CPR Guidelines for All Ages

### CPR Guidelines: Adults and Adolescents

• Compression-ventilation ratio should be 30:2 without advanced airway
• Continuous compression rate should be 100-120/min
• Compression depth should be at least 2 inches (5 cm)

### CPR Guidelines: Children

• Compression-ventilation ratio should be 30:2 with 1 rescuer, 15:2 with 2 or more rescuers without advanced airway
• Compression-ventilation ratio should be 10 breaths/min with advanced airway
• Continuous compression rate should be 100-120/min
• Compression depth should be at least 2 inches (5 cm)

### CPR Guidelines: Infants

• Compression-ventilation ratio should be 30:2 with 1 rescuer, 15:2 with 2 or more rescuers without advanced airway
• Compression-ventilation ratio should be 20 breaths/min with advanced airway
• Continuous compression rate should be 100-120/min
• Compression depth should be at least 1.5 inches (4 cm)

### Rescue Medications

• BLS Clinicians may assist with administration of fast-acting bronchodilator MDI and sublingual nitroglycerin
• ALS Clinicians may administer benzodiazepines, Factor VIII or IX for Hemophilia A or B, or reestablish IV access for vasoactive medication
• Clinicians should obtain on-line medical direction to administer other rescue medications

### On-Scene Resuscitation

• Patients in arrest or who arrest prior to transport and are attended to by ALS clinicians must remain in place until:
  • Medical etiology patient has received three doses of epinephrine, regardless of algorithm being followed
  • Traumatic etiology patient has received treatments for reversible causes per Trauma Arrest protocol
• Clinicians can continue on-scene resuscitation until termination or transport the patient at any time
• Ensure mechanical CPR in place and an airway facilitating ventilation during transport

### Termination of Resuscitation

• Consider Termination of Resuscitation when appropriate

### Cardiac Arrest: Pediatric

• Pediatric patients under 13 years (medical arrest) and 15 years (trauma arrest) who are unconscious, apneic, and pulseless
• BLS Clinicians should perform high-quality uninterrupted chest compressions (manual or mechanical) as soon as possible
• Apply AED as soon as available
• Follow machine prompts regarding rhythm analyses and shocks
• Limit breaks in compressions to 10 seconds or less for rhythm analysis periods and during shocks; perform compressions while defibrillator is charging

### Cardiac Arrest: Adult

• If arrest occurs after ROSC, 2 additional doses of epinephrine may be administered
• Defibrillate 1 time
• Resume CPR for 2 minutes
• Amiodarone 300 mg IV/IO push, may be repeated once 150 mg IV/IO push
• Defibrillate 1 time
• Resume CPR immediately for 2 minutes
• Repeat CPR and defibrillation for shockable rhythms until ROSC or TOR
• For refractory VF/VT after amiodarone, administer magnesium sulfate 1-2 grams IV/IO over 2 minutes
• Sodium bicarbonate 1 mEq/kg IV/IO, only in cases of suspected acidosis, NA channel blocker (tricyclic antidepressant and phenobarbital) overdose
• If torsades de pointes is present, give magnesium sulfate 1–2 grams IV/IO over 2 minutes before amiodarone
• When the patient’s condition changes, indicating the transition to a new treatment algorithm, the new treatment shall take into account prior therapy

MCI

• During a Mass Casualty Incident (MCI), the "Exceptional Call" box must be checked on the PCR
• The EMS Officer-in-Charge (OIC) designates an EMS Communicator to establish communication
• Refer to the Multiple Casualty Incident/Unusual Event Protocol
• EMS clinicians may perform all skills within protocols, except for extraordinary care interventions

Reassessment

• Unstable patients should be reassessed frequently (recommended every 5 minutes)
• Stable patients should be reassessed at least every 15 minutes
• Patients being discharged to home or long-term care should be reassessed at the beginning and end of transport, or more frequently at the clinician's discretion

