PWC

1
PWC

• Protocol 4
• Cardiac Arrest

2
Scene Set Up

• Youve been called for A man down, on arrival
  you find a woman performing CPR on her husband.
• She states that she found him lying here when she
  came out of the grocery store
• He was last seen by her 30 minutes ago
• He has a Hx of 2 AMIs

3
ABCs

• You confirm that your patient is in cardiac
  arrest and you
• Restart CPR
• O2 BVM
• 12 BPM

4
Your Next Action Is To?

• Connect patient to a cardiac monitor and document
  rhythm
• Your patient is in asystole
• Whats next?
• Confirm in another lead
• Its still asystole
• But, what would you do if the second lead looked
  like fine V-fib?
• Thats right, defibrillate _at_ 200 j

5
Whats Next?

• Provide definitive airway management
• ET (three attempts)
• Combitube as a back-up
• Whats next?
• Yeah, Pacing, thats the ticket
• Unless of course its not indicated
• Down time of ten minutes
• No capture!

6
Lets Review What Weve Done

• ABCs
• Confirmed cardiac arrest
• Started CPR
• Cardiac Monitor
• Confirmed asystole in two leads
• Documented rhythm
• Advanced airway
• ET
• Paced
• No capture

7
Whats Next?

• IV Normal Saline
• Standard Admin. Set
• KVO
• Note Initial cardiac arrest medications may be
  given via an ET tube. Dont delay in their
  administration

8
And After That?

• Epinephrine 1/10,000
• Adult dosage
• 1 mg IVP
• 2 mg ET
• Repeat q 3 5 minutes
• Whats the pediatric dosage IVP and IO?
• 0.01 mg/kg (1/10,000)
• q 3 5 minutes
• And ET
• 0.1 mg/kg (1/1,000) diluted
• q 3 5 minutes

9
Were Almost Finished, Whats Next?

• Atropine
• 1 mg IVP
• 2 mg ET
• Repeat q 3 5 minutes up to a total dosage of 3
  mg IVP or 6 mg ET
• Whats the pediatric dosage?
• Not in our protocols!

10
Lastly, If Elephants Could Fly

• Reassess pulse and monitor
• If changed, refer to appropriate protocol
• If no change, perform lead check and continue
  with this protocol

11
Next Case
12
Same Patient, Different Set-Up

• Youve been called for A man down, on arrival
  you find a woman performing CPR on her husband.
• She states that she found him lying here when she
  came out of the grocery store
• He was last seen by her 30 minutes ago
• He has no past medical hx but witnesses state
  they saw this man gleefully running from the scene

13
You Immediately Recognize This Individual As?

• A. Chief Of EMS Operations
• Tim Keen
• B. PWC Medical Director
• Raul Rodriguez
• C. Doctor Death
• Jack Kevorkian

14
ABCs

• You confirm that your patient is in cardiac
  arrest and you
• Restart CPR
• O2 BVM
• 12 BPM

15
Your Next Step Is To

• Connect patient to a cardiac monitor and document
  rhythm
• What is this rhythm?
• What protocol will we use?
• Yea, its NSR and well use the PEA protocol
• Before we get in over our heads, we might want to
  consider the causes of this form of cardiac arrest

16
The Causes Of PEA

• Hypoxia
• Hypovolemia
• Hypothermia
• Hyperkalemia
• Hypokalemia
• Cardiac Tamponade
• Tension Pneumothorax
• Massive PE
• Massive AMI
• Acidosis
• Drug Overdose
• Ok, whats the most common?
• Hypovelmia

17
OK, Were Doing CPR And Thinking About The Causes
Of PEA. Whats next?

• Provide definitive airway management
• ET (three attempts)
• Combitube as a back-up
• Whats next?
• IV Normal Saline
• Standard Admin. Set,
• KVO
• While your at it, how about a fluid challenge
• Fluid resuscitate if a pulse returns

18
And After That?

• Epinephrine 1/10,000
• Adult dosage
• 1 mg IVP
• 2 mg ET
• Repeat q 3 5 minutes
• Whats the pediatric dosage IVP and IO?
• 0.01 mg/kg (1/10,000)
• q 3 5 minutes
• And ET
• 0.1 mg/kg (1/1,000) diluted
• q 3 5 minutes

19
What If The Rhythm Is Bradycardic?

• Can we pace it
• NO
• Can we give Atropine
• Yes
• 1 mg IVP
• 2 mg ET
• Repeat q 3 5 minutes up to a total dosage of 3
  mg IVP or 6 mg ET

20
What About Tension Pneumothorax, Can Pop It?

• Yes
• Per Directive Q, this is the only time we can do
  so without contacting Med Control

21
Next Case
22
The Set Up

• Your called to the local golf course for a
  possible cardiac arrest. On arrival you are
  told that one of the staff members has just
  delivered three shocks with an AED.
• You note no return of spontaneous pulse

23
You Should Next

• A. Connect cardiac monitor and Quick-Combo pads
• Confirm Ventricular Fibrillation
• Deliver three stacked shocks
• 200, 300, 360 joules
• B. Start CPR
• Connect cardiac monitor
• Provide for definitive airway
• ET tube
• C. Start CPR
• Establish an IV
• Normal Saline on a standard admin. Set
• KVO

24
OK, You Knew It Was B

• The cardiac monitor displays the following rhythm

25
Youve Established An ET Airway And An IV.
Whats next?

• Epinephrine 1/10,000
• Adult dosage
• 1 mg IVP
• 2 mg ET
• Repeat q 3 5 minutes
• Whats the pediatric dosage IVP and IO?
• 0.01 mg/kg (1/10,000)
• q 3 5 minutes
• And ET
• 0.1 mg/kg (1/1,000) diluted
• q 3 5 minutes

26
And Than?

• Defibrillate _at_ 360 j
• And after each additional dosage of epinephrine
• Theres a change, what do I do now
• Reassess
• Theres a pulse and good BP

27
Do I Need To Do Anything Else?

• Lidocaine
• 1.5 mg/kg IVP
• 3.0 mg/kg ET
• Lidocaine Infusion
• 2 mg/min
• Half dose if indicated by age, hemodynamics, or
  known liver disease

28
What If Your Patient Didnt Convert After The
Epinephrine And Shock?

• Amiodarone
• 300 mg in 20 ml NS
• Slow IVP (2 minutes)
• Defibrillate _at_ 360 j
• If no change?
• Amiodarone
• 150 mg in 20 ml NS
• Slow IVP (2 minutes)
• Defibrillate _at_ 360 j

29
OK, After The 2nd Amiodarone And Shock _at_ 360 You
Get This

• What do we do now?
• Reassess? Right!
• Strong radial pulse and good BP
• What now?
• Amiodarone Infusion
• 100 mg in 100 ml
• Mini-drip
• 60 gtts/min

30
Lastly, If The Amiodarone Didnt Work?

• Lidocaine
• 1.5 mg/kg IVP or 3 mg/kg ET
• Defibrillate
• Repeat once after three five minutes
• Lidocaine infusion for return of circulation
• 2 mg/min