Cardiac Arrest

V-Fib / Pulseless V-Tach

C300

  • Initiate CPR compressions at 100-120/min rate, 2-2.5 inches in depth, 30 compressions and 2 breaths, and rotate compressors every 2 minutes. Minimize all interruptions to compressions.
  • Attach AED or defibrillator to patient as soon as possible; immediately defibrillate at 360 joules (or biphasic equivalent)
  • Continue CPR for two minutes then perform rhythm check or analysis; initiate IV/IO.
  • If rhythm check indicates VF or pulseless VT, defibrillate again at 360 joules (or biphasic equivalent). Repeat rhythm check or analysis and defibrillate every 2 minutes until rhythm changes
  • Epinephrine 1 mg (10 ml 1:10,000) IV/IO after second shock and every 3 to 5 min until rhythm changes
  • Amiodarone 300 mg IV/IO after third shock. May repeat Amiodarone 150 mg IV/IO in 3-5 min (May substitute Lidocaine 0.5 – 0.75 mg/kg IV/IO push if Amiodarone is unavailable)
  • If rhythm changes, go to the appropriate protocol
  • After successful resuscitation, obtain 12-lead EKG and notify receiving hospital

Given the time sensitive nature of cardiac arrest, treatment is most effective when performed on scene.  Unless otherwise noted, transportation to an Emergency Department should be delayed.

Per SB 204, in the setting of hypothermia

  • Temperature <30°C or 86°F:
    • Continue CPR
    • Only administer one round of ACLS drugs
    • No more than three defibrillations
  • Temperature 30° – 35°C (86° – 95°F):
    • Double the interval of time between drug dosing
    • Defibrillate normally

Per A105, all EMS personnel may terminate resuscitative efforts

  • If resuscitation was started prior to the discovery of an valid DNR as defined in A106, OR
  • If, upon further examination, the patient meets the determination of death criteria, including either an injury incompatible with life (i.e. decapitation, or burned beyond recognition) and/or the victim shows signs of rigor mortis (in a warm environment), dependent lividity, or decomposition, OR
  • If the following medic conditions below are met

Per A105, medics may terminate resuscitative efforts and not transport patients under active CPR if all of the following exist:

  • Good contact between the paramedic unit and the medical control physician
  • Successful airway management and medication administration consistent with other protocols in the SW Ohio EMS Protocol
  • At least 30 minutes of resuscitative efforts
  • NO sustained return of spontaneous circulation at any time (palpable pulse > 60 BPM for at least one five-minute period)
  • NO spontaneous respiration, eye opening, motor response, or other neurologic activity at the time stopping resuscitation is contemplated
  • The cardiac rhythm is NOT persistent or recurrent VF or VT
  • All paramedics and the medical control physician agree with termination of ACLS
  • The suspected cause of the cardiac arrest must be something other than hypothermia, electrocution, or lightning strike

It is recommended to transport pregnant patients even if there has been no return of spontaneous circulation, as an unborn fetus may benefit from emergency caesarian-section delivery

Per M418, in the setting of renal failure/ESRD, consider management of hyperkalemia early in resuscitation

 

Traumatic Cardiac Arrest

C308

  • Do not initiate efforts if injuries are incompatible with life, including decapitation, hemicorporectomy, burned beyond recognition, or obvious signs of prolonged death including rigor mortis (in the absence of hypothermia), decomposition, or lividity
  • For all others, perform CPR and transport to trauma center. Patients under 18 can be transported to a pediatric trauma center.
  • Treat life threatening injuries: control external hemorrhage, decompress chest when appropriate and, when managing BLUNT trauma, initiate fluid resuscitation via IV/IO with normal saline (1L for adults, 20ml/kg for pediatric patients)
  • Treat PEA >40 bpm with fluids; treat V-fib/V-tach per cardiac protocol; consider termination of efforts for asystole

Per SB 204, in the setting of hypothermia

  • Temperature <30°C or 86°F:
    • Continue CPR
    • Only administer one round of ACLS drugs
    • No more than three defibrillations
  • Temperature 30° – 35°C (86° – 95°F):
    • Double the interval of time between drug dosing
    • Defibrillate normally

Per A105, all EMS personnel may terminate resuscitative efforts

  • If resuscitation was started prior to the discovery of an valid DNR as defined in A106, OR
  • If, upon further examination, the patient meets the determination of death criteria, including either an injury incompatible with life (i.e. decapitation, or burned beyond recognition) and/or the victim shows signs of rigor mortis (in a warm environment), dependent lividity, or decomposition, OR
  • If the following medic conditions below are met

