Unresponsive? Go to primary C-A-B and call a “code blue".

• C = Check pulse, if no pulse start chest compressions immediately
• A = Open airway
• B = Breaths (30:2 compression-to-ventilation ratio or 8-10 breaths/min with advanced airway).

1. Use defibrillator to check rhythm:

• If VF/VT: Give 1 shock immediately then follow the algorithm.
• If PEA or asystole: Continue CPR, give epinephrine as soon as possible and follow the algorithm.
• Minimize interruptions of CPR. Continue chest compressions while the defibrillator is charging.

2. Go to secondary ABCD:

• A = Secure airway with endotracheal tube (ETT) or laryngeal mask airway (LMA) is ideal, bag-valve-mask (BVM) is reasonable to avoid CPR interruption.
• B = Confirm position of ETT objectively with end tidal CO2 and secure airway to prevent dislodgement.
• C = IV access, continue CPR, give epinephrine, and then consider antiarrhythmics.
• D = Differential diagnosis: look for the reversible causes (5 H’s and 5 T’s).

3. Follow the appropriate algorithm and switch to a different algorithm as needed.

Ventricular Fibrillation and Pulseless VT

1. CAB

2. Check rhythm

3. If VF/VT then give 1 shock (200 J biphasic, 360 J monophasic; if unknown defib, use maximum available setting). Then resume CPR immediately x 2 minutes.

4. Check rhythm: continue only if still in VT/VF.

5. Continue CPR while defibrillator charges. Then deliver shock (higher than first shock if biphasic, 360 J if monophasic, maximum setting if unknown defibrillator type). Resume CPR immediately.

• During CPR, give epinephrine (1 mg IV q3-5 min)
• Give 2 minutes of CPR
• Check rhythm: continue only if still in VT/VF.
• Shock again, resume CPR.
• During CPR give anti-arrhythmic:
• Amiodarone 300 mg IV x 1, may reload with 150 mg x 1
• Magnesium 1-2 g IV only for torsades de pointes
• Consider Lidocaine 1mg/kg IV if amiodarone ineffective
• This is often done as 100 mg IV and a drip at 1 mg/hr
• After CPR, go back to Step 4 and repeat until return of spontaneous circulation or the team decides to stop the code.
• NOTE: If concern for myocardial ischemia as etiology, call cardiology

Pulseless Electrical Activity/Asystole 

1. CAB
2. Check rhythm
3. If PEA/asystole then continue CPR for 2 minutes.

• During CPR give epinephrine immediately (1 mg IV q3-5 min).

4. Check rhythm
5. Repeat cycle at step 3 and search for and treat reversible causes until the patient regains spontaneous circulation or the team decides to stop the code.

 

Considerations:

• IVF (wide open) and O2 – treat hypovolemia and hypoxia
• HCO3 (1-2 amps IV) and calcium (1 amp) – treat hyperkalemia and acidosis
• Check POC glucose, consider warming blanket – treat hypoglycemia, hypothermia
• Get a history: tablets (ingestion), risk factors for PE, pneumothorax, MI, tamponade
• Bedside US to evaluate for pneumothorax, tamponade, right heart strain, or signs of new bleeding
• Risk of tamponade? → Needle subxiphoid, angled 45 degrees toward left shoulder, call cardiology for assistance
• Risk of tension pneumothorax? → 14G needle in second intercostal space midclavicular line
• Risk of PE or MI? → Consider thrombolysis, order thrombolytics early as they take time to prepare

 

In the Heat of the Moment: Simplifying Rhythm Analysis

Is the heart rate fast or slow?

• If slow →
  • Sinus Bradycardia
  • Second or third degree AV block
  • Junctional escape rhythm
  • Ventricular escape rhythm
  • Sick sinus syndrome
• If fast →
  • Is the QRS wide or narrow?
    • If wide → 
      • Ventricular rhythm
        • Ventricular tachycardia (monomorphic or polymorphic)
        • Ventricular fibrillation
      • Supraventricular tachycardia with aberrancy (rate-dependent BBB)
      • Preexcitation: WPW
      • Ventricular pacing
      • Extrinsic “toxic” delay:
        • Sodium channel blockers
        • TCAs
        • Phenothiazines
        • Class 1 antiarrhythmics
        • Hyperkalemia
    • If narrow →
      • Is it regular?
        • Sinus tachycardia
        • Supraventricular tachycardia
        • Atrial tachycardia
        • AVNRT
        • AVRT with bypass tract
      • Is it irregularly irregular?
        • Atrial fibrillation
      • Is it regularly irregular?
        • Atrial flutter with variable block

Tachyarrhythmia

• ABCDEs first.
• If unstable:
  • Synchronized cardioversion.
  • If synchronized cardioversion fails x3, consider amiodarone 300mg IV over 10-20 minutes, repeat shock, and load 900mg amiodarone over 24 hours.
  • Consider cardiology consultation.
• If stable: 1) QRS wide (>120ms) or narrow 2) regular or irregular.
• Irregular wide complex: Polymorphic VT (pVT) or afib with bundle branch block (BBB). CALL CARDIOLOGY.
  • pVT (Torsades de pointes): Mg 2g over 10 minutes.
  • Afib with BBB: SEE narrow complex, treat as afib with RVR.
• Regular wide complex: Most likely monomorphic VT, also consider SVT with BBB.
  • Monomorphic VT: Consider antiarrhythmic therapy.
    • Amiodarone 150mg IV over 10 minutes followed by 1mg/min for 6 hours.
    • Procainamide 20-50mg/min (STOP if hypotensive, QRS increase >50%, max dose 17mg/kg). Avoid in patients with prolonged QT or CHF.
    • Sotalol 100mg (1.5mg/kg) over 5 min. Avoid in patients with prolonged QT.
  • SVT with BBB: SEE narrow complex regular; trial adenosine.

