Cardiopulmonary Resuscitation

Aka: Cardiopulmonary Resuscitation, ABC Management, Adult Resuscitation, Pediatric Resuscitation, Resuscitation, CPR, Cardiac Arrest, Peri-Arrest, ACLS, Advanced Cardiac Life Support, PALS, Pediatric Advanced Life Support

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II. Precautions

  1. Peri-Arrest (Unstable Arrhythmia)
    1. Per-arrest refers to unstable Arrhythmia that will degenerate into Cardiac Arrest if no immediate intervention
    2. Brief window of opportunity between Peri-Arrest and Cardiac Arrest (treat it as a code situation)
    3. Situations in which prompt management may prevent Cardiac Arrest
      1. Arrhythmia associated with Chest Pain, Heart Failure or shock
      2. Unstable Tachycardia (esp. Ventricular Tachycardia with a pulse)
      3. Unstable Bradycardia
    4. References
      1. Adaka in Herbert (2017) EM:Rap 17(1): 3-4
  2. Epinephrine in Cardiac Arrest
    1. Epinephine appears to have its most beneficial effects in the first 15-20 minutes of onset
      1. Tanaka (2016) Am J Emerg Med 34(12): 2284-90 [PubMed]
    2. After the first 15-20 minutes, Epinephrine may worsen outcomes
      1. Heart at this point has moved from electrical phase (first 5 min) and circulatory phase (10-15 min)
      2. Heart enters metabolic phase with myocardial necrosis, which may be worsened by Epinephrine
      3. Orman and Mattu in Herbert (2017) EM:Rap 17(8): 5
  3. Early intubation during Resuscitation decreases survival
    1. Intubation within first 15 minutes was associated with decreased survival
    2. Focus on effective interventions (high quality CPR, Defibrillation, Reversible Causes of Cardiopulmonary Arrest)
    3. Anderson (2017) JAMA 317(5): 494-506 +PMID: 28118660 [PubMed]
  4. Prehospital extraglottic airways (LMA, I-Gel) offer at least equal if not better survival benefit in out-of-hospital Cardiac Arrest
    1. Bag-Valve-Mask in pediatric patients is a reasonable alternative to Supraglottic Devices and intubation (PALS 2019)
    2. Benger (2018) JAMA 320(8):779-91 +PMID:30167701 [PubMed]
    3. Wang (2018) JAMA 320(8):769-78 +PMID:30167699 [PubMed]
  5. Masseter Spasm preventing Endotracheal Intubation in Cardiac Arrest
    1. Rare, but well reported phenomenon, that may be confused with rigor mortis (despite short-arrest time)
    2. If no response to high dose paralytics, move quickly to surgical airway (Cricothyrotomy)
    3. Lee (2012) Am J Emerg Med 30(6):1014.e1-2 +PMID: 21676574 [PubMed]
    4. Swaminathan and Weingart (2024) Critical Care Hodgepodge, EM:Rap 7/7/2024
  6. Patients who awaken during Cardiac Arrest
    1. High quality CPR (esp with compression devices) may result in a conscious patient before ROSC
    2. Consider Ketamine 1 mg/kg IV which is least likely to affect hemodynamics and successful ROSC
    3. Weingart and Swaminathan in Herbert (2022) EM:Rap 22(2): 2-4
  7. Echocardiogram during Resuscitation
    1. Precautions
      1. Ultrasound during pulse checks doubles the time without Chest Compressions
      2. Have staff count down during pulse check from 10 to 0, and remove Ultrasound probe at 2
      3. Consider recording a 6 second Ultrasound video that can be reviewed after Chest Compressions resume
      4. Avoid using with each pulse check (only use with specific goal, e.g. confirm Asystole)
      5. Orman and Reed in Herbert (2018) EM:Rap 18(3): 3-4
      6. Huis (2017) Resuscitation 119:95-8 +PMID:28754527 [PubMed]
    2. Identifies Reversible Causes of Cardiopulmonary Arrest
      1. Cardiac Tamponade
      2. Hypovolemia
      3. Tension Pneumothorax
      4. Myocardial Infarction
      5. Pulmonary Embolism
      6. Hemorrhagic Shock (e.g. Ruptured Abdominal Aortic Aneurysm, Trauma)
    3. Cardiac activity definition
      1. Intrinsic myocardial movement
      2. Isolated cardiac valve movement occurs with minimal Fluid Shifts (3 mmHg) and is NOT cardiac activity
      3. Absence of cardiac activity on ulrasound is not recommended as a prognostic indicator (AHA 2020)
        1. ROSC is ultimately achieved in 2.4% of patients without wall motion on Ultrasound
          1. Blyth (2012) Acad Emerg Med 19(10):1119-26 +PMID: 23039118 [PubMed]
        2. Cardiac standstill has variable inter-rater reliability
          1. Hu (2018) Ann Emerg Med 71(2):193-8 +PMID: 28870394 [PubMed]
    4. Monitors Compression quality
      1. Consider using Ultrasound over the femoral artery to follow circulation, compression quality
    5. References
      1. Swaminathan, Andrus and Mallon in Herbert (2018) EM:Rap 18(1): 8-9
  8. ECMO-Assisted CPR (PALS-2019)
    1. Consider for in-hospital pediatric arrest in known Congenital Heart Disease or Myocarditis
    2. Survival 48-73% for ECMO-assisted compared with 29-44% for standard CPR and in hospital arrest
    3. However, good neurologic outcome at 12 months in 30% of Cardiac Arrest revived with ECMO-Assisted CPR
    4. Claudius and Behar in Herbert (2020) EM:Rap 20(10): 9

