*Assess Responsiveness (Shake and Shout or if trauma, Touch and Talk
to pt) "Are you awake?"
*Activate emergency response system (call 911 or if in a medical setting
call a code blue or call for a defibrillator) - the main rhythm
associated with cardiac arrest in an adult is V.fib/Pulseless V. Tach
and NEEDS to be shocked as soon as possible to survive.
Begin the Primary Survey
A=Airway, Open and assess airway. Use head tilt-chin lift or if trauma suspected jaw thrust method to open the airway. Look (for chest rise), listen (over the mouth for air movement), and feel (for breathing against our face). Treat occasional gasps as if not breathing. The new guidelines recommend that if in the field and ALONE (one person), open all airways by head tilt-chin lift. The rationale is that one person doing a jaw thrust will need to stay and maintain that head positioning. It is more of a priority to open the airway and breath for the patient than it is to maintain the head in proper alignment.
B=Breathing, take 5-10 seconds to check for breathing. If none, give 2 slow breaths over 1 second and enough to cause visible chest rise. If the first does not go in, reposition the head (reopen the airway) and try again.
C=Circulation, Assess pulse and skin color and movement from pt for signs of circulation. If no carotid pulse within 10 seconds, start Chest Compressions hard (1 1/2 to 2 inches) and fast (100 compressions per minute). (Give 30 chest compressions for every 2 breaths for two minutes, then switch). If there is a pulse, still rescue breathe for the pt 10-12 times per minute, give a breath enough to cause chest rise and complete recoil.
Helps Arrives
D=Defibrillation, Attach to a defibrillator-monitor or with paddles do a quick look for a shockable rhythm. We are looking for V.fib or V.Tach to defibrilate. If any other rhythm shows up, then it is PEA (Pulseless Electrical Activity).
Begin Secondary Survey
A=Airway, Insert oral airway, use a bag-valve-mask with 100% oxygen to ventilate (12-15 times per minute) the patient while equipment is being prepared for intubation.
B=Breathing, Confirm and secure the tube with an approved airway device and ventilate the patient with 100% oxygen (12-15 times per minute).
C=Circulation, Reassess circulation resume CPR, Note: Asynchronous chest compression may now be done with ETTube placement. Place IV, antecubital vein is the first choice and run IVFs if appropriate - Normal Saline or Lactated Ringers are the preferred choices or Intraosseous (IO) access.
If the step below takes more than 10 secs, then do not perform it. Begin CPR. The rationale is that it is safer to perform CPR on someone with a weak pulse than it is to not perform CPR on someone with no pulse. This step is not shown in the algorithm.
**Check for occult blood flow with a hand held doppler to the carotid artery. If you hear blood flow go to bradycardia with hypotension algorithm. If you don't hear anything, proceed as true PEA.**
Epinephrine 1 mg IV q3-5 minutes
OR
Vasopressin 40 Units IV, one time dose or after 1st or 2nd dose of Epinephrine. (wait 10-20 minutes before starting epinephrine)
Consider Atropine if the electrical heart rate is less than 60 bpm or if it is relatively slow for that patient.
Atropine 1mg IV q 3-5 minutes for 3 doses.
Flush with 20mL NS or run IVFs to keep meds running into the vein and raise the arm. After giving the drug, then resume CPR for 30 - 60 seconds to help circulate the medication, remember the only heartbeat is the one your manually give the patient.
D=Differential Diagnosis, Search for and treat reversible causes including but not limited to 6 Hs and 6 Ts:
Hypovolemia-give fluids and/or blood products (the #1 cause of PEA), Hypoxia-give 100% ventilated oxygen,
Hypo/hyperkalemia(low or high K level)-give KCL boluses for low K+ level/-give NaHCO3 1mEq/kg IV q 10 minutes for high K+ level,
Hydrogen Ion (acidosis)-hyperventilate pt or give NaHCO3 depending upon lab values,
Hypothermia/Hyperthermia-warm pt with blankets and warmed IVFs for hypothermia. Keep the patient from getting too warm.