• Regular narrow complex: See above for potential rhythms.
  • Place patient on continuous ECG monitoring.
  • Trial vagal maneuvers.
  • Adenosine 6mg IV then 12mg IV then 12mg IV (NOTE: must bolus push rapidly).
  • If above fails, CALL CARDIOLOGY and consider atrial flutter etiology.
• Irregular narrow complex: Etiology likely atrial fibrillation, consider MAT or atrial flutter with variable conduction.
  • Beta-blocker (BB): i.e. Metoprolol 5mg IV.
  • Calcium-Channel Blocker (CCB): i.e. Diltiazem 10mg IV (0.25mg/kg reasonable). 
    • NOTE: Avoid BB or CCB in patients with evidence of heart failure or hypotension.
  • Digoxin: 0.25 to 0.50 mg IV over several minutes, then 0.25mg IV q6h. Avoid in patients with renal impairment.
  • Amiodarone: 150mg IV over 10 min followed by 1mg/min for 6 hours then 0.5mg/min for 18 hours.
    • NOTE: Consider risk of cardioversion with amiodarone and anticoagulation.

Bradycardia

Also see Night calls: Bradycardia.

• ABCDEs first, place defibrillator (pacing) pads
• Complications: shock, syncope, ischemia, acute heart failure
• Concern for arrest: recent arrest, Mobitz type II AV block, complete heart block, or ventricular pause >3s
  • If no complications or concern for arrest, consider observation
• Interventions:
  • Atropine 0.5mg IV q3-5 minutes up to 3mg
  • If atropine ineffective:
    • Epinephrine 2-10mcg/minute IV
    • Dopamine 5-10mcg/kg/min
    • Transcutaneous pacing (NOTE: this is painful and should be used short-term, CALL CARDIOLOGY)
    • Isoproterenol 5 mcg/minute IV (NOTE: avoid in patients with ischemia)
  • Treatment of underlying causes 
    • Beta-blocker: Glucagon 5mg IV q10 min (up to 3 doses), insulin 1U/kg bolus (see Toxicology chapter)​
    • Calcium channel blocker: Calcium gluconate 3g, insulin 1U/kg bolus (see Toxicology chapter) 
    • Digoxin: Dig immune FAB
    • Opiates: Naloxone 0.4-0.8mg IV
    • Organophosphate: Atropine 2mg IV q5-30 min until secretions controlled, pralidoxime 1-2g IV
• Type II second-degree AV block or third-degree AV block
• Proceed to transcutaneous pacing until transvenous pacer can be placed.

Post Cardiac Arrest Care

• ABCDEs 
• Airway and Breathing
  • Consider intubation
  • SpO2 goal 94-98% (AVOID hyperoxemia)
  • Titrate ventilation to normocapnia via EtCO2 and ABGs
• Circulation
  • 12-lead ECG, arterial blood pressure monitoring, peripheral and central intravenous access
  • Treat hypotension with goal SBP ≥ 90 and MAP >65
    • IV fluid resuscitation: 1-2 L crystalloid
      • It is reasonable to consider colloids in certain populations such as hypoalbuminemic state. However, there is limited evidence on any benefit
    • Norepinephrine 7-35 mcg/min
    • Epinephrine 7-35 mcg/min
  • Consider cardiology consultation and cardiac catheterization
  • Ensure pads are in place or easily accessible
• Disability
  • Be alert for seizures
  • Control hyperglycemia, goal <180 avoiding hypoglycemia
  • Consider targeted temperature management with hypothermia to 32-36 degrees C (See Critical Care: Post-Cardiac Arrest)

References

Bernard SA, Gray TW, Buist MD, Jones BM, Silvester W, Gutteridge G, Smith K. “Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia.” New England Journal of Medicine 2002. 346(8):557-63.

Neumar RW, Shuster M, Callaway CW, et al. Part 1: Executive Summary: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2015; 132:S315.

Soar J, Nolan JP, Böttiger BW, et al. European Resuscitation Council Guidelines for Resuscitation 2015: Section 3. Adult advanced life support. Resuscitation 2015; 95:100.

Andersen LW, Holmberg MJ, Berg KM, Donnino MW, Granfeldt A. In-Hospital Cardiac Arrest: A Review. JAMA. 2019;321(12):1200-1210.

Link MS, Berkow LC, Kudenchuk PJ, et al. Part 7: Adult Advanced Cardiovascular Life Support: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2015; 132:S444.

Monsieurs KG, Nolan JP, Bossaert LL, et al. European Resuscitation Council Guidelines for Resuscitation 2015: Section 1. Executive summary. Resuscitation. 2015;95:1-80.Edelson DP, Sasson C, Chan PS, et al. Interim guidance for basic and advanced life support in adults, children, and neonates with suspected or confirmed COVID-19: from the Emergency Cardiovascular Care Committee and Get With the Guidelines®-Resuscitation Adult and Pediatric Task Forces of the American Heart Association in collaboration with the American Academy of Pediatrics, American Association for Respiratory Care, American College of Emergency Physicians, the Society of Critical Care Anesthesiologists, and American Society of Anesthesiologists: supporting organizations: American Association of Critical Care Nurses and National EMS Physicians. Circulation 2020 April 9