Cardiac Arrest

Description

  • Absence of effective mechanical cardiac activity
  • In children, bradycardia is the most initial form of cardiac arrest in children, so provide oxygen. 

Etiology

  • Asystole (confirm in 2 leads)
  • Ventricular fibrillation (VF)
  • Pulseless ventricular tachycardia (VT)
  • Pulseless electrical activity (PEA)
  • Consider possible reversible causes (6 Hs and 5 Ts):

Physical Exam

GENERAL: signs of trauma?
SKIN: pallor, GI bleed? 
EYES: pupil size, drug OD?
LUNGS: respiratory distress prior to collapse? 
ARMS: dialysis shunt? 

Reversible Causes (Hs & Ts)

  • Hypovolemia – IV fluids and blood products.
  • Hypoxia – Ventilation, Oxygen
  • Hydrogen Ion – Sodium Bicarbonate, Hyperventilation
  • Hyper (hypo) kalemia – Calcium chloride, insulin, glucose, sodium bicarbonate, sodium polystyrene sulfonate, dialysis  
  • Hypothermia – rewarming, oxygen, IV fluids
  • Hypoglycemia – glucose 
  • Toxin (Drug Overdose) – drug screens, intubation, lavage, activated charcoal 
  • Tamponade (Cardiac) – pericardiocentesis 
  • Tension pneumothorax – needle decompression 
  • Thrombosis (coronary) – PCI, thrombolytics, oxygen, nitrogen, heparin, aspirin, morphine 
  • Thrombosis (pulmonary) – pulmonary arteriogram, surgical embolectomy, thrombolytics 
  • Trauma – volume infusion, intracranial pressure monitoring, bleeding control, surgical intervention 

General Measures

  • Perform CPR: 100/min, allowing for chest wall recoil, with minimal interruptions 
  • Sequence should be:
    1. CPR
    2. Rhythm check
    3. Resume CPR
    4. Shock/Meds (charge defibrillator and administer drugs during CPR)

Management

Adult

Pediatrics

Pulseless Electrical Activity

  • Epinephrine: 1 mg IV q3–5min or
  • Vasopressin 40 U IV single

Pediatric dose of Epinephrine: 0.01 mg/kg
Vasopressin is NOT recommended in children.

Torsades de pointes

  • Magnesium sulfate: 1–2 g diluted in 10 mL D5W IV push

Ventricular Tachycardia/Fibrillation

  • Defibrillation – 150–200 J 

  • If VT/VF is unresponsive to 2–3 shocks and the 1st dose of vasopressor consider Amiodarone.

  • Amiodarone is the drug preferred by the AHA. Dosing: 300 mg IV push followed by 2nd dose of 150 mg IV 

Initial dose of 2 J/kg for the 1st attempt, followed by 4 J/kg for the next attempt. Increase energy with subsequent attempts, but do not exceed 10 J/kg or maximum adult dose.

Myocardial Infarction/Pulmonary Embolism (PE)

  • Activase: 50 mg bolus over 2 minutes
    • Repeat a second 50 mg bolus 15 minutes later if return of spontaneous circulation (ROSC) is not achieved.
  • Heparin – systemic anticoagulation (eg, unfractionated heparin) should be administered with or shortly after administration of alteplase
    • Initial: 80 units/kg bolus followed by…
    • Continuous infusion of 18 units/kg/hour
    • Adjust infusion rate to maintain target laboratory values based on institutional protocol

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