The Pre-brief
In part two of this series, we are going to continue to break down this chicken scratch to understand what the priorities are in cardiac arrest. Check out Part 1 before you read this post. Again, much of this is dependent on your personal practice, so we would love to hear from you in the comments about how you like to do things.
Once you have established the first two priorities (high quality chest compressions and defibrillation when appropriate) and assigned team roles or dismissed unnecessary people, you can move on to the next steps, which should all take place concurrently without interfering with high quality chest compressions (HQ CC) and defibrillation:
- Obtain a history
- Establish vascular access
- Determine which meds need to be given and administer them
- Begin basic airway maneuvers and consider whether you need an advanced airway
- Treat the reversible causes of cardiac arrest
Obtain an abbreviated history
Before the arrest
- Story concerning for ischemia?
- Possible reversible causes?
- Toxicological origin of arrest?
- Renal patient? Think hyperkalemia.
- How was the patient found?
- What were the patient’s wishes in the event of a cardiac arrest? DNR?
During the arrest
- What was the no flow time? (time without CPR)
- What was the low flow time? (time with CPR)
- Witnessed arrest? Bystander CPR? Both are correlated with better outcomes.
- Initial rhythm? Shockable rhythms correlated with better outcomes.
- Prehospital interventions (defibrillation, meds, airway management, etc.)?
- Achieved ROSC at any point?
Establish vascular access
While we ideally would like two or more large-bore IVs in large vessels, unfortunately the reality is that it’s close to impossible to have that in every cardiac arrest. Be quick to jump to alternative forms of medication administration:
- Intraosseous: this is quite possibly THE FASTEST form of IV access. For those of you who don’t routinely use IOs, imagine getting vascular access within ONE SECOND! You can infuse any medications through this and draw blood for labs. Two things to keep in mind if you want to draw labs: 1) discard at least 2cc of marrow blood first, and 2) the WBC, platelet count, potassium, and CO2 will be unreliable, but most everything else will be fairly accurate (1). Due to closer proximity to the central circulation and higher flow rates, the humeral IO has been shown to be a great resuscitation line (2).
- Rapid Infusion Catheter: if you can get a smaller gauge IV in the patient, we have a tool to upsize those catheters to larger ones. Introducing: the rapid infusion catheter, or RIC!
These catheters of variable diameters (6F-8F) are exchanged for a smaller gauge IV (typically requires at least a 20ga IV). To do this, a wire is passed through the existing IV and the catheter is removed. A small nick is made with a scalpel. The RIC comes with a dilater within the catheter itself (just like a Cordis catheter). Because of the size and stiffness of the RIC, it’s important not to place this catheter in small vessels. Stick to the AC or above.
Here’s a video of how it’s done by Dr. Andy Buck:
He also compared numerous forms of vascular access in this video and here are the results:
- When all else fails for vascular access, ultrasound-guided central line placement (typically a triple lumen in non-hemorrhagic cardiac arrest) is fast, easy, and gives you multiple ports for medications, labs, and blood products.
Determine which meds need to be administered
We have plenty of algorithms to help us decide which medications to give during a cardiac arrest: from epinephrine to amiodarone to sodium bicarbonate to calcium chloride. Interestingly, the administration of these meds is supported by very low quality evidence (with a few exceptions), and many studies actually showed poorer outcomes associated with the use of typical ACLS medications. For now however, we should continue to use them as recommended by the AHA guidelines. Once vascular access has been obtained, most patients should receive epinephrine. The optimal timing and dosing strategy is still unclear. Sodium bicarbonate and calcium chloride can be useful for treatment of metabolic causes of cardiac arrest; consider these medications when the QRS is wide. Magnesium is the treatment for Torsades de Pointes. You can also use antidysrhythmics such as lidocaine and amiodarone for shockable rhythms.
We will cover cardiac arrest medications in more depth in a future post; the topic requires an entire post unto itself.
Begin basic airway maneuvers and consider whether you need an advanced airway
If your patient came to you endotracheally intubated, then your job is easy: place an in-line waveform end tidal CO2 detector and use it to confirm tube placement. Typically ETCO2 will be low, so you can listen for breath sounds as well.
