Cardiac Arrest á la APQ: Our Current Resus Protocol

All modern international protocols guiding management of cardiac arrest revolve around more or less the same recipe:

• High quality chest compressions,

• Electricity (defib if shockable rhythm noted),

• Airway/breathing (oxygentate and ventilate),

• Meds (mostly epi +/- anti-arrhythmic du jour),

• Monitoring (rhythm and pulse checks, ETCO2 monitoring)

  
  

(APQ resus bay pictured above)

The dilemma our center and centers such as ours face:

How to best approach caring for a patient in cardiac arrest in a remote, resource limited setting with a lean local team?

What follows is our current approach:

~CARDIAC ARREST/RESUS á la APQ~

COMPRESSIONS via LUCAS Mechanical CPR device

the robot does not fatigue + frees up human hands for other high priority tasks

ACCESS via NIO Intraosseous Device

reliable access for med delivery in seconds

AIRWAY via iGel Supraglottic Device

rapid advanced airway without interruption of compressions

OXYGENATION/VENTILATION via Drager Portable Ventilator

dial in desired parameters = cognitive offloading

+POCUS FOR THE WIN: RULE OUT LIFE THREATS & MONITOR FOR ROSC

quickly interrogate for reversible etiologies of arrest such as tension pneumothorax and cardiac tamponade

&

(*here's the most recent addition to our protocol*)

use doppler ultrasound of femoral artery in lieu of manual palpation (which performs dismally) to detect return of pulse as well as adequate perfusion

Special thanks to one of the legends of EM/CritCare, Dr. Scott Weingart, EMCrit himself, for alerting us to the latter point via a recent pod.

A paper published in the journal Resuscitation in 2022 highlights the superior reliability of doppler ultrasound of femoral artery as compared to palpation for detecting a pulse (95.3% vs 54.0%) as well as confirming adequate perfusion (defined in the paper as SBP >60mmHg; PSV >20cm/s outperformed manual palpation to the tune of 91.4% vs 66.2%). (1)

A second paper from 2023, also published in Resuscitation, demonstrated the superiority of doppler US of femoral artery as compared to End Tidal CO2 (ETCO2) for detecting ROSC with SBP >60 (diagnostic accuracy of FA doppler with PSV >20cm/s was 89% versus 59% for ETCO2 of >20). (2)

There you have it.. our current approach to caring for the sickest patients (i.e. dead or nearly dead). From our perspective, the above represents a thoughtful, streamlined approach that gives our patients the best chance at meaningful (neurologically intact) survival.

Simple, yet powerful... consistent with our overarching philosophy of care:

Deploy the latest technology coupled with bleeding edge research findings in a manner that makes sense in our unique setting in order to provide our patients with world-class care.

Thank you for joining us on our upwardly spiraling journey!

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1. Cohen AL, Li T, Becker LB, Owens C, Singh N, Gold A, Nelson MJ, Jafari D, Haddad G, Nello AV, Rolston DM; Northwell Health Biostatistics Unit. Femoral artery Doppler ultrasound is more accurate than manual palpation for pulse detection in cardiac arrest. Resuscitation. 2022 Apr;173:156-165. doi: 10.1016/j.resuscitation.2022.01.030. Epub 2022 Feb 4. PMID: 35131404.

2. Haddad G, Margius D, Cohen AL, Gorlin M, Jafari D, Li T, Owens C, Becker L, Rolston DM. Doppler ultrasound peak systolic velocity versus end tidal carbon dioxide during pulse checks in cardiac arrest. Resuscitation. 2023 Feb;183:109695. doi: 10.1016/j.resuscitation.2023.109695. Epub 2023 Jan 13. PMID: 36646373.