Pulseless Cardiac Arrest

Question 1

Define pulseless cardiac arrest.

Answer 1

Sudden cessation of heartbeat and cardiac function resulting in the loss of effective circulation.

Question 2

What are the clinical features of pulseless cardiac arrest?

Answer 2

1. Sudden collapse
2. Unconsciousness/unresponsiveness
3. Respiratory arrest
4. Cool periphery, pallor

Question 3

What is the differential diagnosis for pulseless cardiac arrest?

Answer 3

1. Ventricular fibrillation
2. Ventricular tachycardia
3. Asystole
4. Pulseless electrical activity
5. Monitor artifact (electrical interference from cautery or EKG lead detachment)

Question 4

What is the differential diagnosis for pulseless electrical activity?

Answer 4

Hypovolemia
Hypoxia
Hydrogen ion
Hypo/Hyperkalemia
Hypoglycemia
Hypothermia

Toxins
Tamponade, cardiac
Tension pneumothorax
Thrombosis (coronary/pulmonary)
Trauma (hypovolemia)

Question 5

What is the management of pulseless cardiac arrest?

Answer 5

1. Quickly verify: check for EKG disconnection and SpO2 waveform
2. Initiate BCLS (check responsiveness, open airway, check for breathing)
   3 Breathing? If no, 2 breaths using BVM (or mask-to-mouth or mouth-to-mouth)
3. 10 seconds max to check for pulse
4. If no pulse, chest compressions at 100/min
5. Cycle compressions/ventilations 30:2 until advanced airway in place (e.g., ETT/LMA) then do not stop compressions (100/min) for ventilation (8 - 10/min)
6. Attach defibrillator and check rhythm
7. Shockable? (VF/VT)
   a. give one shock. Biphasic 12 - 200J, monophasic 360 J
   b. resume CPR x 5 cycles (or two minutes if airway in place)
   c. secure ETT and confirm placement
   d. check rhythm again. Shockable?
   e. Shock again. Resume CPR x 2 min
   f. Give vasopressor q 3 to 5 minutes: epinephrine 1mg IV/IO or vasopressin 40 U IV (vasopressin may replace the 1st or 2nd epinephrine dose and should only be given once)
   g. check rhythm again. Shockable?
   h. consider antiarrhythmics to be given during CPR between shocks
   i. amiodarone 300mg IV
   ii. lidocaine 1 to 1.5mg/kg IV
   iii. magnesium 1 to 2 grams IV for torsade
   i. repeat CPR and shock cycles
   j. if at any time a non-shockable rhythm appears (e.g., sinus rhythm) check for pulse.
8. If initially or at any time NOT shockable and pulseless (i.e. asystole or PEA)
   a. resume CPR x 5 cycles or 2 minutes
   b. give vasopressor q 3 to 5 minutes: epinephrine 1 mg IV/IO or vasopressin 40 U IV
   c. consider atropine 1mg if PEA and rate is slow
9. Search for correctable cause.

Question 6

Describe ACLS for PEA or asystole.

Answer 6

Not shockable.

1. If pulseless cardiac arrest is initially or at any time NOT shockable and pulseless (i.e. asystole or PEA)
   a. resume CPR x 5 cycles or 2 minutes
   b. give vasopressor q 3 to 5 minutes: epinephrine 1 mg IV/IO or vasopressin 40 U IV
   c. consider atropine 1mg if PEA and rate is slow
2. Search for correctable cause.

Question 7

What antiarrhythmics and dosages should be considered in ACLS?

Answer 7

Amiodarone 300mg IV
Lidocaine 1 to 1.5mg/kg IV
Magnesium 1 to 2 grams IV for torsade

Question 8

What vasopressors should be used as part of ACLS?

Answer 8

epinephrine 1 mg IV/IO q3 to 5 minutes

vasopressin 40 U IV can replace the 1st or 2nd dose of epinephrine and should only be given once.

Question 9

What settings for biphasic defibrillation should be used in ACLS?

Answer 9

12 to 200 Joules

Question 10

What settings for monophasic defibrillation should be used in ACLS?

Answer 10

360 Joules

Question 11

What should be done when a pulse is palpated during ACLS?

Answer 11

Begin post-resuscitation care