First Things First (assess for & treat the following)

• The following algorithms are adapted from the 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Additional information & references may be obtained from Circulation 2005;112(24 Supplement) and the American Heart Association CPR and Emergency Cardiovascular Care website (www.americanheart.org).
• Identify life-threatening arrhythmias:
  • Symptomatic bradycardia
  • Symptomatic tachycardia
  • Ventricular fibrillation
  • Pulseless ventricular tachycardia
  • Pulseless electrical activity
  • Asystole
• Minimize the time from cardiac arrest recognition to starting effective CPR.
• Assess and control airway.
• Assess breathing and integrate with chest compressions at 2:30 ratio.
• Immediate defibrillation when indicated
• Maximize hemodynamics by effective chest compression, pharmacological and antidysrhythmic treatment.
• Differential diagnosis

History and Physical (assess for the following)

• Obtain prehospital & pre-resuscitation history.
• Medication profile may be helpful.
• Rule out correctable causes of cardiac arrest.

Diagnostic Tests

• Lab studies are seldom useful during initial phase of resuscitation.
• Potentially useful diagnostic tests for ongoing resuscitation:
  • ABG
  • Base deficit
  • Lactate
  • Potassium
  • Hemoglobin
  • Cardiac enzyme injury markers
  • CXR

General Management Principles

Adult cardiac arrest (>8 years)

BLS primary survey and algorithm

• Activate emergency response system or 911.
• Call for defibrillator.
• A: Assess (open) airway
• B: Assess breathing
  • Yes: Recovery position
  • No: 2 breath to chest rise
• C: Assess circulation (pulse check up to 10 seconds)
  • Yes: One breath every 6 seconds
  • No: Alternate compressions/ventilations 30:2 until AED or ACLS
    • PUSH HARD (1-2” depth) AND FAST (100/min) on the chest and ALLOW COMPLETE CHEST RECOIL.
• Attach AED.
  • Power ON
  • Attach electrode pads.
  • Assess rhythm.
  • Shockable: Clear and give one shock every 5 compression/ventilation (C/V) cycles of 30:2
  • Non-shockable: Immediate CPR for 5 cycles of 30:2 or 2 minutes, then reassess

ACLS secondary survey and algorithm

• A: Assess (open) airway
  • Advanced airway when indicated
• B: Assess breathing
  • Use 100% oxygen
  • O2 saturation and end-tidal CO2 confirmation
  • C/V asynchronous
• C: Assess circulation
  
  • Obtain IV access
  • EKG differential diagnosis
  • Defibrillate if shockable
    • Vfib or pulseless Vtach
      • Shock
        • Shock energy Monophasic 360 J
        • Shock energy Biphasic 120 J (rectilinear) or 150 J (truncated), escalate to 200 J (200 J if unknown wave)
      • CPR 5 cycles (or 2 minutes)
      • Shock
      • Pressors
      • CPR 5 cycles
      • Shock
      • Antiarrhythmic
      • Shock
      • Pressors
      • CPR
    • Asystole or PEA
      • CPR
      • Pressors
      • Atropine
      • Differential diagnosis
      • CPR

Differential diagnosis

• Hypovolemia
• Hypoxia
• Hydrogen ion—acidosis
• Hyper/hypokalemia & other metabolic causes
• Hypo/hyperthermia
• Hypoglycemia
• Toxins (including drug)
• Tamponade
• Tension pneumothorax
• Thrombosis (acute coronary syndrome and pulmonary embolism)
• Trauma (hemorrhage)

Pharmacotherapy

• Vfib or pulseless Vtach
  • CPR (5 cycles or 2 minutes)
  • Shock
  • Epinephrine IV 1 mg every 3-5 min or Vasopressin IV 40U, X 1 and CPR
  • Shock
  • Amiodarone 300 mg IV then 150-mg boluses X 1 or lidocaine 1 mg/kg IV then 0.5-mg/kg boluses X 3 doses
  • Mg 2 g IV if torsades de pointes and CPR
  • CPR
• Asystole or PEA
  • CPR
  • Epinephrine IV 1 mg every 3-5 min or Vasopressin IV 40U, X 1 and CPR
  • Atropine 1 mg IV X 3
  • CPR
  • Consider transcutaneous pacing