Hypoglycemia - treat with oral glucose or IV dextrose, prevent hyperglycemia as well.
Thrombosis Pulmonary (PE)-thrombolytics or surgery to remove the blockage, Thrombosis Cardiac (MI)-thrombolytics or surgery to remove the blockage, Tension Pneumothorax-needle decompression,
Cardiac Tamponade-paracardial centesis,
Tablets (OD)-give NaHCO3 for certain antidepressants.
Trauma - treat the underlying problems such as source of bleeding, surgical needs, respiratory support, electrolyte imbalances, etc.
The following is a detailed explanation for dx and tx of the differential diagnois.
Hypovolemia can be evident from a trauma or from patient assessment. It is the #1 cause of PEA. Give IVFs Normal Saline or Lactated Ringers and even blood products if needed. When the IV is placed, usually IVFs are hung and thereby treating the low volume problem.
Hypoxia is being treated in the A=Airway when the patient was intubated and ventilated with 100% oxygen. The airway is ALWAYS the first priority. It only takes a few minutes to cause a insult to the brain for lack of oxygen, so be vigilant with this assessment as an ongoing concern.
Hypokalemia seen with increased heart rate or arrythmias can be treated with Potassium boluses 10-20mEq over 1 hour (see your policy for total amount to be given as giving too rapid administration will stop a heart).
Hyperkalemia seen with decreased heart rate and various blocks and arrythmias can be treated with Sodium Bicarbonate 1mEq/kg (class 1 intervention). It can be treated with D50W and IV Regular Insulin to get the K+ back into the cells or even Calcium Chloride.
Hydrogen Ion (acidosis) is a little more complicated. 1st we would need a ABG (arterial blood gas) to determine respiratory or metabolic acidosis, but mainly we want to look at the PH (7.35-7.45 is generally the norm, again look at your lab policy). If less than 7.2, then we need to rapidly correct this by possibly hyperventilating the patient or considering NaHCO3 (Sodium Bicarbonate). The problem with hyperventilating is that it can hurt certain types of patients such as head-injuries. The problem with Sodium Bicarbonate is that correcting the patient and making him or her alkalotic causes problems that are not as easily reversed. We don't want to hypoventilate a patient to let their CO2 level increase. So generally, we will treat this specific to the patient problem by looking at the ABGs, telling us the source respiratory or renal (metabolic) cause.
Hypothermia/Hyperthermia is treated by warming the patient and possibly running warmed IVFs. Drugs may need to be held until the temperature is up. The old saying is true: "There is no dead patient, until he or she is warm and dead." There are new studies that show hyperthermia may cause harm. There are no specific recommendations at this time on how to treat the body from getting too warm. There is some evidence that hypothermia may help certain patients. Follow your institution protocols. I look forward to the AHA making some statements regarding hypothermia with the next update.
http://circ.ahajournals.org/cgi/content/full/112/24_suppl/IV-136 This is a link to an article that provides some temperature guidelines. The bottom line for ACLS medications is that at very low temperatures, medications may not be effective.
Hypoglycemia is treated by keeping the blood sugar tightly controlled about 80-110. Hypoglycemia may be deadly, and needs to be treated with IV dextrose. Hyperglycemia can also increase risk of infection and other complications.
Thrombosis, pulmonary can be seen by ventilating the patient well, good bilateral breath sounds; yet, poor saturations and even mottled skin color. What is happening is that the perfusion side of the V/Q (ventilation/perfusion) equation is being affected. The oxygen is being delivered through ventilations, but the oxygen in the blood cannot carry it to the rest of the body because there is a blockage in the vessels of the lungs. This can be corrected with either thrombolytics or through surgery to remove the blockage.
