EMCrit Podcast 31 – Intra-Arrest Management

Update: Some of the information in this post and podcast has been superseded by podcast 125; so click on over there.

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.

Here is the metronome I use.

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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Comments

  1. 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.

      • Jon Anderson says:

        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…

  2. Jonathan Burns says:

    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.

  3. 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

  4. 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.

  5. 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

  6. Bruce Goldthwaite says:

    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

  7. Nona Mills says:

    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

  8. Lance C. Peeples says:

    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.

  9. what settings are the vent for the first breathing and 2nd breathing parts of the arrest. do you have the vent in cpap setting when using the facemask, then cmv or simv setting when you have the the supraglottic device in place

  10. for all phases of the arrest, I use:
    AC VC
    RR 10
    Flowrate 30 lpm
    VT 500
    FiO2 100
    PEEP 0
    pressure alarm limit of 80-100

  11. George Stephenson says:

    Hi Scott, thanks for another really interesting podcast!
    Wondered about the utility of just using high flow nasal cannula for passive oxygenation with continuous compressions until a LMA and defib can be located? One less thing to worry about and no interruption to CPR. May be particularly useful in a ward setting…
    Thanks again for your hard work!

    • we have thouht about that and Ben Bobrow has done some work to prove it. Worry is that compressions may cause atelectasis without any positive pressure breaths.

  12. Hey Scott- Quick question for you:

    I know there has been a great emphasis on excellent chest compressions, and I toally agree with it- it all makes sense. My question is: in the phase before an advanced airway is placed (LMA, etc), I would worry that the more excellent the chest compressions are, the less effective and potentially futile it would be to bag while the compressions are going on. I would think that while stopping chest compressions to deliver breathes before advanced airway is in (which ironically is ACLS protocol) is probably not a good idea, it also almost seems like the transient increase in intra-thoracic pressure and resultant decreased venous return may not even be worth the squeeze at all, as those breathes probably are of very little efficacy during excellent chest compressions… what do you think?

    • I think until a definitive airway is established, only apneic oxygenation with NC at 15 and jaw thrust should be used.

      • Perfect answer- could not agree more. Also, although this “pre-definitive airway” phase should be transient, we would be able to get end tidal with the NC. So I take it you have gotten rid of the BVM/oropharyngeal airway piece.

        (Sorry if you’ve posted a revamped version since this posting that I haven’t gotten to yet)

  13. Steve Young a and e doctor in South Wales, UK says:

    Great podcast love the idea of shocking while on the chest we have those pads but I bet if I did that in Resus I’d get chased out by the angry shocked nurse! Is it really ok? If it is why are we not doing it? Can u really assess a rhythm while someone is pounding the chest?

    • Steve,
      Based on most current evidence, we lift our hands a couple of inches just as the button will be pressed and then immediately resume. This is not something you can spring on your team during the actual arrest. Needs to be discussed beforehand. Rhythm check still needs a stop in cpr.

  14. Nick Lauerman says:

    Scott,
    Just catching up on the podcasts. Wondering if there is any data to suggest that we should be contining coding patients when ETCO2 is >10, >20 after 20-30 mins. I usually look with the echo and stop if there is no cardiac activity, but what if there is?

    • data looked at when to stop if your clinical judgement is pointing you that way. I would not necessarily interpret this as a higher value forcing you to go forward

  15. Lakshay Chanana says:

    Hey Scott,
    Have a question, When do we charge the paddles during a PulselessVT/VF Arrest (In the Air OR On the patient’s Chest). If we charge them in air, it saves about 5 seconds.

    Thanks
    Lakshay

    • always charge with ongoing compressions

      • Lakshay Chanana says:

        So we keep the paddles on the Chest and charge with ongoing compressions..and then Stop Compressions just before shocking..Is that right?

        • Hey Scott,
          I figured something out today messing around with the LifePak in simlab with the residents…not sure if you already know about this and are doing it or not, but ya know that annoying and stressful noise the LifePak makes when it’s charged and ready, before you click Shock? Well I always found that it was counter-productive to the calmness I like to have in the air during a code, and so throughout the chest compression cycle that thing is super annoying… (one option was always to just wait and time it about right to charge during the compressions but towards the end, right before a pulse check) but I realized that if you push the energy select button again after it’s already charged and ready, that noise goes away (and pushing shock at that point won’t delivery a shock), but the charge is stored, and when you go back and hit charge again when you’re ready to shock, it’s still already charged, fully juiced up and ready to go. So you can just charge immediately at the beginning of the compression cycle, and then shut it up until you need it to shock again! Is this what you are doing?

          Sam

          • our zoll’s noise is not offputting, so it never occurred to me. will check it out on a lifepak–great tip

            • Scott,
              Saw a blunt traumatic arrest flow in last night- Once in the bay, no chest compressions.. (b/l neg finger thoracostomies and no tamponade on u/s.. just standstill) .. tube appeared to be in the right place, but end-tidal was 0. I have read both that if you have prolonged downtime in a cardiac arrest you can have an end-tidal of zero (with the tube in the right place), and have also read that conversely, this not true as “even dead people have end tidal” and seen those few very small studies on this subject, etc.. what is your take: Can an ET tube in the trachea, without obstruction, ensuring the end-tidal is non malfunctioning, read a true and correct end-tidal of 0? Have you ever experienced this?

              Sam

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