The team has done a bunch of stuff on cardiac arrest here on the EMCrit site:
- Podcast 125 – The New Intra-Arrest (Cardiac Arrest Management)
- EMNerd: The Tell-Tale Heart
- Hemodynamic-Directed Dosing of Epinephrine for Arrest
- The Future of CPR
There has been a lot of interesting stuff that has come out since my SMACCgold talk. This podcast will bring you up to date on the crap running though my mind. Beware: very little evidence lies here.
The Syndromes of Cardiac Arrest
Refractory Vfib/Vtach (Electrical Storm)
- Anti-Dysrhythmics
See EMNERD's ALPS Post - Dual-Sequential Defib
Amazing session on EMRAP by Zack Shinar (membership required)
Study of Dual-Sequential shows early double better than single (Resuscitation. 2019 Jun;139:275-281) - Esmolol
Driver et al. (Resuscitation. 2014 Oct;85(10):1337-41 PMID 25033747)
500 mcg/kg IVP, can add a drip starting at 50 mcg/kg/min
See this great EMPharmD Post - Take them to the Lab
- ECMO anyone?
Vasoplegia
Note: I (we) have probably been misunderstanding this Vasoplegia, it is imperative you read this post (choosing the correct DBP); you should also probably listen to that podcast.
- High-Dose Epi
- Methylene Blue
What's the dose? Who knows? I give 2 mg/kg (but not in pts on SSRIs) - REBOA
- Junctional Tourniquet
PREM/PRES
We did an episode on this topic on the EDECMO podcast (ignore the ECG stratification stuff–since been debunked).
Monitoring
- ETCO2
- Cerebral ox
- Ultrasound (preferably TEE)
Time Zero Prognostication
- What can we use??
- This retrospective study from France indicates that if the pt has the following 3: 1. OHCA not witnessed by emergency medical services personnel, 2. nonshockable initial cardiac rhythm, and 3. no return of spontaneous circulation before receipt of a third 1-mg dose of epinephrine then there was no RONF and the pts should be put on the donation path. (Ann Intern Med. 2016 Dec 6;165(11):770-778. doi: 10.7326/M16-0402. Epub 2016 Sep 13. Early Identification of Patients With Out-of-Hospital Cardiac Arrest With No Chance of Survival and Consideration for Organ Donation)
Blood Gases during Cardiac Arrest
Nurse-Run Codes
- 30 seconds to rhythm check
- Rhythm Check
- Administer Epi
- Task-Handler
- EMCrit 204 The Nurse-Led Code with Joe Bellezzo
Peri-Shock Pause
- Pre
Look-Through Analysis
Precharge the Defib (blogpost), (Podcast) - During
Shock during compressions!!!
- It is safe to keep your hands on the chest [10.1016/j.resplu.2022.100284]
- Post
Update: POCUS Pulse Check
Some folks have finally put in the literature what I have been discussing for years: use ultrasound to do pulse check
Mechanical CPR
- Check a rhythm on EMS' monitor
- Transfer on the EMS stretcher
-
The Use of Mechanical Cardiopulmonary Resuscitation May Be Associated With Improved Outcomes Over Manual Cardiopulmonary Resuscitation During Inhospital Cardiac Arrests
Crowley, Conor P. AG-ACNP1,2; Wan, Emily S. MD3–5; Salciccioli, Justin D. MD1,6; Kim, Edy MD, PhD5,6
Critical Care Explorations: November 16, 2020 – Volume 2 – Issue 11 – p e0261
doi: 10.1097/CCE.0000000000000261
Consciousness during CPR
Awake and Dead by Nikiah G. Nudell Resuscitation June 2016 Volume 103, Pages e15–e16
and here is a study in the journal, Resuscitation
More on DBP (in Kids)
Association Between Diastolic Blood Pressure During Pediatric In-Hospital Cardiopulmonary Resuscitation and Survival. Circulation. 2017 Dec 26. pii: CIRCULATIONAHA.117.032270. doi: 10.1161/CIRCULATIONAHA.117.
Additional New Information
AHA Consensus Statement on Improving CPR Quality with advanced monitoring (aka ACLS for resuscitationists) [10.1161/CIR.0b013e31829d8654]
More on EMCrit
Additional Resources
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Professor
Nassau University Medical Center
No conflicts of interest (coi).
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Hey Scott , amazing blogpost as everytime.
