� Imaging

If the patient has a ROSC, obtain a chest x-ray to evaluate

endotracheal tube placement and an electrocardiogram to

evaluate for cardiac ischemia.

PROCEDURES

Pericardiocentesis is indicated if there is a suspicion of

cardiac tamponade in the setting of PEA. Bedside ultra ­

sound can be useful if tamponade is suspected. A long

spinal needle is inserted s ubxiphoid into the pericardia! sac

aimed toward the left shoulder. Pull back on a 60-mL

syringe while advancing the needle until blood is obtained.

A needle thoracostomy is indicated if there is a s uspicion of tension pneumothorax in the setting of PEA. I nsert

an 1 8-gauge needle into the second intercostals space in

the midclavicular line. A needle thoracostomy must always

be followed by a tube thoracostomy in patients with

ROSC.

MEDICAL DECISION MAKING

The differential diagnosis for SCD is broad. Management

of SCD depends on the presenting rhythm; however, every

patient should receive continuous high-quality uninterrupted chest compressions. Defibrillate VF/pulseless VT.

Administer epinephrine for asystole and PEA. Attempt to

correct reversible causes of PEA, the H's, and T's

(Table 10-1). Once ROSC occurs, initiate postresuscitative

care, including therapeutic hypothermia, which improves

neurologic outcome.

Table 1 0-1. The H's and T's of PEA.

Hypoxia

Hypovolemia

Hydrogen ion (acidosis)

Hypo-/hyperkalemia

Hypothermia

Toxins

Tamponade (cardiac)

Tension pneumothorax

Thrombosis (pulmonary, cardiac)

TREATMENT

If there is a clear, written, advanced directive signed by the

patient or medical power of attorney stating that resuscitative efforts should not be instituted, or if the resuscitation

would be futile because of clear signs of irreversible death

(decapitation, rigor mortis), resuscitative efforts should

not be initiated or continued.

The resuscitative team must orchestrate simultaneous

assessment and management of patients in cardiopulmo ­

nary arrest.

1. Defibrillation. Indicated for patients in VF or pulseless

VT. The rate of successful defibrillation when attempted

within 1 minute of VT is >90o/o, but falls lOo/o with each

subsequent minute.