Cardiovascular Critical Care II

Medication background (rhythm independent considerations)

Goal: Increase myocardial blood flow during CPR and help achieve ROSC

ii.

Drug delivery

should not interrupt CPR. The advantage of central administration is higher peak

followed by a 20-mL bolus of an intravenous fluid (e.g., 0.9% sodium chloride) to facilitate

are similar to central venous access. If proximal or distal tibial intraosseous access is

used, administration and drug delivery are similar to peripheral venous access and would

necessitate a 20-mL bolus or pressure bag to facilitate drug administration. In a randomized

cadaver study, tibial IO access has been shown to be easier to obtain, which allows for

faster medication administration (Medicine 2016; 95: e3724). Data analyses suggest that

intraosseous access is associated with poorer OHCA survival and fewer favorable neurologic

96). Intraosseous access may have initially been selected by first responders because of

perceived complexity and influential patient characteristics. However, additional analysis

has found that tibial intraosseous access compared with intravenous access is associated

with a lower likelihood of ROSC and survival to hospitalization (Resuscitation 2017;117:91-

6). The most recent guidelines now support the use of intravenous access preferentially

unless it cannot be obtained (Circulation 2020;142:S366-S468). In these circumstances,

intraosseous access is reasonable.

tracheal absorption by ET tube delivery. N – naloxone, A – atropine, V – vasopressin,

E – epinephrine, L – lidocaine.

injected directly into the ET tube, ideally during pulse check to avoid medication

defibrillation may precipitate cardiac instability and re-arrest. May be avoided by using

physiological monitoring such as quantitative waveform capnography, intra-arterial

pressure monitoring, or continuous central venous oxygen saturation monitoring and

avoiding administration of vasopressors if ROSC occurs (J Emerg Med 2009;38:614-21;