You did not mention vasopressin as therapeutic option of vasoplegic shock. Last week i had a nice experience with vasopressin dose of 6IE/h reducing norepinephrin by 80% in a patient on ECMO after CA and eCPR in our cath lab.
we’ve all seen the same post-arrest. ? is what it does during arrest. I discussed it extensively in the SMACC-gold lecture
Really like the little LUCAS video – shows you can place the arm between the second rescuers arms to continue CPR with minimal interruptions
I recently had a VT/VF arrest where the first shock failed. I requested another defibrillator, with the goal of planning ahead (e.g. maybe doing dual sequential defibrillation 5-10 minutes down the road). However, the defibrillator materialized immediately and was set up in seconds. So then we get to the second shock, and the question is: should we perform standard defibrillation or go straight to dual-sequential defibrillation on the second shock? I ended up going straight to dual-sequential which worked. Would love to know your current thoughts on these questions: (a) is there a risk/drawback to using lots of energy? (dual-sequential… Read more »
in your circumstance, I prob. would have done the same. It is there already. We have cath lab data showing no damage from higher than normal electricity Lack of myocardial damage from DCC (Heart 1998, 80:3) and (Resuscitation 1998;36:193-199). I guess it all depends on the logistics. I prob. would be going to dual at the 4th shock in most cases.
Hi Scott
Great as always
Q – does being “awake” correspond to a better neurological outcome?
Hi Dr. Weingart,
Thank you for another excellent post. What are your thoughts on intra-arrest TPA for refractory VT/VF in a setting without ECMO or a cardiac cath lab? Thanks!
-Pri
To start (at least in an ALS-based EMS system, or one with ALS-intercept availability), EMS should not be transporting cardiac arrest patients to the hospital (unless there are extenuating circumstances: refractory VT/VF, pregnancy >20 weeks, hypothermia, etc.). I agree with your thoughts and highly promote the idea of dual-sequential defibrillation, along with the ideas behind mechanical CPR. From an EMS standpoint (as a Paramedic), many agencies simply can’t afford mechanical devices…so we’re stuck with old-school practices. Meds and defibrillation, however, our trends are changing to promote cardiac arrest as a “stay and play” type of event, rather than “load and… Read more »
Actually, Scott, this whole philosophical conundrum (should EMS be transporting CA patients?) would be a great topic for your SMACC panel. I suspect you and some of your panelists would like to see more of these patients in the ED than Mr. Nowak’s EMS system would allow you to see. But if so, what are the system factors and the patient factors that should play into this analysis? Great post as always!
you read my mind, buddy
Maybe consider adding to this question if there would a difference in this answer between tertiary centers and community/critical access centers as the receiving facility for EMS CA.
Team – Mr Nowak and Mr James do bring up a concern being actively debated in our system. Should all of our cardiac arrests be transported anymore? If not, which ones should be and why, to what downsteam benefit? If we are to “stay and play”, what is the optimum time before we decide to TOR or transport? How much scene time is too long? If our ED’s aren’t offering VA ECMO, PCI, or REBOA – is there any benefit to transport besides the fact EMS only gets reimbursed for transports? Welcome all of your thoughts on these questions. Sincerely.… Read more »
These elaborate resuscitations happen in real life in a HHC NY hospital or only take place on a blogosphere? Seen my fare share of hospital run codes and handoffs over the years in a various NY EDs and it’s a cluster, add to that femoral lines, TEE, REBOA, double defibs, abgs, drugs that are not part of a resus crash cart “insert popcorn gif”.
Who is doing these procedures and who is running the code?
It is possible you are not aware of how incredibly condescending this comment is, so in just in case, I’m letting you know.
First of all I’m a HUGE fan or EMCrit and gretaly appreciate all of your efforts to push medicine and the status quo. Secondly, I can understand how Nikolay’s comment above can come across as offensive but he does bring up a valid point. We all have seen our share of codes in the ED that were shall we say a disaster. Furthermore, not all EDP’s are created equal or able to translate theory into real-life practice. I say all of this to say that I think we as advanced providers have to know our abilities and a very healthy… Read more »
in a physician based prehospital system (like i my country) there is the “which patients to transport” question, but also and a ” when to initiate transport” question. This is much like the old “stay and play” discussion in prehospital trauma care.
I our system we have an eCPR/ECMO programme and we focus on identifying eligible patients and initiate transport. During transport we would continue ACLS with LUCUS and should maybe try Esmolol or Dual Sequential Defib.
So I’we listen once more to the podcast….here’s another thought
I really liked the “we’re in the land of no evidence” mind set and the ACLS algorithm are more or less exhausted at this point. But up until this point I think we should emphasize that following the algorithm and providing good quality ACLS still is the basis.
Heard a talk recently by the great michael pinsky, who said they’re soon coming out with a device that will preserve the negative pressure in the chest from chest recoil during CPR to increase venous return and improve survival.
