Chapter 39
Responding to the
Field Code
National EMS Education
Standard Competencies
Shock and Resuscitation
Integrates comprehensive knowledge of
causes and pathophysiology into the
management of cardiac arrest and prearrest
states.
Introduction
• Return of spontaneous circulation during
resuscitation is now expected with sudden
cardiac arrest.
− Public trained in CPR
− AEDs in public places
− Guidelines revised every 5 years
Chain of Survival
• Following recognition of a cardiac
emergency, the Chain of Survival is critical.
− A team of skilled providers is required.
• Directed by a code team leader
Developing Prehospital
Program Objectives
• SMART objectives
− Specific
− Measurable
− Attainable and achievable
− Realistic and relevant
− Timely
Developing Prehospital
Program Objectives
• Universal access number?
• Dispatchers trained to provide hands-only
CPR telephone instruction?
− All cardiac arrests and tapes analyzed by
medical director?
Developing Prehospital
Program Objectives
• Community CPR training readily available?
• CPR required to graduate high school?
• Responders trained in CPR and AED use?
Developing Prehospital
Program Objectives
• AEDs, trained personnel at key locations?
− Schools? Sporting events?
• Fitness center personnel trained?
• Timely arrival on the scene?
− Data published regularly?
Developing Prehospital
Program Objectives
• Review of all cardiac arrests?
• Reports use “The Utstein Style”?
• Hospitals participate in the AHA’s Get With
The Guidelines improvement suite?
• Regular practice with simulated patients?
Simulation Training, or “Mock
Code” Training
• Simulation can help train you for lowfrequency, high-risk situations.
− “High-fidelity” manikins and videotaping used
to mock the code.
− Preprogrammed scenarios involving alterations
in vital signs and other parameters
Development of New CPR
Guidelines
• Reemphasis on quality CPR
− During the 1990s, CPR quality slipped.
− CPR is important before and after defibrillation.
• Immediate CPR can double or triple the survival rate
with V-fib or sudden cardiac arrest.
Development of New CPR
Guidelines
• Reemphasis on
quality CPR
(cont’d)
− Guidelines
emphasize the
importance of highquality CPR
beginning with
compressions.
Development of New CPR
Guidelines
• Airway management
− Reduced emphasis on endotracheal intubation
− Consider advanced airways if a basic airway is
not adequate.
• Place with minimum interruption in compressions.
Development of New CPR
Guidelines
• Airway management (cont’d)
− Important to control:
• Ventilation rate (1 second in duration)
• Ventilation volume (visible chest rise)
− Do not overventilate.
Development of New CPR
Guidelines
• Airway management (cont’d)
− Impedance threshold device (ResQPOD)
• Vacuum allows more blood flow to heart, brain
• Prompt helps keep track of ventilation rate
Development of New CPR
Guidelines
• Airway management (cont’d)
− With Chain of Survival in place, about a 40%
chance of ROSC.
• Place advanced airway based on the situation.
Development of New CPR
Guidelines
• Blood flow during CPR
− Heart pump theory
• Heart is directly squeezed by compression.
− Thoracic pump theory
• Compression raises pressure in chest cavity.
− Harder, faster compressions increase pressure.
Development of New CPR
Guidelines
• Blood flow during CPR (cont’d)
− Current theories consider the importance of
negative intrathoracic pressure.
• Not produced by patients in cardiac arrest
• Full chest recoil aids negative pressure.
Adult CPR
• Follows adult BLS
algorithm
• Key is to initiate
compressions
quickly.
− 10 seconds or less
to determine
pulselessness
Adult CPR
• If no pulse, begin CPR
− 2 minutes, or
− 5 cycles of 30 compressions and 2 ventilations
• Always bring AED or defibrillator/monitor to
a cardiac arrest call.
Adult CPR
• Bystanders are often reluctant to begin
CPR.
− Steps may be hard to remember.
− Training methods may have been inadequate.
