Cardiopulmonary Resuscitation

1. See Also
   1. Newborn Resuscitation
   2. Guidelines for Emergency Cardiovascular Care
2. Protocol
   1. ATLS is integrated with ACLS and PALS for the purposes of this reference
      1. Typically ACLS, ATLS, PALS are taught in isolation
   2. ACLS guidelines 2010 focuses on cardiac compressions as the first line intervention
      1. New Mnemonic is 'C-A-B'
      2. First-responders start compressions without a pulse check to minimize delays
      3. Cardiac compressions are continued, interrupted only for <10 seconds for rhythm checks and Defibrillation
      4. Automatic compression devices (e.g. Lucas) are recommended where available
3. Preparation
   1. Roles are assigned prior to patient arrival
   2. Provider Running the Resuscitation or code stands at the foot of the bed
   3. Provider managing the airway and neurologic evaluation stands at the head of the bed
4. Management: Initial
   1. Assess Responsiveness
      1. See Altered Level of Consciousness
   2. Call for Help
      1. Call for Defibrillator if available
      2. Activate EMS after initial ABC assessment
5. Management: Emergency Airway
   1. See Primary Survey Airway Evaluation
   2. Position
      1. Turn on back as unit
      2. Support head and neck while positioning
      3. Place on hard firm surface
   3. Open airway
      1. Jaw Thrust (if suspected neck injury)
      2. Head Tilt-Chin Lift Maneuver
   4. Trauma points (Primary Survey Airway Evaluation )
      1. Is the patient speaking or vocalizing?
      2. Observe for foreign bodies, dentures and facial deformities interfering with airway maintenance
      3. Primary Survey Disability Evaluation (brief Neurologic Exam)
         1. Can be performed with airway (GCS, pupils and motor in all extremities)
         2. Also described below as the D-part of the ABCDE trauma algorithm
6. Management: Emergency Breathing
   1. See Primary Survey Breathing Evaluation
   2. Look Listen and feel for breathing
   3. Attempt 2 ventilations (each lasting 1 second) if not breathing
      1. Observe chest rise
      2. Allow deflation between breaths
      3. Reposition if first breath does not go in
   4. Airway Obstruction (if ventilations unsuccessful)
      1. No blind finger sweeps at any age
      2. Unconscious
         1. Deliver full CPR regardless of airway obstruction
      3. Conscious
         1. Perform Heimlich Maneuver
            1. Infants: 5 chest thrusts and 5 back blows
            2. Children: 5 abdominal thrusts
            3. Adults: 6-10 abdominal thrusts
         2. Attempt ventilation
         3. Repeat cycle until obstruction cleared
   5. Trauma points (Primary Survey Breathing Evaluation)
      1. Palpate the chest for deformities, Flail Chest or open wounds
      2. Breath sounds are most useful when absent
         1. Treat asymmetrically absent breath sounds as a Pneumothorax
         2. Presence of breath sounds does not exclude Pneumothorax
7. Management: Emergency Circulation
   1. See Primary Survey Circulation Evaluation
   2. Assess for Pulse (health care providers)
      1. Brachial pulse in infants
      2. Carotid pulse in children and adults
   3. Pulse Present: Perform Rescue Breathing (reassess every 2 minutes)
      1. Endotracheal Tube: 1 breath per 6-8 seconds for all ages (8-10 breaths per minute)
      2. Adult: 12 breaths per minute (every 5 seconds)
      3. Child: 15 breaths per minute (every 3-5 seconds)
      4. Infant: 20 breaths per minute (every 3-5 seconds)
   4. Pulse Absent: Chest Compressions
      1. General
         1. Pulse check should be <10 seconds
         2. Perform 5 cycles in 2 minutes
         3. Reassess pulse and rhythm every 2 minutes
         4. Focus on pressing hard and fast with minimal interruptions
         5. Connect Automatic External Defibrillator as soon as available
         6. Time interval for lone rescuer calling for help
            1. Sudden Collapse: Call immediately
               1. Minimizes time to AED application
