Let’s look at the Adult Cardiac Arrest Algorithm and apply it to our scenario from the previous chapter. Please review the scenario.
Video Demonstration
Adult Cardiac Arrest Algorithm
Management: Initiate the cardiac arrest algorithm if the patient still has no pulse and does not respond to BLS
Continue CPR for 2 minutes, starting with chest compressions and get IV/IO access
Pause to check rhythm for 10 seconds. If unshockable rhythm, do a 3 point pulse check (carotid, radial, femoral) and if there is a pulse continue to post-cardiac arrest
care. If the rhythm is shockable, give 1 shock of 120-200 Joules and resume CPR for 2 minutes
During CPR give the following vasopressors
Epinephrine 1 mg IV/IO and repeat every 3 to 5 minutes then
Amiodarone with 1st dose of 300 mg bolus, and 2nd dose of 150 mg bolus OR lidocaine with 1st dose of 1 to 1.5mg/kg, and 2nd dose 0.5 to 0.75mg/kg
Pause to check rhythm for 10 seconds. If rhythm is shockable, give 1 shock of 120-200 Joules and resume CPR for 2 minutes
Administer the following antiarrhythmic drugs after 1st or 2nd dose of epinephrine
Amiodarone 300 mg IV/IO bolus then another 150 mg IV/IO once more
Lidocaine (only if Amiodarone not available) 1 to 1.5 mg/kg IV/IO first dose, then 0.5 to 0.75 mg/kg IV/IO at 5 to 10 minute intervals, to a maximum dose of 3 mg/kg
Magnesium Sulfate only for torsades de pointes or if hypomagnesemia is suspected. Loading dose of 1-2g IV/IO diluted in 10mL of D5W or NS, given as a bolus over 5-60 minutes.
Consider advanced airway if needed. Once an advanced airway is placed, the breaths can be continuous. Use waveform capnography to confirm and monitor ET placement.
The following algorithm is for Adult Cardiac Arrest:
Treatment of VF/VT in Hypothermia
Severe accidental hypothermia in patients with VF and/or VT have a body temperature of <30 degrees Celsius or <86 degrees F. Defibrillation is appropriate in this case, however, additional shocks may need to be given. For those in cardiac arrest with moderate hypothermia (under 36 degrees Celsius), do CPR, defibrillation, give medications, and continue warming the core temperature to raise it above 35 degrees Celsius (95 degrees F).
Administration of drugs is usually contraindicated in patients as it may increase levels of toxins due to decreased metabolism. Best treatment for the patient is to focus on raising the core temperature. Administration of vasopressor as per the guidelines of ACLS can be effective while rewarming the patient. Administration of antiarrhythmic drugs is not effective to hypothermic patients.
Route of Administration of Drugs in Cardiac Arrest
There are 2 routes of drug administration which are effective and will not interfere with high-quality CPR and defibrillation. These routes are:
IV (Intravenous)
IO (Intraosseous)
The IV route is the most approved route for administrating fluids and medications. The 2 routes are through the peripheral IV line and the central IV line.
The IO route is used to inject medication directly into the bone marrow. The IO access can be used in all age groups, but is preferred in pediatric patients. It can be accessed in 30-60 seconds and can be used with any medication that is used in the IV route.
Medications used in Cardiac Arrest
Vasopressors
Epinephrine – administer 1 mg IV/IO every 3-5 minutes
Vasopressin – 1 dose of 40 units (IV or IO) may replace the first or second dose of epinephrine
Antiarrhythmic Agents
Amiodarone – given in VF or pulseless VT
First dose of 300 mg IV/IO push
If no response to first dose, consider 2nd dose of 150 mg after 3-5 minutes
Lidocaine – consider this if no amiodarone
First dose of 1 to 1.5 mg/kg IV/IO
Repeat every 5 to 10 minutes at dosage of 0.5 to 0.75 mg/kg IV/IO
Magnesium Sulfate – stop recurrent torsades de pointes
Loading dose of 1 to 2 g IV/IO diluted with 10 ml D5W should be administered for 5 to 20 minutes.
