Update: Some of the information in this post and podcast has been superseded by podcast 125; so click on over there.

This week we talk about managing the intra-arrest period of cardiac arrest. My paradigm has changed dramatically over the past few years. In the past, I viewed the arrest as a period to teach my residents how to place a subclavian central line, how to intubate when the patient is moving, and how to cram as many drugs as possible into a patient in a short period of time.

Looking at how I manage an arrest today, so much has changed.

I use the ACLS ABCDABCD mnemonic, though I've changed some of the intent:

A

Place an Oropharyngeal Airway

B

Place the patient on the ventilator with a BVM mask.

Set the vent to VT 500, Flow 30 lpm, Rate 10, FiO2 100%. Increase the pressure limit to 80-100 cm H20.

C

Compressions, Compressions, Compressions

The most important thing these days are continuous, rhythmic, chest compressions. If you want to get perfusion to the coronaries and get a chance at shocking (the only other effective therapy for arrest), you need perfect compressions.

I use a metronome and switch out providers every 1-2 minutes. Got the idea from this article.

Here is the metronome I use.

ETCO2 can be used as a marker of how well compressions are being performed.

D

Defib. Shock early and shock often.

You can shock without having the compressor stop compressions if they are wearing gloves and you have a biphasic defib with pads. (Circulation 2008;117:2510-2514.)

A

Advanced airway = LMA, not an ET Tube

Here is my LMA video

B

Advanced Breathing

Put the patient back on the vent. If you know how, switch them to pressure control at 20 cm H20, with an insp time of 1-2 seconds

C

Advanced circulation

pop in an IO

listen to the podcast for my feelings on meds

D

Differential

I recommend the RUSH exam created by my colleagues and me.

Last, we talk about when to stop: for me ETCO2 < 10 and no heart motion = stop, if I have been trying for 10-20 minutes.