            2. Asphyxial arrest: Perform CPR for 2 minutes
         7. Two rescuers switch places every 2 minutes
            1. Prevents rescuer Fatigue with Chest Compressions
            2. Repeat pulse and rhythm checks with the change
      2. Infants (Under 1 year old)
         1. Place 2 fingers at just below mid-nipple line
         2. Compress over 100 times per minute
            1. Depth: One third of chest depth (1.5 inches or 4 cm)
            2. Ratio: 30 compressions to 2 breaths
      3. Children (1-8 years old)
         1. One hand placed over Sternum at center of chest (superior to xiphoid)
         2. Compress over 100 times per minute
            1. Depth: One third of chest depth (2 inches or 5 cm)
            2. Compression to ventilation ratio
               1. One rescuer: 30:2
               2. Two health care providers: 15:2
      4. Adults (over 8 years old)
         1. Two hands places over Sternum at center of chest (superior to xiphoid)
         2. Compress 100 times per minute
            1. Depth: 2 inches or 5 cm
            2. Compression to ventilation ratio: 30:2 (one or two rescuers)
   5. Trauma Points (Primary Survey Circulation Evaluation)
      1. See Primary Survey Circulation Evaluation
      2. Warm feet are a reassuring sign (cold feet might suggest shock state)
      3. Palpate the Abdomen for distention or signs of injury
      4. Compress the Pelvis by pushing both iliac crests together with force
         1. Assess for anterior or posterior palvis injury
         2. If the Pelvis moves inward on compression, hold this position and apply a pelvic binder for stabilization
         3. Do not repeat this exam in an unstable Pelvis
8. Management: Trauma Disability Points (Primary Survey Disability Evaluation)
   1. May be performed simultaneously with the airway evaluation above
   2. Glasgow Coma Scale
   3. Pupil Reaction
   4. Can patient move all extremities?
      1. In Trauma, do not paralyze and intubate the patient prior to assessing for spinal cord injury with paralysis
9. Management: Trauma Exposure Points (Primary Survey Exposure Evaluation)
   1. All clothing should be removed to completely assess for injuries
   2. Exposure penetrating trauma first
   3. Mnemonic: Armpits, Back, Butt cheeks and Sac
      1. Assess for easily missed sites of injury
   4. Apply warm blankets
10. Management: Trauma - Additional Points
    1. Fast and Glucose/Girl (F and G in the trauma ABCDEFG)
       1. Perform FAST exam (Ultrasound)
       2. Check Serum Glucose
       3. Check serum or urine Pregnancy Test
    2. Spine Precautions
       1. Backboard may be discontinued when Primary Survey completed (if spine evaluation negative)
    3. Imaging
       1. CT C-Spine (intsead of Cross Table lateral) for any ill patient who needs spine imaging
       2. Chest XRay for all trauma patients
       3. CT Abdomen and Pelvis
          1. May skip if benign Abdomen and Pelvis without pain, tenderness and if vitals signs stable
11. Management: Rhythm - Pulse Absent (ACLS)
    1. See Reversible Causes of Cardiopulmonary Arrest (5H5T)
    2. Shockable Rhythm: Ventricular Fibrillation or Pulseless Ventricular Tachycardia
       1. Defibrillate every 2 minutes
       2. CPR performed continuously between shocks (minimal interruptions)
       3. Give Epinephrine 1 mg every 3-5 minutes or Vasopressin 40 units for 1 dose
       4. Give Amiodarone 300 mg IV (may subsequently repeat dose at 150 mg)
          1. Alternative: Lidocaine 1-1.5 mg/kg IV (may subsequently repeat dose at 0.5 to 0.75 mg/kg)
       5. Give Magnesium 1-2 mg IV for Torsades de Pointes
    3. Non-shockable Rhythm: Asystole or Pulseless Electrical Activity (PEA)
       1. Give Epinephrine 1 mg every 3-5 minutes or Vasopressin 40 units for 1 dose
       2. Atropine is no longer recommended as of 2010 guidelines
          1. Was previously given at 1 mg IV for Asystole or Slow PEA
       3. Key management is to identify and treat Reversible Causes of Cardiopulmonary Arrest (5H5T)
