Cardiac Arrest (VF/VT/Asystole/PEA)

Table of Contents

Aliases

Heart attack, arrest, full arrest

Patient Care Goals

  1. Return of spontaneous circulation (ROSC)
  2. Preservation of neurologic function
  3. High-quality chest compressions/CPR with minimal interruption from recognition of cardiac arrest until confirmation of ROSC or field termination of care

Patient Presentation

Inclusion Criteria

Patients with cardiac arrest

Exclusion Criteria

  1. Patients suffering cardiac arrest due to severe hypothermia [see Hypothermia/Cold Exposure guideline]
  2. Patients with identifiable Do Not Resuscitate (or equivalent such as POLST) order [see Do Not Resuscitate Status/Advance Directive/Healthcare Power of Attorney (POA) Status guideline]
  3. Patients in arrest due to traumatic etiology [see General Trauma Management guideline]

Patient Management

Assessment

  1. The patient in cardiac arrest requires a prompt balance of treatment and assessment
  2. In cases of cardiac arrest, assessments should be focused and limited to obtaining enough information to reveal the patient is pulseless
  3. Once pulselessness is discovered, treatment should be initiated immediately and any further history must be obtained by bystanders while treatment is ongoing

Treatment and Interventions

The most important therapies for patients suffering from cardiac arrest are prompt cardiac defibrillation and minimally interrupted effective chest compressions.

Follow Non-Traumatic Cardiac Arrest Checklist

  1. Initiate chest compressions in cases with no bystander chest compressions or take over compressions from bystanders while a second rescuer is setting up the AED or defibrillator
  2. Determine if Pitcrew CPR is indicated. Refer to Pitcrew CPR Procedure.
  3. For patient not eligible for Pitcrew CPR, follow the remaining steps.
  4. Pre-charge Manual Defibrillator at 1:45 into every cycle. Dump charge if non-shockable rhythm present.
  5. The maximum setting on the defibrillator should be used for initial and subsequent defibrillation attempts for patients aged 15 or greater. Patients 14 or younger should follow PALS recommendations (2 J/kg – 1st shock, 4 J/kg – additional shocks)
  6. For pediatrics, use length-based tape or age-based card to determine dosages of electricity and medications.
  7. Chest compressions should resume immediately after defibrillation attempts with no pauses for pulse checks for 2 minutes regardless of the rhythm displayed on the cardiac monitor
  8. All attempts should be made to prevent avoidable interruptions in chest compressions, such as pre-charging the defibrillator and hovering over the chest, rather than stepping away during defibrillations
  9. If feasible, IV or IO access should be obtained. Administer epinephrine 0.01 mg/kg, max of 1 mg and repeat as needed every 5 minutes.
    1. Due to questionable benefit of epinephrine, frequency will be decreased
  10. Continue the cycle of chest compressions for 2 minutes, followed by rhythm analysis and defibrillation of shockable rhythms; during this period of time, the proper strategy of airway management is currently not defined and many options for airway management exist – Regardless of the airway management and ventilation strategy, consider the following principles:
    1. The airway management strategy should not interrupt compressions
    2. Successful resuscitation from cardiac arrest depends primarily on effective, minimally-interrupted chest compressions and prompt defibrillation; airway management is of secondary importance and should not interfere with compressions and defibrillation – Options for airway management include:
      1. Place an appropriately sized I-Gel Airway and attach waveform capnography if available
        1. ADULT CONSIDERATION: Use oxygen port and passive oxygenation at 15 lpm for the first 6 minutes of cardiac arrest management
          1. After 6 minutes, ventilations at 10 breaths/minute
        2. Pediatric Consideration: for children, 1 breath every 3-5 seconds is recommended (12-20 breaths/minute) after I-Gel placement
        3. For all patients: deliver volume needed to achieve chest rise
      2. If I-Gel unavailable or unsuccessful, BVM ventilation with 30:2 ventilation to compression ratio: Each 30 compressions, the compressions are paused briefly to allow 2 BVM ventilations, then compressions immediately resumed
        1. Pediatric Consideration: For multiple rescuer CPR in children, 15:2 is the recommended compression to ventilation ratio. (30:2 for single rescuer).
        2. Pediatric Consideration: For neonates, 3:1 is the recommended compression to ventilation ratio.
      3. Advanced airway placement:
        1. An endotracheal tube may be placed without interruption of compressions
        2. Ventilations are provided at 10 breaths/minute for adults
        3. Pediatric Consideration: for children, 1 breath every 3-5 seconds is recommended (12-20 breaths/minute)
        4. For all patients: deliver volume needed to achieve chest rise
  11. Consider use of antiarrhythmic for recurrent VF/Pulseless VT
    1. Lidocaine
      1. Initial Dose: 1 mg/kg IVP
      2. Repeat Dose: 0.5 mg/kg IVP every 5 minutes
      3. Max of 3 mg/kg
    2. For torsades de pointes, give magnesium sulfate 25 mg/kg, max of 2 g, IVP
  12. If shockable rhythm presents after 3 defibrillations and second defibrillator is available
    1. Initiate dual sequential defibrillation
    2. Use maximal joules settings for both defibrillators
    3. Attempt shock as close to simultaneous as possible
  13. Consider reversible causes of cardiac arrest which include the following:
    1. Hypothermia – additions to care include attempts at active rewarming [see Hypothermia/Cold Exposure guideline]
    2. The dialysis patient/known or strongly suspected hyperkalemic patient – Additions to care include the following:
      1. Calcium chloride 10% 10ml IV (for pediatrics, the dose is 20 mg/kg which is 0.2 mL/kg)
      2. Sodium bicarbonate 1 mEq/kg, max of 50 mEq IV, once.
      3. Albuterol 10 mg via small volume nebulizer
    3. Tricyclic antidepressant overdose – Additions to care include sodium bicarbonate 1 mEq/kg IV, repeat every 5 minutes until QRS narrows
    4. Hypovolemia – Additions to care include normal saline 2 L IV (or 20 mL/kg, repeated up to 3 times for pediatrics)
    5. If the patient is intubated at the time of arrest, assess for tension pneumothorax and misplaced ETT
      1. If tension pneumothorax suspected, perform bilateral needle decompression.
    6. Assess ETT, if misplaced, replace ETT
  14. Aim for at least 20 minutes of on scene cardiac arrest care if scene safety allows.
    1. Includes pediatric cardiac arrest
    2. Excludes women with a gravid abdomen or traumatic cardiac arrest
      1. Requires immediate transport
  15. If at any time during this period of resuscitation the patient regains return of spontaneous circulation, treat per Adult Post-ROSC Care guideline
  16. If resuscitation remains ineffective, consider termination of resuscitation [see Termination of Resuscitative Efforts guideline]

Notes – Cardiac Arrest (VF/VT/Asystole/PEA)