Thrombosis, cardiac can be confirmed with a 12 lead ECG, seeing a Q wave with ST elevation and T wave inversion; however, a patient can have a non-Q wave MI. ST elevation STEMI is what we are looking for on the ECG or a nonSTEMI where clinically the patient presents with symptoms but does not show ST elevation on the 12 lead ECG. A patient with a cardiac history, or signs and symptoms of a "heart attack" like chest pain, "heavy" feeling on the chest, neck or jaw discomfort, nausea, diaphoresis, arm or shoulder discomfort before the code blue may give you an idea that an MI has occurred. The fact that a patient is in V.fib or V.tach generally leads us to believe a "heart attack" has occurred. The ways to correct this is by thrombolytics, heart catherization, or heart surgery (CABG-coronary artery bypass graft).
Tension pneumothorax is heard in a loss of breath sounds, generally on one lung field (both lungs could be affected). While continually assessing the B=Breathing, this should be noticed if the patient suddenly has one sided chest rise or low oxygen saturations. Check this first by listening for breath sounds and checking E.T. tube placement. To correct this take a large bore needle such as 14g needle and along the side where lung sounds are diminished find the 2nd-3rd anterior ribs at the mid-clavicular line and place the needle to hit the 2nd rib and go just underneath it into the 2nd ICS, and we should hear pop, then a release of air. A chest tube will need to be placed, but until then, if available connect to a flutter valve. A flutter valve can be made with a torn finger of a glove with a small hole poked in the finger tape the finger over the hub. The small hole will act as a flutter valve. Also, IV tubing connected to the needle and placed in water will crudely act as a water seal until more appropriate equipment can be applied.
Cardiac Tamponade is a life-threatening condition caused by fluid under pressure around the heart. Fluid that collects in the pericardial sac (the tissue sac in which the heart lies) can develop enough pressure to prevent the heart from relaxing completely between beats. Usually, this fluid has accumulated rapidly, and the increase in pericardial pressure causes a sudden decrease in cardiac output. Commonly seen symptoms require a live patient with the ability to complain of dyspnea, chest pain or of a heart beat and circulation as heard with muffled heart sounds and seen with Pulsus Paradoxus (inspiratory drop in blood pressure greater than 10mm Hg) and jugular venous distention (JVD)-to perform this, the patient needs to be sitting up ideally 45 degrees, in a code most patients will be flat and will have JVD, so trauma history, cardiac history, and events leading up to the code blue become very important. To fix the problem, we need to withdraw the fluid with a needle and syringe. Only experienced personnel should attempt this because of the risk of further damaging the heart or its vessels. Procedure: A small puncture is made just below and to the left of xiphoid process. A long needle is positioned at 45 degrees abovethe body and 45 degrees to the right of midline. Through the skin puncture, the needle is advanced (the 60 mL syringe attached should be aspirated the entire time) in the position towards head and towards the left scapula. Withdraw the syringe and aspirate unclotted blood from pericardial sac. Note: This blood will not clot and is one way to tell if your in the pericardial sac. From a 12 lead ECG machine, attaching the lead V aligator clip to the needle as you insert. This will help determine position and if any arrythmias occur.
Tablets (Drug Overdose) is another issue with multiple treatments depending upon the problem. The treatment depends upon the drug taken. For tricyclic antidepressants and for phenobarbitone overdoses, give Sodium Bicarbanate to alkalize the urine. If pt has an established heart history look for drugs such as Digoxin to be the culprit and treat accordingly. This is not an attempt to cover all drug possibilities. This is too broad of an area to discuss all possible drug overdoses. The clinician will use their assesment skills for the patient and the environment to pick up on clues causing the problem. Dialysis can also be used as a treatment in a critical situation as in Hyperkalemia to remove the unwanted substance quickly, but even then, some drugs cannot be removed by dialysis. Many times clinicians treat the symptoms of the overdose until the cause can be determined or counteracted.
Trauma - is another issue with multiple treatments depending upon the problem. Trauma is a huge problem that may fall into some of these other areas like hypovolemia due to blood loss or hypoxia or hydrogen ion (acidosis), but unlike the other problems, managing this type of patient requires identfying the cause of the problem, like a head injury or a spleen rupture, or a required surgical intervention. It means that rapid response and idenfication of the causing concerns is the priority.