− Fear of transmitted diseases
− Fear of doing the wrong thing
Two or More Rescuer CPR
• Facilitates effective chest compressions
− Far superior to the one-rescuer approach
• Prior to assisting, a second rescuer should:
− Apply the AED.
− Set up airway adjuncts.
− Insert an oral airway.
Two or More Rescuer CPR
• Rotate the compressor every 2 minutes.
− “On-deck compressor” can take over after five
cycles or 2-minute intervals.
− Compressor tires after 2 to 5 minutes; quality
will suffer if not replaced.
Two or More Rescuer CPR
• With an advanced airway, compressions
and ventilations are asynchronous.
− Compressor: at least 100 per minute without
pauses for breaths
− Ventilator: 8–10 breaths/min (6–8 seconds)
CPR for Infants and Children
• Age group definitions for resuscitation:
− Newly born—first few hours after birth
− Neonate—first month after birth
− Infant—1 month to 1 year
− Child—1 year to adolescence (signs of puberty)
− Adult—adolescent and older
CPR for Infants and Children
• Cardiac arrest in infants and children often
follows respiratory arrest.
− Rapid oxygen consumption
− Open the airway and ventilate.
• Often enough to prevent cardiac arrest
CPR for Infants and Children
CPR for Infants and Children
• Respiratory problems in children can have a
number of different causes.
• Pediatric BLS steps
−
−
−
−
Determine responsiveness.
Circulation
Airway
Breathing
Technique for Children
• Varies slightly compared to adult technique
− Switch rescuer positions every 2 minutes.
• If the child is past the onset of puberty, use the adult
CPR sequence.
Technique for Children
• Once advanced airway is inserted,
compressions and ventilations are
asynchronous.
− Compressor: at least 100 per minute
− Ventilator: 8 to 10 breaths/min (6 to 8 seconds)
− Switch compressors every 2 minutes.
Technique for Infants
• Varies slightly from
child technique
• Two thumbencircling-hands
technique used.
− If chest does not
rise, use the head
tilt–chin lift.
© Jones & Bartlett Learning
Defibrillation
• Delivers electricity to the heart
• Use with V-fib or pulseless V-tach.
• If you are the first responder, you are likely
to use an AED.
Defibrillation
• Adults
− Standard adult AED unit
• Children
− Use with dose-attenuation if available
− Or adult AED
Defibrillation
Defibrillation
• Infants
− Manual defibrillator if available
− Or pediatric dose-attenuator
− Or adult AED with pads in A/P position
• Newborns
− CPR with emphasis on ventilation
Defibrillation
• Carry out as soon as possible in 2 rhythms.
− V-fib
− Pulseless V-tach
• If you witness the cardiac arrest:
− Begin CPR; attach AED as soon as available.
Defibrillation
• If you did not witness the arrest:
− Perform 5 cycles of CPR, then apply AED.
• Response is more likely within the first few minutes
of ventricular fibrillation
Defibrillation
• With prolonged arrest, CPR for 2 minutes
prior to AED can:
− Restore oxygen to the heart, remove waste
− Increase the chance of successful defibrillation
Defibrillation
• If arrest is not witnessed and CPR not in
progress:
− Administer CPR for 2 minutes before delivering
shock.
• If rhythm converts to V-fib or pulseless
V-tach and AED is attached:
− Perform CPR until AED is charged.
Defibrillation
• Defibrillation is not useful in asystole.
− If you are unsure about asystole after checking
more than one lead, resume CPR and follow the
asystole pathway.
Manual Defibrillation
• You interpret the cardiac rhythm and
determine if defibrillation is needed.
• Select the appropriate dose.
− Default setting of 200 J is usually used.
Manual Defibrillation
• After delivering shock, immediately begin
2-minute cycle of compressions.
− Reassess for pulse return and rhythm change.
• Manual mode is faster.
Manual Defibrillation
• To perform on an infant
or child:
− Confirm
unresponsiveness,
pulselessness.
− Begin CPR if defibrillator
is not available.
− Use defibrillation pads or
select paddle size.
− Place both pads in their
appropriate locations.
