Managing Cardiac Arrest
Published on Feb 09, 2016
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PRESENTATION OUTLINE
OBJECTIVE
Discuss therapeutic hypothermia as implemented by ACCESS agencies
Untitled Slide
ROSC
(Return Of Spontaneous Circulation)
a. ROSC
i. Per AHA “It is recommended that comatose adult patients with ROSC after out of hospital VF-associated cardiac arrest be cooled… (Class I, LOE B).”
ii. Per AHA “Therapeutic hypothermia may be considered… after out of hospital cardiac arrest with an initial rhythm of PEA or asystole (Class IIb, LOE B).”
iii. While intra-arrest cooling studies in animal models show some promise, human studies are underway but have not yet been published.
i. Per AHA “It is recommended that comatose adult patients with ROSC after out of hospital VF-associated cardiac arrest be cooled… (Class I, LOE B).”
ii. Per AHA “Therapeutic hypothermia may be considered… after out of hospital cardiac arrest with an initial rhythm of PEA or asystole (Class IIb, LOE B).”
iii. While intra-arrest cooling studies in animal models show some promise, human studies are underway but have not yet been published.
Age > 16 years
b. Age > 16
i. Studies have only been done in adult patients.
i. Studies have only been done in adult patients.
Photo by Collin Key (away)
Temp > 34C/93.2F
c. Temp > 34C/93.2F
i. Target temperature per AHA recommendation is 32-34C.
i. Target temperature per AHA recommendation is 32-34C.
Photo by pedrik
SBP > 90 mmHg
d. SBP > 90 mmHg
i. Physician “Pearl”: SBP >90 needed before initiation of cooling. Patients may require vasopressors to meet this inclusion criteria.
1. Dopamine infusion
a. IV: 5-20 mcg/kg/min
2. Epinephrine infusion
a. IV: 2-10 mcg/min
b. … appears to not require medical control in this case
i. Physician “Pearl”: SBP >90 needed before initiation of cooling. Patients may require vasopressors to meet this inclusion criteria.
1. Dopamine infusion
a. IV: 5-20 mcg/kg/min
2. Epinephrine infusion
a. IV: 2-10 mcg/min
b. … appears to not require medical control in this case
Photo by 427
Comatose
e. Neuro exam 5 min post-ROSC shows no purposeful pain response
i. AHA recommends “comatose” patients.
i. AHA recommends “comatose” patients.
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Exclusion Criteria
Photo by Richard Clark (Digimist)
POST/DNR
a. DNR/POST, or other advance directive
i. Naturally.
i. Naturally.
Obvious Terminal Illness
b. Obvious Terminal Illness
i. You’d think they would have a POST/DNR.
ii. Kind of a judgement call.
i. You’d think they would have a POST/DNR.
ii. Kind of a judgement call.
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Obvious Pregnancy
c. Obvious Pregnancy
i. Literature shows this as a “relative contraindication”…
i. Literature shows this as a “relative contraindication”…
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Obvious Traumatic Arrest
d. Obvious Traumatic Arrest
i. He’s got bigger problems.
i. He’s got bigger problems.
Photo by Dan Brown Photography
Procedure
Assess (and document)
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If the patient isn't intubated, and you elect to induce hypotermia...
... they should be.
Ventilate to ETCO2
of 35 mmHg
Midazolam
To PREVENT shivering
IV/IO/IM:
0.5-2.5 mg slow IV push every 5-10 minutes (max dose 5 mg)
IN:
2.5 mg every 10 min (max dose 5 mg)
Vecuronium
Only when shivering is WITNESSED
Only when patient intubated and placement confirmed with SpO2 and ETCO2
IV/IO:
0.1 mg/kg repeated PRN
If vecuronium is administered, ensure midazolam is provided for patient sedation.
Photo by Magalie L'Abbé
Medical Control Contact?
Inducing Hypothermia
It's actually pretty simple...
Establish a 2nd IV if possible
i. Establish a 2nd IV if possible
1. This may be left over from when we used chilled crystalloid.
2. Can’t hurt, though.
1. This may be left over from when we used chilled crystalloid.
2. Can’t hurt, though.
Photo by Threthny
Expose
The patient while protecting modesty
Apply
Cold packs to the groin, axilla and neck
(The patient's groin, axilla and neck.)
Apply
Saline/water soaked sheet to trunk
Early Notification
"Ensure early notification to receiving facility for expeditious coordination of care."
Photo by bark
