CARDIAC ARREST

Inclusion Criteria:  These guidelines help establish treatment priorities for all apneic and pulseless patients.  Do not attempt resuscitation in patients who meet criteria outlined in the relevant section of the DETERMINATION OF DEATH IN THE FIELD Policy.  The NEONATAL CARE Guidelines cover cardiac arrest in newborns or neonates. Other guidelines may also apply, including ASYSTOLE/PEA, TRAUMA, and VENTRICULAR FIBRILLATION/pulseless VENTRICULAR TACHYCARDIA. On-scene CPR is preferable (as long as the scene is safe) and is associated with higher survival rates to hospital discharge.

Basic Level

1. Assess for signs of responsiveness and signs of circulation (no more than 5 to10 seconds for pulse check).  If the pulse is absent or if you are uncertain, begin high-quality chest compressions:

• Push hard at a rate of 100-120 compressions per minute. 
• Use a metronome for every cardiac arrest.
• Allow full recoil of the chest after each compression.
• Minimize interruptions in compression.
• Avoid pausing compressions for more than 10 seconds for any reason.

2. Perform CPR at a ratio of:

Adults and Children age 8 or older

• 30 compressions and 2 ventilations (pause for breaths); compression depth – at least 2 inches.

Infants and Children Younger than age 8

• 15 compressions and 2 ventilations (pause for breaths); compression depth – at least ⅓ the diameter of the chest:
• About 1½ inches for infants under 1 year old;
• About 2 inches for children 1 to 8 years old

3. Assess and support an open airway with a head-tilt chin-lift maneuver and an oropharyngeal airway.
• If you suspect spinal injury, use the jaw thrust maneuver and an oropharyngeal airway.

4. Assess and support breathing.
• Support ventilations with 100% oxygen, 1-hand squeezes of the BVM over 1.5 second each, and only enough tidal volume to produce visible chest rise.
• DO NOT over-ventilate.
• Use the compression-to-ventilation ratio as specified by age (above).

5. For cardiac arrest in cases of suspected trauma, initiate SPINAL MOTION RESTRICTION.
1. BLS agencies should begin transport if transfer to the closest appropriate Trauma Center is faster than waiting for an ALS unit.  Minimize scene time and continue treatment guidelines en route.
2. Contact BioTel as early as possible so that they can notify the receiving Trauma Center to begin preparation for the patient’s arrival.
6. As soon as a defibrillator or AED arrives, apply hands-free defibrillation pads without interrupting CPR.  For manual defibrillators, use pediatric defibrillation pads (if available) for patients up to 8 years old.  For AEDs, use special pediatric dose-attenuating AED pads for patients between 1 and 8 years old.  Do not apply the AED to infants under 1 year old.  If using a manual defibrillator, perform all care while in the PADDLES mode.

• If using an AED, follow all voice and visual prompts.  Continue defibrillation and CPR sequence until advanced providers place the patient on a manual defibrillator.
• If using a manual defibrillator, deliver one unsynchronized shock at a time, if needed, for VF or pVT.
• Do not place manual defibrillators in the AED Mode:
• Unless specifically permitted by Medical Direction and agency MOP for adults.
• At any time for children younger than the 8th birthday.
• Immediately after delivering a shock, resume high quality chest compressions for 2 full minutes without first checking the rhythm or pulse.
• At the end of the 2-minute CPR cycle, briefly pause chest compressions for no more than 10 seconds to check the rhythm:
• If the rhythm is organized, check for the presence of a pulse.
• If ROSC, refer to POST-CARDIAC ARREST CARE Guidelines.
• If asystole or PEA is present, resume CPR, and refer to the ASYSTOLE/PEA Guidelines.
• If the patient remains in a shockable rhythm, immediately resume CPR and refer to the VENTRICULAR FIBRILLATION/PULSELESS VENTRICULAR TACHYCARDIA Guidelines.

For All Defibrillation Attempts

• Consider pre-charging the defibrillator to the next energy level during CPR before the next shock.
• Perform chest compressions for 15-20 seconds while charging the defibrillator.
• Do not interrupt chest compressions for more than 5 seconds before or after shock delivery.

Advanced Level

7. For cardiac arrest in cases of suspected blunt or penetrating trauma, manage as follows:
• SIGNS OF LIFE:  If the patient has EMS-witnessed signs of life (movement, vocalization, respiratory effort, swallowing, reactive pupils, reflexes, or measurable vital signs), initiate SPINAL MOTION RESTRICTION and immediately transport to the closest Trauma Center (Refer to the DESTINATION Policy).
• NO SIGNS OF LIFE:  Use the DETERMINATION OF DEATH IN THE FIELD Policy when there are no signs of life AND the patient remains in asystole.

8. Do not attempt placement of an advanced airway (supraglottic or endotracheal) for at least 6 minutes after starting CPR (after three 2-minute cycles) unless necessary because of regurgitation:
• Advanced airway insertion attempts MUST NOT interrupt chest compressions.
• After securing the advanced airway, deliver ventilations without interrupting chest compressions:
• Medical etiology cardiac arrest: 8 to 10 ventilations per minute.
• Trauma etiology cardiac arrest: 6 ventilations per minute.
• Do NOT over-ventilate.

9. Establish IV or IO access with Normal Saline as soon as feasible during the resuscitation attempt.
• IV/IO access attempts MUST NOT interrupt chest compressions.
• Flow rate:
• TKO rate for medical cardiac arrests.
• Wide open rate for cardiac arrest caused by trauma.  If ROSC is achieved, adjust rate to TKO.

10. If mechanism of injury AND symptoms AND physical exam suggest a tension pneumothorax:

11. Identify the presenting dysrhythmia and proceed to the appropriate dysrhythmia treatment guidelines.
    
12. Refer to the POST-CARDIAC ARREST CARE Guidelines for a patient who achieves ROSC.
    
    

13. SUMMARY OF THERAPIES BY AGE:

* For neonatal resuscitation, refer to the NEONATAL CARE Guidelines

14. For additional patient care considerations not covered under standing orders, consult BioTel.