INDEX

SUSPECTED EVENT

Air Embolism – Venous 1

Operating Room Anaphylaxis 2
Crisis Checklists Bradycardia – Unstable 3

>> Do not remove book from this room << Cardiac Arrest – Asystole / PEA 4

Cardiac Arrest – VF / VT 5

Failed Airway 6

Fire 7

Hemorrhage 8

Hypotension 9

Hypoxia 10

Malignant Hyperthermia 11
Based on the OR Crisis Checklists at www.projectcheck.org/crisis. All reasonable precautions have been taken to verify the
information contained in this publication. The responsibility for the interpretation and use of the materials lies with the reader.
© 2013–2017 Ariadne Labs: A Joint Center for Health Systems Innovation.
Licensed under the Creative Commons Attribution-NonCommercial-ShareAlike 4.0
International License, http://creativecommons.org/licenses/by-nc-sa/4.0/ Revised April 2017 (042417.1)
Tachycardia – Unstable 12
 INDEX
1 Air Embolism – Venous
Decreased end-tidal CO2 , decreased oxygen saturation, hypotension
1

START Critical CHANGES

If PEA develops, go to   CHKLST 4
1 Call for help and a code cart
 Ask: “Who will be the crisis manager?”

2 Turn FiO2 to 100%

3 Turn off nitrous oxide
4 Stop source of air entry
 Fill wound with irrigation
 Lower surgical site below level of heart, if possible
 Search for entry point (including open venous lines)

5 Consider...
 Positioning patient with left side down
• Continue appropriate monitoring while repositioning

 Placing bone wax or cement on bone edges

 Transesophageal echocardiography (TEE) if diagnosis unclear
 Using ETCO2 to monitor progression and resolution of embolus or for
assessment of adequate cardiac output

All reasonable precautions have been taken to verify the information contained in this publication. The responsibility for the interpretation and use of the materials lies with the reader. Revised April 2017 (042417.1)
 INDEX
2 Anaphylaxis
Hypotension, bronchospasm, high peak-airway pressures, decrease or lack of breath sounds, tachycardia, urticaria

START DRUG DOSES and treatments

2
Epinephrine: BOLUS: 10 – 100 mcg, repeat as
1 Call for help and a code cart necessary (dilute 1 mg in
 Ask: “Who will be the crisis manager?” 250 mL = 4 mcg/mL)
INFUSION: 1 – 10 mcg/min
2 Give epinephrine bolus (may be repeated) Vasopressin: 1 – 2 units IV

3 Open IV fluids and/or give fluid bolus Diphenhydramine: 25 – 50 mg IV

H2 blockers: Ranitidine:  50 mg IV
4 Remove potential causative agents Cimetidine:  300 mg IV
Hydrocortisone: 100 mg IV
5 Turn FiO2 to 100%
Common CAUSATIVE AGENTS
6 Establish/secure airway
• Neuromuscular blocking agents

7 Consider... • Antibiotics
• Latex products
 Turning off volatile anesthetics if patient remains unstable • IV contrast

 Vasopressin for patients with continued hypotension despite

repeated doses of epinephrine Critical CHANGES

 Epinephrine infusion for patients who initially respond to bolus If cardiac arrest, go to:
doses of epinephrine but experience continued symptoms  CHKLST 4 Cardiac Arrest – Asystole / PEA
 CHKLST 5 Cardiac Arrest – VF/VT
 Diphenhydramine
 H2 blockers
 Hydrocortisone
 Tryptase level: Check within first hour, repeat at 4 hr and at
18 – 24 hrs post reaction
 Terminate procedure

All reasonable precautions have been taken to verify the information contained in this publication. The responsibility for the interpretation and use of the materials lies with the reader. Revised April 2017 (042417.1)
 INDEX
3 Bradycardia – Unstable
HR < 50 bpm with hypotension, acutely altered mental status, shock, ischemic chest discomfort, or acute heart failure

