What is the initial management for a crashing patient in the emergency room (ER) with potential cardiac issues and hypotension?

Initial Management of a Crashing Patient in the ER

Immediately assess responsiveness, activate emergency response, check for breathing and pulse simultaneously within 10 seconds, and if no pulse is detected, begin high-quality CPR at 100-120 compressions per minute with a depth of at least 2 inches while preparing for defibrillation. 1

Immediate Assessment and Airway Management

Check for responsiveness by shouting for the patient and simultaneously assess breathing and pulse within 10 seconds. 1 If the patient is unresponsive with no pulse or only gasping respirations, this constitutes cardiac arrest requiring immediate CPR. 1

• Ensure scene safety first, then immediately shout for nearby help and activate the emergency response system. 1
• Get an AED and emergency equipment immediately (or send someone to retrieve them). 1
• If the patient has no pulse or is only gasping, proceed directly to CPR without delay. 1

For airway management in the crashing patient:

• Early airway securing should occur if there are signs of airway obstruction or threat. 2
• If the patient is not breathing but has a pulse, provide rescue breathing at 1 breath every 6 seconds (10 breaths per minute). 1
• Administer supplemental oxygen immediately to maintain oxygen saturation >95%. 2

High-Quality CPR Protocol

Begin CPR immediately with cycles of 30 compressions and 2 breaths. 1 The quality of chest compressions is the most critical component of CPR. 1

CPR quality parameters: 1

• Push hard: at least 2 inches (5 cm) depth
• Push fast: 100-120 compressions per minute
• Allow complete chest recoil between compressions
• Minimize interruptions in compressions
• Avoid excessive ventilation
• Change compressor every 2 minutes or sooner if fatigued

Rhythm Assessment and Defibrillation

Use the AED as soon as it is available and check the rhythm. 1

For shockable rhythms (VF/pulseless VT): 1

• Deliver one shock immediately
• Biphasic defibrillator: 120-200 Joules initially (use manufacturer recommendation; if unknown, use maximum available)
• Monophasic defibrillator: 360 Joules
• Resume CPR immediately for 2 minutes after shock delivery
• Recheck rhythm after 2 minutes and repeat cycle

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

• Resume CPR immediately for 2 minutes
• Focus on identifying and treating reversible causes (H's and T's)
• Recheck rhythm after 2 minutes

Vascular Access and Medication Administration

Establish IV or IO access as soon as possible during resuscitation. 1

Epinephrine Administration

Administer epinephrine 1 mg IV/IO every 3-5 minutes during cardiac arrest. 1 This should be given as soon as vascular access is obtained and continued throughout the resuscitation. 1

Antiarrhythmic Therapy for Refractory VF/pulseless VT

For refractory VF/pulseless VT (after initial defibrillation attempts), administer: 1

• Amiodarone: First dose 300 mg IV/IO bolus, second dose 150 mg IV/IO 1, 3
• Alternative: Lidocaine: First dose 1-1.5 mg/kg IV/IO, second dose 0.5-0.75 mg/kg IV/IO 1

Important caveat: Amiodarone commonly causes hypotension (16% of patients), which is related to infusion rate rather than dose. 3 Monitor the infusion rate closely and slow it if hypotension develops. 3

Advanced Airway Management

Once an advanced airway (endotracheal tube or supraglottic airway) is placed, provide 1 breath every 6 seconds (10 breaths per minute) with continuous chest compressions. 1

• Use waveform capnography to confirm and monitor ET tube placement. 1
• Persistently low PETCO2 values (<10 mm Hg) during CPR indicate poor CPR quality or low likelihood of ROSC. 1
• An abrupt sustained increase in PETCO2 (typically ≥40 mm Hg) indicates return of spontaneous circulation. 1

Identifying and Treating Reversible Causes (H's and T's)

During each 2-minute CPR cycle, systematically consider reversible causes: 1

H's:

• Hypovolemia: Establish IV access and administer rapid crystalloid bolus 2
• Hypoxia: Ensure adequate oxygenation and ventilation 2
• Hydrogen ion (acidosis): Treat underlying cause
• Hypo-/hyperkalemia: Consider empiric treatment if suspected
• Hypothermia: Prevent further heat loss 2

T's:

• Tension pneumothorax: Perform needle decompression if clinically suspected 1
• Tamponade (cardiac): Consider pericardiocentesis
• Toxins: Consider naloxone for suspected opioid overdose 1, 4
• Thrombosis (pulmonary): Consider empirical fibrinolytic therapy if PE suspected 1
• Thrombosis (coronary): Prepare for emergent cardiac catheterization if STEMI suspected

Management of Hypotension Without Cardiac Arrest

For the crashing patient with hypotension but a pulse, immediately establish IV access and begin fluid resuscitation. 2

If cardiogenic shock is suspected: 1

• Administer dopamine 5-15 mcg/kg/min IV if systolic BP 70-100 mm Hg 1
• Administer dobutamine 2-20 mcg/kg/min IV if systolic BP 70-100 mm Hg 1
• Consider norepinephrine 30 mcg/min IV for refractory hypotension 1
• Avoid beta-blockers or calcium channel blockers in patients with frank cardiac failure 1

Recognition of Return of Spontaneous Circulation (ROSC)

Signs of ROSC include: 1

• Palpable pulse and measurable blood pressure
• Abrupt sustained increase in PETCO2 (typically ≥40 mm Hg)
• Spontaneous arterial pressure waves with intra-arterial monitoring

Once ROSC is achieved, immediately initiate post-cardiac arrest care, including treatment of hypoxemia and hypotension. 1

Critical Pitfalls to Avoid

• Do not delay CPR to establish vascular access or administer medications. 1 High-quality chest compressions are the priority. 1
• Do not administer atropine during PEA or asystole—it has been removed from cardiac arrest algorithms due to lack of benefit. 1
• For suspected opioid overdose, standard resuscitation measures take priority over naloxone administration. 1, 4
• Avoid hyperoxia after ROSC, as arterial hyperoxemia (PaO2 ≥300 mm Hg) is associated with increased mortality. 5 Titrate oxygen to maintain adequate saturation while avoiding excessive supplementation. 5
• Do not use mechanism of injury or electrical rhythm as the sole determinant to discontinue resuscitation efforts. 6
• Avoid excessive ventilation during CPR, as this impairs venous return and cardiac output. 1