Disposition

• Priority 1 patients should be transported to the closest appropriate hospital-based emergency department, designated trauma, or designated specialty referral center
• Priority 2 patients should be transported to the closest appropriate hospital-based emergency department, designated trauma, or designated specialty referral center, unless directed otherwise by EMS system medical consultation
• Stable Priority 2 patients may be referred to a freestanding emergency medical facility
• Stable Priority 3 or 4 patients who do not need time-critical intervention may be transported to the local emergency department or freestanding emergency medical facility

Scene Arrival and Size-Up

• Consider Body Substance Isolation (BSI)
• Consider Personal Protective Equipment (PPE)
• Evaluate scene safety
• Determine the number of patients
• Consider the need for additional resources

Patient Approach

• Determine the Mechanism of Injury (MOI)/Nature of Illness (NOI)
• If appropriate, begin triage and initiate Mass Casualty Incident (MCI) procedures.

Initial Assessment

• Rapidly develop a general impression of the patient on first contact
• Identify the critically unstable patient – any patient in extremis or with imminent risk for deterioration to arrest:
• New onset of altered mental status (AVPU not alert)
• Airway compromise
• Acute respiratory distress
• Signs of poor perfusion
• Any other patient judged by the clinician to be in extremis or at risk for deterioration to cardiac arrest
• If a critically unstable patient is identified:
• STOP ALL MOVEMENT OF PATIENT
• DO NOT INITIATE TRANSPORT
• PROCEED TO CRITICALLY UNSTABLE PATIENT PROTOCOL IMMEDIATELY
• Use the Pediatric Assessment Triangle for pediatric patients
• Appearance
• Work of Breathing
• Circulation to Skin

Spinal Motion Restriction

• Midline spinal pain, tenderness, or deformity
• Signs and symptoms of new paraplegia or quadriplegia
• Focal neurological deficit
• Altered mental status or disorientation
• Distracting injury: Any injury (e.g., fracture, chest, or abdominal trauma) associated with significant discomfort that could potentially distract from a patient's ability to accurately discern or define spinal column pain or tenderness
• Neck pain or torticollis
• High-impact diving incident or high-risk motor vehicle crash (head on collision, rollover, ejected from the vehicle, death in the same crash, or speed greater than 55 mph)
• Substantial torso injury
• Conditions predisposing to spine injury
• Infant or child car seats may not be used as a spinal immobilization device for the pediatric patient
• If a patient is unable to communicate or appropriately respond, apply Spinal Motion Restriction protocol

Exposure

• Remove clothing as necessary to assess patient injuries, considering condition and environment

Clinical Priority

• Priority 1 - Critically ill or injured person requiring immediate attention; unstable patients with life-threatening injury or illness

Notifications and Medical Consults

• Assigned patient priority (1 to 4)
• Age
• Chief complaint
• Clinician impression
• Pertinent patient signs and symptoms
• HR, RR, BP, Pulse Ox
• Pertinent physical findings
• ETA

Specialty Center Patients

• Trauma
• Number of victims, if more than one
• GCS including motor GCS score
• Patient Trauma Decision Tree Category (Alpha, Bravo, Charlie, Delta)
• Stroke
• Last known well time
• Specific neurological findings (sensory, motor, cognitive)
• STEMI
• 12-lead interpretation
• Duration of symptoms

Mass Casualty Incident (MCI) Communications

• When a local jurisdiction declares an MCI, it is extremely important to maximize patient care resources and reserve EMS communications for emergent situations.
• TRAUMA DECISION TREE CATEGORY CHARLIE OR DELTA, RECEIVING TRAUMA CENTER MEDICAL CONSULTATION IS REQUIRED WHEN CONSIDERING WHETHER HELICOPTER TRANSPORT IS OF CLINICAL BENEFIT.
• If the time of arrival at the trauma or specialty referral center via ground unit is less than 30 minutes, there will generally be no benefit in using the helicopter, especially for Trauma Decision Tree categories Charlie and Delta.
• Refer to the Trauma Decision Tree when considering use of aeromedical transport, provide SYSCOM with the patient’s category (Alpha, Bravo, Charlie, or Delta).
• Obtain on-line medical direction from the local trauma center and the specialty referral center when transport to the specialty center would require more than 10–15 minutes additional transport time.
• Pediatric Trauma Patients: Indications as per the pediatric section of the Trauma protocols.
• Spinal Trauma Patients: Indications as per Spinal Motion Restriction protocol.
• Burn Patients: Indications as per Burn protocol.
• Hand Injury Patients: Indications as per Hand Trauma protocol.
• Special Note: Isolated burn patients without airway injury or other associated trauma should normally be flown to a burn center, regardless of the location of the closest trauma center.
  • Special Note: Medevac patients with appropriate indications for hand center referral should normally be flown to the hand center, regardless of the location of the closest trauma center.

