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

Treatable ACLS Conditions (H's and T's)

• Hypovolemia
• Hypoxia
• Hydrogen ion (i.e. acidemia)
• Hypo/hyperkalemia
• Hypothermia
• Tension Pneumothorax
• Tamponade
• Toxins
• Thrombosis, pulmonary
• Thrombosis, coronary

PEA Evaluation by QRS

Differential based on QRS being narrow or wide and aided by ultrasound

QRS Narrow

Mechanical RV Problem – Ultrasound should show hyperdynamic LV and potential cause

• Cardiac tamponade
• Tension pneumothorax
• Mechanical hyperinflation
• Pulmonary embolism
• Acute MI with myocardial rupture

QRS Widened

Metabolic LV Problem – Ultrasound should show hypokinetic LV

• Severe hyperkalemia
• Sodium-channel blocker toxicity (Ex. Tricyclic (TCA) toxicity)
• Agonal rhythm
• Acute MI with pump failure

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

Refractory Ventricular Fibrillation

A patient is considered refractory after ≥3 defib, ≥3mg epi, and 300mg amio

Esmolol for Failure of Standard ACLS

1. Place a second set of defib pads in an alternative location on the chest
2. Continue CPR
3. Deliver 360J simultaneously from both defibrillators
4. Continue CPR
5. Give Esmolol bolus at 0.5mg/kg and start drip at 0.1mg/kg
6. Deliver 360J simultaneously from both defibrillators
7. Continue CPR

See Also

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

References

• 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