Manual Defibrillation
• To perform on an infant or child (cont’d):
− For children younger than 1 year or less than
22 lb, use anterior-posterior placement.
− Assess the cardiac rhythm.
− Select the setting, and charge the defibrillator.
− Ensure that no one is in contact with the patient.
Manual Defibrillation
• To perform on an infant or child (cont’d):
− Deliver the shock at the appropriate setting.
− Give five cycles of CPR.
− Reassess the rhythm.
− If shockable rhythm persists, give additional
shock.
Manual Defibrillation
• To perform on an infant or child (cont’d):
− Establish IV/IO access, and begin therapy.
− Consider an advanced airway.
− Repeat after five cycles of CPR if refractory
V-fib or pulseless V-tach persists.
Manual Defibrillation
• Most systems use pregelled pads.
− Place pads in the same location as you would
when using an AED.
− Ensure that there are no air pockets.
Manual Defibrillation
• Initial pediatric setting: 2 J/kg
• Ongoing CPR: search for, treat Hs and Ts
• Give epinephrine only after two shocks.
• Consult director, control physician, or local
protocols for transport decisions.
Automated External
Defibrillation
• Interprets the rhythm and determines if
defibrillation is needed
• Without rescuer intervention, AED can:
− Assess rhythm and charge pads.
− Prompt rescuer to deliver a countershock.
Automated External
Defibrillation
• Semiautomated: detects V-fib, rapid V-tach
− Voice prompt may direct you to shock.
• Observe safety measures:
− Distance yourself from the patient.
− Patient not in pooled water or touching metal
− Remove nitroglycerin patch; wipe chest clean.
Automated External
Defibrillation
• Follow local protocols after use.
• Likely outcomes:
− Pulse is regained.
− No pulse is regained; no shock advised.
− No pulse is regained; shock advised.
Shockable ECG Rhythms
• Two shockable ECG rhythms
− V-fib and pulseless V-tach
• Defibrillation stuns the heart muscle, allows
normal conduction system to resume.
Shockable ECG Rhythms
• In the first moments of arrest, heart is
oxygenated, ready for shock
− Begin CPR, attach AED as quickly as possible.
− If recommended, administer shock immediately.
Shockable ECG Rhythms
• When V-fib or V-tach is not “fresh,” rapid
shock is not always best initial treatment.
− Begin CPR, and then analyze the ECG.
− If the patient is still in V-fib or V-tach, he or she
is ready for a dose of electricity.
Shock First or Compressions
First?
• Decision is made locally
• Policy similar to the following is common:
− If you witness arrest, begin CPR and attach
AED as soon as possible.
− If you do not witness, perform five cycles of
CPR, then apply AED.
Shock First or Compressions
First?
• Success rate for biphasic dose is better
than 93% if heart is ready to receive shock.
− If it does not work, perform 2 minutes of CPR.
− Reanalyze the rhythm and shock as
recommended.
Effective Shocks and Special
Circumstances
• Occasionally the patient wakes up with an
effective shock.
• Majority of effective defibrillations take a
minute or so to bring back circulation.
− Begin compressions immediately.
Effective Shocks and Special
Circumstances
• CPR for 2 minutes, then check pulse and
review rhythm.
− If there is ROSC, stop compressions.
− Check pulse, respirations, and blood pressure.
• Once AED is charged, deliver the shock.
Effective Shocks and Special
Circumstances
• The code team member who delivers the
shock must always first clear the patient!
• Remove the ventilation device or detach it
from the advanced airway.
Effective Shocks and Special
Circumstances
• Infant: Use pediatric pads and attenuator.
• Hairy chest: Shave patient.
• Wet patient: Move or dry prior to shock.
• AICD or pacemaker: Avoid by a few inches.
• Medication patch: Remove; wipe chest dry.
Advanced Cardiac Life Support
Algorithm
• Builds on BLS Healthcare Provider
Algorithm
Advanced
Cardiac Life
Support
Algorithm
Managing Patients in Ventricular
Fibrillation or Ventricular Tachycardia
• Continue CPR; check rhythm every 2 min.
