Cardiac Arrest and Dysrhythmias

Question 1

Zoll infant pads

Answer 1

<10kg

Question 2

For cardiac arrest, after initiating CPR, the most important intervention

Answer 2

a. Shockable rhythms - immediate defibrillation.
b. Non-shockable rhythms (PEA or asystole), immediate administration of epinephrine.

Question 3

For ventricular fibrillation or pulseless ventricular tachycardia refractory to defibrillation x 5, epinephrine, and 450 mg amiodarone, prior to terminating resuscitation efforts, consider:

Answer 3

a. Moving the pads (or adding new pads) 90° from the initial axis (e.g. anterior- lateral chest placement moved to anterior-posterior) and defibrillating at full energy.
b. Esmolol to counteract excess sympathetic tone
i. Load 500 mcg/kg, then infuse 50 mcg/kg/min.

Question 4

Esmolol during cardiac arrest

Answer 4

i. Load 500 mcg/kg, then infuse 50 mcg/kg/min.
ii. If ROSC is obtained then lost, consider titrating esmolol per Aortic Dissection protocol.

Question 5

Epi during pediatric cardiac arrest

Answer 5

a. IV/IO: Epinephrine (1:10,000) 0.1 mL/kg
b. Per ET Tube: Epinephrine (1:1000) 0.1mL/kg.
c. May repeat q3–5min.

Question 6

Hypotension after ROSC

Answer 6

Fluid bolus (NS or LR)
i. Adult: 1 – 2 liters IV
ii. Peds: 20mL/kg IV, may repeat x 2 PRN.
Consider 10 mL/kg for patients with poor cardiac function.

Question 7

Hypotension not responsive to fluid boluses after ROSC

Answer 7

Epinephrine
1. Adult: 0.1 – 0.5 mcg/kg/minute IV, titrated PRN.
2. Pediatric: 0.1 – 1.0 mcg/kg/min IV, titrated PRN.
No maximum epinephrine dose listed per ACLS and PALS, but consider adding Norepinephrine if hypotension persists beyond 30 mcg/min in adults and 1 mcg/kg/min in pediatric patients.
If hypotension persists after maximum dose epinephrine, add Norepinephrine:
1. Adult: 2 – 45 mcg/min OR 0.05 – 2 mcg/kg/min (not to exceed
45mcg/min).
2. Pediatric: 0.05 – 2 mcg/kg/min (not to exceed 45mcg/min)

Question 8

Sedation after ROSC

Answer 8

**Ketamine is contraindicated due to negative chronotropic effects.
Utilize midazolam for sedation, starting at low doses.
i. Adult:1–2mg IV. If BP stable, repeat q5minutes, to a max of 5mg IV q 15 minutes.
ii. Pediatric: 0.025 mg/kg. If BP stable, repeat q 5 minutes to a max of 0.1 mg/kg q 15 minutes (not to exceed 5 mg/dose)
**If BP stable add fentanyl for synergy

Question 9

Fentanyl for ROSC

Answer 9

Adult: 25 mcg IV, repeated q 10 minutes to a max of 100 mcg q 30 minutes
Pediatric: 0.5 – 1 mcg/kg IV, repeated q 10 minutes to a max of 2 mcg/kg q 30 minutes (not to exceed 100 mcg q 30 minutes).

Question 10

Energy for cardioversion for unstable A Fib and A Flutter

Answer 10

i. Atrial flutter: 50J–100J–200J
ii. Atrial fibrillation: 200 J
(HR less than 150 rarely require cardioversion)

Question 11

Medical management of A Fib/Flutter

Answer 11

1. Metoprolol 2.5 – 5 mg IV
   a. May repeat q5min to a total of 15mg OR
2. Esmolol – dosing per Aortic Dissection guidelines OR
3. Diltiazem 0.25 mg/kg IV bolus.
   a. If rate not controlled after 15 min, repeat dose at 0.35 mg/kg IV.
   b. Once rate is controlled, place on a Diltiazem drip at 5 – 10 mg/hr, titrated to a maximum dose of 15 mg/hr.