Do you know anything about this?
so the ResQPod already does this. When used in concert with active decompression device from Lurie, there was studied benefit in the Lancet paper. He may be speaking about that or perhaps a new similar device.
I am not trying to be condescending, the material presented is great. However there is a great dichotomy from what is presented, and to what I witnessed happening. Given the logistics presented with various invasive procedures (you have more than one physician at bedside), codes lasting 120 minutes, nurse team leader and additional nurses for tasks, etc. Who is taking care of ~40 patients assigned to you in a busy ED for those 2 hours? And 8-15 patients that each nurse has?
Here are some literature to support what I am saying (and my experience is in line with the literature): A factor that may affect IHCA outcomes is that most academic or teaching hospitals have historically relied on physicians-in-training (e.g., residents and fellows) to provide resuscitation care. Studies have shown that younger physicians and physicians-in-training may lack competence and confidence in the nontechnical skills, such as leadership and teamwork, required to respond to cardiac arrests (Hayes et al., 2007). Resuscitation teams may have limited opportunities to work together over time in emergency situations, frequently coming together on an ad hoc basis… Read more »
Substantial variability in IHCA care delivery throughout the United States, which suggests an opportunity for improving IHCA care processes and closing gaps in care across hospitals. For example, one study determined that delayed defibrillation (defined as provision of defibrillation more than 2 minutes after the initial arrest) occurred in care for approximately 30 percent of patients and was associated with a significantly lower probability of surviving to hospital discharge after multivariable risk adjustment (Chan et al., 2008). Another study reported adjusted rates of delays in time to defibrillation that was nearly 25-fold (delayed defibrillation rates ranging from 2 to 51… Read more »
Doctors…Well, I was about to make a single comment on the podcast until I read the comments section, and now I have four separate (I think) things to say. FIRST, regarding Nowak’s comment on declaration in the field, aka “no pulse, no ride” – there are multiple factors involved as Tim points out. I guess from my point of view, “down time”, pt age and comorbidities play important roles, along with the points Tim made. And there are more, of course. Also, sequential shocks are indeed impossible for us much of the time. Occasionally, if I arrive first (or second)… Read more »
SECOND, regarding Dr. Weingart’s mention that virtually all of his CPR patients arrive on either a backboard or a scoop stretcher – what about heads-up CPR? If we are to bend the patient approximately 30 degrees at the waist we can’t do that on a backboard, and yet heads-up CPR using a LUCAS and ResQPod seems to have much to recommend it. THIRD, regarding Dr. Weingart’s discussion of cerebral oxygenation – I’m sort of doing my own little experiment these days by checking temporal pulses. I have not had the opportunity to do so on a cardiac arrest patient, but… Read more »
Early Identification of Patients With Out-of-Hospital Cardiac Arrest With No Chance of Survival and Consideration for Organ Donation. Ann Intern Med. 2016 Dec 6;165(11):770-778
https://www.ncbi.nlm.nih.gov/pubmed/27618681
Hello, I’ve been your huge fun for a couple of years. I want to share our recent experience of refractory VF patient treated by ECPR. About 50 to 60 year-old male collapsed from VF. It was a witnessed cardiac arrest and he got by-stander chest compression and EMTs gave 3 defibs before HP arrival. Downtime was 20 min. He was still VF on HP arrival and we put him on VA-ECMO within 30min. Interestingly enough, VF spontaneously disappeared without shocking after ECMO initiation. We did administer Epi and Amio before ECMO, but I’m not sure these drugs were related to… Read more »
Sorry, I didn’t introduce myself. I’m Tomoyuki Endo, Emergency Physician in Sendai CIty, Japan. I’ve been an ED-Crit Care practitioner and simulation educator in Japan.
we’ve seen the same!
Hi Scott, my name is Bas Bens, ED doc from the Netherlands, currently working in Wales. 3 possible topics for your discussion at SMAC. I think best survival in OHCA comes from excellent pre hospital care, so as a society in total we have to focus on this part of the chain. Recently the Dutch cardiac society came out with survival rates of all OHCA in large regions of our country. The overall survival with good neurological outcome is 23%. https://www.hartstichting.nl/downloads/reanimatie-in-Nederland-2016 (Wales has an estimate of 4-5%). One of the reasons for this percentages is early involvement of laymen nearby… Read more »
Excellent episode!
Question from the pre-hospital side of the table. I’m interested in your thoughts on using NIBP during the arrest to consider vasoplegia into your differential for treatment options. We obviously don’t have the ability to obtain ART lines during our codes, however NIBP can be placed on the patient. Is there significant discrepancies between NIBP and arterial line pressures?