• Shockable rhythm
− Single shock, then immediate compressions
• Three rescuers, advanced airway
− Asynchronous compressions, ventilations
Managing Patients in Ventricular
Fibrillation or Ventricular Tachycardia
• Drug therapy includes a vasopressor.
− Epinephrine (1:10,000)
• 1-mg IV push
• Repeat every 3 to 5 minutes if pulse is absent.
− Vasopressin
• 40 units IV push
• One time only
• Single dose may substitute for 1st or 2nd
epinephrine dose.
Managing Patients in Ventricular
Fibrillation or Ventricular Tachycardia
• Antidysrhythmics: option after third shock
− Amiodarone
• 300-mg bolus during CPR
• May be repeated once at 150 mg, 3 to 5 minutes
after the initial dose.
− Lidocaine
• 1 to 1.5 mg/kg IV push, then 0.5 to 0.75 mg/kg
• Maximum: 3 doses
• Do not combine with amiodarone.
Managing Patients in Ventricular
Fibrillation or Ventricular Tachycardia
• Torsades de pointes: consider magnesium.
− Loading dose 1 to 2 g IV or IO
• Allow each drug to circulate.
− Reanalyze at the next 2-minute point.
Managing Patients in Pulseless
Electrical Activity or Asystole
• PEA: organized cardiac rhythm, no
detectable pulse
− Continue CPR
− Rhythm check at 2-minute points
• Nonshockable rhythm: consider Hs and Ts.
Managing Patients in Pulseless
Electrical Activity or Asystole
• With three rescuers and an advanced
airway, compressions and ventilations can
be asynchronous.
• Prepare and administer medications while
performing CPR.
Managing Patients in Pulseless
Electrical Activity or Asystole
• Drug therapy includes a vasopressor.
− Epinephrine (1:10,000)
• 1-mg IV push
• Repeat every 3 to 5 minutes if pulse is absent.
− Vasopressin
• 40 units IV push
• One time only
• Single dose may substitute for 1st or 2nd
epinephrine dose.
Managing Patients in Pulseless
Electrical Activity or Asystole
• If patient changes to V-fib or V-tach, move
back to shockable side of the algorithm.
• Allow each drug to circulate.
− Reanalyze at the next 2-minute point.
• Follow the algorithms; use good judgment.
Managing Patients in Pulseless
Electrical Activity or Asystole
• Key points when managing arrest:
− Perform high-quality CPR, minimal interruptions
from start to end of code.
− If shockable rhythm, continue compressions
until defibrillator is charged to appropriate dose.
− Without interrupting CPR, obtain IV/IO access
and administer epinephrine.
Managing Patients in Pulseless
Electrical Activity or Asystole
• Key points when managing arrest (cont’d):
− For asystole or PEA, do not deliver shocks.
− Consider and treat reversible causes.
− If inserting an advanced airway, confirm and
monitor with waveform capnography.
− If patient experiences ROSC, capnography
might show a sustained increase in ETCO2.
Mechanical Adjuncts to
Circulation
• Provide immediate feedback on
compression quality.
− Rate, depth, chest recoil
• Four devices show promise in improving:
− Quality, consistency of compressions
− Blood flow during CPR
Impedance Threshold Device
(ITD)
• Marketed as
ResQPOD in U.S.
• Enhances vacuum
during chest recoil
− Increases:
• Cardiac output
• Blood pressure
• Perfusion
Courtesy of Advanced Circulatory Systems, Inc.
Impedance Threshold Device
(ITD)
• May improve circulation, increase ROSC
• Class IIa rating by AHA
• Remove as pulse returns.
Load-Distributing Band CPR or
Vest CPR Device
• AutoPulse delivers
uninterrupted adult
compressions.
− Automated,
portable device
• LifeBand squeezes
chest, improving
blood flow to heart,
brain during arrest.
Courtesy of ZOLL
Load-Distributing Band CPR or
Vest CPR Device
• Integration:
− Ensure high-quality CPR.