III. Protocol

  1. ATLS is integrated with ACLS and PALS for the purposes of this reference
    1. Typically ACLS, ATLS, PALS are taught in isolation (outside CALS Course)
  2. PALS and APLS (2019 guidelines)
    1. Rapid global assessment tool
      1. See Pediatric Assessment Triangle
    2. Most pediatric Cardiac Arrests result from respiratory decompensation
    3. Bag-valve-mask is a resonable alternative to Advanced Airway (LMA, Endotracheal Intubation) out of hospital
    4. ECMO may be considered in pediatric Cardiac Arrest patients with a cardiac diagnosis (e.g. Congenital Heart Disease)
    5. Targeted Temperature Management (TTM) of 36 C to 37.5 C appears equivalent to lower Temperature targets
      1. If TTM is used, may follow either target, and overall prevent fever >37.5 C (99.5 F)
    6. References
      1. Duff (2019) Circulation 140(24):e904-14 +PMID:31722551 [PubMed]
  3. ACLS guidelines 2010 focuses on Cardiac Compressions as the first line intervention
    1. Mnemonic is 'C-A-B' to emphasize compressions
      1. Chest Compressions are started within 10 seconds of recognition of arrest
        1. Health care providers start with a pulse check prior to compressions
        2. First-responders start compressions without a pulse check to minimize delays
      2. Compressions are hard (at least 2 inches or 5 cm deep in adults)
      3. Compressions are fast (30 compressions within 18 seconds)
        1. Avoid rates above 140 beats per minute (associated with worse outcomes)
        2. Idris (2012) Circulation 125(24): 3004-12 [PubMed]
      4. Hands-only CPR (without breaths) is recommended for untrained rescuers
    2. Cardiac Compressions are continued, interrupted only for <10 seconds for rhythm checks and Defibrillation
      1. Bedside focused Echocardiogram performed during rhythm checks
      2. Intubate without interrupting compressions
    3. Automatic compression devices (e.g. Lucas) are recommended where available
      1. Improved short-term outcomes (but not long-term outcomes to date)
    4. Induced Therapeutic Hypothermia
      1. Improved neurologic outcomes in patients with ROSC
    5. Start charging the Defibrillator before CPR is paused (decreases hands-off time)
      1. Defibrillator fully charged when CPR paused
      2. Immediate shock can be delivered at rhythm check and CPR resumed
      3. Edelson (2010) Resuscitation 81(11):1521-6 +PMID:20807672 [PubMed]
    6. Avoid cardiac compression interruptions (minimize most procedures until ROSC)
      1. Obtain early IV Access (or IO Access if failed 2 attempts)
        1. Defer early central venous access or Arterial Lines until ROSC
      2. Avoid early intubation (see above)
        1. Consider Supraglottic Airway (e.g. LMA) to assist oxygenation and ventilation

