Part 7.2: Management of Cardiac Arrest V-6I amiodarone available, lidocaine may be considered. should insert an advanced airway (eg, endotracheal tube Consider magnesium for torsades de pointes associated with Combitube, LMA). Once the airway is in place, 2 rescuers a long QT interval(see below). You should administer the should no longer deliver cycles of CPr(ie, compressions drug during CPR, as soon as possible after rhythm analysis. If interrupted by pauses when breaths are delivered). Instead the a nonshockable rhythm is present and the rhythm is organized compressing rescuer should give continuous chest compres- (complexes appear regular or narrow), try to palpate a pulse sions at a rate of 100 per minute without pauses for ventila tion. The rescuer delivering ventilation provides 8 to 10 Rhythm checks should be brief, and pulse checks should breaths per minute. The 2 rescuers should change compressor generally be performed only if an organized rhythm is and ventilator roles approximately every 2 minutes(when the observed. If there is any doubt about the presence of a pulse, rhythm is checked) to prevent compressor fatigue and dete- resume CPR. If the patient has ROSC, begin postresuscitation rioration in quality and rate of chest compressions. When care. If the patient's rhythm changes to asystole or PEA, see multiple rescuers are present, they should rotate the compres- Asystole and Pulseless Electrical Activity "below (Boxes 9 and sor role about every 2 minutes. Rescuers should minimize 10) interruptions in chest compressions while inserting the airway If a perfusing rhythm is transiently restored but not and should not interrupt CPR while establishing I or IO successfully maintained between repeated shocks(recurrent access VF/VT), the patient may be a candidate for early treatment If the rhythm check confirms asystole or PEA, resume CPR with antiarrhythmic medications(see Part 7.3: " Management immediately. A vasopressor (epinephrine or vasopressin) may of Symptomatic Bradycardia and Tachycardia") be administered at this time. Epinephrine can be administered During treatment of VF/pulseless VT, healthcare providers approximately every 3 to 5 minutes during cardiac arrest; or must practice efficient coordination between CPR and shock dose of vasopressin may be substituted for either the first or delivery. When VF is present for more than a few minutes, second epinephrine dose(Box 10). For a patient in asystole the myocardium is depleted of oxygen and metabolic sub- slow PEA, consider atropine(see below). Do not interrupt and energy substrates, increasing the likelihood that a possible after the rhythm check. Give the drug as soon as ng rhythm will return after shock delivery.38 Analyses After drug delivery and approximately 5 cycles(or about 2 waveform characteristics predictive of shock success minutes)of CPR, recheck the rhythm(Box 11). If a shockable have documented that the shorter the time between chest rhythm is present, deliver a shock(go to Box 4). If no rhythm compression and shock delivery, the more likely the shock is present or if there is no change in the appearance of the will be successful. 38,39 Reduction in the interval from com- electrocardiogram, immediately resume CPR(Box 10). If an pression to shock delivery by even a few seconds can increase organized rhythm is present(Box 12), try to palpate a pulse. he probability of shock If no pulse is present (or if there is any doubt about the presence of a pulse), continue CPR(Box 10). If a pulse is Asystole and Pulseless Electrical Activity(Box 9) present the provider should identify the rhythm and treat PEA encompasses a heterogeneous group of pulseless appropriately(see Part 7.3: " Management of Symptomatic rhythms that includes pseudo-electromechanical dissociation Bradycardia and Tachycardia"). If the patient appears to have (pseudo-EMD), idioventricular rhythms, ventricular escape an organized rhythm with a good pulse, begin postresuscita- rhythms, postdefibrillation idioventricular rhythms, and bra- dyasystolic rhythms Research with cardiac ultrasonography and indwelling pressure catheters has confirmed that pulse When Should Resuscitative Efforts Stop? less patients with electrical activity have associated mechan- The resuscitation team must make a conscientious and com- ical contractions, but these contractions are too weak to petent effort to give patients a trial of CPR and ACLS duce a blood detectable by palpation or nonin- provided that the patient has not expressed a decision to vasive blood pressure monitoring. PEA is often caused by forego resuscitative efforts. The final decision to stop efforts reversible conditions and can be treated if those conditions can never be as simple as an isolated time interval. Clinical are identified and corrected judgment and respect for human dignity must enter into al rate from cardiac arrest with asystole is decision making. There is little data to guide this decision. dismal. During a resuscitation attempt, brief periods of an Emergency medical response systems should not re rganized complex may appear on the monitor screen, but field personnel to transport every victim of cardiac arrest to a spontaneous circulation rarely emerges. As with PEA, the hospital or emergency department(ED). Transportation with hope for resuscitation is to identify and treat a reversible continuing CPR is justified if interventions are available in cause the ED that cannot be performed in the field, such as Because of the similarity in causes and management of cardiopulmonary bypass or extracorporeal circulation for these two arrest rhythms, their treatment has been combined victims of severe hypothermia( Class IIb) in the second part of the ACLS Pulseless Arrest Algorithm Unless special situations are present(eg, hypothermia), for Patients who have either asystole or PEA will not benefit nontraumatic and blunt traumatic out-of-hospital cardiac from defibrillation attempts. The focus of resuscitation is to arrest, evidence confirms that ACLS care in the ED offers perform high-quality CPR with minimal interruptions and to advantage over ACLS care in the field Stated succinctly, if identify reversible causes or complicating factors. Providers ACLS care in the field cannot resuscitate the victim, ED careamiodarone is unavailable, lidocaine may be considered. Consider magnesium for torsades de pointes