What are the initial steps in managing a crashing patient with potential hypotension and cardiac arrest?

Managing a Crashing Patient

Immediately begin high-quality chest compressions at 100-120/min with a depth of at least 2 inches if the patient is unresponsive with no breathing or only gasping and no pulse, while simultaneously activating the emergency response system. 1, 2

Initial Recognition and Response

Check for responsiveness by tapping the patient's shoulder and shouting "Are you all right?" 1, 2

Simultaneously assess breathing and pulse within 10 seconds, looking specifically for no breathing or only gasping while checking for a definite pulse. 1, 2 Agonal gasping must be recognized as cardiac arrest, not adequate breathing. 1

Immediately activate the emergency response system if the patient is unresponsive with no breathing or only gasping. 1, 2 Shout for nearby help and have someone retrieve the AED/defibrillator and emergency equipment. 1

High-Quality CPR Technique

Begin chest compressions immediately without waiting to remove clothing or obtain history. 1, 3 For healthcare providers, start with compressions rather than ventilation to minimize time to first compression. 1

Compression specifications: 1, 2

• Rate: 100-120 compressions per minute
• Depth: At least 2 inches (5 cm) for adults
• Allow complete chest recoil after each compression
• Minimize interruptions to less than 10 seconds
• Change compressor every 2 minutes or sooner if fatigued

Compression-to-ventilation ratio: Deliver 30 compressions followed by 2 breaths until an advanced airway is placed. 1, 2 Once an advanced airway is secured, provide continuous compressions with 1 breath every 6 seconds (10 breaths/min). 1, 4, 2

Defibrillation

Apply the AED/defibrillator as soon as it arrives and is ready for use. 1 Do not delay CPR while waiting for the defibrillator. 1

For shockable rhythms (VF/pVT): 1, 2

• Deliver 1 shock immediately
• Resume CPR immediately for 2 minutes without pausing to check rhythm
• Recheck rhythm every 2 minutes

For non-shockable rhythms (PEA/asystole): 1

• Continue CPR immediately for 2 minutes
• Recheck rhythm every 2 minutes

Medication Administration

Establish IV/IO access during CPR without interrupting compressions. 1, 4, 2

Administer epinephrine 1 mg IV/IO every 3-5 minutes for all cardiac arrest rhythms. 1, 4, 2, 5 This remains the primary vasopressor for cardiac arrest. 4

For shock-refractory VF/pVT, administer either amiodarone or lidocaine after the second shock. 1, 2

Advanced Airway Management

Place an endotracheal tube or supraglottic airway when feasible without prolonged interruption of compressions. 4, 2

Confirm placement with waveform capnography. 4, 2 An ETCO₂ <10 mmHg suggests inadequate CPR quality and requires improved compressions. 2

Once the advanced airway is placed, provide continuous chest compressions with 1 breath every 6 seconds (10 breaths/min). 1, 4, 2 Avoid excessive ventilation, which increases intrathoracic pressure and decreases cardiac output. 4, 3

Addressing Reversible Causes (H's and T's)

Systematically evaluate and treat potential reversible causes during resuscitation: 4

• Hypovolemia: Administer IV fluids rapidly 4
• Hypoxia: Ensure adequate oxygenation and ventilation 4
• Hydrogen ion (acidosis): Correct with adequate ventilation 4
• Hypo/hyperkalemia: Check and correct electrolytes 4
• Hypothermia: Rewarm if accidental hypothermia caused arrest 4
• Tension pneumothorax: Perform needle decompression if suspected 4
• Tamponade (cardiac): Consider pericardiocentesis 4
• Toxins: Administer specific antidotes if available 4
• Thrombosis (pulmonary): Consider thrombolytics 4
• Thrombosis (coronary): Evaluate for acute coronary syndrome 4

Post-ROSC Management

Confirm return of spontaneous circulation (ROSC) by checking pulse and blood pressure, monitoring for abrupt sustained increase in ETCO₂, or observing spontaneous arterial pressure waves. 4

Maintain adequate oxygenation, targeting SpO₂ 94-98% to avoid both hypoxemia and hyperoxemia. 4, 2, 6 Both extremes are associated with worse outcomes. 6

Maintain normocapnia by adjusting ventilation parameters and monitoring with waveform capnography. 4, 2, 6 Hyperventilation decreases cerebral blood flow and may worsen neurologic injury. 4, 6

Support hemodynamics with vasopressors to maintain mean arterial pressure ≥65 mmHg. 4, 2, 7 Post-ROSC hypotension occurs in nearly 50% of patients and is associated with worse outcomes. 7, 6

Obtain a 12-lead ECG immediately to identify ST-elevation myocardial infarction. 4, 2

Consider urgent coronary angiography for patients with suspected cardiac etiology, particularly those with ST-elevation. 4, 2

Initiate targeted temperature management for all patients who don't follow commands after ROSC. 4, 2

Critical Pitfalls to Avoid

Do not delay CPR to assess for injuries, obtain history, or remove clothing—resuscitation takes absolute priority. 1, 3

Do not pause compressions to check rhythm or pulse except during scheduled rhythm checks every 2 minutes. 1, 2

Do not hyperventilate the patient, as this decreases venous return and cerebral perfusion. 4, 3, 6

Do not use high-dose epinephrine, as it provides no benefit over standard dosing. 4