Cardiac Arrest Management – Help From Dr. Weingart Of EMCrit # 125

Posted on March 7, 2017 by Tom Wade MD

The Basic Life Support Course and Protocols and the Advanced Cardiac Life Support Course And Protocols are the foundations on which  we build our excellent CPR care.

But as Dr. Weingart of EMCrit teaches us, there is even more that we can do to help our cardiac arrest patients. And he gives us four outstanding podcasts that review the current state of cutting edge CPR.

My post today covers #125 – The new Intra-arrest (Cardiac Arrest Management)

Dr. Weingart’s four podcasts are:

EMCrit Podcast 69 – The Future of CPR with Keith Lurie and Demetris Yannopoulos [Link is to the show notes and podcast]. March 19, 2012 by Dr. Scott Weingart

Podcast 125 – The New Intra-Arrest (Cardiac Arrest Management) [Link is to the show notes and video podcast.] June 2, 2014 by Dr. Scott Weingart.

EMCrit Podcast 130 – Hemodynamic-Directed Dosing of Epinephrine for Cardiac Arrest [Link is to the show notes and podcast] August 10, 2014 by Dr. Scott Weingart.

EMCrit Podcast 191 – Cardiac Arrest Update [Link is to the show notes and podcast]
January 23, 2017 by Dr. Scott Weingart.

My notes below on Podcast #125 are simply my medical notes (a part of my peripheral brain which is my blog) so that I can do a quick review. You need go to the link to the show notes and podcast and review everything.

Here are my notes which are not direct quotes of Dr. Weingart but again just my notes for quick review:

  • Dr. Weingart states at the very start of his talk that everything he will be discussing in this talk was discussed in 1997 by Dr. Max Harry Weil in Disease-A-Month – Cardiopulmonary Resuscitation: A Promise As Yet Largely Unfulfilled. [Full Text PDF courtesy of crashingpatient.com]
  • Don’t stop CPR for any reason.
  • Dr. Weingart no longer leaves in a supraglottic airway. This is because the occlusion pressure of the device is insufficient to allow ventilation during the cardiac downstroke of CPR. Thus the patient is only being ventilated during the upstroke which may decrease venous return to the heart. [start at 5:51]
  • There is no need to stop CPR for endotracheal intubation. The bougie and the video laryngoscope make stopping CPR unnecessary. Slide 18 in the show notes show a custom bent Bonfils fiberoptic stylet that Dr. Weingart discusses in the talk.
  • Place the cardiac arrest patient on a ventilator because due to the stress of the situation the person doing bag mask ventilation is very likely to give too large a tidal volume at way to fast a rate. This is very bad because it decreases venous return to the heart and hence decreases cardiac output from CPR.
    • Vent Settings for Arrest:
      • Volume AC,
      • Vt 500,
      • Peak Flow 30 lpm,
      • RR 10,
      • PEEP 0,
      • FiO2 100%,
      • Pressure limit 100 cm H20 (this high pressure limit is necessary so that ventilation can occur during cardiac compression.)
  • Perishock pauses are very bad. Here are some ways to shorten them:
    • Get a see through monitor. There are new monitors that can display the underlying rhythm despite or through ongoing cardiac compressions. This can markedly shorten the perishock pause.
    • Precharge the defibrillator. Don’t wait until the rhythm check. Have the timer say – it is 30 seconds to rhythm check. That’s the cue for the monitor-defibrillator person to charge the defibrillator.
  • Dr. Weingart states that mechanical CPR, the Lucas device (among others), is the wave of the future. Studies have shown the Lucas device is not superior to well performed standard CPR in terms of mortality.
    • However, the Lucas has, Dr. Weingart states, has a number of advantages over standard CPR.
    • First, it quiets the resuscitation room as a code now requires far fewer participants (rotating on and off chest compressions)
    • Second, the Lucas device can allow you to take an arrest patient to the cardiac cath lab for PCI (say just prior to the arrest you have a 12-lead ekg that shows ST elevation infarction-that person should be taken to cath lab.)
    • [There are circumstances, for example, in a moving ambulance where it seems very likely that mechanical CPR may be superior to standard CPR–I’m not sure if Dr. Weingart said this.]
    • If you are giving epinephrine, you should also be giving vasopressin and steroids, Dr. Weingart states. [VSE stuff (from show notes):JAMA 2013;310(3):2701 mg Epi and 20 IU Vasopressin Q3 minutes for 5 cycles, plus 40mg methylprednisolone for the 1st cycle. Hydrocortisone if in persistent shockJournal Club Crit Care 2014;18:308
    • [See HIGHLIGHTS of the 2015 American Heart Association Guidelines Update for CPR and ECC  Full Text PDF and note that these highlights and all the AHA Emergency Cardiac Guidelines were published after Dr. Weingart’s talk.]
    • [See 2015 American Heart Association
      Guidelines for CPR & ECC – NEW Web-Based Integrated Guidelines ]
    • Esmolol is the drug you want to knock out the beta effects of epinephrine and the patient’s endogenous catecholamines. Epinephrine has alpha and beta effects but it is the alpha that we want in our resuscitation.
      • Dr. Weingart is using it in patients with a pulse when he can’t break v-tach.
      • And he is also using esmolol in v-fib patients when he can’t shock them out of v-fib
    • He discusses the use of nitroprusside for microcirculation (this is very prelimary, he states, and is not ready for prime time).