associated with a long QT interval (see below). You should administer the drug during CPR, as soon as possible after rhythm analysis. If a nonshockable rhythm is present and the rhythm is organized (complexes appear regular or narrow), try to palpate a pulse (see Box 12). Rhythm checks should be brief, and pulse checks should generally be performed only if an organized rhythm is observed. If there is any doubt about the presence of a pulse, resume CPR. If the patient has ROSC, begin postresuscitation care. If the patient’s rhythm changes to asystole or PEA, see “Asystole and Pulseless Electrical Activity” below (Boxes 9 and 10). If a perfusing rhythm is transiently restored but not successfully maintained between repeated shocks (recurrent VF/VT), the patient may be a candidate for early treatment with antiarrhythmic medications (see Part 7.3: “Management of Symptomatic Bradycardia and Tachycardia”). During treatment of VF/pulseless VT, healthcare providers must practice efficient coordination between CPR and shock delivery. When VF is present for more than a few minutes, the myocardium is depleted of oxygen and metabolic sub￾strates. A brief period of chest compressions can deliver oxygen and energy substrates, increasing the likelihood that a perfusing rhythm will return after shock delivery.38 Analyses of VF waveform characteristics predictive of shock success have documented that the shorter the time between chest compression and shock delivery, the more likely the shock will be successful.38,39 Reduction in the interval from com￾pression to shock delivery by even a few seconds can increase the probability of shock success.40 Asystole and Pulseless Electrical Activity (Box 9) PEA encompasses a heterogeneous group of pulseless rhythms that includes pseudo-electromechanical dissociation (pseudo-EMD), idioventricular rhythms, ventricular escape rhythms, postdefibrillation idioventricular rhythms, and bra￾dyasystolic rhythms. Research with cardiac ultrasonography and indwelling pressure catheters has confirmed that pulse￾less patients with electrical activity have associated mechan￾ical contractions, but these contractions are too weak to produce a blood pressure detectable by palpation or nonin￾vasive blood pressure monitoring. PEA is often caused by reversible conditions and can be treated if those conditions are identified and corrected. The survival rate from cardiac arrest with asystole is dismal. During a resuscitation attempt, brief periods of an organized complex may appear on the monitor screen, but spontaneous circulation rarely emerges. As with PEA, the hope for resuscitation is to identify and treat a reversible cause. Because of the similarity in causes and management of these two arrest rhythms, their treatment has been combined in the second part of the ACLS Pulseless Arrest Algorithm. Patients who have either asystole or PEA will not benefit from defibrillation attempts. The focus of resuscitation is to perform high-quality CPR with minimal interruptions and to identify reversible causes or complicating factors. Providers should insert an advanced airway (eg, endotracheal tube, Combitube, LMA). Once the airway is in place, 2 rescuers should no longer deliver cycles of CPR (ie, compressions interrupted by pauses when breaths are delivered). Instead the compressing rescuer should give continuous chest compres￾sions at a rate of 100 per minute without pauses for ventila￾tion. The rescuer delivering ventilation provides 8 to 10 breaths per minute. The 2 rescuers should change compressor and ventilator roles approximately every 2 minutes (when the rhythm is checked) to prevent compressor fatigue and dete￾rioration in quality and rate of chest compressions. When multiple rescuers are present, they should rotate the compres￾sor role about every 2 minutes. Rescuers should minimize interruptions in chest compressions while inserting the airway and should not interrupt CPR while establishing IV or IO access. If the rhythm check confirms asystole or PEA, resume CPR immediately. A vasopressor (epinephrine or vasopressin) may be administered at this time. Epinephrine can be administered approximately every 3 to 5 minutes during cardiac arrest; one dose of vasopressin may be substituted for either the first or second epinephrine dose (Box 10). For a patient in asystole or slow PEA, consider atropine (see below). Do not interrupt CPR to deliver any medication. Give the drug as soon as possible after the rhythm check. After drug delivery and approximately 5 cycles (or about 2 minutes) of CPR, recheck the rhythm (Box 11). If a shockable rhythm is present, deliver a shock (go to Box 4). If no rhythm is present or if there is no change in the appearance of the electrocardiogram, immediately resume CPR (Box 10). If an organized rhythm is present (Box 12), try to palpate a pulse. If no pulse is present (or if there is any doubt about the presence of a pulse), continue CPR (Box 10). If a pulse is present the provider should identify the rhythm and treat appropriately (see Part 7.3: “Management of Symptomatic Bradycardia and Tachycardia”). If the patient appears to have an organized rhythm with a good pulse, begin postresuscita￾tive care. When Should Resuscitative Efforts Stop? The resuscitation team must make a conscientious and com￾petent effort to give patients a trial of CPR and ACLS, provided that the patient has not expressed a decision to forego resuscitative efforts. The final decision to stop efforts can never be as simple as an isolated time interval. Clinical judgment and respect for human dignity must enter into decision making. There is little data to guide this decision. Emergency medical response systems should not require field personnel to transport every victim of cardiac arrest to a hospital or emergency department (ED). Transportation with continuing CPR is justified if interventions are available in the ED that cannot be performed in the field, such as cardiopulmonary bypass or extracorporeal circulation for victims of severe hypothermia (Class IIb). Unless special situations are present (eg, hypothermia), for nontraumatic and blunt traumatic out-of-hospital cardiac arrest, evidence confirms that ACLS care in the ED offers no advantage over ACLS care in the field. Stated succinctly, if ACLS care in the field cannot resuscitate the victim, ED care Part 7.2: Management of Cardiac Arrest IV-61