Specific Treatments

Symptomatic bradycardia (HR < 60)

• Primary survey
  • Assess ABCs.
  • Secure airway noninvasively.
  • Ensure monitor/defibrillator is available.
• Secondary survey
  • Assess secondary ABCs. (Is invasive airway mgt indicated?)
  • O2, IV access, monitor, fluids
  • Vital signs, pulse ox, monitor blood pressure
  • ECG 12-lead
  • CXR
  • Problem-focused history
  • Problem-focused physical exam
• If signs or symptoms are due to bradycardia:
  • Atropine: 0.5-1.0 mg IV q 3-5 min until 0.04 mg/kg
  • Transcutaneous pacing if available
  • Dopamine: 2-10 mcg/kg/min
  • Epinephrine: 2-10 mcg/min
• Prepare for transvenous pacemaker if above interventions are unsuccessful.

Symptomatic tachycardia, unstable (>150 with severe hypotension)

• Synchronized cardioversion algorithm
  • Have available at bedside:
    • O₂ saturation monitor
    • Suction device
    • IV access
    • Intubation equipment
  • Premedicate when possible.
    • Diazepam: 0.1-0.2 mg/kg IV
    • Midazolam: 0.05-0.1 mg/kg IV
    • Etomidate: 0.3 mg/kg IV
    • Ketamine: 1-2 mg/kg IV
    • Methohexital: 1 mg/kg IV
  • Turn on defibrillator.
  • Attach monitor leads.
  • Engage synchronization mode by pressing the “sync” button.
  • Identify markers on R waves indicating sync mode.
  • If necessary, adjust monitor gain until sync markers occur with each R wave.
  • Select appropriate energy level.
    • Synchronized cardioversion monophasic at 100 J, 200 J, 300 J, 360 J
    • Synchronized cardioversion biphasic at 100 J and escalating
    • PSVT & atrial flutter may respond to lower energy levels (start at 50 J).
    • Polymorphic VT, treat as Vfib.
  • Position conductor pads or gel on patient.
  • Position paddle/pads on patient (sternum apex).
  • Announce to team members, “charging defibrillator; stand clear.”
  • Press charge button.
  • When the defibrillator is charged:
    • Ensure resuscitation team members are away from & not touching pt.
    • Apply 25 lbs of pressure on paddles or use automatic device.
    • Press discharge buttons simultaneously.
  • Check monitor; if tachycardia persists, increase joules as above.
  • Reset sync mode after each synchronized cardioversion because most defibrillators default to the unsynchronized mode. This default allows immediate defibrillation if the cardioversion produces VF.

Symptomatic tachycardia, stable (< 150 without severe hypotension)

• Identify as 1 of 4 types of tachycardia:
  • Atrial fibrillation/atrial flutter
  • Narrow complex tachycardia
  • Stable wide-complex tachycardia (unknown type)
  • Stable monomorphic VT and/or polymorphic VT

Atrial fibrillation/atrial flutter

• Is pt clinically unstable?

• Is cardiac function impaired (EF < 40%)?

• Is Wolff-Parkinson-White present (delta wave, short P-R segment, heart rate >300)?

• Is the duration of the rhythm < 48 or >48 hrs?

• Treatment
  • Treat unstable pts urgently.
  • Control rate.
  • Control rhythm.
  • Provide anticoagulation.

• Category 1, normal EF
  • Control rate.
  • Beta blockers (I)
  • Calcium channel blockers (I)
  • Convert rhythm.
    • If onset of symptoms is < 48 hrs, consider cardioversion.
      • Amiodarone
      • Ibutilide
      • Flecainide
      • Propafenone
      • Procainamide
    • If onset of symptoms is >48 hrs (Avoid drugs that may cardiovert patient, as patient is at risk for embolization of atrial thrombi.)
      • Anticoagulate for 3 wks, then elective cardioversion & anticoagulate for additional 4 wks.
      • Early cardioversion may be considered. Initiate IV heparin & perform TEE to exclude atrial clot, then cardiovert within 24 hrs & anticoagulate for 4 wks.