START DRUG DOSES and treatments

Atropine: 0.5 mg IV, may repeat up to 3 mg total
1 Call for help and a code cart
 Ask: “Who will be the crisis manager?”
Epinephrine: 2 – 10 mcg/min IV 3
– or– Dopamine: 2 – 20 mcg/kg/min IV

2 Turn FiO2 to 100% OVERDOSE treatments

 Verify oxygenation/ventilation adequate Beta-blocker:  Glucagon:  2 – 4 mg IV push
Calcium channel blocker:  Calcium chloride: 1 g IV
3 Give atropine Digoxin:  Digoxin Immune FAB; consult pharmacy for patient-specific dosing

4 Stop surgical stimulation (if laparoscopy, desufflate) TRANSCUTANEOUS PACING instructions

5 If atropine ineffective: 1. Place pacing electrodes front and back

 Start epinephrine or dopamine infusion 2. Connect 3-lead ECG from pacing defibrillator to the patient
– or – 3. Turn monitor/defibrillator to PACER mode
4. Set PACER RATE (ppm) to 80/minute
 Start transcutaneous pacing (adjust based on clinical response once pacing is established)
5. Start at 60 mA of PACER OUTPUT and increase until electrical capture
6 Consider... (pacer spikes aligned with QRS complex)
 Turning off volatile anesthetics if patient remains unstable 6. Set final milliamperes 10 mA above initial capture level
 Calling for expert consultation (e.g., Cardiologist) 7. Confirm effective capture
• Electrically: assess ECG tracing
 Assessing for drug induced causes (e.g., beta blockers, • Mechanically: palpate femoral pulse (carotid pulse unreliable)
calcium channel blockers, digoxin)
Critical CHANGES
 Calling for cardiology consultation if myocardial infarction
suspected (e.g., ECG changes) If PEA develops, go to   CHKLST 4

During RESUSCITATION
Airway: Assess and secure
Circulation: • Confirm adequate IV or IO access
• Consider IV fluids wide open

All reasonable precautions have been taken to verify the information contained in this publication. The responsibility for the interpretation and use of the materials lies with the reader. Revised April 2017 (042417.1)
 INDEX
4
Asystole PEA

Cardiac Arrest – Asystole / PEA

Non-shockable pulseless cardiac arrest

START DRUG DOSES and treatments

Epinephrine: 1 mg IV, repeat every 3 – 5 mins.
1 Call for help and a code cart
 Ask: “Who will be the crisis manager?” TOXIN treatment
Local anesthetic: • Intralipid 1.5 mL/kg IV bolus
 Say: “The top priority is high-quality CPR” • Repeat 1 – 2 times for persistent asystole

2 Put backboard under patient, supine position • Start infusion 0.25 – 0.5 mL/kg/min for 30 – 60 minutes
for refractory hypotension
4
3 Turn FiO2 to 100%, turn off volatile anesthetics Beta-blocker:  Glucagon 2 – 4 mg IV push 
4 Start CPR and assessment cycle... Calcium channel blocker: Calcium chloride 1 g IV
 Perform CPR HYPERKALEMIA treatment
• “Hard and fast” about 100 – 120 compressions/min to depth of 2 – 2.3 inches 1. Calcium gluconate • 30 mg/kg IV
• Ensure full chest recoil with minimal interruptions - or -
Calcium chloride • 10 mg/kg IV
• 10 breaths/minute, do not overventilate
2. Insulin • 1 0 units regular IV with
 Give epinephrine 1– 2 amps D50W as needed
• Repeat epinephrine every 3 – 5 minutes
3. Sodium bicarbonate if pH < 7.2 • 1– 2 mEq/kg slow IV push
 Assess every 2 minutes
• Change CPR compression provider Hs & Ts
• Check ETCO2 • Hydrogen ion • Hypoxia • Toxin
If: < 10 mm Hg, evaluate CPR technique (acidosis) • Tamponade (cardiac) (local anesthetic,
If: Sudden increase to > 40 mm Hg, may indicate return of spontaneous circulation • Hyperkalemia • Tension pneumothorax beta blocker, calcium
• Hypothermia channel blocker)
• Check rhythm; if rhythm organized check pulse • Thrombosis
If: Asystole / PEA continues: • Hypovolemia (coronary/pulmonary)
– Resume CPR and assessment cycle (restart Step 4)
– Read aloud Hs & Ts (see list in right column) During CPR