Status

• Evaluate the need for emergent versus non-emergent transportation.
• Do not wait on-scene for Advanced Life Support.

Adult Cardiac Arrest

• Adult patients (13+ years for medical arrest, 15+ years for trauma arrest) who are unconscious, apneic, and pulseless should receive immediate high-quality chest compressions (manual or mechanical).
• An Automated External Defibrillator (AED) should be applied as soon as available.
• On-scene resuscitation efforts should include the following:
  • Patients who are either in arrest or who experience arrest prior to transport must remain in place until the following have been accomplished:
    • Medical Etiology: Patient receives three doses of epinephrine
    • Traumatic Etiology: Patient receives treatments for reversible causes as per Trauma Arrest protocol
• Clinicians may choose to continue on-scene resuscitation until termination or transport the patient.

Pediatric Cardiac Arrest

• Administer epinephrine via the endotracheal route for pediatric or neonatal arrest situations only
• Meds administered via the endotracheal tube route for pediatric patients should be:
  • Naloxone and Atropine Sulfate: 2-2.5 times the IV dose
  • Epinephrine: 10 times the IV dose (1mg/mL)
• All ET medications should be diluted in 5mL of Lactated Ringer's for pediatric patients.
• On-scene resuscitation for pediatric cardiac arrest patients follows the same guidelines as adults.
• The patient should be transported to Children’s National Medical Center or Johns Hopkins Children’s Center by ground or medevac if ROSC occurs.
  • If transport time to these destinations exceeds 30 minutes, transport to the closest appropriate facility.
• If No ROSC, transport to the closest appropriate facility or consider Termination of Resuscitation protocol.

Pediatric Cardiac Arrest Algorithm (BLS)

• The Pediatric High-Performance CPR (HPCPR) algorithm focuses on high-quality chest compressions (100-120 compressions per minute) with minimal interruptions
  • The depth of chest compressions is crucial.
    • Less than 1 year: 1 1/2 inches (4 cm)
    • 1 year or older: 2 inches (5 cm)
• The compression-to-ventilation ratio is 30:2
• Minimizing any interruption of chest compressions to less than 10 seconds is crucial.
• Team coordination is key.

Cardioversion

• Confirm that the defibrillator is set to synchronize mode
• If the calculated joules setting is lower than the cardioversion device is able to deliver, use the lowest possible joules setting or obtain medical consultation.
• Consider pre-procedural sedation or analgesia if necessary. However, the patient's overall status, including blood pressure, could affect the ability to administer sedation or analgesia

Medications

• Adenosine:
  • Administer 0.1 mg/kg rapid IV/IO (Intravenously or Intraosseously), maximum 6 mg.
  • Second and third doses can be administered at 0.2 mg/kg rapid IV/IO, maximum single dose 12 mg.
  • Be prepared for up to 40 seconds of asystole (Contraindicated in polymorphic or irregular wide complex tachycardia)
• Amiodarone:
  • Administer 5 mg/kg IV/IO over 20 minutes (mixed in 50 - 100 mL of approved diluent)
  • Obtain a 12-lead EKG prior to administration of amiodarone.
• Magnesium Sulfate:
  • Administer 25 mg/kg IV/IO to a maximum of 2 grams over 2 minutes for torsades de pointes