− Align patient on AutoPulse platform.
− Close chest band over chest.
− Press start button.
Load-Distributing Band CPR or
Vest CPR Device
• Integration (cont’d):
− Provide two bag-mask ventilations per
30 compressions.
− With advanced airway, compressions are
continuous; ventilation rate is 8–10 per minute.
− After 2 minutes of CPR, reassess for pulse
and/or shockable rhythm.
Thumper CPR Device
• Provides
continuous chest
compressions and
ventilations
− Can use with
pocket mask or
advanced airway
− Powered by and
delivers oxygen
Courtesy of Michigan Instruments, Inc.
Thumper CPR Device
• Carry additional oxygen tanks with highpressure hose adapters.
• Particularly useful in lengthy arrests
− Apply as early as possible.
Mechanical Piston Device
• Depresses
sternum via a
compressed gaspowered plunger
− Lucas 2
• No ventilation
• No air hoses
Courtesy of Physio-Control, Inc.
Postresuscitative Care
• If cardiac rhythm is restored, transport.
• If patient is comatose after ROSC, begin
hypothermia treatment immediately.
Postresuscitative Care
• Summary of postresuscitative care:
− Stabilize the cardiac rhythm.
− Normalize the blood pressure.
− Elevate the head to 30° if blood pressure
allows.
When to Start and When to
Stop CPR
• Two exceptions to starting CPR:
− Obvious signs of death along with:
• Rigor mortis
• Dependent lividity (livor mortis)
• Putrefaction
• Evidence of nonsurvivable injury
− Prior agreement not to resuscitate
When to Start and When to
Stop CPR
• Patient’s wishes may be expressed by:
− Do not resuscitate (DNR) orders
− Medical Orders for Life-Sustaining Treatment
− Advance directives
• Learn laws, protocols, and standards for
treating terminally ill patients.
When to Start and When to
Stop CPR
• Always start CPR if any doubt exists.
• Don’t stop until one of the following occurs:
− ROSC
− Patient is transferred to another provider
− You are not physically able to perform CPR
− Physician assumes responsibility
When to Start and When to
Stop CPR
• Always continue until care is transferred to
a physician or higher medical authority.
− Your medical director or medical control
physician may order you to stop.
Terminating Resuscitative
Efforts
• Few instances require transporting a
nontraumatic cardiac arrest patient who has
failed ACLS resuscitation effort.
• In the absence of mitigating factors,
prolonged efforts are unlikely to succeed.
Terminating Resuscitative
Efforts
• Rare exceptions include severe prehospital
hypothermia and drug overdose.
• Transporting a deceased patient is usually
not appropriate.
Termination Rules
• If patient is receiving only BLS, consider
ending before transport if:
− Arrest is not witnessed by anyone.
− No ROSC after 3 rounds of CPR, AED analysis
− No AED shocks were delivered.
Termination Rules
• With ALS personnel present, consider
ending efforts before transport if:
− Arrest was not witnessed by anyone.
− Bystander CPR was not provided.
− No ROSC after complete ALS care in the field
− No AED shocks were delivered.
Scene Choreography and
Teamwork
• Teamwork multiplies chances for success.
• Steps to success:
− Know the plays expertly and automatically.
− Listen to your “coaches.”
− Have a “practice ethic.”
Code Team Member and Code
Team Leader Roles
• Code team member roles
− Ventilator—manage airway.
− Active compressor—provide high-quality chest
compressions.
− On-deck compressor—be ready to relieve the
compressor without any interruption.
Code Team Member and Code
Team Leader Roles
• Code team member roles (cont’d)
− Other support personnel
• Analyze the ECG and deliver shocks.
• Gain venous (IV or IO) access.
• Provide documentation for the patient care report.
• Support family members.
Code Team Member and Code
Team Leader Roles
• Code team leader:
− Must be able to perform all skills expertly
− Will occasionally back up a team member
− Often responsible for making sure everything
gets done correctly and at the right time
Code Team Member and Code
Team Leader Roles
• Code team leader roles may include:
− Obtain patient history.