IV. Preparation: Emergency Department

  1. Pre-Briefing
    1. First 2-3 minutes prior to patient arrival is critical to successful Resuscitation and survival
    2. Gather Resuscitation team together prior to Ambulance arrival
      1. Review known information with expected course and interventions
      2. Discuss backup plans
      3. Leader scripts the first 3-5 minutes of Resuscitation with specific tasks for specific team members
    3. Roles are assigned prior to patient arrival (consider applying labels to front of gowns)
      1. Provider Running the Resuscitation or code stands at the foot of the bed
      2. Provider managing the airway and neurologic evaluation stands at the head of the bed
      3. Divide into teams for certain complex tasks (e.g. airway management)
  2. Preparation Mnemonic: AEIOU
    1. Advanced Airway equipment
      1. Place in Resuscitation room
      2. Provider responsible for airway is at head of bed
    2. End-Tidal CO2 detector
      1. Connect and prepare device
    3. Intraosseous Line
      1. Confirm IO kit is available
    4. Organization and Order
      1. Gather and role assignment (see above)
      2. Delegation of tasks allows for cognitive unloading (see above)
        1. See Decision Making Strategy
        2. Employ decision making aids (e.g. Broselow Tape)
      3. Sustain a Shared Mental Model
        1. Summarize and walk through decision making out loud
        2. Train together in simulations to develop strategy and patterns of communication
      4. Keep two way communication open
        1. Make team members comfortable with offering suggestions, feedback
        2. Team leader may ask "What am I missing?" to open conversation for suggestions
    5. Ultrasound
      1. Place in Resuscitation room and prepare (turn on, select probe and apply gel)
  3. Paramedic report and transfer of care should be initial focus on patient arrival
    1. Allow Paramedics to give history, findings, answer team questions, relay Resuscitation efforts
    2. Avoid chatter that interferes with the team hearing Paramedic report
  4. Additional team management techniques
    1. Use closed loop communication
      1. Use precise language directed at a specific person by name you intend to perform a task
      2. Practice clarification and acknowledgement of assigned tasks
      3. Limit orders to no more than 2 to 3 per each team member at a time
    2. Offer feedback with graded assertiveness (Mnemonic: CUSS)
      1. Concern expressed regarding interventions with unclear reason or that are unsafe
      2. Uncomfortable
      3. Safety
      4. Stop
    3. Other measures
      1. Establish clear leadership roles at the time of presentation
      2. Allow for patient access in a near 360 degree circle around the patient
      3. Ensure monitors are visible from all patient care positions
      4. Keep highly used Resuscitation equipment near bedside including bedside procedure carts
      5. Keep a Running code log of interventions visible to all (e.g. white board)
      6. Divide clinical work evenly to avoid overwhelming individual team members
  5. References
    1. Herbert et al in Herbert (2016) EM:Rap 16(3): 5-6
    2. Swaminathan and Hicks in Herbert (2019) EM:Rap 19(12): 8-9
    3. Swaminathan, Petrosoniak and Hicks in Herbert (2021) EM:Rap 21(9): 4-6

V. Approach: Pronouncement of Death (in the Field or Emergency Department

  1. Specific circumstances
    1. Ventricular Fibrillation or Ventricular Tachycardia (shockable rhythms)
      1. Most likely to identify a reversible cause and to respond to Resuscitation efforts
      2. Maintain high quality CPR
      3. Consider transport to ECMO or cath lab if refractory Ventricular Fibrillation or Ventricular Tachycardia
    2. Asystole
      1. Indications to continue efforts
        1. Initial rhythm of Asystole in unwitnessed arrest without obvious signs of death
      2. Indications to cease efforts
        1. Persistent Asystole for >20 minutes of Resuscitation efforts (Neuro intact survival <1%)
    3. Pulseless Electrical Activity (PEA)
      1. Indications to continue efforts
        1. Heart Rate >40-60 per minute
        2. End-Tidal CO2 trending >20
      2. Indications to cease efforts
        1. Point-Of-Care Ultrasound without cardiac activity
        2. End-Tidal CO2 persistently 5-10 or less for 20-25 minutes despite Resuscitation
        3. Persistent PEA for >60 minutes of Resuscitation efforts (Neuro intact survival <2%)
        4. Age alone does not impact decision to continue Resuscitation
    4. Obesity and pseudo-PEA
      1. Obese patients are at high risk for Pseudo-EMD (pulses not palpable due to Obesity)
      2. Consider empiric IV fluid bolus (and Vasopressor) if Pseudo-EMD suspected
      3. EMS should transport for bedside Echocardiogram for cardiac standstill if in doubt
      4. Allow for adequate Resuscitation efforts before pronouncement
        1. Duration of code until ROSC is >20 minutes in 25% of Cardiac Arrest cases
        2. Goldberger (2012) Lancet 380(9852): 1473-81 [PubMed]
    5. Prolonged Resuscitation
      1. Consider ceasing Resuscitation efforts after >45 to 55 minutes of high quality CPR, ACLS
      2. Low likelihood of good neurologic outcomes with prolonged Resuscitation
        1. Witnessed arrest with maintained high quality CPR to ECMO may warrant continued efforts
    6. Low Baseline Quality of Life (e.g. Advanced Dementia, end-stage COPD, CHF, metastatic cancer)
      1. Those who survive Cardiac Arrest will have a lower quality of life than before the arrest
      2. Discuss with family or other POA when considering Stopping Resuscitation efforts
  2. Criteria (all three together predict nearly 0% chance of survival)
    1. No Return of Spontaneous Circulation (ROSC) prior to transport AND
    2. Cardiac Arrest was not witnessed AND
    3. Rhythm was not shockable
    4. Morrison (2009) Resuscitation 80(3): 324-8 [PubMed]
  3. References
    1. Braude and Myers in Herbert (2016) EM:Rap 16(2): 18-9
    2. Shinar and Swadron in Herbert (2013) EM:Rap 13(3): 4-5
    3. Weingart and Swaminathan in Swadron (2022) EM:Rap 22(1): 3-5

