Immediate Management of Cardiac Arrest During Hemodialysis with Manual Defibrillator
If only a manual defibrillator is available during cardiac arrest in a hemodialysis patient, immediately initiate high-quality CPR while a second provider charges the manual defibrillator, briefly pause compressions to "clear" and deliver the shock, then immediately resume CPR starting with chest compressions for 2 minutes before the next rhythm check. 1, 2
Initial Response Algorithm
Stop dialysis immediately and activate emergency response while simultaneously beginning CPR with cycles of 30 compressions and 2 breaths at a rate of 100-120 compressions per minute with depth of at least 2 inches. 1, 3
Manual Defibrillator Workflow (Requires ACLS-Certified Operator)
First provider begins CPR immediately while second provider retrieves and charges the manual defibrillator to appropriate energy level (biphasic: 120-200 Joules per manufacturer recommendation; monophasic: 360 Joules). 1
Minimize interruption in compressions by having the second provider charge the defibrillator while CPR continues, pausing only briefly to "clear" the patient and deliver the shock. 1
Resume CPR immediately after shock delivery without checking pulse or rhythm—this is critical as each interruption decreases coronary and cerebral perfusion pressure. 1, 2
Continue CPR for full 2-minute cycles before pausing briefly (less than 10 seconds) to check rhythm on the manual defibrillator monitor. 1, 2
Change compressors every 2 minutes at the time of rhythm checks to prevent fatigue and maintain compression quality. 1, 2
Dialysis-Specific Considerations
Assume hyperkalemia until proven otherwise in any dialysis patient with cardiac arrest, as 61% of cardiac deaths in dialysis patients are from arrhythmic mechanisms, with hyperkalemia being the most common precipitant. 1, 3
Immediate Electrolyte Management
Administer calcium chloride 10% 10 mL IV (or calcium gluconate 10% 30 mL IV) immediately if hyperkalemia is suspected or ECG shows peaked T waves, widened QRS, or sine wave pattern. 3
Give sodium bicarbonate 50 mEq IV bolus to shift potassium intracellularly. 3
Administer regular insulin 10 units IV with dextrose 50% 50 mL (D50W) to further shift potassium intracellularly. 3
Standard ACLS Medications
Establish IV/IO access and administer epinephrine 1 mg IV/IO every 3-5 minutes for all cardiac arrest rhythms. 1, 3
For refractory VF/pulseless VT, administer amiodarone 300 mg IV/IO bolus (second dose 150 mg) or lidocaine as alternative antiarrhythmic. 1, 3
Critical Prognostic Context
The combination of cardiac arrest during dialysis carries 30% overall survival to hospital discharge, with 62% of dialysis-related cardiac arrests presenting as shockable rhythms (VF/VT) that respond better to defibrillation. 1, 3 Mortality increases 7-10% per minute without defibrillation, making rapid manual defibrillation by ACLS-certified operators essential. 1
Why Manual Defibrillators Require ACLS Training
Manual defibrillators require operators certified in ACLS because they demand more maintenance, require manual rhythm interpretation, and necessitate manual energy selection—unlike AEDs which automatically analyze rhythm and select appropriate energy. 1 However, manual defibrillators are appropriate devices for dialysis units when operated by properly trained staff. 1
Common Pitfalls to Avoid
Never check pulse or rhythm immediately after shock delivery—this wastes critical time when chest compressions should be ongoing. 1, 2
Never interrupt compressions for frequent rhythm checks—keep rhythm checks brief (less than 10 seconds) and only perform every 2 minutes. 1, 2
Do not treat hypokalemia or hypocalcemia without checking and correcting magnesium first, as these will be refractory to replacement without adequate magnesium. 3, 4
Avoid moving the patient from the dialysis chair to the floor unless absolutely necessary—51% of experienced dialysis technicians indicate optimal CPR can be performed directly in the dialysis chair, and moving wastes critical time. 5
Post-ROSC Management
After achieving return of spontaneous circulation (ROSC), obtain urgent 12-lead ECG and check stat electrolytes (K, Mg, Ca), glucose, and arterial blood gas. 3 Maintain potassium 3.5-4.5 mmol/L as this range shows the lowest risk of VF, cardiac arrest, or death in dialysis patients. 3, 4