This week we talk about managing the intra-arrest period of cardiac arrest. My paradigm has changed dramatically over the past few years. In the past, I viewed the arrest as a period to teach my residents how to place a subclavian central line, how to intubate when the patient is moving, and how to cram as many drugs as possible into a patient in a short period of time.
Looking at how I manage an arrest today, so much has changed.
I use the ACLS ABCDABCD mnemonic, though I’ve changed some of the intent:
A
Place an Oropharyngeal Airway
B
Place the patient on the ventilator with a BVM mask.
Set the vent to VT 500, Flow 30 lpm, Rate 10, FiO2 100%. Increase the pressure limit to 80-100 cm H20.
C
Compressions, Compressions, Compressions
The most important thing these days are continuous, rhythmic, chest compressions. If you want to get perfusion to the coronaries and get a chance at shocking (the only other effective therapy for arrest), you need perfect compressions.
I use a metronome and switch out providers every 1-2 minutes. Got the idea from this article.
ETCO2 can be used as a marker of how well compressions are being performed.
D
Defib. Shock early and shock often.
You can shock without having the compressor stop compressions if they are wearing gloves and you have a biphasic defib with pads. (Circulation 2008;117:2510-2514.)
A
Advanced airway = LMA, not an ET Tube
Here is my LMA video
B
Advanced Breathing
Put the patient back on the vent. If you know how, switch them to pressure control at 20 cm H20, with an insp time of 1-2 seconds
C
Advanced circulation
pop in an IO
listen to the podcast for my feelings on meds
D
Differential
I recommend the RUSH exam created by my colleagues and me.
Last, we talk about when to stop: for me ETCO2 < 10 and no heart motion = stop, if I have been trying for 10-20 minutes.
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Hi, my name is Scott Weingart. 
{ 16 comments… read them below or add one }
thanks for another awesome view from ahead of the curve.
I replace your first A with your second A and place an LMA straight away. Instead of 4 seconds for an oral airway, placing an LMA, which should be ready and inflated, takes about 6.
Agree entirely with your assessment of drugs; epinephrine in undifferentiated cardiac arrest only serves as food for worms. I would only add to consider antidotes if a specific ingestion or exposure is thought to be the underlying cause.
Yes, yes on the quantitative EtCO2. I would dampen your assertion that a negative capnograph = non-tracheal placement and replace it with a negative capnograph = non-tracheal placement *until proven otherwise*. There are occasional false negatives (complete obstruction, long down time, equipment failure). If EtCO2 is negative with an ETT placed pre-hospital, I either pull the tube and place an LMA or repeat laryngoscopy. If there is a reason not to do either of those maneuvers (for example, an airway that may have been easier then than now – bullets/bites/burns) the next tool is an esophageal detector device.
False positive ETCO2 after a few breaths, however, is essentially impossible.
The notion of replacing pulse checks with ETCO2 assessment is interesting but might put a bit too much faith in the response of ETCO2 to ROSC. Most of the literature I’m aware of is in animals. You may be a bit too far ahead of the curve on that one to make that recommendation unreservedly.
I have started doing intracompression defibrillation, but I take over the compressions myself and am still a bit nervous.
Lastly, the metronome idea is golden. Are you happy with the metronome you use? Are there any ways you wish it were better? I’m going to buy one and stick it on our airway cart.
Reub,
great comments.
The article you want to look at for ETCO2 guiding your pulse checks is this one:
The Journal of Emergency Medicine 38, Issue 5, June 2010, Pages 614-621
For some reason, the authors used the word specificity when they meant (1-specificity) but otherwise, pretty good indicator for me that if the ETCO2 rises by > 10, check for a pulse, if it doesn’t stick with the normal occ. pulse checks when you see a potentially perfusing rhythm on your rhythm checks. Only proviso : ) is if you are using sodium bicarb as you’ll get a big burst of ETCO2.
yes, i like the metronome b/c it is cheap, it works, and if i lost it i would not cry.
Sorry, posted in another thread, but more relevant here!
I tried the metronome idea, and I think it works GREAT.
There are a number of free iphone and droid metronome aps, if you always have your smart phone on you at work… an alternative to buying one. Though I do like the idea of keeping one on the code cart in the resus bay of a busy ED…
Great idea re: the iphone metronome!
I’ve considered the use of a metronome, but I’ve been swayed by that great little study out of UIC Peoria: If you have your rescuer keep to the beat of the Beeg Gees song ‘Stayin’ Alive’, you hit a perfect 100 compressions per minute. (plus you get the pleasure of getting that song stuck in your teams’ heads for the rest of the shift).
The IO has been a great benefit as well.
Hey.
I just wanted to say thanks for a great podcast.
I really respect what you do. Even tho I am just in undergrad preparing for medical school, these podcast give me great motivation.
Thanks again.
-DSpencer
Thanks so much Dax
Great talk, I am a new listener to your podcasts and I am already in love with them.
Still in our facility, intubations and lines have a prime importance during codes, and it was very interesting when you showed that thier importance has been going down. We have started doing IO’s though not frequently. I would appreciate if you know any recent papers emphasizing the importance of not doing those things during code, which I can present to my code team to change our practice.
Thanks.
Ankit
No studies showing direct tie, many studies showing compression interruption is very, very bad and I have witnessed very few lines or tubes that don’t cause some interruption.
Great podcast thanks.
Love the idea of intracompression defibrillation. How do you get a reasonable waveform during compressions to make the decision about shocking?
until the new algorithms for detection of vfib/vtach during compressions are ready for prime time, the way it actually plays out is:
stop compressions for rhythm check
see vfib/vtach
immediately restart compressions
as soon as the machine is ready, shock the patient without stopping compressions
Hey Scott your pod casts are great. I work as a Paramedic in an ER as well as my full time job as a Fire Captain. We have adopted the EZ IO, the King Air Way and the use of quantitative ETCO2 for all our pre hospital codes. This really stream lines our codes. We run one Paramedic per shift and two EMT-Is. Per State of NH protocol EMT-Is can place a EZ IO on patients in cardiac arrest, this way there is any one of the three of us can perform any of the initial skills and thus interventions are performed rapidly. It has worked well for us. We have also been using ETCO2 for about eight years to confirm tube placement. I agree ETCO2 is a great indicator of CPR quality. I use your pod casts as a great adjunct for con ed and discussion with my EMTs. Thanks
Bruce,
thank you for this kind feedback. so glad to hear this stuff is useful to the EMS world.
scott
Hey Scott your pod casts are great. I work as a Paramedic in an ER as well as my full time job as a Fire Captain. We have adopted the EZ IO, the King Air Way and the use of quantitative ETCO2 for all our pre hospital codes. This really stream lines our codes. We run one Paramedic per shift and two EMT-Is. Per State of NH protocol EMT-Is can place a EZ IO on patients in cardiac arrest, this way there is any one of the three of us can perform any of the initial skills and thus interventions are performed rapidly. It has worked well for us. We have also been using ETCO2 for about eight years to confirm tube placement. I agree ETCO2 is a great indicator of CPR quality. I use your pod casts as a great adjunct for con ed and discussion with my EMTs. Thanks
In your first “A” you advocate the placement of an oropharygeal airway. I wonder if in skilled hands an LMA can be placed just as rapidly as the oral airway negating the need for an oral airway as the initial airway adjunct. Intubating LMAs could be used initially posssibily preventing gastric insuflation and possibly reducing the risk of aspiration. Intubation could then be semi-elective following ROSC.
absolutely, and in fact my residents often do just that b/c they have the LMA ready to go when they get the notification from EMS
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