Beginning at about 15:00 into the talk, Dr. Weingart discusses monitoring during the code.

  • Dr. Weingart puts an arterial line in every cardiac arrest patient without stopping CPR so that he can monitor diastolic blood pressure during CPR.
    • And by having an arterial line you don’t have to stop compression to do a pulse check.
    • But more important this is how he doses his epinephrine. He does not give epinephrine every three to five minutes. He says that it makes no sense and probably contributes to post cardiac arrest cardiomyopathy.
      • He uses the diastolic pressure during compression to dose epinephrine.
        • We are looking for a minimal coronary perfusion pressure of 15 mm Hg. And lacking that perfusion pressure they will not come back come back and they will not be able to be shocked out of VF.
        • We don’t [can’t easily] monitor CVP (and coronary perfusion pressure = diastolic bp – CVP) so we can’t know the coronary perfusion pressure.
        • But generally the CVP will [during CPR] hover around 25 – 30.
        • So when you add the CVP to the coronary perfusion pressure that you want, you’ll get a diastolic pressure goal of 40 mm Hg.
        • So if the patient’s diastolic pressure is 40 mm Hg in the arterial line, then they don’t need epinephrine at that time.
        • If the diastolic pressure is less than that, then give epinephrine so that you can get the coronary perfusion pressure to where you want it for successful defibrillation.
  • The next important way that Dr. Weingart monitors the cardiac arrest patient is with bedside ultrasound
    • He performs the RUSH exam (Rapid Ultrasound in Shock)
      • A memory aid for the components of the RUSH exam is HI – MAP:
        • H – Look at the Heart with the subcostal view.
        • I – Examine the Inferior Vena Cava just to the right of the midline in the epigastrium
        • M – Examine Morrison’s pouch in the right midaxillary line to look for unexpected abdominal fluid (blood or ascites).
        • A – Examine the Aorta for evidence of aneurysm.
        • P – Examine both lungs looking for evidence of Pneumothorax
    • For a how to on the RUSH exam see:
  • And finally Dr. Weingart reminds us that codes should be quiet (what he terms in another lecture, the silent cockpit) to avoid distraction. No one should be talking unless what the person is saying relates directly to the task at hand.

Additional Resources:

(1) Part 6: Alternative Techniques and Ancillary Devices for Cardiopulmonary
Resuscitation: Web-based Integrated 2010 & 2015 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care [Full Text PDF] (Accessed 3-6-2017)

(2) Trick of the Trade: Pre-Charge the Defibrillator By: Sam Ghali, MD from Academic Life In Emergency Medicine. May 16th, 2016

(3) Zoll See-Thru CPR:

See-Thru CPR® technology filters out compression artifact on the ECG monitor so that rescuers can see the underlying heart rhythm during cardiopulmonary resuscitation (CPR), thereby reducing the duration of pauses in compressions.

(4) How To Put On the Lucas With Minimal CPR Interruption, brief video from Dr. Weingart of EMCrit.

(5) CPR induced consciousness: It’s time for sedation protocols for this growing population, [PubMed Abstract] [Full Text PDF]. Resuscitation. 2016 Jun;103:e15-6. doi: 10.1016/j.resuscitation.2016.02.013. Epub 2016 Mar 5. Here is the Sedation Protocol For CPR Induced Consciousness:

(6) The Physiology of Cardiopulmonary Resuscitation [PubMed Abstract] [Full Text PDF]. Anesth Analg 2016;122:767–83

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