Protocol 2-198 - Cardiac Arrest

CMH EMS & MIH Protocols

COMMUNITY RESPONDER:

• Call or have someone call 9-1-1. Follow the instructions given by the dispatcher.
• Ensure the scene is safe and protect yourself from body substances.
• If the patient is unresponsive and not breathing (or only gasping):
• Get or have someone get the AED. Follow the instructions given by the AED once it arrives.
• Lay the patient flat on his/her back on the ground and remove any pillows.
• Place the heel of your hand on the breastbone and put your other hand on top of that hand.
• Pump the chest hard and fast at a rate of about 110 compressions per minute. Compressions should be about 2 inches deep on an adult or 1/3 the depth of the chest on a child.
• Rotate compressors (if possible) after 200 compressions (about 2 minutes).
• Continue compressing at a rate of about 110 per minute until emergency responders relieve you.
• As soon as the AED is available:
• Put the AED on the ground next to the patient’s head on the side closest to you.
• Undo or remove any clothing from his/her chest. If the chest is wet, dry it off.
• Open the AED (if necessary) and press the "ON" button (if there is one).
• Open the pads package and plug them into the machine.
• Peel off the pad backing and apply them to his/her bare chest as shown on the pads.
• Follow the AED’s instructions.
• Refer to Equipment 8-018 - Automated External Defibrillator for AED accessibility, supplies, maintenance, and instructions after use

EMD:

• MPDS Protocol 9 (Cardiac Arrest) - Cardiac arrest pathway: Continuous compressions instructions provided to callers until responder arrival is the treatment preference for adult arrest with suspected cardiac origin
• MPDS Protocol 9 (Cardiac Arrest) - Obvious death: The following conditions indicate obvious death:
• Decapitation,
• Decomposition,
• Putrefaction, OR
• Incineration.
• MPDS Protocol 9 (Cardiac Arrest) - Expected death: The following conditions indicate expected death:
• DNR order, OR
• Hospice care.

EMR:

• Ensure completion of applicable items above.
• Resuscitation should not be started if:
• Decapitation,
• Rigor mortis,
• Tissue decomposition,
• Extreme dependent lividity,
• Obvious mortal injury,
• Properly documented DNR order, OR
• Properly documented advance directive.
• Request ALS support if not already en route.
• Confirm pulselessness and apnea.
• Consider AED or Cardiac Monitor in AED mode
• Perform Compressions.
• Consider Chest Compressor.
• Minimize interruptions.
• Use CPR metronome set at 110/min, if available or count out loud.
• Rotate human compressors every 2 minutes.
• Continuous Compressions at 110/min with Oxygen 15 LPM via BVM or or tube with one breath every 5-6 seconds.
• Attach Cardiac Monitor combo pads then limb leads.
• Attempt to determine down-time, history, and DNR status.
• The documented wishes of patients not wanting to be resuscitated shall be honored. DNR Documentation must contain both the patient's and physician's signature. If any doubt exists regarding the validity of the documentation, immediate resuscitation should be initiated.
• All therapeutic care and vigorous support (IVs, medications, etc.) shall be given until the point of cardiac respiratory arrest.
• If a valid DNR form is present, it may be honored without contacting medical control. If a valid DNR is presented after resuscitation has been initiated, it can also be honored without contacting medical control and resuscitation may be terminated.

EMT:

• Ensure completion of applicable items above.
• Prepare IV/IO supplies and any requested medications from ALS.
• Consider inserting an NPA, OPA, or iGel airway.
• Attach Capnography even if only using BVM and no airway device.
• When utilizing AED mode on the Lifepak15 the ETCO2 numbers are viewable and will give feedback on quality of compressions and help in confirming patency of airway.
• Target compression to an ETCO2 of 20 mm Hg or greater.
• Check blood sugar.
• Pregnant: Oxygenation and airway should be prioritized. Fetal monitoring should not be done during resuscitation.
• Prepare for termination or transport.
• If ETCO2 spikes rapidly above 45 mm Hg or greater while performing compressions expect Return of Spontaneous Circulation (ROSC) at the next rhythm and pulse check. Refer to Post Resuscitation protocol for ROSC care.