• Category 2, EF, < 40% or CHF
  • Control rate. (If AF >48 hrs, use extreme caution in pts not receiving anticoagulation.)
    • Digoxin
    • Diltiazem
    • Amiodarone
  • If onset of symptoms is < 48 hrs, consider DC cardioversion or amiodarone.
  • If onset of symptoms is >48 hrs, anticoagulate for 3 wks, then elective cardioversion & anticoagulate for additional 4 wks.
  • Early cardioversion may be considered. Initiate IV heparin & perform TEE to exclude atrial clot, then cardiovert within 24 hrs & anticoagulate for 4 wks.

• Category 3, Wolff-Parkinson-White syndrome
  • Avoid use of adenosine, beta blockers, calcium channel blockers, digoxin.
  • If onset of symptoms is < 48 hrs
    • Normal EF (One of the following can be used for rate control & cardioversion.)
      • Amiodarone
      • Flecainide (IIb)
      • Procainamide (IIb)
      • Propafenone (IIb)
      • Sotalol (IIb)
    • EF < 40% or CHF
      • Amiodarone (IIb)
      • Consider DC cardioversion.
  • If symptoms >48 hrs, anticoagulate for 3 wks, then elective cardioversion & anticoagulate for additional 4 wks.
  • Early cardioversion may be considered. Initiate IV heparin & perform TEE to exclude atrial clot, then cardiovert within 24 hrs & anticoagulate for 4 wks.

Narrow-complex tachycardia (reentry SVT or PSVT, QRS >0.12 sec), EF < 40%

• No cardioversion for stable pts

• Attempt diagnostic maneuvers.
  • Vagal maneuver (Valsalva, carotid sinus massage)
  • Adenosine: 6 mg IV, 12 mg IV, 12 mg IV (rapid bolus technique)
  • Attempt to identify rhythm.

• EF >40%
  • Calcium channel blocker
  • Beta blocker
  • Digoxin
  • Cardioversion
  • Consider procainamide, amiodarone, sotalol.
• EF < 40%
  • No cardioversion
  • Digoxin
  • Amiodarone
  • Diltiazem

Wide-complex tachycardia (QRS >0.12 sec)

• EF >40%
  • No cardioversion unless symptomatic
  • Adenosine
  • Amiodarone
  • Procainamide
  • Sotalol

• EF < 40%
  • No cardioversion unless symptomatic
  • Amiodarone
  • Procainamide
  • Sotalol

Ectopic or multifocal atrial tachycardia

• EF >40%
  • No cardioversion unless unstable
  • Calcium channel blocker
  • Beta blocker
  • Amiodarone
• EF < 40%
  • No cardioversion unless unstable
  • Amiodarone
  • Diltiazem

Stable monomorphic VT: See wide-complex tachycardia above.
Stable polymorphic VT

• Is QT interval prolonged?
  • Normal QT
    • Correct electrolytes.
    • Treat myocardial ischemia.
    • EF >40%
      • Beta blockers
      • Lidocaine
      • Amiodarone
      • Procainamide
      • Sotalol
    • EF < 40%
      • Amiodarone: 150 mg IV over 10 min, or
      • Lidocaine: 0.5-0.75 mg/kg IV, then
      • Synchronized cardioversion
    • Switch to defibrillation if unstable.
  • Prolonged QT
    • Correct electrolytes.
    • Consider toxic drug effect.
    • Magnesium: 1-2 g IV
    • Overdrive ventricular pacing
    • Isoproterenol: 5 mcg/min
    • Switch to defibrillation if unstable.

Ongoing Assessment

• If no change in condition: repeat primary survey.
• Continue appropriate clinical & hemodynamic monitoring.
• Identify inciting events.
• Appropriate consultation

Author

• Written by Craig Manifold, MD
• Revised by Andrea Gabrielli, MD