VI. Management: Assess Responsiveness

  1. Responsive
    1. See Rapid ABC Assessment
  2. Unresponsive
    1. See Altered Level of Consciousness
    2. Call for Help
      1. Call for Defibrillator if available
      2. Activate EMS after initial ABC assessment

VII. Management: Emergency Airway

  1. See Primary Survey Airway Evaluation
  2. Position
    1. Turn on back as unit
    2. Support head and neck while positioning
    3. Place on hard firm surface
  3. Open airway
    1. Jaw Thrust (if suspected neck injury)
    2. Head Tilt-Chin Lift Maneuver
  4. Trauma points (Primary Survey Airway Evaluation )
    1. Is the patient speaking or vocalizing?
    2. Observe for foreign bodies, dentures and facial deformities interfering with airway maintenance
    3. Primary Survey Disability Evaluation (brief Neurologic Exam)
      1. Also described below as the D-part of the ABCDE Trauma algorithm
      2. Can be performed with airway (GCS, pupils and motor in all extremities)
      3. Critical to perform with airway if Rapid Sequence Intubation (RSI) or Conscious Sedation administered

VIII. Management: Emergency Breathing

  1. See Primary Survey Breathing Evaluation
  2. Breathing is assessed by medical providers concurrently with responsiveness
    1. Look Listen and feel for breathing has been removed from the ACLS and PALS sequence
  3. Rescue breaths are now started after one cycle of compressions (in Cardiac Arrest)
    1. New sequence: Compressions, open airway, give breaths
  4. Attempt 2 ventilations (each lasting 1 second) if not breathing
    1. Observe chest rise
    2. Allow deflation between breaths
    3. Reposition if first breath does not go in
  5. Airway Obstruction (if ventilations unsuccessful)
    1. No blind finger sweeps at any age
    2. Unconscious
      1. Deliver full CPR regardless of airway obstruction
    3. Conscious
      1. Perform Heimlich Maneuver
        1. Infants: 5 chest thrusts and 5 back blows
        2. Children: 5 abdominal thrusts
        3. Adults: 6-10 abdominal thrusts
      2. Attempt ventilation
      3. Repeat cycle until obstruction cleared
  6. Trauma points (Primary Survey Breathing Evaluation)
    1. Palpate the chest for deformities, Flail Chest or open wounds
    2. Breath sounds are most useful when absent
      1. Treat asymmetrically absent breath sounds as a Pneumothorax
      2. Presence of breath sounds does not exclude Pneumothorax