AEMT:

• Ensure completion of applicable items above.
• Start IV with LR fluid bolus.
• Consider Narcan 2 mg IN for possible overdose.

RN:

• Ensure completion of all applicable items above.
• Consider IO with LR fluid bolus. IV is preferred and should be attempted first.
• Epinephrine IV/IO every 3-5 min or drip over 5 min.

• Adult:	Pediatric:
  1 mg.	0.01 mg/kg. Click "calculate" to get dose.

• Pulseless Electrical Activity (PEA): Refer to Protocol 2-748 - Pulseless Electrical Activity.
• Ventricular fibrillation, ventricular tachycardia, ventricular ectopy, or Torsades de Pointes: Refer to Protocol 2-968 - V-Fib / Pulseless V-Tach.
• Consider Atropine 1 mg IV/IO for Bradycardia every 3-5 min.
• Consider Narcan 2 mg IV/IO for possible overdose.
• Consider Sodium Bicarbonate 1 mEq/kg IV/IO for acidosis.
• Click "calculate" to get dose.
• Consider Pacing.
• Consider Dextrose 25 g IV/IO for Hypoglycemia.
• Dialysis Patient or Known Hyperkalemia: Consider contacting MEDICAL CONTROL for Calcium Chloride 1 g IV/IO.
• Perform Physical Exam.
• Consider and correct treatable causes: Hypovolemia, hypoxia, hypo/hyperkalemia, hypothermia, hypoglycemia, acidosis, tension pneumothorax, toxins, thrombosis, and cardiac tamponade.
• If abrupt jump in ETCO2 level during CPR great than 45. Expect Return of Spontaneous Circulation finding at next pulse check and refer to Post Resuscitation protocol for further treatments.
• Begin termination/transportation conversation.
• Conditions for consideration of termination:
• Full ACLS efforts have been attempted for 20 minutes, AND
• Patient is an adult, AND
• Suspected cause of arrest is NOT Poisonings, overdose, drowning, hypothermia, or pregnant with a fetus greater than 24 weeks gestation, AND
• Capnography has been less than 10 for at least 10 minutes, AND
• Cardiac rhythm is asystole.
• In all cases where termination of resuscitation is considered, MEDICAL CONTROL shall be consulted.
• Conditions where termination of resuscitation should NOT be considered:
• Patient is pediatric, OR
• Suspected cause of arrest is Poisonings, overdose, drowning, hypothermia, or pregnant with a fetus greater than 24 weeks gestation OR
• If airway cannot be maintained OR
• IV/IO cannot be accessed.
• When considering termination, RN/Paramedic/CP should consult with the family. If family believes the patient would wish continued resuscitative efforts, resuscitation will continue and the patient shall be transported to closest appropriate facility.
• In the event there is no clear evidence to withhold CPR, however patient has a terminal condition and the patient’s wishes have been conveyed by the family, contact MEDICAL CONTROL to withhold resuscitation.
• Field termination may be requested from MEDICAL CONTROL for victims of trauma with no signs of life regardless of how long ACLS efforts have been underway.
• After resuscitation has been terminated, contact local law enforcement and remain on scene until at least law enforcement or coroner arrival on the scene. If at healthcare facility, scene may be cleared prior to body retrieval.
• Peri-arrest patient requiring comfort measures (Hospice, TPOPP, MOLST, or POLST): Refer to Protocol 2-198-50 - Peri-Arrest Comfort Measures.

Medic:

• Ensure completion of all applicable items above.
• Consider Intubation without interruption of Compressions to facilitate continuous Compressions.

CP:

• Ensure completion of all applicable items above.

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