Cardiac Arrest

Inclusion Criteria: These guidelines will help establish treatment priorities for all apneic and pulseless patients. Do not attempt resuscitation in patients who meet criteria outlined in the Determination of Death Policy or the Do Not Resuscitate Policy. The Neonatal Care guideline covers cardiac arrest in newborns or neonates. Other guidelines may also apply including Asystole, PEA, Trauma, and Ventricular Fibrillation/Pulseless Ventricular Tachycardia.

Basic Level

Assess for signs of responsiveness and signs of circulation (no more than 5-10 seconds for pulse check). If the pulse is absent or if you are uncertain, begin high-quality chest compressions.
a. Push hard at a rate of 100 compressions per minute. Turn on metronome, if available
b. Allow maximum recoil of the chest after each compression.
c. Minimize interruptions in compression.
d. Avoid pausing compressions for more than 10 seconds if at all possible

Perform CPR at a ratio of

Adults and Children age 8 or older

30 compressions and 2 ventilations (pause for breaths)

Infants and Children Younger than age 8

15 compressions and 2 ventilations (pause for breaths)

Assess and support an open airway with head-tilt chin-lift maneuver and an oropharyngeal airway.
a. If you suspect spinal injury, use the jaw thrust maneuver and an oropharyngeal airway.
Assess and support breathing.
a.   Support ventilations with 100% oxygen, 1-hand squeezes of the BVM over 1 second each, and only enough tidal volume to produce visible chest rise.
b.   DO NOT over-ventilate.
c.   Use the compression-to-ventilation ratio as specified by age (above).
For cardiac arrest in cases of suspected trauma, initiate spinal movement restrictions.
a. BLS agencies should begin transport if transfer to the closest appropriate medical facility is faster than waiting for an ALS unit. Minimize scene time and continue treatment guidelines en route.
b. Contact BioTel as early as possible so that they can notify the receiving Trauma Center who can begin preparation for the patient’s arrival.
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 countershock at a time, if needed for VF or pVT.
• Do not place manual defibrillators in the AED mode:
    o Unless specifically permitted by Medical Direction and agency MOP for adults.
    o 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.
   o If the rhythm is organized, check for the presence of a pulse.
   o If ROSC, refer to Post Cardiac Arrest Management Guidelines.
   o If asystole or PEA is present, resume CPR, and refer to the Asystole/PEA Guidelines.
   o 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
• 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
For cardiac arrest in cases of suspected blunt or penetrating trauma and manage as follows:
1. SIGNS OF LIFE: If the patient has EMS-witnessed signs of life (movement, vocalization, respiratory effort, swallowing, reactive pupils, reflexes, measurable vital signs), initiate spinal immobilization and immediately transport to the closest Trauma Center
2. NO SIGNS OF LIFE: Use the Determination of Death Guidelines when there are no signs of life AND the patient is asystolic
Do not attempt placement of an advanced airway (supraglottic or endotracheal) for at least 6 minutes (after three 2-minute cycles) unless necessary because of regurgitation.
a.   Advanced airway insertion attempts MUST NOT interrupt chest compressions.
b.   After securing the advanced airway, deliver ventilations without interrupting chest compressions:
     1.   Medical etiology cardiac arrest - 8 to 10 ventilations each minute
Establish IV or IO access using normal saline as soon as feasible during the resuscitation attempt.
a.   IV/IO access attempts MUST NOT interrupt chest compressions.
b.   Flow rate:
     1.   TKO rate for medical cardiac arrests
     2.    Wide open rate for cardiac arrest caused by trauma. Upon ROSC, adjust rate to TKO
If mechanism of injury AND symptoms AND physical exam suggest a tension pneumothorax

Adult
• Perform needle thoracostomy Pediatric
• Contact BioTel
Identify the presenting dysrhythmia and proceed to the appropriate dysrhythmia treatment guidelines.

Summary of therapies by age:

Therapy	Adult	Child	Infant
Definition by Age	8th birthday and above	1 year to 8th birthday	Before 1st birthday
CPR	30 compressions to 2 ventilations (pause foe ventilations)	15 compressions to 2 ventilations (pause for ventilations)	15 compressions to 2 ventilations (pause for ventilations)
Defibrillation	Adult AED/defibrillator pads	1st choice: Manual defibrillator with pediatric defibrillator pads: 2 J/kg, 4 J/kg, 4-10 J/kg 2nd choice: AED with special, dose-attenuating pediatric AED pads 3rd choice: AED with adult pads	Manual defibrillator with pediatric defibrillator pads: 2 J/kg, 4 J/kg, 4-10 J/kg Do not use an AED
Drugs	Standard adult dosing for patients 14 and older; weight-based dosing for children 8 through 13	Weight-based dosing	Weight-based dosing

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