IX. Management: Emergency Circulation

  1. See Primary Survey Circulation Evaluation
  2. Assess for Pulse (health care providers)
    1. Brachial pulse in infants
    2. Carotid pulse in children and adults
  3. Pulse Present: Perform Rescue Breathing (reassess every 2 minutes)
    1. Endotracheal Tube: 1 breath per 6-8 seconds for all ages (8 to 10 breaths per minute)
    2. Adult: 10 breaths per minute (every 6 seconds) in BLS
      1. Replaces Adult: 12 breaths/min (every 5 sec)
    3. Infant and Child breaths: 20-30 breaths/min (every 2-3 seconds) in BLS
      1. Replaces Child: 15 breaths per minute (every 4 seconds)
      2. Replaces Infant: 20 breaths per minute (every 3 seconds)
  4. Pulse Absent: Chest Compressions
    1. General
      1. Pulse check should be <10 seconds
        1. EtCO2 is a reliable marker for ROSC (if pulses are difficult to palpate)
        2. Bedside Ultrasound may prolong pulse checks (restart compressions on timer)
        3. Huis (2017) Resuscitation 119:95-98 PMID:28754527 [PubMed]
      2. Perform 5 cycles in 2 minutes
      3. Reassess pulse and rhythm every 2 minutes
      4. Focus on pressing hard and fast with minimal interruptions
      5. Connect Automatic External Defibrillator as soon as available
      6. Time interval for lone rescuer calling for help
        1. Sudden Collapse: Call immediately
          1. Minimizes time to AED application
        2. Asphyxial arrest: Perform CPR for 2 minutes
      7. Two rescuers switch places every 2 minutes
        1. Prevents rescuer Fatigue with Chest Compressions
        2. Repeat pulse and rhythm checks with the change
    2. Infants (Under 1 year old)
      1. Place 2 fingers at just below mid-nipple line
        1. Alternatively, hands encircle chest and both thumbs compress chest
      2. Compress over 100 times per minute
        1. Depth: One third of chest depth (1.5 inches or 4 cm)
        2. Compression to ventilation ratio
          1. Infant <1 month old: 3:1
          2. One rescuer: 30:2
          3. Two health care providers: 15:2
    3. Children (1-8 years old)
      1. One hand placed over Sternum at center of chest (superior to xiphoid)
      2. Compress over 100 times per minute
        1. Depth: One third of chest depth (2 inches or 5 cm)
        2. Compression to ventilation ratio
          1. One rescuer: 30:2
          2. Two health care providers: 15:2
    4. Adults (over 8 years old)
      1. Two hands placed over Sternum at center of chest (superior to xiphoid)
      2. Compress 100 times per minute
        1. Depth: 2 inches or 5 cm
        2. Compression to ventilation ratio: 30:2 (one or two rescuers)
  5. Trauma Points (Primary Survey Circulation Evaluation)
    1. See Primary Survey Circulation Evaluation
    2. Warm feet are a reassuring sign (cold feet might suggest shock state)
    3. Palpate the Abdomen for distention or signs of injury (source of occult bleeding)
    4. Compress the Pelvis by pushing both iliac crests together with force
      1. Assess for anterior or posterior Pelvis injury
      2. If the Pelvis moves inward on compression
        1. Hold this position and apply a Pelvic Binder for stabilization
        2. Do not repeat this exam in an unstable Pelvis

X. Management: Trauma Disability Points (Primary Survey Disability Evaluation)

  1. May be performed simultaneously with the airway evaluation above
  2. Glasgow Coma Scale
  3. Pupil Reaction
  4. Can patient move all extremities?
    1. In Trauma, do not paralyze and intubate the patient prior to assessing for Spinal Cord Injury with paralysis

XI. Management: Trauma Exposure Points (Primary Survey Exposure Evaluation)

  1. All clothing should be removed to completely assess for injuries
  2. Exposure Penetrating Trauma first
  3. Mnemonic: Armpits, Back, Butt cheeks and Sac
    1. Assess for easily missed sites of injury
  4. Apply warm blankets

XII. Management: Trauma - Additional Points

  1. Fast and Glucose/Girl (F and G in the Trauma ABCDEFG)
    1. Perform FAST Exam (Ultrasound)
    2. Check Serum Glucose
    3. Check serum or Urine Pregnancy Test
  2. Spine Precautions
    1. Backboard may be discontinued when Primary Survey completed
    2. Even with Spinal Injury, Backboard risks are much greater than benefit and should be removed soon after arrival
  3. Imaging
    1. CT Head
      1. Indicated for signs of Head Injury (especially if anticoagulated, Intoxication)
      2. See Head Injury CT Indications in Adults
      3. See Head Injury CT Indications in Children (PECARN)
    2. CT C-Spine
      1. Indicated for any ill patient who needs spine imaging (replaces Cross Table lateral XRay)
      2. See Cervical Spine Imaging in Acute Traumatic Injury (e.g. NEXUS Criteria)
    3. Chest XRay for all Trauma patients
    4. CT Abdomen and Pelvis
      1. May skip if benign Abdomen and Pelvis without pain, tenderness and if vitals signs stable

