Resuscitation Precautions

Aka: Resuscitation Precautions

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II. Precautions: General

  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. Shock refractory VT/VF
    1. Consider dual sequential external Defibrillation in refractory shockable rhythm
  3. 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
  4. Pulse checks during CPR
    1. Manual pulse palpation is inaccurate, often delays CPR, and defers it when it is indicated
      1. Central pulses may be palpated despite inadequate organ perfusion
      2. Rescuers may mistakenly feel a pulse that is not actually there
      3. Eberle (1996) Resuscitation 33(2):107-16 +PMID: 9025126 [PubMed]
    2. Alternatives to manual pulse checks are preferred when available
      1. Femoral Arterial Line
        1. Accurate and immediate, realt-time SBP, DBP, MAP and perfusion pressures
      2. Quantitative End-Tidal CO2 (EtCO2)
        1. Sudden increase in EtCO2 >10 mmHg suggests ROSC (best prognosis if >20 mmHg)
      3. Linear probe Ultrasound over carotid or Femoral Pulses
        1. Arterial pulsations (carotid, femoral) despite venous compression (IJ, femoral) suggests perfusing pulse
        2. Pulse wave doppler with Peak Systolic Velocity >20 cm correlates with SBP>60 mmHg
    3. References
      1. Mallemat and Swaminathan (2025) Pulse Checks, 2/25/2025
  5. 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. Precautions: Airway

  1. 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]
  2. 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]
  3. 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

IV. Precautions: Medications

  1. 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
  2. Naloxone
    1. Consider Naloxone 2 mg IV/IO early in Resuscitation when suspected Opiate-induced Cardiac Arrest
    2. Dillon (2024) JAMA Netw Open 7(8):e2429154 +PMID: 39163042 [PubMed]
    3. Strong (2024) Resuscitation 201:110263 +PMID: 38848964 [PubMed]

V. Precautions: Imaging

  1. Transthoracic Echocardiogram (TTE) 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
  2. Transesophageal Echocardiogram (TEE) during Resuscitation
    1. Technique
      1. TEE is placed in similar fashion to a large Orogastric Tube
    2. Benefits over TTE
      1. Does not interfere with CPR (continuous with compressions)
      2. Differentiates fine Ventricular Fibrillation from Asystole
      3. Identifies reversible Cardiac Arrest causes
        1. Fine Ventricular Fibrillation (differentiates from Asystole)
        2. Cardiac Tamponade
        3. Aortic Dissection
        4. Right ventricular strain in massive Pulmonary Embolism
      4. May improve cardiac compression quality
        1. Identifies chest region of maximal left ventricular compression
        2. Can measure chest compression depth (using M-Mode over Sternum)
      5. Changes management in up to 75-80% of Cardiac Arrests
        1. Mortality benefit has not been studied
    3. Disadvantages
      1. Requires an intubated patient
      2. Requires specific training, credentialing, supervision and experience
      3. Risk of probe injury to pharynx, Esophagus and Stomach
    4. References
      1. Mallemat and Swaminathan (2025) EM:Rap, published 12/8/2025
      2. Teran (2025) J Intensive Care Med 40(11):1133-1142 +PMID: 40096050 [PubMed]
      3. Kegel (2023) Scand J Trauma Resusc Emerg Med 31(1):24 +PMID: 37210538 [PubMed]

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