12. Management: Rhythm - Pulse Present - Unstable (ACLS)
    1. See Reversible Causes of Cardiopulmonary Arrest (5H5T)
    2. Indications for unstable status
       1. Chest Pain
       2. Hypotension
       3. Altered Level of Consciousness
    3. Bradycardia (symptomatic with hemodynamic instability)
       1. See Unstable Bradycardia
       2. Atrioventricular Block (AV Block): Mobitz 2 or third degree
          1. Transcutaneous Pacing
          2. Prepare for Transvenous Pacing
       3. No AV Block (or first degree or Wenckebach)
          1. Atropine 0.5 mg IV (may repeat up to a cummulative total of 3 mg)
          2. Transcutaneous Pacing
          3. If pacing unavailable
             1. Epinephrine 2-10 mcg/min or
             2. Dopamine 2-10 mcg/min
    4. Tachycardia: Synchronized Cardioversion
       1. See Unstable Tachycardia
       2. Conscious Sedation if no delays
       3. Start at 120 joules for biphasic Defibrillator or 50 Joules for monophasic Defibrillator
          1. Paroxysmal Supraventricular Tachycardia (PSVT)
          2. Atrial Flutter
       4. Start at 150 joules for biphasic Defibrillator or 100 Joules for monophasic Defibrillator
          1. Atrial Fibrillation
          2. Monomorphic Ventricular Tachycardia
       5. Start at 200 joules for biphasic Defibrillator or 360 Joules for monophasic Defibrillator
          1. Polymorphic Ventricular Tachycardia (Unsynchronized shock will likely be required)
13. Management: Rhythm - Pulse Present - Stable - Bradycardia
    1. Indicated if unstable criteria above not met
    2. Bradycardia
       1. Evaluate for Sinus Bradycardia causes
       2. Observe for change in status
14. Management: Rhythm - Pulse Present - Stable - Tachycardia (ACLS)
    1. Indicated if unstable criteria above not met
    2. See Reversible Causes of Cardiopulmonary Arrest (5H5T)
    3. Wide Complex Tachycardia (QRS wider than 0.12 msec)
       1. Regular Wide Complex Tachycardia
          1. Start with Adenosine 6 mg IV (may repeat with 12 mg IV)
             1. Benign, slows the rhythm for interpretation and helps to differentiate SVT with aberrancy from VT
          2. Supraventricular Tachycardia with Aberrancy
             1. Treat as Regular Narrow Complex Tachycardia (see below)
          3. Ventricular Tachycardia
             1. Amiodarone 150 mg IV
             2. Synchronized Cardioversion
       2. Irregular Wide Complex Tachycardia
          1. Atrial Fibrillation with WPW
             1. Amiodarone 150 mg IV
             2. Consult with cardiology
             3. Avoid Beta Blockers, Calcium Channel Blockers, Digoxin, Adenosine
          2. Atrial Fibrillation with aberrancy
             1. Treat as Irregular Narrow Complex Tachycardia (see below)
          3. Torsades de Pointes
             1. Magnesium 1-2 grams IV
             2. Synchronized Cardioversion
    4. Narrow Complex Tachycardia
       1. Regular Narrow Complex Tachycardia
          1. Vagal maneuvers
          2. Adenosine 6 mg and may repeat at 12 mg dose
             1. Conversion with Adenosine suggests Paroxysmal Supraventricular Tachycardia (PSVT)
             2. Recurrence can be treated with Adenosine, Diltiazem or Lopressor
          3. Rate control
             1. Refractory to Adenosine suggests Atrial Flutter, ectopic Atrial Tachycardia or junctional Tachycardia
             2. Rate control with Diltiazem or Lopressor
       2. Irregular Narrow Complex Tachycardia
          1. Occurs with Atrial Fibrillation, Atrial Flutter or Multifocal Atrial Tachycardia (MAT)
          2. Rate control
             1. Diltiazem or
             2. Lopressor (avoid in acute CHF exacerbation)
15. References
    1. Trauma
       1. (2008) ATLS Manual, American College of Surgeons
       2. Majoewsky (2012) EMR:RAPC3 2(1): 1-2
    2. Cardiopulmonary Resuscitation Guidelines
       1. http://www.circulationaha.org
       2. (2010) Guidelines for CPR and ECC
       3. (2005) Circulation 112(Suppl 112):IV
       4. (2000) Circulation, 102(Suppl I):86-9