EMU 365: A New Frontier in Cardiac Arrest Management
This EMU365 video features Dr. Salim Rezaie, who reveals the latest evidence in airway and epinephrine management during out-of-hospital cardiac arrest. He presents the optimal airway device to use, controversies surrounding epinephrine dosing and timing, as well as hemodynamic directed dosing of epinephrine during cardiac arrest.
Key messages: Save a life AND the brain
- High quality CPR & early defib
- Airway: SGA > BVM > ETT
- Epinephrine: Hemodynamic guided epinephrine drip
Airway management in cardiac arrest
- CAB instead of ABC. Our focus should be on high quality CPR with minimal interruptions and early defibrillation
- No difference in neurologic outcomes in OHCA with use of supraglottic airway (SGA) vs. ETT (AIRWAYS 2)
- Bottom line: SGA > BVM > ETT
Epinephrine in cardiac arrest
Problem: weak evidence for increased chances of ROSC and short-term survival at the expense of survival with an unfavourable neurological outcome (PARAMEDIC 2), with no increased long-term survival. The optimal dosing and frequency of epinephrine are unclear.
Salim’s Approach: Hemodynamic-directed dosing of epinephrine for cardiac arrest
Initial set up: Dirty Epi Drip – 1mg crash cart epinephrine in 1000mL of NS in with final concentration of 1mcg/mL.
- Option 1: Run this wide open under a pressure bag
- Option 2: Quarter dose Epi Drip, running at 0.5mcg/kg/min. In a 100kg patient, this would be the equivalent of 250mcg over 5 minutes (ie. quarter dose)
Titration of epinephrine to (based on combination of animal studies, case reports and expert opinions)
- Art line DBP >30 mmHg and/or
- ETCO2 > 20 mmHg (surrogate marker of perfusion, can have false readings if V/Q mismatch)
- If DBP < 30 or EtCO2 < 20 Optimize your CPR
- Argument for Epi drip in OHCA: 1. Cognitive offload. 2. Supports Cerebral PP and coronary PP and 3. Avoids post ROSC hypotension
Dr. Salim Rezaie completed his medical school training at Texas A&M Health Science Center and continued his medical education with a combined Emergency Medicine/Internal Medicine residency at East Carolina University. Currently, Dr. Rezaie works as a community emergency physician at Greater San Antonio Emergency Physicians (GSEP), where he is the director of clinical education. He is also the creator and founder of REBEL EM and REBEL Cast.