XIII. Management: Rhythm - Pulse Absent in adults and children (ACLS and PALS)

  1. See Reversible Causes of Cardiopulmonary Arrest (5H5T)
  2. Shockable Rhythm: Ventricular Fibrillation or Pulseless Ventricular Tachycardia
    1. Defibrillate every 2 minutes
      1. Adult: Biphasic dose varies by device (120-200 J); Monophasic dose 360 J
      2. Children: Start at 2-4 J/kg, then 4 J/kg
      3. Start charging the Defibrillator before CPR is paused (decreases hands-off time)
        1. See above for reference
    2. CPR
      1. Performed continuously between shocks (minimal interruptions)
    3. Alpha-adrenergic agent (choose one)
      1. Epinephrine
        1. Adult: 1 mg every 3-5 minutes
        2. Child: 0.01 mg/kg (0.1 ml/kg of 1:10,000) repeated every 3-5 minutes
      2. Vasopressin (not commonly used in community EDs and removed from 2015 ACLS guidelines)
        1. Adult: 40 units for 1 dose
    4. Antiarrhythmic
      1. Amiodarone (preferred)
        1. Adult: 300 mg IV (may subsequently repeat once at dose 150 mg)
        2. Child: 5 mg/kg bolus (and may be repeated up to twice for refractory VF/VT)
      2. Lidocaine (alternative for adults, not recommended in children)
        1. Adult: 1-1.5 mg/kg IV (may subsequently repeat dose at 0.5 to 0.75 mg/kg)
    5. Magnesium (for Torsades de Pointes)
      1. Adult: 1-2 g IV
      2. Child: 25 to 50 mg/kg IV or IO
  3. Non-shockable Rhythm: Asystole or Pulseless Electrical Activity (PEA)
    1. Key management is to identify and treat Reversible Causes of Cardiopulmonary Arrest (5H5T)
    2. Epinephrine
      1. Adult: 1 mg every 3-5 minutes
      2. Child: 0.01 mg/kg (0.1 ml/kg of 1:10,000) repeated every 3-5 minutes
    3. Vasopressin (not commonly used in community EDs and out of 2015 AHA guidelines)
      1. Adult: 40 units for 1 dose
    4. Atropine is no longer recommended as of 2010 guidelines
      1. Was previously given at 1 mg IV for Asystole or Slow PEA
  4. Other experimental measures
    1. Vasopressin 20 units
      1. No longer part of AHA pulseless algorithm guidelines as of 2015 (prior alternative to epi)
      2. Vasopressin is given in addition to Epinephrine per protocol
        1. Vasopressin may be better at maintaining brain perfusion
        2. Epinephrine appears better at achieving ROSC
      3. Consider Vasopressin when low End-Tidal CO2 (e.g. 20) despite high quality CPR
      4. Early studies suggest improved survival
      5. Orman and Weingart in Herbert (2015) EM:Rap 15(1): 14-6
      6. Mentzelopoulus (2013) JAMA 310(3): 270-9 [PubMed]
    2. Esmolol
      1. May be considered for refractory Ventricular Fibrillation in adults (based on small study)
      2. Dose: 500 mcg/kg (folllowed by infusion at 0-100 mcg/kg/min)
      3. Driver (2014) Resuscitation 85(10): 1337-41 +PMID:25033747 [PubMed]
    3. Double sequential external Defibrillation
      1. Two Defibrillators with pads right-left, front-back deliver maximal shock simultaneously
      2. May be considered in refractory Ventricular Fibrillation in adults (esp. obese)
      3. Cheskes (2023) Intensive Care Med 49(4):455-7 +PMID: 36754880 [PubMed]
  5. Other measures to avoid unless specifically indicated
    1. Empiric Calcium Administration (without specific indication)
      1. Routine Calcium administration is associated with worse outcomes in out of hospital Cardiac Arrest
      2. Messias Hirano Padrao (2022) Resusc Plus 12:100315 +PMID: 36238582 [PubMed]