− Perform exam.
− Interpret ECG.
−
−
−
−
Keep track of time.
Make medication decision.
Delegate tasks.
Complete documentation.
− Talk with medical control.
− Control the scene.
Code Team Member and Code
Team Leader Roles
• Code team leaders should:
− Help train future team leaders.
− Continually improve team.
− Practice to help prepare for the next code.
Plan for a Code
• Sample plan:
− Compressor 1 and Compressor 2
• Performs high-quality chest compressions
• Stays in position and compresses for 2 minutes
• May assist with application of the Thumper or other
adjunct to circulation
Plan for a Code
• Sample plan (cont’d):
− Ventilator
• Ventilates at a ratio of 30:2
• Suction; switch to ATV as needed/appropriate.
• Assist with transition to advanced airway.
• Ventilate 8 to 10 times/min once airway is placed.
Plan for a Code
• Sample plan (cont’d):
− Code team leader
• Initial ECG analysis and defibrillation
• Responsible for overall timing, reassessment
• IV or IO access, administer vasopressor
• Help transition to advanced airway.
• Make decision to terminate resuscitation.
Plan for a Code
• Sample plan (cont’d):
− EMS field supervisor
• Brings in Thumper or other adjunct
• Help compressors transition to mechanical CPR
• Assist with IV or IO, advanced airway, and
medications.
• Contact medical control.
Summary
• The Chain of Survival includes recognition
of a cardiac emergency; early access to
9-1-1; early CPR, defibrillation, and
advanced life support; and transport to a
hospital for postresuscitative care.
• Guidelines emphasize high-quality CPR
beginning with compressions (hard, fast, full
chest recoil).
Summary
• Only consider advanced airways if a basic
airway is not adequate or the airway needs
better protection. Focus on CPR.
• Basic BLS principles are the same for
infants, children, and adults.
• First assess circulation. If the patient has no
pulse, start compressions.
Summary
• CPR can be performed with 1–2 rescuers.
Two rescuers or a team is always best.
Adult CPR has a 30:2 ratio of compressions
to ventilations.
• Defibrillate as soon as possible with
ventricular fibrillation and pulseless
ventricular tachycardia. The chance of
success declines rapidly with time.
Summary
• With a manual defibrillator, you interpret the
cardiac rhythm and determine if
defibrillation is needed. An automated
external defibrillator does this for you.
• Defibrillate patients in nontraumatic arrest
who are older than 1 month. For AED use
between 1 year and the onset of puberty,
use pediatric-sized pads and a doseattenuating system if available.
Summary
• The ACLS algorithm has two basic
treatment pathways: shockable rhythms
(ventricular fibrillation or ventricular
tachycardia) or nonshockable rhythms
(asystole or pulseless electrical activity).
• Always consider and treat reversible
causes.
• For asystole or pulseless electrical activity,
do not deliver shocks.
Summary
• Adjuncts to circulation can improve
compression quality and include the
impedance threshold device, mechanical
piston device, and load-distributing band.
• If an effective cardiac rhythm is restored,
transport immediately. If the patient is
comatose after ROSC, consider
hypothermia treatment.
Summary
• Follow the ALS termination of resuscitation
rule.
• Teamwork divides tasks while multiplying
the chances for a successful resuscitation.
• The team’s leader and its members should
know all the roles during a resuscitation
attempt.
Credits
• Chapter opener: © Imageshop/Alamy Images
• Backgrounds: Orange–© Keith Brofsky/Photodisc/
Getty Images; Gold–Jones & Bartlett Learning.
Courtesy of MIEMSS; Green–Courtesy of Rhonda
Beck; Purple–Courtesy of Rhonda Beck.
• Unless otherwise indicated, all photographs and
illustrations are under copyright of Jones & Bartlett
Learning, courtesy of Maryland Institute for
Emergency Medical Services Systems, or have
been provided by the American Academy of
Orthopaedic Surgeons.