By Jacqueline Dash, MD
“Attention Einstein emergency department 55 male code blue arriving in 5-10 minutes.” Residents and attendings gather in the room, airway at the head, lead at the end, nurse with her timer, and eager interns awaiting to place lines. The lead will follow the algorithm that is ingrained in their mind: transfer patient, resume high-quality CPR, place pads on patient, intubate, gain access, pulse and rhythm checks every 2 minutes, Epi every 3 minutes, maybe shock, other ACLS medications as needed. If every patient that presents as a cardiac arrest is different then why do we do the same thing for all of them? Do the 300lb 30 year old male and the 97 year old 80lb female both need chest compressions to a depth of 2 inches? Do the 18 year old healthy drowning arrest and the 75 year old ESRD arrest both need 1mg code dose epinephrine? The simple answer to this is no, we personalize treatments for almost everything except for our codes. We have the ability to monitor coronary perfusion pressure (CPP), diastolic blood pressure (DBP), and end tidal carbon dioxide (EtCO2), therefore we should use this to guide our resuscitation.
The AHA recommends a CPP>20mmhg, DBP>25mmhg, and an EtCO2>20. Studies show that patients do better with an SBP>100 during the resuscitation. SBP can be adjusted with adjustment of the depth of chest compressions. SBP can be measured during a code with arterial line placement and therefore can theoretically be titrated during a code. Patients achieving ROSC had higher CPPs than those who did not achieve ROSC. Unfortunately CPP is difficult to obtain during a code scenario, however intra-arrest DBP appears to be an acceptable substitute as similar studies demonstrated a significant difference in DBP amongst those who achieved ROSC compared to those who did not. DBP can also be measured with insertion of an arterial line.
As discussed above SBP can be titrated simply by adjusting the depth of chest compressions. DBP can be increased with the use of vasopressors, such as epinephrine, norepinephrine, or vasopressin. During ACLS the standard dose of 1mg of 1:10,000 epinephrine is given by IV/IO no matter the patient or DBP. If an A-line is placed the effects of epinephrine and other vasopressors can be observed and titrated accordingly with a goal DBP>25. Epinephrine push dose has a duration of 5-10 minutes, so adding a longer acting vasopressor to maintain an adequate DBP may benefit the patient. Adding norepinephrine at 1.0 mg/kg/min with epinephrine as needed when access is obtained would help to maintain DBP>25.
Applying this in the emergency department would require arterial and venous access. The best option during a code would be to obtain arterial access in the femoral artery under ultrasound guidance as radial would be difficult due to the size of the artery and nursing attempting to gain venous access in that area. This would also allow a central line to be placed in femoral vein.
Guide to place a non-sterile common femoral arterial line:
*Please note that during a code scenario a sterile technique is not necessary, however an attempt to remain sterile and remembering to clean the site is important.
- Set up the line
You will need a 500cc bag of saline, transducer set, pressure bag, and transducer cable. Grab spike and spike the 500cc bag of saline. Place bag in pressure bag with pressure of 300 mmhg. Fill the line with saline. Put the stopcock to off at patient and pull the tab above stopcock to flush out air. Once the air is out turn stopcock to allow fluid to flow to the second stopcock. Pull tab again to flush. Then close second stopcock to allow fluid to flow to end and pull tab until flushed. Connect line to transducer.
- Place arterial line
Obtain arterial line kit which contains needle, wire, and other standard components. You will want the kit with 18 gauge needle and longer catheter as the femoral artery will be cannulated. Using ultrasound locate femoral artery, you will see pulsations with each chest compression. Clean area to be cannulated and place sterile probe cover on ultrasound probe. During a code you will not have the luxury of positioning the leg at the perfect angle, taping up a large pannus, ect. Once you have located the femoral artery and the area is clean you will take the 18 gauge needle and enter at a 45 degree angle. You may not get the flash of blood usually seen in a patient who is not in cardiac arrest so you may have to use ultrasound to be sure you are in the correct position. Once needle tip is in place you will advance wire. Depending on the type of kit the catheter may already be inserted with needle, in which case you will just remove needle. If catheter was not inserted with needle then you will advance over guide wire. Secure the catheter with suture and tegaderm. You will then attach primed line to catheter and zero the line. To zero the line, you will close stopcock to patient, open cap to air and press zero ABP button on monitor. Replace cap and turn stopcock to patient and it should begin to read pressure.
For more information on line set-up you can watch video below from EMCRIT:
For more information on A-line placement you can watch this video from EM:RAP:
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