MCMAID Resuscitation Protocol

This post is a stub, and is a supplement to “Advances in Resuscitation – CCR, if you’re not doing it now you will be”

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EMERGENCY MEDICAL RESPONDER/EMT

A CODE COMMANDER should assign duties according to MCMAID prior to arrival

  • Establish that the patient is unresponsive, and not breathing normally
  • Rule out DNR status, dependent lividity, rigor mortis

First Priority: M(metronome) Quality Chest Compressions

  • Turn on Metronome, ensuring a rate of 100/minute
  • Initiate 2 minutes of chest compressions, pediatric-follow AHA 2005 Guidelines

Second Priority: C-(compressions) Quality Chest Compressions

  • Assign two compressors switching every minute, checking each others quality
  • Depth should be at least 2 inches
  • The heal of the compressor’s hand should come off the chest, ensuring full recoil

Third Priority: M-(monitor) Defibrillate

  • AED, push analyze (pediatric patient >1 yr , use peds pads up to 8 yrs if available if not use adult pads)
  • Manual, charge max joules during CPR, analyzing for no more than 5 sec (EMT-I/P) – (pediatric 4 joules/kg)
  • Immediately resume 2 more minutes of compressions

Fourth Priority: A-(airway)

  • Oropharyngeal airway and 10 liters O2 via NRB mask
  • Check patency if chocking is suspected
  • No ventilations until after 3 cycles - (unless pediatric-follow AHA 2005 Guidelines)
  • CombiTube/ET after 3 cycles of compressions, unless 1st  rhythm is nonshockable, then as soon as possible, ventilate at 6/minute only enough volume to just make chest rise

 If ROSC, acquire 12-Lead EKG, ***ACUTE MI SUSPECTED*** see STEMI Guidelines.

Give a status report to the ambulance crew by radio ASAP and ensure ALS has been dispatched.

 AEMT

Fourth Priority: I-(IV) Establish venous access

  • Initiate IO 0.9% Normal Saline unless IV is assured and quick, run wide open (20ml/kg boluses for pediatric patients)
  • Consider second IV and chilling both for unresponsive ROSC. Refer to Therapeutic Hypothermia Procedure

 INTERMEDIATE

 Monitor basic rescuer interventions closely, ensure quality, uninterrupted chest compressions

Fifth Priority: D-(drugs) Proceed to ACLS resuscitation medications

  • Obtain venous access, if not already done
  • Epinephrine 1:10,000 1 mg IV/IO every other cycle of compressions (4 minutes)
  • Vasopressin 40 units IV/IO, repeat dose in 10 minutes if no ROSC
  • If multiple shocks have been given, Amiodarone (Cordarone) 300 mg IV/IO, followed by another 150 mg if still refractory (shocks being delivered)
  • After 3 cycles of compressions, (unless first rhythm in non shockable) place advanced airway without interrupting compressions and begin ventilations at 6/minute, using only the volume to just make the chest rise.
  • If initially non-shockable, Identify and correct reversible causes: The Five H’s and the Five T’s This applies mostly to PEA, but to a lesser extent, Asystole, as well.
  • If rate is <60, Atropine Sulfate 1 mg IV. Repeat every 3 – 5 min to a maximum of 3 mg

 “The Five H’s” (treatment orders are in parentheses)

  1. Hypovolemia (Infuse Normal Saline wide open)
  2. Hypoxia (Place an advanced airway and administer high-flow oxygen at a ventilation rate of 6/minute with only enough volume to make chest rise. [1])
  3. Hydrogen Ion, i.e. acidosis (Perform ventilation [1])
  4. Hyperkalemia [2]
    1. Give Calcium Chloride (10%) 1000mg IV over 2 – 5 minutes. May repeat X 1
    2. Give Sodium Bicarbonate (8.4%) 50 mEq IV
    3. Give Albuterol Sulfate 2.5 mg HHN may repeat X 1
  5. Hypokalemia (not treated in the field.)
  6. Hypothermia (See Hypothermia & Frostbite Guidelines)

“The Five T’s” (treatment orders are in parentheses)

  1. Tablets (See Toxic Exposure/Overdose Guidelines)
  2. Tamponade (EMT-P: Perform Pericardiocentesis)
  3. Tension pneumothorax (Perform needle decompression)
  4. Thrombosis, cardiac i.e. myocardial infarction (See Chest Pain Guidelines)
  5. Thrombosis, pulmonary i.e. pulmonary embolism (No specific pre-hospital treatment available)

Paramedic

 If there is ROSC, as seen as a sudden large increase in EtCO2 and/or patient movement

  • Give Amiodarone (Cordarone) 150 mg IV/IO over 10 minutes, if multiple shocks given
  • Reassess the need for airway devices
  • Maintain advanced airway, if the patient remains unconscious
  • If the patient wakes up, the airway may be removed. Use the procedures for removing advanced airway devices in the Respiratory Distress Guidelines.
  • Monitor patient’s EtCO2 and ventilate accordingly (12-20 per minute to maintain EtCO2 around 35 mmHg)
  • Maintain SBP >80 mmHg, Consider Dopamine Hydrochloride 10-20mcg/kg/minute IV infusion
  • Consider inducing hypothermia, See Therapeutic Hypothermic Guidelines
  • Consider RSI See Respiratory Distress Guidelines
  • If post-resuscitation 12-lead EKG shows STEMI refer to STEMI Guidelines
  • Contact Medical Control for the following:
    • To discuss termination of resuscitation in the absence of a valid Wisconsin DNR Bracelet
    • Additional medication orders

 FOOTNOTES:

 1. Do not hyperventilate during cardiac arrest, even if hypoxia and acidosis are suspected causes. Strictly follow the ventilation guidelines described above.

2. Suspect Hyperkalemia when patients with a history of chronic renal failure (dialysis patients) develop cardiac arrest. Pre-arrest history may include weakness, missed dialysis appointment(s), vomiting, concurrent illness, and T waves that are peaked and as large as the R wave.

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This post is a stub, and is a supplement to “Advances in Resuscitation – CCR, if you’re not doing it now you will be”

  • roguemedic

    I have not read through the paper, yet. Why just the CombiTube for an alternative airway?

    Any plans to switch to switch to, or add, other alternative airways?

  • roguemedic

    I have not read through the paper, yet. Why just the CombiTube for an alternative airway?

    Any plans to switch to switch to, or add, other alternative airways?

  • roguemedic

    I have not read through the paper, yet. Why just the CombiTube for an alternative airway?

    Any plans to switch to switch to, or add, other alternative airways?

  • http://roguemedic.blogspot.com/ Rogue Medic

    I have not read through the paper, yet. Why just the CombiTube for an alternative airway?

    Any plans to switch to switch to, or add, other alternative airways?