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

Cardiac Arrest (VF/VT/Asystole/PEA)

Patient Safety Considerations

  1. Performing manual chest compressions in a moving vehicle may pose a provider safety concern
  2. In addition, manual chest compressions during patient movement are less effective in regard to hands on time, depth, recoil and rate
  3. Ideally, patients should be resuscitated as close to the scene as operationally possible
  4. Risks and benefits should be considered before patient movement in cardiac arrest situations.

Notes/Educational Pearls

Key Considerations

  1. Effective chest compressions and defibrillation are the most important therapies to the patient in cardiac arrest. Effective chest compressions are defined as:
    1. A rate of greater than 100 and less than 120 compressions/minute
    2. Depth of at least 2 inches (5 cm) and less than 2.4 inches (6cm) for adults and children or 1.5 inches (4 cm) for infants; adolescents who have entered puberty should receive the same depth of chest compressions as an adult
    3. Allow for complete chest recoil (avoid leaning)
    4. Minimize interruptions in compressions
    5. Avoid rescuer fatigue by rotating rescuers at least every 2 minutes. Some EMS pit crew approaches use a provider on either side of the chest, alternating compressions every minute or every 100 compressions to avoid fatigue
  2. Avoid excessive ventilation:
    1. BVM/OPA ventilation: Upstroke ventilation between compressions.30:2 ventilation to compression ratio for adults, and 15:2 for children when 2 rescuers are present
    2. If an advanced airway is placed, ventilations should not exceed 10 breaths/minute (1 breath every 6 seconds or 1 breath every 10 compressions) in adults.
    3. Pediatric Consideration: For children with an advanced airway, 1 breath every 3-5 seconds is recommended (equivalent to 12-20 breaths/minute)
  3. Quantitative end-tidal CO2 should be used to monitor effectiveness of chest compressions
    1. If ETCO2 less than 10 mmHg during the initial phases of resuscitation, attempt to improve chest compression quality
    2. Consider additional monitoring with biometric feedback which may improve compliance with suggested Resuscitation section guidelines
  4. Chest compressions are usually the most rapidly applied therapy for the patient in cardiac arrest and should be applied as soon as the patient is noted to be pulseless. If the patient is being monitored with pads in place at the time of arrest, immediate defibrillation should take precedence over all other therapies, however, if there is any delay in defibrillation (for instance, in order to place pads), chest compressions should be initiated while the defibrillator is being applied. There is no guidance on how long these initial compressions should be applied; however, it is reasonable to either complete between 30 seconds and 2 minutes of chest compressions in cases of no bystander chest compressions or to perform defibrillation as soon as possible after chest compressions initiated in cases of witnessed arrest.
  5. There is insufficient evidence to recommend the routine use of extracorporeal CPR (ECPR) for patients with cardiac arrest – In settings where it can be rapidly implemented, ECPR may be considered for select cardiac arrest patients for whom the suspected etiology of the cardiac arrest is potentially reversible during a limited period of mechanical cardiorespiratory support
  6. Chest compressions should be reinitiated immediately after defibrillation as pulses, if present, are often difficult to detect and rhythm and pulse checks interrupt compressions
  7. Continue chest compressions between completion of AED analysis and AED charging
  8. Effectiveness of chest compressions decreases with any movements
    1. Patients should therefore be resuscitated as close to the point at which they are first encountered and should only be moved if the conditions on scene are unsafe or do not operationally allow for resuscitation
    2. Chest compressions are also less effective in a moving vehicle
    3. It is also dangerous to EMS providers, patients, pedestrians, and other motorists to perform chest compressions in a moving ambulance
    4. For these reasons and because in most cases the care provided by EMS providers is equivalent to that provided in emergency departments, resuscitation should occur on scene
  9. The maximum setting on the defibrillator should be used for initial and subsequent defibrillation attempts.
  10. IV or IO access without interrupting chest compressions
