RISK FACTORS : Male, Increasing age, Hypercholesterolemia, Hypertension, Cigarette smoking, Positive family history of atherosclerosis
GENERAL MEASURES :
. DEFIBRILATION FIRST
. Adult: 200, 300, or 360J
. Children: Use largest paddles that will fit on child even adult size if can get good contact. Defibrillate at 2J/kg once. Increase to 4J/kg twice.
. 100% oxygen by bag-valve-mask or endotracheal tube (preferred)
. Start 2 IVs as close to the heart as possible (central line OK but dont waste time). Large bore peripheral
lines can deliver fl uid more quickly than a central line. This is especially important in PEA secondary to
hypovolemia.
. Perform CPR including closed chest compression. Intermittent abdominal compression and active compression/decompression show no survival advantage.
. Keep patient warm if possible, especially in children
. Monitor:
. Pulse after three initial defibrillations
. Check monitor between each defibrillation and after any intervention
. Use end-tidal CO2 monitor to assess gas exchange, if available. Esophageal intubation will produce a very
low end-tidal CO2.
SURGICAL MEASURES : If indicated:
. Pericardiocentesis to treat cardiac tamponade
. Needle decompression (second intercostal space midclavicular line), then chest tube insertion to treat tension pneumothorax
DRUG(S) OF CHOICE :
. Lidocaine, atropine, naloxone, and epinephrine [LANE] can all be given by endotracheal tube. Follow by 10 cc of NS or sterile water followed by bagging.
. Epinephrine:
. 1 mL = 1 mg (1:1000)
. 1 mL = 0.1 mg (1:10,000)
ADULT: Ventricular tachycardia and pulseless ventricular tachycardia. Use in order listed below:
. Defibrillate x3 at 200J, 300J, 360J
. Check monitor rhythm
. Follow each drug administration by repeated defibrillation at 360J
. Check monitor and pulses after each subsequent intervention
. Epinephrine: 1 mg IV every 3-5 minutes or vasopressin 40U IV single dose, one time only. May choose to
resume epinephrine if no response after a single dose of vasopressin. High dose epinephrine is permissible
but discouraged and may actually worsen outcomes.
. Amiodarone 300 mg IV push may be used prior to lidocaine
. Lidocaine: 1.5 mg/kg IV, repeat in 5 minutes to total dose of 3 mg/kg
. Magnesium sulfate: 1-2 mg IV in suspected Torsades de pointes or refractory V-fi b/V-tach
. Procainamide 30 mg/min IV in refractory V-fi b/V-tach (maximum dose of 17 mg/kg) is permissible. However,
since the time to a useful level by infusion is so long, it is discouraged and is unlikely to be of any benefi t. No
improvement in survival to discharge.
. Bicarbonate: 1 mEq/kg IV only in known preexisting bicarbonate responsive acidosis, tricyclic overdose, to
alkalinize the urine in known overdose
ADULT: Asystole
. CPR
. Confirm in 2 leads
. Consider possible causes including hypoxia, hyperkalemia, hypokalemia, preexisting acidosis, drug overdose, hypothermia
. Consider defibrillation as per V-tach/V-fib since V-fib may be mistaken for asystole
. Consider immediate transcutaneous pacing
. Epinephrine: 1 mg IV push repeated every 3-5 minutes
. May use intermediate dose or high dose epinephrine (2-5 mg IV or 0.1 mg/kg IV) every 3-5 minutes
. Atropine: 1 mg IV push every 3-5 minutes to total dose of 0.04 mg/kg
. Shorter atropine dosing intervals are acceptable (every 1-2 minutes)
. Consider termination of efforts if no reversible underlying cause is found
For pulseless electrical activity (PEA) :
. Includes EMD, idioventricular rhythms, ventricular escape rhythms, bradyasystole rhythms, post-defibrillation
idioventricular rhythms
. Assess blood flow by Doppler ultrasound if available
. Consider possible reversible causes: cardiogenic shock (weak pump), cardiac tamponade, tension pneumothorax, severe hypovolemia, pulmonary embolism (consider thrombolytics), hypothermia, hypoxia, acidosis, hyperkalemia, drug overdose such as beta-blockers, calcium channel blockers, tricyclics, digoxin
. Epinephrine: 1 mg IV push. Repeat every 3-5 minutes. Can use intermediate or high dose epinephrine (2-5 mg IV or 0.1 mg/kg IV respectively) every 3-5 minutes, but this shows no proven improvement in survival.
. Atropine: 1 mg IV every 3-5 minutes to total dose of 0.04 mg/kg: if absolute bradycardia (< 60 beats per
minute) or relative bradycardia. May decrease interval to 1-2 minutes if desired.
CHILDREN:
(in alphabetical order)
. Amiodarone for pulseless VF/VT 5 mg/kg IV or IO rapid bolus. For perfusing tachyarrhythmias loading 5
mg/kg IV or IO over 20-60 minutes, maximum dose 15 mg/kg/d.
. Atropine 0.01-0.02 mg/kg/dose; minimum dose is 0.1 mg, maximum single dose is 0.5 mg in child, 1.0 mg in
adolescent
. Epinephrine
. Bradycardia: 0.01 mg/kg IV/IO or 0.1 mg/kg ET (1:1000)
. Asystolic or pulseless arrest: First dose is 0.01-0.03 mg/kg IV/IO. Doses as high as 0.2 mg/kg may be
effective.
. Infusion: 0.1 ΖΓg/kg/min. Titrate to desired effect (0.1MIC g/kg/min-1.0 MIC g/kg/min)
. Lidocaine
. Bolus: 1 mg/kg/dose (maximum 3 mg/kg)
. Infusion: 20-50 MICRO g/kg/min
. Sodium bicarbonate 1 mEq/kg/dose or 0.3 x kg x base deficit. Infuse slowly and only if ventilation adequate
PRECAUTIONS :
β’ Calcium can be used if known (pre-existing) hyperkalemia precipitated arrhythmia. Calcium is contraindicated
in hyperkalemia secondary to digoxin.
β’ Magnesium is relatively contraindicated in renal failure but given consequences of not terminating rhythm, this is only a relative contraindication in this setting
PATIENT MONITORING Intensive care setting on continuous monitor, look for precipitating cause including serial EKGs and enzymes to rule out myocardial infarction
PREVENTION/AVOIDANCE : Treat underlying disease
POSSIBLE COMPLICATIONS :
. Can have significant neurologic, hepatic, renal, and cardiac ischemic injury
. May have rib fractures or pneumothorax from CPR
EXPECTED COURSE/PROGNOSIS :
. Outcome related to underlying disease, age, duration of arrest, etc.
. Outcome poor if
. > 4 minutes to CPR or > 8 minutes to ACLS
. Arrest in field
. Resuscitation effort > 30 minutes
. About 14% survive in-hospital arrest; fewer after field arrest.