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Adult Cardiac Arrest Algorithm

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In Cardiac arrest, the pulse cannot be felt, the patient is unresponsive, and respirations are absent or agonal. The arrest rhythms include:

The goal of intervention in cardiac arrest is Return of spontaneous circulation (ROSC).

Cardiac Arrest Sequence

This sequence is structured around 2 minute periods of CPR during which the rest of the team should be preparing for the next step in the process.

  1. If it has not been done already, activate the Emergency response system.

  2. Continue the BLS sequence.

  3. Establish an airway and provide oxygen if available.

  4. Connect the patient to cardiac and blood pressure monitors when available.

  5. If the patient is in asystole or PEA on the monitor, go to step 13.

  6. If the patient is in Ventricular tachycardia (VT) or ventricular fibrillation (VF) on the monitor, immediately apply the pads and shock the patient with 120-200 Joules on a biphasic defibrillator or 360 Joules on a monophasic defibrillator.

  7. Continue CPR for 2 minutes while establishing IV or IO access.

  8. If the patient is still in VT or VF, shock again.

  9. Continue CPR for 2 minutes while giving Epinephrine 1 mg every 3-5 minutes.

  10. If the patient is still in VT or VF, shock again.

  11. Continue CPR for 2 minutes while giving Amiodarone 300 mg bolus; may repeat with a 2nd dose of 150 mg bolus as needed. If amiodarone is not available, Lidocaine 1-1.5 mg/kg may be given followed by half doses ever 5-10 minutes to a maximum of 3 mg.

  12. Continue shocking any shockable rhythms.

  13. If it is determined at any time that the patient is in asystole or PEA, continue CPR while giving Epinephrine 1 mg every 3-5 minutes.

  14. Reevaluate the rhythm every 2 minutes and shock if the patient develops VT or VF.

  15. Continue to Evaluate, Identify and Intervene on underlying reversible causes. Use the H's and T's to identify the possible cause of arrest.

    1. Hypovolemia –Treatment includes infusion of saline or lactated Ringer's solution.
       
    2. Hypoxia –Treatment should include airway management and effective ventilation and oxygenation.
       
    3. Hydrogen Ion excess (Acidosis) –Treatment should include hyperventilation and bolus of sodium bicarbonate.
       
    4. Hypoglycemia –Treatment includes bolus of dextrose.
       
    5. Hypokalemia – Treatment may include infusion of potassium.
       
    6. Hyperkalemia – Treatment may include calcium chloride, sodium bicarbonate, and glucose with insulin.
       
    7. Hypothermia – Treatment should include rewarming.
       
    8. Tension Pneumothorax – Treatment will include needle decompression or thoracostomy.
       
    9. Tamponade (Cardiac) – Treatment will be pericardiocentesis by experienced team member.
       
    10. Toxins – Treatment will be based on the specific overdose.
       
    11. Thrombosis (pulmonary embolus) – Treatment may include fibrinolytics or surgical embolectomy.
       
    12. Thrombosis (acute MI) - Consult cardiology.
       
  16. If able to identify the cause(s), treat the cause.
  17. If Return of Spontaneous Circulation occurs at any point, go to the Post Cardiac Arrest case.

Medications During Cardiac Arrest

Vasopressors (Epinephrine and Vasopressin) may improve the patient's chances for ROSC. A vasopressor should be given every 3-5 minutes during cardiac arrest.

Antiarrhythmics, particularly amiodarone, may increase short term survival. If amiodarone is not available, lidocaine may be used. Lidocaine is the antiarrhythmic that can be administered through an ET tube.

For pulseless persistent torsades de pointes, magnesium sulfate may be given with a loading does of 1-2 gram over 5-20 minutes. Magnesium should also be given in a case of known or suspected hypomagnesemia.