# Cardiac arrest in dialysis patients, medication questions



## djthemac (Mar 3, 2015)

Howdy, I was wondering what you guys thought about treating dialysis patients in cardiac arrest.  

Our local protocols call for 1 gram of calcium chloride, and 50 mEqs of Bicarb for a dialysis patient in cardiac arrest: "administer after first shock and first eppie in VF/VT or after first eppie in Asystole/PEA."  Just to confirm the drug sequence should be like so

Unwitnessed VF - CPR 2 min

VF on monitor - shock
CPR 2 minutes

VF on monitor - shock
CPR 2 minutes
Epi 1 MG 
1 G calcium chloride
50 mEq Bicarb

VF on monitor - shock
CPR 2 minutes
Amio 300mg


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## paradoxicalmotion (Mar 4, 2015)

If you suspect the cardiac arrest was caused by hyperkalemia, why would you wait upwards of 4 to 6 minutes to administer calcium?


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## cprted (Mar 4, 2015)

I don't think we should necessarily be giving the Ca and BiCarb just because they're a renal patient.  Think about the history.  A renal pt who had their regular dialysis yesterday shouldn't have a life threatening electrolyte imbalance.  The guy who normally goes for dialysis every mon-wed-fri, and here he is in arrest on Saturday and hasn't been dialysed since Monday?  Yeah, that guy could be a hyperK.  Obviously welcome others thought on that.

Also, under the current ACLS guidelines there is no need to perform a full 2 minute cycle of CPR in an unwitnessed arrest.  Start compression while pads are going on.  As soon as you can do a rhythm check, do so and shock as required.

My 1.6 cents ... (the exchange rate sucks these days)


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## JPINFV (Mar 4, 2015)

cprted said:


> Also, under the current ACLS guidelines there is no need to perform a full 2 minute cycle of CPR in an unwitnessed arrest.  Start compression while pads are going on.  As soon as you can do a rhythm check, do so and shock as required.



Actually, there was a discussion on delayed defibrillation in extended response times in the 2010 guidelines.

"In studies in which EMS call-to-arrival intervals were 49 to 58 minutes or longer, 1 ½ to 3 minutes of CPR before defibrillation increased the rate of initial resuscitation (return of spontaneous circulation or ROSC), survival to hospital discharge,8,9 and 1-year survival8 when compared with immediate defibrillation for VF SCA. However, in 2 randomized controlled trials,14,15 a period of 1 ½ to 3 minutes of CPR by EMS personnel before defibrillation did not improve ROSC or survival to hospital discharge in patients with out-of-hospital VF or pulseless ventricular tachycardia (VT) compared with immediate defibrillation, regardless of EMS response interval, in systems with low overall survival. In 1 retrospective before/after study,16 immediate CPR by EMS personnel was associated with no significant difference in survival to discharge but significantly improved neurological status at 30 days or 1 year compared with immediate defibrillation in patients with out-of-hospital VF. In a retrospective observational study,17 probability of survival was increased if chest compressions were performed during a higher proportion of the initial CPR period as compared to a lower proportion.

When VF is present for more than a few minutes, the myocardium is depleted of oxygen and metabolic substrates. A brief period of chest compressions can deliver oxygen and energy substrates, increasing the likelihood that a shock may terminate VF (defibrillation) and a perfusing rhythm will return (ie, ROSC).18

When an out-of-hospital cardiac arrest is not witnessed by EMS personnel, EMS may initiate CPR while checking the ECG rhythm and preparing for defibrillation. There is insufficient evidence to determine if 1 ½ to 3 minutes of CPR should be provided prior to defibrillation. CPR should be performed while a defibrillator is being readied (Class I, LOE B). One cycle of CPR consists of 30 compressions and 2 breaths. When compressions are delivered at a rate of about 100 per minute, 5 cycles of CPR should take roughly 2 minutes (range: about 1 ½ to 3 minutes).

EMS system medical directors may consider implementing a protocol that allows EMS responders to provide CPR while preparing for defibrillation of patients found by EMS personnel to be in VF. In practice, however, CPR can be initiated while the AED is being readied."

http://circ.ahajournals.org/content/122/18_suppl_3/S706.full


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## cprted (Mar 4, 2015)

This is what I was getting: 





> When an out-of-hospital cardiac arrest is not witnessed by EMS personnel, EMS may initiate CPR while checking the ECG rhythm and preparing for defibrillation. There is insufficient evidence to determine if 1 ½ to 3 minutes of CPR should be provided prior to defibrillation. CPR should be performed while a defibrillator is being readied (Class I, LOE B).


 Not a hard and fast rule that you need to run through 2 mins of CPR prior to defibrillation. 

Perhaps worthy of its own thread


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## JPINFV (Mar 4, 2015)

Ironically, insufficient evidence regarding that provides more support than what they say about epinephrine (no survival benefit). 

http://circ.ahajournals.org/content/122/18_suppl_3/S729.full


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## cprted (Mar 4, 2015)

JPINFV said:


> Ironically, insufficient evidence regarding that provides more support than what they say about epinephrine (no survival benefit).
> 
> http://circ.ahajournals.org/content/122/18_suppl_3/S729.full


Indeed it does!  Very interested to see what comes out of the London Epi vs Placebo trial.


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## cruiseforever (Mar 4, 2015)

Partner told me about a call he had today.  Pt. is a renal failure that was in cardiac arrest on their arrival.  Pt. had a PEA rhythm.  They placed him on the Lucas, ET with a Rescue Pod, Epi, Vasopressin, no change.  Med control contacted ordered Calcium.  Pt. quickly developed ROSC.  He thought the pt. was able to go home after hospital stay.


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## Brandon O (Mar 4, 2015)

I would have a fairly low threshold for throwing calcium at these people. Low harm, potential benefit (theoretically even in non-hyperkalemic arrests -- some people think many sick patients may have a bit of inotropy to be boosted -- but that's probably voodoo), sad faces if you don't think of it. It's not like the stuff's expensive.


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## Ewok Jerky (Mar 4, 2015)

^ditto


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## djthemac (Mar 5, 2015)

What are the current ACLS guidelines regarding administering these drugs?

If you have a patient with a known overdose on potassium supplements who presents with V-Fib as in my original post, does the order of medications make sense?


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## ERDoc (Mar 5, 2015)

ACLS says to consider treating hyperkalemia when appropriate.

http://circ.ahajournals.org/content/122/18_suppl_3/S829.full#sec-68


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## Brandon O (Mar 5, 2015)

Yeah, for the most part they've never really gotten into how and when to address H's and T's (and to some extent are getting away from that for all the algorithms). Case by case basis.


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## Ewok Jerky (Mar 5, 2015)

I would be giving Ca as soon as I can after finding the indication, in this case suspect hyperkalemia.


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