POST-CARDIAC ARREST CARE

Inclusion Criteria:  These guidelines will establish treatment priorities for patients with a return of spontaneous circulation (ROSC) following cardiac arrest.  BioTel defines ROSC as the return of an organized cardiac rhythm with a palpable pulse.

Advanced Level

1. Titrate supplemental oxygen delivery to maintain a SpO2 of 94-99%.
2. If ROSC occurs before EMS insertion of an advanced airway and the patient does not regain consciousness, insert an advanced airway.  Any approved supraglottic airway is a suitable alternative to endotracheal intubation.
3. After securing the advanced airway:
   1. MEDICAL Etiology: Begin assisted ventilations at no more than 10 to 12 breaths per minute.  Paramedics should expect a transiently elevated ETCO2 level after achieving ROSC.  Do not attempt to correct this value aggressively by over-zealous assisted ventilation or hyperventilation.
   2. TRAUMA Etiology:  Deliver 6 to 8 breaths per minute.  Do not attempt to correct an elevated ETCO2 level by over-zealous assisted ventilation or hyperventilation.
4. If the patient’s systolic blood pressure is less than 90 mmHg (less than 70 mmHg for the pediatric patient):
   1. Medical Etiology

   Adult

• Administer 20 mL/kg IV/IO fluid boluses as needed, to maintain a palpable radial pulse.
• Norepinephrine bitartrate drip 8-12 mcg/min, if no response to 1000 mL total boluses.

Pediatric

• Administer a single 10-20 mL/kg IV/IO fluid bolus, if the patient shows signs/symptoms of shock:
  • Administer only 5-10 mL/kg if heart failure or respiratory etiology is suspected;
• BioTel must approve additional fluid bolus(es).

   
  b.  Trauma Etiology

Adult

• Administer 20 mL/kg fluid boluses as needed, to maintain a palpable radial pulse
  
  
  Pediatric
  
  
• Administer 20 mL/kg IV/IO fluid bolus.
• Repeat twice, if needed, unless signs of volume overload (e.g. JVD, rales).
• Contact BioTel for additional boluses.

4. Obtain a 12-lead ECG for medical causes of cardiac arrest.  Transport patients with STEMI  to a hospital capable of immediate activation of a catheterization lab.
5. During transport of a patient either in cardiac arrest or after ROSC, two rescuers should be present in the back of the ambulance.
6. If a patient begins to awaken with an advanced airway in place post-cardiac arrest, consider sedation if coughing, gagging, or movement might lead to inadvertent extubation.
   1. Endotracheal tubes:
      

   Adult

• Diazepam 2.5 – 5 mg IV/IO/IN/IM; OR
• Midazolam 2.5 – 5 mg IV/IO/IN/IM.
• May repeat once.
• Contact BioTel if the patient requires additional doses.

Pediatric

• Midazolam 0.1 mg/kg IV/IO/IN/IM (maximum SINGLE dose 5 mg).
• May repeat once.
• Contact BioTel if the patient requires additional doses.

  b.  Adult patients with supraglottic airway:  Either remove the airway or use the sedation guidelines for endotracheally intubated patients.

• For agencies with a field hypothermia protocol, initiate cooling:

Adult

• Administer 500 mL chilled saline IV/IO wide open.
• Once initiated, continue chilled saline infusion even if the patient deteriorates back into cardiac arrest.
  • Upon completion, resume NS IV/IO at TKO rate.
• If time permits, place cold packs at the patient’s axillae and major vessels of the groin and neck.
• Assess neurological and shivering status frequently. If the patient begins to awaken or shiver, administer midazolam 2.5 mg IV Push or IO;
  • May repeat once.

  Pediatric

Do NOT initiate cooling in the pediatric patient

Do NOT initiate cooling if the patient

• Is younger than 18 years old
• Regains consciousness with a GCS equal to or greater than 9
• Suffered cardiac arrest as the result of trauma, including burns and/or electrocution
• Is pregnant
• Was hypothermic (less than 34° C or 93° F) when EMS arrived on the scene
• Has evidence of florid pulmonary edema and/or volume overloa

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