Thankk you,
no way
Scott: I’m catching up on your podcasts (made it through in order to Jan 2016) and have the same question as Andrew but maybe for a different reason. I don’t know how to interpret “No way”. Instead of robotically giving 1mg Epi every 3-5 minutes in arrest, is there a utility to NIBP to manage the MAP/SBP during compressions using push-dose to titrate? As Andrew mentioned, prehospital cannot drop an art line as you so often recommend for ED resuscitationists. If not, what would you recommend to prehospital folks for an Epi regimen which doesn’t shut down the brain? (Feel… Read more »
We often get radial pulses during CPR and it’s our practice to feel for pulses at the 180th compression so at 2 mins we can quickly determine pulse/no pulse when checking the rhythm.
If we’re also achieving reasonable blood pressure during CPR, is it safe to assume volume and vascular resistance is adequate in these pts? For some reason we still give these pts 2-3L of fluid during the code.
Thanks
1. radial pulse is inaccurate during arrest. put a linear probe over femoral vessels if you have it. otherwise preposition over carotid
2. no fluid should be given unless the pt has a some weird reason to be hypovolemic
Hi Scott, I had an interesting conversation with Zac at REAMIMATE about using REBOA in CA. I am glad to see you have mentioned it in this post. I would like to know your thoughts on using it in PREM.
Hi Scott/all
Great podcast!
We’re interested in implementing nurse-led cardiac arrests in Derby – I wondered if anyone had any protocols/SOPs, example training logs etc etc to save us reinventing the wheel?
Many thanks
Andrew Tabner
ED Teaching/Research Fellow, Royal Derby Hospital
Scott – huge fan. Couple of EMS questions for future areas of discussion (or those I may have missed!). We’ve looked into dual sequence defibrillation and learned Lifepack will not stand behind it and they consider any such usage as totally voiding warranties. Thus, our system is holding off. Thoughts? Re – ITD’s, we’re aggressively using these on VF/VT cases and struggling with the refractory VF conundrum. Since EMS doesn’t have esmolol in the field, but does carry and use metoprolol, are you aware of any evidence for metoprolol in refractory VF? Did see one study/recommendation on changing defib pads… Read more »
ITD needs more lit–only benefits have been with ACD-cpr. If FDNY puts dual-sequential into protocol, you can pretty much tell lifepack you are switching to zoll if they are actually drawing a line in the sand with warranties–i think the tune will change fairly quickly. dopamine is dirty and not a great code drug, would prefer norepi or epi. 30 degree headup doesn’t have enough human data to rec. yet. under the lucas cup should go the accelerometer/cpr quality monitor pad
Any thoughts on metoprolol vs esmolol in these cases? I’ve only been able to find one case study using metoprolol in refractory VF; but referring back to Mr. DeWolf’s point re: the availability of esmolol drip (and time required to get from pharmacy, bolus, and set up pump) vs the ease of access to and administration of metoprolol IVP, would it be fair to recommend metoprolol?
great ? you are not looking for esmolol drip. you are pushing 500 mcg/kg. esmolol is a drug that should be stocked in the ED for aoritc dissection/AAA patients. i imagine metoprol would work, but not sure of the relative dosing.
hello Scott
thank you, another incredible podcast.
we don’t have ECMO capability , but REBOA for certain cardiac arrest “syndromes” is interesting, and
perhaps doable.
tom
Hey Scott, Great podcast as always. I was particularly interested by your SCtO2/cerebral oximetry comment as it is a tool I use a lot, and in some cases have been able to use in CA (ICU CAs) but should probably drag it to the ED for cases as well. Certainly for ROSC the utility has been shown, but no crystal clear number has emerged during the CPR. Do you know of any data that looked at SCtO2/epi use/neuro outcome? It would seem that physiologically that would be the mode of epi “failure” et lots of small vessel overvasoconstriction, drop in… Read more »
Scott–do you know of any literature to
Back up nurse run codes? We are trying to start a conversation about this in our hospital and we are being asked for studies. Ideas for search terms?
Is anyone still using the Vasopressin, Methylprednisolone, and Epinephrine protocol?
Scott, great post as always!
Your comment about the junctional tourniquets caught my attention. The helicopter service I work for carries one on each aircraft. Just to clarify, are you recommending applying the junctional to the abdominal area in order to compress the descending aorta, and thus improve coronary perfusion? We rarely, if ever, transport cardiac arrests due to the logistics of CPR in cramped quarters and not having a mechanical device, but this is something we might be able to try on those rare occasions where a patient codes in flight.
that’s the idea, but be aware, this is a completely unstudied concept
Just out of curiosity, do we know why some of these patients become alert during compressions only to find them go unconscious when compressions are stoped with no pulse?