  11. Administer epinephrine (0.01 mg/kg, maximum dose 1 mg) IV/IO during the first or second round of compressions
  12. At present, the most effective mechanism of airway management is uncertain due to some systems managing the airway aggressively and others managing the airway with basic measures and both types of systems finding excellent outcomes. Regardless of the airway management style, consider the following principles:
    1. Airway management should not interrupt chest compressions
    2. Carefully follow ventilation rate and prevent hyperventilation
    3. Consider limited tidal volumes
    4. There is uncertainty regarding the proper goals for oxygenation during resuscitation
      1. Current recommendations suggest using the highest flow rate possible through NRB or BVM
      2. This should not be continued into the post-resuscitation phase in which the goal should be an oxygen saturation of 94-98%
    5. Pediatric Considerations: Special attention should be applied to the pediatric population and airway management/respiratory support. Given that the most likely cause of cardiac arrest is respiratory, airway management may be considered early in the patient’s care
      1. However, the order of Circulation-Airway-Breathing is still recommended as the order of priority by the American Heart Association for pediatric resuscitation in order to ensure timely initiation of chest compressions to maintain perfusion, regardless of the underlying cause of the arrest
      2. In addition, conventional CPR is preferred in children, since it is associated with better outcomes when compared to compression-only CPR
  13. Special Circumstances in Cardiac Arrest
    1. Trauma, treat per the General Trauma Management guideline
    2. Pregnancy
      1. The best hope for fetal survival is maternal survival
      2. Position the patient in the supine position with a second rescuer performing manual uterine displacement to the left in an effort to displace the gravid uterus and increase venous return by avoiding aorto-caval compression
      3. If manual displacement is unsuccessful, the patient may be placed in the left lateral tilt position at 30°. This position is less desirable than the manual uterine displacement as chest compressions are more difficult to perform in this position
      4. Chest compressions should be performed slightly higher on the sternum than in the non-pregnant patient to account for elevation of the diaphragm and abdominal contents in the obviously gravid patient
      5. Defibrillation should be performed as in non-pregnant patients
    3. Arrests of respiratory etiology (including drowning) – In addition to the above, consider early management of the patient’s airway. Passive ventilation with a NRB is not indicated for these patients.
  14. The EMS agency must perform a QI review of care and outcome, overseen by the agency medical director, for every patient that receives CPR
    1. The QI should be coordinated with local receiving hospitals to include hospital admission, discharge, and condition information. This EMS agency QI can be accomplished by participation an organized cardiac arrest registry
    2. The QI should be coordinated with local PSAP/dispatch centers to review opportunities to assure optimal recognition of possible cardiac arrest cases and provision of dispatch-assisted CPR (including hands-only CPR when appropriate)

Quality Improvement

Associated NEMSIS Protocol(s) (eProtocol.01)

  • 9914011 – Cardiac Arrest-Asystole
  • 99014013 – Cardiac Arrest-Hypothermia-Therapeutic
  • 9914015 – Cardiac Arrest-Pulseless Electrical Activity
  • 9914017 – Cardiac Arrest-Ventricular Fibrillation/Pulseless Ventricular Tachycardia)
  • 9914055 – General-Cardiac Arrest
  • 9914087 – Injury-Cardiac Arrest

Key Documentation Elements

  • Should be tailored to any locally utilized data registry but may include as a minimum the following elements:
    • Resuscitation attempted and all interventions performed
    • Arrest witnessed
    • Location of arrest
    • First monitored rhythm
    • CPR before EMS arrival
    • Outcome
    • Any ROSC
    • Presumed etiology
      • Presumed cardiac
      • Trauma
      • Submersion
      • Respiratory
      • Other non-cardiac
      • Unknown

Performance Measures

  • Time to scene
  • Time to patient
  • Time to first CPR
  • Time to first shock
  • Time of ROSC
  • Review of CPR Quality
    • Compression Fraction
    • Average and longest peri-shock pause
    • Rate and depth of compressions

References

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