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! Find us on Patreon here! Buy your merch here! 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; breat...
