While there is not a substantial body of evidence to either support of refute the utility of bicarbonate administration in cardiac arrest, the bulk of the evidence does not suggest any benefit. Instead, providers should focus on those factors that have been shown to improve outcomes, such as high quality chest compressions with minimal interruptions and early defibrillation (when appropriate). bicarbonate, meanwhile, should be reserved for specific case, such as hyperkalemia or suspected TCA overdose.
Give 2 minutes of CPR prior to defibrillation
if you suspect that the duration of cardiac
arrest is longer than 4 to 5 minutes. If the
duration of cardiac arrest is greater than 4
minutes, the patient most likely is in the circulatory phase of cardiac arrest.
Outside of early defibrillation and high-quality CPR, little has been shown to improve outcomes in out-of-hospital cardiac arrest (OHCA). In theory, rapid identification of the underlying cause of arrest can be beneficial. Many emergency clinicians have adopted Point-of-care ultrasound (POCUS) into cardiac arrest care by for this reason.
Cardiac arrest care is protocolized in ACLS for universal access, simplified for those who rarely run codes. As consultants specializing in Emergency Medicine, we should be on the forefront of resuscitation management, using cutting edge technologies and research to advance the field and save lives.
Current guidelines no longer recommend routine use of sodium bicarbonate, except in cases of arrest secondary to hyperkalemia, TCA overdose or preexisting metabolic acidosis. Regardless of these recommendations, sodium bicarbonate continues to be utilized during routine management of cardiac arrest, and studies are limited in investigating its appropriate use.
You think to yourself… Is there something we could have done to improve this patient’s chance at a better neurological outcome?
There is no evidence that any antiarrhythmic drug given routinely during human cardiac arrest increases survival to hospital discharge. Amiodarone, however, has been shown to increase short-term survival to hospital admission when compared with placebo or lidocaine (this may be considered harmful, as it merely changes the geography of death to the ICU)
There is a growing body of evidence suggesting a strategy that deemphasizing early definitive airway management may lead to improved outcomes.
I expect epinephrine to have a continued role in cardiac arrest research going forward, but I think that while we wait for those results, the bulk of this data suggests that epinephrine is, on balance, causing more harm than good, and should be removed from standard cardiac arrest algorithms.
As there are currently no RCTs evaluating intubation during the first 15 minutes of an in-hospital cardiac arrest, this study may be some of the current best evidence that supports focusing on the interventions that matter most early on: High-Quality CPR and Defibrillation.
There is a danger in summarizing a complicated topic with a one liner but, in regards to amiodarone, the best available evidence does not show any clear benefit for any of the major indications for ED use. However, the drug does have proven harms (i.e. hypo/hyperthyroidism, pulmonary toxicity, acute liver disorders). Given that we have better options for stable AF and VT cardioversion and that we have more important interventions to focus on in cardiac arrest, amiodarone should not be routinely used for any of these indications.
Something I have advocated for in cardiac arrest is the death of pulse checks, as our fingers are poorly sensitive for detecting which patients have a pulse in a shock state.
The use of NaHCO3 does not appear to improve clinically meaningful outcomes. A larger study should be undertaken to further evaluate this clinical question.
Fortunately, many causes of cardiac arrest are reversible... These conditions are often referred to by the mnemonic “Hs and Ts”:
First pass intubation success, high-quality chest compressions at rate of 100 bpm, and PetCO2 >14.3 mmHg during CPR are important predictors for success in the resuscitation of patients in cardiac arrest.
There is a lack of high-quality evidence and significant difficulty in conducting a randomized controlled trial to determine the best strategy for airway management in cardiac arrest. STICK TO THE BASICS: Intubation should have a lower priority compared to high-quality chest compressions and early defibrillation when needed. Remember to consider your reversible causes and treat appropriately.
One of the unique aspects of hypothermia is how differently cardiac arrest should be treated from normal ACLS protocol. Patients can have good neurologic outcomes despite prolonged resuscitative times, as demonstrated by several case reports and reviews.
Younger cardiac arrest patients often have different causes than older patients. Pay strong consideration to congenital abnormalities, conduction disorders, or other cardiac causes outside of coronary artery disease.
Introduction of ultrasound into the trauma evaluation has advanced management considerably. In the setting of TCA, bedside use of the focused assessment with sonography for trauma (FAST) exam allows for rapid determination of the presence of two potentially reversible causes of PEA arrest: pericardial effusion with cardiac tamponade and hypovolemia due to massive hemoperitoneum.
The pulseless cardiac arrest is caused by 4 different types of primary arrhythmias that consist of 2 shockable rhythms (ventricular tachycardia and ventricular fibrillation), and 2 non-shockable rhythms (pulseless electrical activity and asystole).
Managing a cardiac arrest can be mentally and emotionally taxing. Being methodical with each resuscitation will help mitigate the nuances of each individual patient.
A better understanding of this variability is fundamental to better prevention and resuscitation strategies. In this event, experts from around the world will focus on OHCA in their region, highlighting what can be learned, and the challenges yet to be addressed, to improve outcomes for individuals and communities locally and improve survival worldwide.