At the Bedside

  • Core prehospital priorities
  • Confirm arrest, start high-quality CPR: rate 100–120/min, depth 5–6 cm, full recoil, minimal pauses, rotate compressors q2 min.
  • Attach AED/monitor ASAP; defibrillate shockable rhythms early.
  • Airway: BVM with OPA/NPA initially; supraglottic airway or ETT if skilled and does not interrupt compressions.
  • Ventilation: avoid hyperventilation. After advanced airway: 1 breath q6 sec, continuous compressions.
  • Vascular access: IV or IO; IO is appropriate early if IV delayed.
  • Use ETCO₂:
  • Confirms advanced airway placement.
  • Low ETCO₂ may indicate poor compression quality or low pulmonary blood flow.
  • Abrupt rise may indicate ROSC.
  • Persistently very low ETCO₂ after prolonged resuscitation supports poor prognosis but should not be used alone.
  • Rhythm-based management
  • VF/pulseless VT: CPR → defib → CPR → epi → defib → antiarrhythmic → search reversible causes.
  • PEA/asystole: CPR + epi + reversible cause management; defibrillation not indicated.
  • Reversible causes: “Hs & Ts”
  • Hypoxia, hypovolemia, hydrogen ion/acidosis, hypo/hyperkalemia, hypothermia.
  • Tension pneumothorax, tamponade, toxins, thrombosis coronary, thrombosis pulmonary.
  • Termination of resuscitation
  • EMS protocols vary, but termination is generally considered when:
  • Arrest unwitnessed by EMS.
  • No bystander CPR.
  • No shocks delivered.
  • No ROSC after high-quality resuscitation.
  • Do not terminate early in potentially reversible or special cases: hypothermia, pregnancy, toxicologic arrest, lightning/electrocution, pediatric arrest, drowning, suspected PE with possible thrombolysis, refractory VF candidate for ECPR.
  • Transport vs stay-and-play
  • Routine intra-arrest transport worsens compression quality and increases hazards.
  • Transport during CPR is best reserved for:
  • Refractory VF/pVT with possible cath/ECPR.
  • Reversible cause requiring hospital procedure.
  • Unsafe scene.
  • Pregnancy/perimortem cesarean capability.
  • Hypothermia/toxin scenarios.
  • Interface with regionalized systems
  • STEMI/PCI center: post-ROSC with STEMI or high suspicion of coronary occlusion.
  • Cardiac arrest center: post-ROSC comatose patients needing ICU, targeted temperature management/fever prevention, cath capability, neuroprognostication.
  • ECPR/ECMO center: selected refractory arrest, especially witnessed arrest, short no-flow time, high-quality CPR, presumed reversible cardiac cause, shockable rhythm, younger/low comorbidity patient.
  • ED role: receive EMS handoff with rhythm timeline, no-flow/low-flow times, shocks, meds, airway, ETCO₂, ROSC times, suspected cause, downtime, bystander CPR.
A Classic Presentation
EMS brings a 58-year-old man with witnessed collapse at work. Coworkers started CPR, AED delivered 2 shocks, EMS found VF, gave epinephrine and amiodarone, and achieved ROSC after 18 minutes. Initial ED ECG shows anterior STEMI, patient remains comatose but has intact pulses and SBP 88. ED priorities are airway/oxygenation, avoid hyperventilation, norepinephrine for shock, cath lab activation, temperature management/fever prevention, and transfer/admission to a cardiac arrest-capable ICU.

Study Directive

  • Draw the adult ACLS cardiac arrest algorithm from memory, including drug timing and shock timing.
  • Practice a 30-second EMS handoff script: downtime, witnessed status, bystander CPR, initial rhythm, shocks, meds, airway, ETCO₂, ROSC.
  • Review your local EMS termination-of-resuscitation and ECPR activation criteria.
  • Simulate one post-ROSC case: set ventilator goals, pressor choice, cath activation decision, and ICU disposition.