Per A105, medics may terminate resuscitative efforts and not transport patients under active CPR if all of the following exist:

  • Good contact between the paramedic unit and the medical control physician
  • Successful airway management and medication administration consistent with other protocols in the SW Ohio EMS Protocol
  • At least 30 minutes of resuscitative efforts
  • NO sustained return of spontaneous circulation at any time (palpable pulse > 60 BPM for at least one five-minute period)
  • NO spontaneous respiration, eye opening, motor response, or other neurologic activity at the time stopping resuscitation is contemplated
  • The cardiac rhythm is NOT persistent or recurrent VF or VT
  • All paramedics and the medical control physician agree with termination of ACLS
  • The suspected cause of the cardiac arrest must be something other than hypothermia, electrocution, or lightning strike

It is recommended to transport pregnant patients even if there has been no return of spontaneous circulation, as an unborn fetus may benefit from emergency caesarian-section delivery

Post-ROSC

C307

  • Follow protocol for presumptive underlying medical condition
  • Maintain patent airway and give oxygen
  • Ventilate as needed 8-10X/min; do NOT over ventilate
  • Continue cardiac monitoring; obtain and transmit a 12-lead EKG to receiving hospital
  • If cause is suspected cardiac, transport to hospital with 24-hour cardiac cath lab
  • If cause is suspected trauma, follow Trauma Triage Guidelines
  • If patient is not alert, transport to hospital capable of post-resuscitative cooling or targeted temperature management
  • Aggressively treat hypotension (SBP < 90) with fluid bolus and push dose epinephrine (0.5-2.0 ml of a 10 mcg/ml solution every 2-5 minutes (5-20 mcg) per hypotension protocol

Asystole / PEA

C301

  • Initiate CPR compressions at 100-120/min rate, 2-2.5 inches in depth, 30 compressions and 2 breaths, and rotate compressors every 2 minutes. Minimize all interruptions to compressions.
  • Attach AED or defibrillator to patient as soon as possible and analyze rhythm; recheck every 2 min
  • Attach monitor leads
  • Search for and treat possible causes: Hs & Ts
  • IV 1-liter NS bolus if hypovolemia suspected (may be chilled)
  • Epinephrine 1 mg (10 ml of 1:10,000) IV/IO. Repeat every 3-5 minutes for duration of cardiac arrest
  • Consider needle thoracostomy or Sodium bicarbonate 1 mEq/kg IV/IO for pre-existing conditions.
  • Consider termination

Given the time sensitive nature of cardiac arrest, treatment is most effective when performed on scene.  Unless otherwise noted, transportation to an Emergency Department should be delayed.

Per SB 204, in the setting of hypothermia

  • Temperature <30°C or 86°F:
    • Continue CPR
    • Only administer one round of ACLS drugs
    • No more than three defibrillations
  • Temperature 30° – 35°C (86° – 95°F):
    • Double the interval of time between drug dosing
    • Defibrillate normally

Per A105, all EMS personnel may terminate resuscitative efforts

  • If resuscitation was started prior to the discovery of an valid DNR as defined in A106, OR
  • If, upon further examination, the patient meets the determination of death criteria, including either an injury incompatible with life (i.e. decapitation, or burned beyond recognition) and/or the victim shows signs of rigor mortis (in a warm environment), dependent lividity, or decomposition, OR
  • If the following medic conditions below are met

Per A105, medics may terminate resuscitative efforts and not transport patients under active CPR if all of the following exist:

  • Good contact between the paramedic unit and the medical control physician
  • Successful airway management and medication administration consistent with other protocols in the SW Ohio EMS Protocol
  • At least 30 minutes of resuscitative efforts
  • NO sustained return of spontaneous circulation at any time (palpable pulse > 60 BPM for at least one five-minute period)
  • NO spontaneous respiration, eye opening, motor response, or other neurologic activity at the time stopping resuscitation is contemplated
  • The cardiac rhythm is NOT persistent or recurrent VF or VT
  • All paramedics and the medical control physician agree with termination of ACLS
  • The suspected cause of the cardiac arrest must be something other than hypothermia, electrocution, or lightning strike

It is recommended to transport pregnant patients even if there has been no return of spontaneous circulation, as an unborn fetus may benefit from emergency caesarian-section delivery

Per M418, in the setting of renal failure/ESRD, consider management of hyperkalemia early in resuscitation

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