XIV. Management: Rhythm - Pulse Present - Unstable in adults and children (ACLS and PALS)

  1. See Reversible Causes of Cardiopulmonary Arrest (5H5T)
  2. Indications for Unstable Status
    1. Chest Pain
    2. Hypotension or other signs of shock
    3. Altered Level of Consciousness
  3. Bradycardia (symptomatic with hemodynamic instability)
    1. See Unstable Bradycardia
    2. Perform CPR in children for Heart Rate <60/min with signs of hypoperfusion
    3. Atrioventricular Block (AV Block): Mobitz 2 or third degree
      1. Transcutaneous Pacing
      2. Prepare for Transvenous Pacing
    4. No AV Block (or first degree or Wenckebach)
      1. Adults
        1. Atropine 0.5 mg IV (may repeat up to a cummulative total of 3 mg)
        2. Transcutaneous Pacing
        3. Chronotropes (alternative to Transcutaneous Pacing)
          1. Epinephrine 2-10 mcg/min
          2. Dopamine 2-10 mcg/kg/min
      2. Children
        1. Epinephrine 0.01 mg/kg (0.1 ml/kg of 1:10,000) repeated every 3-5 minutes
        2. Atropine 0.02 mg/kg and may repeated once (min to max dose: 0.1 mg to 0.5 mg)
          1. Indicated if increased vagal tone or primary Atrioventricular Block
        3. Transcutaneous Pacing
  4. Tachycardia: Synchronized Cardioversion
    1. See Unstable Tachycardia
    2. Conscious Sedation if no delays
    3. Adults
      1. Start at 120 joules for biphasic Defibrillator or 50 Joules for monophasic Defibrillator
        1. Paroxysmal Supraventricular Tachycardia (PSVT)
        2. Atrial Flutter
      2. Start at 150 joules for biphasic Defibrillator or 100 Joules for monophasic Defibrillator
        1. Atrial Fibrillation
        2. Monomorphic Ventricular Tachycardia
      3. Start at 200 joules for biphasic Defibrillator or 360 Joules for monophasic Defibrillator
        1. Polymorphic Ventricular Tachycardia (Unsynchronized Shock will likely be required)
    4. Children
      1. Initial: 0.5 to 1 J/kg
      2. Refractory: 2 J/kg

XV. Management: Rhythm - Pulse Present - Stable - Bradycardia in adults and children (ACLS and PALS)

  1. Indicated if unstable criteria above not met
  2. Bradycardia
    1. Evaluate for Sinus Bradycardia causes
    2. Observe for change in status

XVI. Management: Rhythm - Pulse Present - Stable - Tachycardia in Adults (ACLS)

  1. Indicated if unstable criteria above not met
  2. See Reversible Causes of Cardiopulmonary Arrest (5H5T)
  3. Wide Complex Tachycardia (QRS wider than 0.12 msec)
    1. Regular Wide Complex Tachycardia
      1. Start with Adenosine 6 mg IV (may repeat with 12 mg IV)
        1. Benign and slows the rhythm for interpretation
        2. Helps to differentiate SVT with aberrancy from VT
      2. Supraventricular Tachycardia with Aberrancy
        1. Treat as Regular Narrow Complex Tachycardia (see below)
      3. Ventricular Tachycardia
        1. Amiodarone 150 mg IV over 10 min (followed by infusion)
          1. Procainamide is more effective than Amiodarone
          2. Procainamide may be preferred if no CHF or Prolonged QT Interval
        2. Synchronized Cardioversion
        3. Alternative Antiarrhythmics
          1. Procainamide (if no CHF and no Prolonged QT Interval)
          2. Sotalol 100 mg (1.g mg/kg) IV over 5 min (if no Prolonged QT Interval)
    2. Irregular Wide Complex Tachycardia
      1. Atrial Fibrillation with WPW
        1. Amiodarone 150 mg IV
        2. Consult with cardiology
        3. Avoid Beta Blockers, Calcium Channel Blockers, Digoxin, Adenosine
      2. Atrial Fibrillation with aberrancy
        1. Treat as Irregular Narrow Complex Tachycardia (see below)
      3. Torsades de Pointes
        1. Magnesium 1-2 grams IV
        2. Synchronized Cardioversion (or Defibrillation if unable to sync)
        3. Over-drive Transcutaneous Pacing
  4. Narrow Complex Tachycardia
    1. Regular Narrow Complex Tachycardia
      1. Vagal Maneuvers
      2. Adenosine 6 mg and may repeat at 12 mg dose
        1. Conversion with Adenosine suggests Paroxysmal Supraventricular Tachycardia (PSVT)
        2. Recurrence can be treated with Adenosine, Diltiazem or Lopressor
      3. Rate control
        1. Rate control with Diltiazem or Lopressor (see below)
        2. Refractory to Adenosine causes
          1. Atrial Flutter
          2. Ectopic Atrial Tachycardia
          3. Junctional Tachycardia
    2. Irregular Narrow Complex Tachycardia
      1. Occurs with Atrial Fibrillation, Atrial Flutter or Multifocal Atrial Tachycardia (MAT)
      2. Avoid Adenosine (risk of Ventricular Fibrillation)
      3. Rate control
        1. Diltiazem
          1. Bolus 1: 20 mg (0.25 mg/kg) IV bolus over 2 min
          2. Bolus 2: 25 mg (0.35 mg/kg) IV bolus over 2 min
            1. Administer if indicated, and at least 15 min after first
          3. Drip: 10 mg/hour (typical range: 5-15 mg/hour)
        2. Metoprolol (Lopressor)
          1. Avoid in acute CHF or COPD exacerbation
          2. Bolus: 2.5 to 5 mg IV every 2-5 min (maximum 15 mg in 15 min)