There is a lack of high-quality evidence and significant difficulty in conducting a randomized controlled trial to determine the best strategy for airway management in cardiac arrest. However, based on the existing literature (which I analyzed in this post on emDocs.net) it seems that basic airway interventions, such as jaw maneuvers, airway adjuncts (oropharyngeal/nasopharyngeal airway), and bag valve masks, are associated with better outcomes than advanced airway interventions (supraglottic airway, endotracheal intubation) in OHCA (3). For out-of-hospital cardiac arrests, there does not seem to be an outcome benefit when comparing supraglottic airways (SGA) to endotracheal intubation (ETI); however, it is much easier to place an SGA and allows for more attention to be placed on HQ CC and early defibrillation. In fact, just published last month was a 3- and 6-month follow-up publication that showed consistent results of no significant difference between SGA and ETI (4).
At this time, it is still unclear whether an ED physician with more training in airway management would have improved outcomes after intubation compared to a paramedic who performs fewer intubations each year on average, has the increased stresses of an uncontrolled environment, and is frequently working in very small groups. Based on the existing research, when your next cardiac arrest comes in, it seems best to focus your airway efforts on those basic maneuvers; if you choose to use an advanced airway, use what you are most comfortable with. Transport time should also be taken into consideration, as an SGA may be much easier to use for prolonged transports.
For in-hospital cardiac arrests, a study found that patients without preexisting respiratory insufficiency and patients with a shockable rhythm tend to do worse when intubated (5). Patients intubated in the first 15 minutes of resuscitation had lower survival compared to those intubated after 15 minutes. In a sensitivity analysis, they concluded that tracheal intubation was associated with lower likelihood of positive outcomes. A retrospective analysis from 2012 found that BVM use WITH airway adjuncts was associated with good neurological recovery (CPC 1); conversely, ETI had worse outcomes (6). Using what research we do have and considering practical aspects of care, it seems prudent to delay intubation until the most important parts of cardiac arrest management are taken care of or are in process.
Treat the reversible causes of cardiac arrest
This topic deserves a post unto itself and is going to be the focus of part 3. We will cover a few different paradigms for the reversible causes and a review of how to use ultrasound to your advantage during cardiac arrest.
The Debrief
After high-quality chest compressions and early defibrillation have been addressed, the next priorities in cardiac arrest are:
- Obtain a history
- Establish vascular access
- Determine which meds need to be given and administer them
- Begin basic airway maneuvers and consider whether you need an advanced airway
- Treat the reversible causes of cardiac arrest
References
- Miller LJ, Philbeck TE, Montez D, Spadaccini CJ. A new study of intraosseous blood for laboratory analysis. Arch Pathol Lab Med. 2010 Sep;134(9):1253-60. doi: 10.1043/2009-0381-OA.1. PMID: 20807043.
- https://www.emra.org/emresident/article/resuscitation-and-the-humeral-intraosseous-line/#:~:text=Humeral%20IO%20placement%20is%20just,adequate%20for%20large%20volume%20resuscitation
- http://www.emdocs.net/airway-management-in-cardiac-arrest/
- Benger JR, Lazaroo MJ, Clout M, Voss S, Black S, Brett SJ, Kirby K, Nolan JP, Reeves BC, Robinson M, Scott LJ, Smartt H, South A, Taylor J, Thomas M, Wordsworth S, Rogers CA. Randomized Trial of the i-gel Supraglottic Airway Device Versus Tracheal Intubation During Out of Hospital Cardiac Arrest (AIRWAYS-2): Patient Outcomes at Three and Six Months. Resuscitation. 2020 Sep 30:S0300-9572(20)30490-1. doi: 10.1016/j.resuscitation.2020.09.026. Epub ahead of print. PMID: 33010371.
- Andersen LW, Granfeldt A, Callaway CW, et al. Association Between Tracheal Intubation During Adult In-Hospital Cardiac Arrest and Survival. JAMA. 2017;317(5):494–506. doi:10.1001/jama.2016.20165. PMID: 28118660.
- Yamada A, Takeuchi Y, Nishizaki Y, et al. Bag-valve-mask ventilation with airway adjuncts improves neurological outcomes of in-hospital cardiac arrest. Intern Med. 2012 ;51(12):1517-21. PMID: 22728483.
