Update: Some of the information in this post and podcast has been superseded by podcast 125; so click on over there.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:
Place an Oropharyngeal Airway
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.
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.
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.)
Advanced airway = LMA, not an ET Tube
Here is my LMA video
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
pop in an IO
listen to the podcast for my feelings on meds
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.
- EMCrit 289 – Ketamine Only Intubation Paper with Brian Driver - January 12, 2021
- EMCrit 288 – Neurogenic Shock & Should we be Using Vasopressors for Hemorrhagic Shock? - December 29, 2020
- EMCrit 287 – Thoracotomy Masterclass with Dennis Kim - December 10, 2020