CARDIAC ARREST / MEDICAL
PARAMEDIC
1. Notes on intubation and oxygenation:
a. Apply NRB mask with high flow oxygen during first two cycles of CPR.
b. Then place nasal cannula to patient at 15 liters/minute prior to and during intubation attempts. It may be necessary to place bilateral NPAs.
2. Any patient who presents in cardiac arrest assumed to be from a medical cause will have CPR performed on scene for a minimum of 30 minutes. If ROSC is achieved at any time during resuscitation efforts the patient will be transported to the closest most appropriate hospital.
3. If after 30 Minutes the patient remains in Cardiac arrest, TERMINATION OF RESUSCITATION should be reviewed. It is optional to contact on-line medical direction.
4. The following information should be collected if available.
The Patient’s:
• Age
• PMH
• General health (skin turgor, muscle tone, mobility of patient prior to arrest)
• Last time patient was seen alive
• Witnessed arrest
• Bystander CPR
• Pupillary Response
• Temperature
• Initial and current cardiac Rhythm
• Current ETCO2 reading
• Family wishes of resuscitation efforts
4. Resuscitation efforts may be terminated in the field if the patient meets the requirements for TERMINATION OF RESUSCITATION guidelines. On-line medical direction is optional to terminate a resuscitation.
a. CPR and ALS interventions have been attempted for at least 30 minutes,
b. No ROSC at any time during resuscitation efforts
c. The arrest is not the result of hypothermia
d. ETCO2 <15
e. Absence of Palpable Carotid/Femoral pulses
f. Family is accepting of the decision to terminate efforts for resuscitation.
g. The patient does not have an LVAD in place
5. All patients with a LVAD (left ventricular assist device) in cardiac arrest should be transported unless there is an active DNR.
6. The patient may be transported prior to reaching the 30-minute benchmark if responders feel that staying on scene does not promote good patient care or exposes them to harm or there are other mitigating circumstances.
Use of NALOXONE (Narcan) in cardiac arrest. Do not routinely administer NALOXONE. Use only when strong suspicion of opioid overdose exists such as prescription opioids, paraphernalia, or history suggestive of opioid use/abuse. NALOXONE has been shown to be ineffective once there is cardiac standstill.
HYPOTENSION AND SHOCK POST-ARREEST ROSC
1. Consider a vasopressor: Norepinephrine or Epinephrine either by Push-Dose or infusion.
2. Recent studies suggest that Norepinephrine is less likely to cause rearrest in ROSC patients and may be the preferred agent.
b. NOREPINEPHRINE (Levophed) drip @ 2-10 mcg/min IV infusion
i. Solution: 1 mg in 250 ml NS (4 mcg/ml); 40 ml/hr (~3 mcg/min); dose may be titrated to patient response
b) NOREPHINEPHRINE PUSH-DOSE Inject 4 mg. of Norepinephrine into 250 ml bag. Draw out 10 ml. in a syringe. Administer 0.5 ml. every minute. One advantage of this concentration is it can be transitioned to a drip as needed.
a. EPINEPHRINE drip @ 2-10 ug/min
i. EPINEPHRINE drip (1 mg in 250 ml of NS = 4 mcg/ml) and start at 2 mcg/min. Titrate drip up to 10 ug/min or until an acceptable perfusing heart rate and BP are achieved. A second IV line is desired, however, do not withhold medication if second IV is unobtainable.
b. EPI PUSH-DOSE Inject 1 mg. (1 ml) of 1:1,000 Epinephrine into 100 ml. bag NS.
i. Push 0.5-1 ml (5-10 mcg) q 1 min prn hypotension
PARAMEDIC
1. Notes on intubation and oxygenation:
a. Apply NRB mask with high flow oxygen during first two cycles of CPR.
b. Then place nasal cannula to patient at 15 liters/minute prior to and during intubation attempts. It may be necessary to place bilateral NPAs.
2. Any patient who presents in cardiac arrest assumed to be from a medical cause will have CPR performed on scene for a minimum of 30 minutes. If ROSC is achieved at any time during resuscitation efforts the patient will be transported to the closest most appropriate hospital.
3. If after 30 Minutes the patient remains in Cardiac arrest, TERMINATION OF RESUSCITATION should be reviewed. It is optional to contact on-line medical direction.
4. The following information should be collected if available.
The Patient’s:
• Age
• PMH
• General health (skin turgor, muscle tone, mobility of patient prior to arrest)
• Last time patient was seen alive
• Witnessed arrest
• Bystander CPR
• Pupillary Response
• Temperature
• Initial and current cardiac Rhythm
• Current ETCO2 reading
• Family wishes of resuscitation efforts
4. Resuscitation efforts may be terminated in the field if the patient meets the requirements for TERMINATION OF RESUSCITATION guidelines. On-line medical direction is optional to terminate a resuscitation.
a. CPR and ALS interventions have been attempted for at least 30 minutes,
b. No ROSC at any time during resuscitation efforts
c. The arrest is not the result of hypothermia
d. ETCO2 <15
e. Absence of Palpable Carotid/Femoral pulses
f. Family is accepting of the decision to terminate efforts for resuscitation.
g. The patient does not have an LVAD in place
5. All patients with a LVAD (left ventricular assist device) in cardiac arrest should be transported unless there is an active DNR.
6. The patient may be transported prior to reaching the 30-minute benchmark if responders feel that staying on scene does not promote good patient care or exposes them to harm or there are other mitigating circumstances.
Use of NALOXONE (Narcan) in cardiac arrest. Do not routinely administer NALOXONE. Use only when strong suspicion of opioid overdose exists such as prescription opioids, paraphernalia, or history suggestive of opioid use/abuse. NALOXONE has been shown to be ineffective once there is cardiac standstill.
HYPOTENSION AND SHOCK POST-ARREEST ROSC
1. Consider a vasopressor: Norepinephrine or Epinephrine either by Push-Dose or infusion.
2. Recent studies suggest that Norepinephrine is less likely to cause rearrest in ROSC patients and may be the preferred agent.
b. NOREPINEPHRINE (Levophed) drip @ 2-10 mcg/min IV infusion
i. Solution: 1 mg in 250 ml NS (4 mcg/ml); 40 ml/hr (~3 mcg/min); dose may be titrated to patient response
b) NOREPHINEPHRINE PUSH-DOSE Inject 4 mg. of Norepinephrine into 250 ml bag. Draw out 10 ml. in a syringe. Administer 0.5 ml. every minute. One advantage of this concentration is it can be transitioned to a drip as needed.
a. EPINEPHRINE drip @ 2-10 ug/min
i. EPINEPHRINE drip (1 mg in 250 ml of NS = 4 mcg/ml) and start at 2 mcg/min. Titrate drip up to 10 ug/min or until an acceptable perfusing heart rate and BP are achieved. A second IV line is desired, however, do not withhold medication if second IV is unobtainable.
b. EPI PUSH-DOSE Inject 1 mg. (1 ml) of 1:1,000 Epinephrine into 100 ml. bag NS.
i. Push 0.5-1 ml (5-10 mcg) q 1 min prn hypotension