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 1^st  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”