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We talk about the nitty-gritty details of a well-run cardiac arrest, with Scott Weingart of Emcrit (@emcrit), ED intensivist.
Learn more at the Intensive Care Academy!
Takeaway lessons
- In any sudden loss of pulse/consciousness, particularly in a known cardiac patient, the presumption should be for a shockable arrhythmia and rapid defibrillation should be prioritized above all else.
- Anterior-posterior pad placement may or may not be superior, but tends to be logistically helpful, as it allows rolling the patient a single time then never again; a second set of pads can be added for double sequential defibrillation without moving them, and a mechanical compression device can be applied at the same time as the pads.
- The primary or highest-trained provider should not be the sole “code runner,” but ideally offering high-level leadership, thinking about reversible causes and judgment calls, and performing procedures, while another leader (often a nurse) runs the standard activities of ACLS such as timing, coordinating rhythm checks, assigning jobs, quality assurance, and directing the room. That frees your cognitive bandwidth by handling all your logistics, and they can act as the one-stop-shop for passing needs and issues up and down the chain.
- IOs are probably the go-to for immediate access, if no IVs are present. But Scott likes to always place central access, usually femoral. He does ECPR, so the access may be needed, and even if not, it maintains the skill for next time. He also likes an arterial line, so it’s easy to place venous alongside it. He would generally not place it fully sterile (gowns, drapes, etc), but will use sterile gloves and prep the skin, assuming that any femoral line placed in the ED is going to be replaced within 24 hours.
- Scott loves an arterial line. It eliminates the “pulse check,” allowing instant confirmation of pulsatility, while also allowing a very sophisticated assessment of coronary perfusion.
- A diastolic BP above 35–40 mmHg, measured from the arterial line during cardiac arrest, suggests adequate coronary perfusion. This must be measured manually, as the automated number will falsely measure the wrong spot in the waveform during the “suction” of chest recoil (see link below); the true point of measurement is just before the upstroke of systole begins. If you’re above this DBP, just skip epinephrine, which will probably merely be toxic (ie promoting arrhythmias).
- A low DBP should be used as a general marker of poor perfusion, and prompt other changes. Try modifying the point of compressions on the chest to avoid obstructing the LVOT (TEE is even better for this, but not available most places). Swap out compressors to ensure the most vigorous compressions, even if they still “look okay” or claim to be. Look for a reversible cause, such as hemorrhage or obstruction. Finally, if it’s truly just vasoplegia, consider other moves, such as adding vasopressin/steroids (an evidence-based practice) or high-dose epinephrine (5 mg epinephrine).
- ETCO2 should be used in all arrests, to confirm airways, prognosticate, and provide a marker of perfusion much like the arterial DBP.
- Scott thinks we should stick to 30:20 mask ventilation when an airway is not in place; breaths don’t really go in during compressions, and bagging during the upstroke is very tough. But he prefers to just insert a supraglottic airway quickly and use that, a skill anyone attending cardiac arrests should have. If using the BVM, you should use capnography to confirm breaths are actually going in.
- Intubation should be done with video if available. Hyperangulated or regular geometry are both fine. Use a bougie if you have regular geometry (and are good with it). There should never be an intentional pause in compressions for the airway, however; just intubate during compressions, not so hard with video and a bougie. Position the patient optimally, just as in any situation; don’t rush.
- Never perform “pulse checks,” only rhythm checks. If the rhythm is non-perfusing, resume compressions. If it’s organized and potentially perfusing, only then check for a pulse (or preferably your arterial line).
- POCUS is essential: look for pericardial effusions, a dilated RV (although this is usually present), signs of hemorrhage, and pneumothorax. Maybe even more importantly, use it for pulse checks rather than your fingers. Scott will start with this, and if a “sonographic pulse” (visual pulsatility of the vessel) is found, he’ll then apply his fingers to see if it’s strong enough to feel. At this moment in time, he thinks palpability is a reasonable cutoff for when to call flow PEA vs hypotension.
- Once he’s ruled out reversible causes, he tries not to look at the heart with ultrasound, since it tends to detract from compressions (without TEE); sonographic pulse implies organized cardiac activity. An arterial line obviates all of this, although it’s not clear what BP is adequate; Scott still uses a DBP 35-40 but would accept a MAP of 40 as a reason to defer compressions, if rapid efforts are undertaken to increase it.
- Scott always likes mechanical compression devices when available (he likes the Lucas), which ensures good quality, provides a backboard, and reduces the energy in the room, even if it doesn’t improve outcomes. Buy one for your hospital’s code team and bring it to the arrests. If not available, he likes a backboard.
- The impedence threshold device (ITD), potentially in combination with active compression-decompression devices, is interesting but the initial promising data has not been replicated; he would not consider this ready for use.
- Heads-up CPR is also interesting but not yet proven.
- When defibrillating, always max out the current on the machine. It creates no meaningful injury and maximizes your chance of conversion.
- When a shockable rhythm is seen, he resumes compressions while charging, and in fact often performs hands-on defibrillation (shocking during compressions, using some kind of standoff between hands and chest, such as a towel, or even just gloves); mechanical compressions make this easiest.
- Pre-charging before the rhythm check is wise, and the nurse code leader can coordinate this; do it every time.
- Amiodarone or lidocaine are equally reasonable first line antiarrhythmics. If they’ve had one and you’re still in electrical storm, try the other.
- If storm persists, these are excellent ECPR cases. Otherwise, you can try esmolol (bolus 500 mcg, usually no drip), then double sequential defibrillation.
- DSD: don’t let pads touch; shock as simultaneously as possible (used to be intentionally separated, but some data now suggests closer together is better). There is a very small but real risk of damaging defibrillators doing this (and the damage may actually not be obvious, i.e. the machine will still pass a later self-check).
- How long to go? Depends on baseline functional status, rhythms seen, and other factors. Past 40 minutes of low-flow time, arrest is probably not survivable without ECPR (for which the cutoff is probably 90 minutes), unless there has been stuttering flow (intermittent ROSC), which tends to reset that timer. ETCO2 persistently <10 is very poor. No cardiac motion seen on echo in PEA is poor.
- One exception might be if your interventional cardiologists are willing to cath intra-arrest during mechanical compressions; in that case you might go longer to bridge to this.
- In a young or baseline well patient, Scott would almost never stop before 40–45 minutes.
- Scott always runs a norepinephrine drip at 50 mcg during the arrest, making it easy to transition to the drip after ROSC and avoiding any delays.
- After ROSC, a STEMI or high-risk patient should go to the cath lab. Everyone else should have a pan-CT, including head, chest, abdomen/pelvis. This ideally is gated/timed to triple rule out PE, coronary occlusion, and aortic dissection. It also identifies important post-CPR trauma.
- In 2025, Scott’s take on TTM is reactive: place an invasive temp probe (esophageal or Foley, not rectal, which is too slow and inaccurate) and monitor for fever; if it occurs, then cool actively to normothermia. There are probably some patients who benefit from more cooling, but nobody knows who (longer downtimes?). This method is as good and cheaper than empirically applying a cooling device to maintain normothermia before fever occurs, and that might cause problems, such as if it aggressively cools for a trivially increased temperature and induces shivering. Put the cooling device at the bedside without opening the pads if you really want to be ready.
- If having trouble inserting your floppy esophageal temp probe, use an esophageal stethoscope from the OR, or use a split 8.0 ET tube to introduce a lubricated probe into the esophagus.
- For out-of-unit codes, it’s all the more important to have a nurse code leader. A code team should bring the specialized equipment (maybe make a cart) to the bedside, such as mechanical compression devices, ultrasound, capnography, etc.