Megacode PEA Part 5

Vasoconstrictors

·         Epinephrine

·         Vasopressin

Note:  Available evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit. For this reason, atropine has been removed from the Cardiac Arrest Algorithm.

To date no placebo-controlled trials have shown that administration of any vasopressor agent at any stage during management of VF, pulseless VT, PEA, or asystole increases the rate of neurologically intact survival to hospital discharge. There is evidence, however, that the use of vasopressor agents is associated with an increased rate of ROSC.

Drug Therapy: Epinephrine

·         Epinephrine 1mg (1:10,000 solution) IV/IO q3-5min

·         ETT dose 2mg diluted in 10cc of NS

·         Increases systemic vascular resistance (vasoconstriction)

·         Increase coronary and cerebral perfusion pressures during CPR

·         Escalating or high doses without demonstrable benefit

·         After drug delivery and approximately 5 cycles (or about 2 minutes) of CPR then recheck the rhythm 

Drug Therapy: Vasopressin

·         Vasopressin 40U IV

·         May be given first or as a second dose to epinephrine

·         Increases systemic vascular resistance

·         After drug delivery and approximately 5 cycles (or about 2 minutes) of CPR then recheck the rhythm

Evaluate Reversible Causes: 5Hs & 5Ts

·         Hypoxia

·         Hypovolemia

·         Hyper/hypokalemia

·         Hydrogen ions (acidosis)

·         Hypothermia

Evaluate Reversible Causes: 5Hs & 5Ts

·         Tension pneumothorax

·         Thrombosis: cardiac

·         Thrombosis: lungs

·         Tables/toxins

·         Tamponade, cardiac

3:26 PM.   With no change in the patient's rhythm after continuous CPR and medications, there was little question that the patient was going to live.   Up to this time, the patient had received some epinephrine, bicarbonate, and fluids but remained in a refractory bradyasystolic rhythm.   There are a lot of factors that weigh in when you reach the decision to stop the code:  the patient's age, co-morbities,  the family's wishes, and quality of life afterwards.  It is not an easy decision.   In my experience, there is usually a general consensus among the team members that every reasonable thing that could have been done for the patient had been done and that any further efforts would not improve the patient's chance of survival.

Consider Termination of Efforts

The final decision to stop can never rest on a single parameter, such as duration of resuscitative efforts. Rather, clinical judgment and respect for human dignity must enter into decision making. In the out-of-hospital setting, cessation of resuscitative efforts in adults should follow system specific criteria under direct medical control.