Pulseless arrest

Immediate

1. Start CPR
2. Give oxygen
3. Attach monitor/defibrilator
4. Rhythm shockable?

V-Fib and Pulseless V-Tach (Shockable)

• Shock as quickly as possible and resume CPR immediately after shocking
  • Biphasic - 200J
  • Monophasic - 360 J
• Give Epi 1mg if (shock + 2min of CPR) fails to convert the rhythm
• Give antiarrhythmic if (2nd shock + 2min of CPR) again fails
  • 1st line: Amiodarone 300mg IVP w/ repeat dose of 150mg as indicated
  • 2nd line: Lidocaine 1-1.5 mg/kg then 0.5-0.75 mg/kg q5-10min
  • Polymorphic V-tach: Magnesium 2g IV, followed by maintenance infusion

Asystole and PEA (Non-Shockable)

• Epi 1mg q3-5min

• 3 & 3 Rule:

Three major mechanisms of PEA

1. Severe Hypovolemia
2. Obstruction
   • Tension Pneumothorax
   • Cardiac Tamponade
   • Massive Pulmonary Embolus
3. Pump Failure

Consider H's and T's

1. Hypovolemia
2. Hypoxia
3. Hydrogen ion (i.e. acidemia)
4. Hypo/hyperkalemia
5. Hypothermia

1. Tension Pneumothorax
2. Tamponade
3. Toxins
4. Thrombosis, pulmonary
5. Thrombosis, coronary

See Also: ACLS (Treatable Conditions)

General

• A (adjunct) - Place oropharyngeal airway
• B (breathing) - place on Ventilator to assure slow ventilation rate (attach to BVM mask)
  • 10-12 bpm, 500cc tidal volume, Fio2 100%
• C (compressions) - Switch out providers q pulse check; use metronome
• D - defibrillation
  • Ok to shock during compressions if wearing gloves and using biphasic device

• A (advanced airway)
  • Use LMA (NOT ET tube - no break in compressions required)
• B (advanced breathing)
  • Connect LMA to Ventilator
    • Pressure control 20, RR 10, insp rate 1.5-2s
• C (advanced circulation)
  • Place IO instead of central line
• D (differential)
  • Ultrasound: In Shock and Hypotension

See Also

• ACLS (Main)
• Brain Death
• Post Cardiac Arrest
• Pediatric Pulseless Arrest

Source

• Desbiens NA. Simplifying the diagnosis and management of pulseless electrical activity in adults: a qualitative review. Critical Care Medicine. 2008;36(2):391–396.
• AHA 2010 ACLS Guidelines
• EMCrit Podcast #31