What are the 3 stages of the of cardiac arrest outlined in the OOHCA SOP?
- Early electrical (0-6minutes)
- Circulatory (7-17minutes)
- Metabolic/refractory (>18minutes) phases of cardiac arrest.
What does the OOHCA SOP recommend with regards to airway in the early ‘electrical’ phase of cardiac arrest and why?
OP airway and NRB mask because it:
- limits interruptions in continuous closed chest compressions (CCC)
- improves venous return
- liberates bandwidth
What coronary perfusion pressure should we aim for?
What DBP does this equate to?
> 20mmHg
CPP= DBP-RAP (15-20mmHg)
Therefore aim DBP > 40mmHg
What parameters should trigger EHAAT teams to re-evaluate hand/LUCAS placement? (2)
- ETC02 <2.7 kPa
- DBP < 30mmHg
After how much adrenaline is there poor evidence for any benefit?
8mg
When should we consider omitting adrenaline in OOHCA?
Refractory VF/VT with ETCO2 >2.7mmHg/DBP + >35mmHg
(unless asthma/anaphx or anything for which adrenaline would have benefit aside from improving CPP)
In which condition should amioderone be avoided if possible and what is the alternative (and dose)?
- Prolonged QT
- Lidocaine
- 1.5mg/kg to max 100mg
What dose of bicarbonate should be given in arrest if indicated?
1-2 mmol/kg 8.4%
= 1-2ml/kg
What modifications can we make to ALS in refractory VF/FT? (6)
- Replace Pads if >5 shocks.
- AP pad placement
- Dual sequential shocks
- Sodium Bicarbonate in later metabolic phase.
- Magnesium Sulphate (8mmol/2g) early, particularly polymorphic VT.
- Consider intra-arrest transfer to either a PCI capable centre with ECMO capabilities if can be delivered within 45minute low flow time.
What is the dose of adrenaline in arrest in neonates?
20mcg/kg
What are the paeds arrest doses of:
1. Shock
2. Fluid bolus
3. Adrenaline
4. Amioderone
5. Atropine
- 4J/kg
- 20ml/kg
- 10mcg (0.1ml)
- 5mg/kg
- 20mcg/kg
What features of an arrest does the SOP state should make you think about transferring to an ECMO centre in arrest? (6)
- Refractory cardiac arrest
- < 70 years
- Witnessed
- Rapid bystander CPR (<5mins)
- Suspected reversible pathology
- CRP/ ‘low flow’ time limited. Guideline of arriving at ECMO centre < 45mins of arrest
What are the ECMO centres with helipads in EEAST? (3)
- Harefield
- Papworth
- KCH
How is coronary perfusion pressure measured?
CPP - diastolic blood pressure - right atrial pressure (assume 15-20mmHg)
In the electrical phase of cardiac arrest what should be prioritised? (3)
- Basic airway maneuver and NRB mask
- Good CCC (100/min)
- Early shock
What additional things in the HP-CPR bundle can be done once an OOHCA has moved to circulatory/metabolic stages? (8)
- Improve CPR - use ETC02/DBP/echo to move position
- Intubate
- LUCAS
- Ventilator (CMV, TV 500ml, RR 8, FiO2 1, PEEP 0 and P-high alarm 50)
- Right femoral arterial line
- Consider advanced drugs depending on suspected aetiology)
- Echo
- Consider ECMO centre if <45mins
What ventilator settings should we apply if using in arrest? (6)
CMV
TV 500ml
RR 8
FiO2 1.0
PEEP 0
P-high alarm 50)
What should we consider if LUCAS and ventilator being used in arrest?
Continuous CPR (look at ETC02 trends/signs of life and re-assess if changes)
Post ROSC what should be our physiological targets?
- SATs 94-98%
- ETCO2 4.0-5.0 Kpa
- MAP > 65
- Glucose > 6.0
- Temp <37.5 degrees C
Post ROSC, outside of aiming for our normal physiological parameters what can we add?
- Arterial line insertion +/- adrenaline infusion
- 12 lead ECG
- Screening TTE considered
- Measure glucose
- Measure temperature
- Head up, neutral head position and loose ETT tie
- Pupil assessment documented
- Appropriate sedation
- Dual antiplatelet agent loading if appropriate