XVII. Management: Rhythm - Pulse Present - Stable - Tachycardia in Children (PALS)

  1. Indicated if unstable criteria above not met
  2. See Reversible Causes of Cardiopulmonary Arrest (5H5T)
  3. Wide Complex Tachycardia (QRS wider than 0.09 msec; contrast with 0.12 in adults)
    1. Consider Ventricular Tachycardia
    2. Unstable Wide Complex Tachycardia
      1. See Unstable Tachycardia above
      2. Synchronized Cardioversion
    3. Stable, regular Wide Complex Tachycardia
      1. Consider SVT with aberrancy if monomorphic QRS and regular rhythm
      2. Adenosine
        1. Do not use Adenosine if rhythm irregular (risk of WPW or rhythm degeneration)
        2. First: 0.1 mg/kg (maximum 6 mg)
        3. Second: 0.2 mg/kg (maximum 12 mg)
    4. Stable, irregular or refractory Wide Complex Tachycardia
      1. Precautions
        1. Consult cardiology about recommended Antiarrhythmic
        2. Avoid combining Amiodarone and Procainamide
      2. Agents
        1. Amiodarone 5 mg/kg over 20-60 minutes
        2. Procainamide 15 mg/kg IV over 30-60 minutes
  4. Narrow Complex Tachycardia (QRS 0.09 msec or less; contrast with 0.12 in adults)
    1. Sinus Tachycardia
      1. Findings
        1. Normal P Waves, variable R-R with a constant PR Interval
        2. Heart Rate <180 in children (<220 in infants)
      2. See Sinus Tachycardia
      3. Indentify and treat underlying cause
    2. Supraventricular Tachycardia
      1. Findings
        1. Abnormal or absent P Waves
        2. Constant Heart Rate >180 in children (>220 in infants)
      2. Vagal Maneuvers if no delays
      3. Adenosine (if regular rhythm)
        1. Do not use Adenosine if rhythm irregular (risk of WPW or rhythm degeneration)
        2. First: 0.1 mg/kg (maximum 6 mg)
        3. Second: 0.2 mg/kg (maximum 12 mg)
      4. Synchronized Cardioversion
        1. Indicated for irregular rapid rhythm or SVT refractory to above measures

XVIII. Management: Additional measures

  1. See Reversible Causes of Cardiopulmonary Arrest
  2. See Post-Cardiac Arrest Care
  3. Post-arrest pronouncement in the emergency department
    1. Consider a moment of silence for deceased patient at end of Resuscitation attempt
    2. Strayer in Herbert (2018) EM:Rap 18(2): 3

XIX. Resources

  1. Cardiopulmonary Resuscitation Guidelines
    1. http://www.circulationaha.org

XX. References

  1. Trauma
    1. (2008) ATLS Manual, American College of Surgeons
    2. Majoewsky (2012) EMR:RAPC3 2(1): 1-2
  2. Cardiopulmonary Resuscitation Guidelines
    1. Mace (2013) Crit Dec Emerg Med 27(1): 11-20
    2. Mace (2013) Crit Dec Emerg Med 27(2): 2-10
    3. (2010) Guidelines for CPR and ECC [PubMed]
    4. (2005) Circulation 112(Suppl 112):IV [PubMed]
    5. (2000) Circulation, 102(Suppl I):86-9 [PubMed]

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