2-2 ADULT CARDIAC ARREST: CARDIO-CEREBRAL RESUSCITATION

EMR - Emergency Medical Responder

1. Establish that the patient is unresponsive, without a pulse, and not breathing.
2. Check for DNR bracelet, dependent lividity, rigor mortis, or other indications to withhold CPR.
3. Initiate Resuscitation:
   1. Follow American Heart Association Guidelines for use of the AED.
4. Perform Effective Chest Compressions:
   1. Push hard and fast, between 100 - 120 compressions per minute.
   2. Allow for complete chest recoil between compressions.
   3. Use a metronome to maintain a consistent rhythm is recommended
   4. If a second rescuer is present, place have them place the AED pads without interrupting chest compressions.
   5. Switch rescuers every 200 compressions if possible
5. Determine, to the extent possible, the time the patient became pulseless.
6. Decide if the arrest is likely to be cardiac in origin. If cardiac etiology most likely, continue this algorithm. If cardiac arrest is likely due to hypoxia, choking, overdose or trauma, follow standard AHA ACLS guidelines
7. If inadequate or no bystander CPR was given administer 200 chest compressions prior to attempts at defibrillation, then proceed to next step.
8. Manage the airway if a second rescuer is present
   1. Head tilt/chin lift (jaw thrust if c-spine injury suspected)
   2. Insert an Oropharyngeal airway.
   3. Do not interrupt compressions to do this, unless absolutely necessary.
   4. Apply a NRBM at 15L/min while compressions in progress.
   5. Do not place a non-visualized airway until 3 cycles of 200 compressions have been completed, unless multiple providers are present and it can be done without interrupting CPR.
   6. If there is ROSC, provide the following supportive interventions:
      1. Support ventilation at 10-12 breaths/minute
      2. Titrate oxygen therapy to the lowest level required to maintain an oxygen saturation greater than 93%
9. If adequate bystander CPR has been performed, or 200 compressions done by EMS, prepare for immediate defibrillation by attaching defibrillator pads (if not already done) while continuing chest compressions, stopping compressions long enough to allow the AED to analyze the rhythm and shocking one time at maximum energy if a shockable rhythm is present. Restart compressions immediately after shock is delivered or no shock advised.
   1. Administer 200 chest compressions.
   2. Analyze rhythm and shock at maximum energy if shockable rhythm is present.
   3. Immediately resume chest compressions for another 200 chest compressions
   4. Analyze rhythm and shock at maximum energy if shockable rhythm is present.
   5. If no signs of circulation are present after the 3rd analysis, continue with uninterrupted compressions, move the patient to the ambulance and initiate transport. If persistent shockable rhythm is present and ALS on scene, may consider continuing to work the code on the scene.
10. Insert a non-visualized airway (NVA) while transporting, minimizing any interruptions in chest compressions. Once placed, ventilate the patient at 6 breaths a minute without interruptions in chest compressions. If unsuccessful in placement of NVA, use AHA recommended 30:2 compression to ventilation ration utilizing a bag-valve-mask (BVM).
11. If AED advises "analyze" during transport after previously regaining signs of circulation, immediately halt transport and restart the above sequence of analysis, shock and compressions. If non-shockable rhythm present, resume chest compressions and transport.
12. Call for ALS intercept
13. Prepare for transport

EMT- Emergency Medical Technician  perform/confirm all above interventions

1. Assure ALS intercept is en route
2. Reassess PNB status, continue resuscitation
3. Transport as early as possible, continuing resuscitation
4. Apply ECG monitor & run strip (if trained, if time allows and after all other interventions are completed)
5. Perform 12-lead ECG (if trained) as indicated

CONTACT MEDICAL CONTROL

AEMT – Advanced Emergency Medicine Tech   Perform/Confirm All Above Interventions

1. Initiate IV/IO NS, if approved, after 3rd analysis or sooner if possible, without interrupting CPR give NS fluid bolus, 500 mL wide open (do not delay transport) CONTACT MEDICAL CONTROL
2. Administer additional NS fluid bolus, as directed

Intermediate/Paramedic  perform/confirm all above interventions

1. Proceed with resuscitation per ACLS Guidelines.
2. Direct EMRs and EMTs to continue CPR.
3. If an advanced airway is not already in place, consider an endotracheal tube (if trained) without interrupting CPR.  Confirm placement by capnography.
4. Initiate cardiac rhythm monitoring and analysis.
5. Initiate IO if not able to initiate IV
   1. Drug administration routes in order of preference: IV – IO – ET
   2. Do not attempt to administer medications via a non-visualized airway
      1. Lack of venous access is not an acceptable indication for converting a non-visualized airway that is functioning well for ventilations to an ET tube.
      2. Rather, use IO access.
6. Asystole/PEA
   1. If Asystole appears on the monitor, confirm true asystole:
      1. Check on/off switches
      2. Check leads
      3. Check gain and sensitivity settings
      4. Confirm asystole in 2 or 3 leads
   2. Proceed to Asystole/PEA Guideline.
7. Ventricular Fibrillation / Pulseless Ventricular Tachycardia (VF / VT)
   1. Immediately defibrillate at manufacturer’s recommended energy settings
   2. Resume CPR immediately for 2 minutes do not check for pulse
   3. Rhythm/Pulse Check:  If persistent VF/VT, defibrillate at manufacturer’s recommended energy settings
   4. Resume CPR immediately for 2 minutes
   5. Administer Epinephrine 1 mg (1:10,000) IV/IO every 3-5 minutes
   6. Rhythm/Pulse Check:  If persistent VF/VT, defibrillate at manufacturer’s recommended energy settings
   7. Resume CPR immediately for 2 minutes
   8. Administer Amiodarone 300mg IV/IO bolus.  If VF/VT persists, may administer Amiodarone 150mg IV/IO bolus on second round.
   9. Restart cycle at line “C” and continue resuscitation per AHA Guidelines.
   10. Additional Anti-arrhythmic Considerations:
       1. Torsades de Pointe:
          1. Magnesium Sulfate 2 g IV/IO push over 1-2 minutes
       2. If chronic dialysis patient and/or suspected hyperkalemia:
          1. Administer Calcium Chloride 1 gram IV/IO
          2. Administer Sodium Bicarbonate 1 mEq/kg IV/IO
       3. If a Tricyclic Antidepressant overdose is suspected:
          1. Administer Sodium Bicarbonate 1 mEq/kg IV/IO
       4. If patient is taking a calcium blocking agent such as Verapamil, Nifedipine, Cardizem or Diltiazem:
          1. Administer Calcium Chloride 1 gram IV/IO
8. If pulse regained at any time, reassess rhythm & go to appropriate algorithm CONTACT MEDICAL CONTROL
9. If persistent asystole, consider quality of resuscitation and termination CONTACT MEDICAL CONTROL