtach/Vfib arrests. There is no benefit for amiodarone over lidocaine. Amiodarone can be continued if started by another team. Do not give amiodarone in patients who are pregnant.

ECMO Criteria -Call Med Control for consideration if patient is in Vfib/Vtach after 3 shocks. If Medical Control agrees with ECMO, transport to BJH and ask for ECMO activation when giving report to the Charge Nurse.

Inclusion Criteria

  • 18-60 year old
  • Witnessed cardiac arrest
  • CPR initiated within 5 minutes of arrest
  • ETCO2 >10 mmHg
  • Initial rhythm VF/VT
  • Persistent arrest s/p 3rd shock
  • Arrest to ED arrival time 60 minutes or less

Exclusion Criteria

  • Life limiting comorbidities including but not limited to the following
    o ESRD
    o COPD on home oxygen
    o Terminal cancer
    o Liver failure
    o Congestive heart failure
    o Other terminal condition
  • Unable to apply LUCAS device to patient
  • Arrest due to suspected trauma etiology