What is the protocol for cardiac arrest?

From the Guidelines

The cardiac arrest protocol should follow a systematic approach to restore circulation, prioritizing early, high-quality CPR and defibrillation, as recommended by the 2020 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care 1.

Key Components of the Protocol

• Begin with high-quality CPR immediately, providing chest compressions at a rate of 100-120 per minute with minimal interruptions.
• Establish IV/IO access and apply cardiac monitoring as soon as possible.
• For shockable rhythms (ventricular fibrillation or pulseless ventricular tachycardia), deliver defibrillation at 120-200J biphasic or 360J monophasic, then immediately resume CPR.
• Administer epinephrine 1mg IV/IO every 3-5 minutes throughout the resuscitation, as recommended by the 2019 American Heart Association focused update on advanced cardiovascular life support 1.

Additional Considerations

• For persistent shockable rhythms, give amiodarone 300mg IV/IO bolus, with a possible second dose of 150mg.
• For non-shockable rhythms (asystole or PEA), focus on high-quality CPR and epinephrine administration while identifying and treating potential reversible causes, including the "H's and T's": hypoxia, hypovolemia, hydrogen ion (acidosis), hypo/hyperkalemia, hypothermia, tension pneumothorax, tamponade, toxins, thrombosis (pulmonary or coronary).
• Reassess rhythm every 2 minutes with minimal interruption to compressions.
• Post-resuscitation care includes targeted temperature management, hemodynamic support, and neurological assessment.

Evidence-Based Recommendations

The 2020 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care provide a comprehensive framework for cardiac arrest management 1. The 2019 American Heart Association focused update on advanced cardiovascular life support emphasizes the importance of epinephrine administration in cardiac arrest 1. By following these evidence-based recommendations, healthcare providers can optimize cardiac arrest management and improve patient outcomes.

From the FDA Drug Label

In cardiac arrest, a rapid intravenous dose of one to two 50 mL vials (44.6 to 100 mEq) may be given initially and continued at a rate of 50 mL (44. 6 to 50 mEq) every 5 to 10 minutes if necessary (as indicated by arterial pH and blood gas monitoring) to reverse the acidosis. The cardiac arrest protocol for sodium bicarbonate (IV) involves administering a rapid intravenous dose of one to two 50 mL vials (44.6 to 100 mEq) initially, and continuing at a rate of 50 mL (44.6 to 50 mEq) every 5 to 10 minutes if necessary, as indicated by arterial pH and blood gas monitoring to reverse the acidosis 2.

• The dose may be repeated as necessary to reverse acidosis.
• Caution should be observed in emergencies where very rapid infusion of large quantities of bicarbonate is indicated.
• Bicarbonate solutions are hypertonic and may produce an undesirable rise in plasma sodium concentration in the process of correcting the metabolic acidosis.

From the Research

Cardiac Arrest Protocol

• Cardiac arrest is a serious condition that requires immediate management in the emergency department (ED) 3
• Medications play a crucial role in cardiac arrest management, with epinephrine being a core component of guidelines 3, 4
• The recommended dose of epinephrine is 1 mg for patients with shockable rhythms if initial CPR and defibrillation are unsuccessful, and as soon as feasible for those with nonshockable rhythms 3

Medication Administration

• Intravenous (IV) administration is recommended, but intraosseous (IO) access can be used if IV access is unsuccessful 3
• The combination of vasopressin, steroids, and epinephrine may improve return of spontaneous circulation (ROSC) among patients with in-hospital cardiac arrest, but does not improve survival to discharge or survival with a favorable neurologic outcome 3, 4
• Antiarrhythmics, such as amiodarone and lidocaine, may not improve short-term or long-term survival or neurologic outcomes, but can be used in patients with refractory pulseless ventricular tachycardia (pVT)/ventricular fibrillation (VF) 3, 4, 5, 6

Specific Medications

• Calcium and sodium bicarbonate should not be routinely administered in patients with cardiac arrest 3
• Beta-blockers may be considered in patients with shock-resistant pVT/VF 3, 4
• Amiodarone and lidocaine have been compared in several studies, with no significant differences in short-term mortality or neurological outcome found 5, 6