If: VF / VT Airway: Bag-mask sufficient (if ventilation adequate)

– Resume CPR Circulation: • Confirm adequate IV or IO access
• Consider IV fluids wide open
– go to  CHKLST 5
Assign roles: Chest compressions, Airway, Vascular access,
Documentation, Code cart, Time keeping

All reasonable precautions have been taken to verify the information contained in this publication. The responsibility for the interpretation and use of the materials lies with the reader. Revised April 2017 (042417.1)
 INDEX
5
VF VT

Cardiac Arrest – VF / VT

Shockable pulseless cardiac arrest

START DRUG DOSES and treatments

Epinephrine: 1 mg IV, repeat every 3 – 5 mins.
1 Call for help and a code cart
 Ask: “Who will be the crisis manager?” ANTIARRHYTHMICS
 Say: “Shock patient as soon defibrillator arrives” Amiodarone: • 1st
dose: 300 mg/IV/IO
• 2 dose: 150 mg/IV/IO
nd
2 Put backboard under patient, supine position
Magnesium: 1 to 2 g IV/IO for Torsades de Pointes
3 Turn FiO2 to 100%, turn off volatile anesthetics
4 Start CPR — defibrillation — assessment cycle DEFIBRILLATOR instructions
 Perform CPR 1. Place electrodes on chest.
5
• “Hard and fast” about 100 – 120 compressions/min to depth of 2 – 2.3 inches 2. Turn defibrillator ON, set to DEFIB mode, and increase ENERGY LEVEL...
• Ensure full chest recoil with minimal interruptions • Biphasic: Follow manufacturer recommendation;
if unknown use highest setting
• 10 breaths/minute, do not overventilate
• Monophasic: 360J
 Defibrillate 3. Deliver shock: press CHARGE then press SHOCK.
• Shock at highest setting
• Resume CPR immediately after shock Hs & Ts
 Give epinephrine • Hydrogen ion • Hypoxia • Toxin

• Repeat epinephrine every 3 – 5 minutes (acidosis) • Tamponade (cardiac) (local anesthetic,
• Hyperkalemia • Tension pneumothorax beta blocker, calcium
 Consider giving antiarrhythmics for refractory VF/ VT • Hypothermia • Thrombosis
channel blocker)
(amiodarone preferred, if available) • Hypovolemia (coronary/pulmonary)
 Assess every 2 minutes
• Change CPR compression provider During CPR
• Check ETCO2 Airway: Bag-mask sufficient (if ventilation adequate)
If: < 10 mm Hg, evaluate CPR technique Circulation: • Confirm adequate IV or IO access
If: Sudden increase to > 40 mm Hg, may indicate return of spontaneous circulation • Consider IV fluids wide open
• Treat reversible causes, consider reading aloud Hs & Ts (see list in right column) Assign roles: Chest compressions, Airway, Vascular access,
• Check rhythm; if rhythm organized check pulse Documentation, Code cart, Time keeping
If: VF / VT continues: Resume CPR – defibrillation – assessment cycle (restart Step 4)
If: Asystole / PEA: go to  CHKLST 4
All reasonable precautions have been taken to verify the information contained in this publication. The responsibility for the interpretation and use of the materials lies with the reader. Revised April 2017 (042417.1)
 INDEX
6 Failed Airway
2 unsuccessful intubation attempts by an airway expert

START

1 Call for expert anesthesiology help and a code cart

 Ask: “Who will be the crisis manager?”

2 Get Difficult Airway Cart and a video laryngoscope

3 Bag-mask ventilate with 100% oxygen
4 Is ventilation adequate?
Ventilation NOT ADEQUATE Switch list Ventilation ADEQUATE
if ventilation
NOT ADEQUATE Remains NOT ADEQUATE
status 
Consider awakening patient or 6
changes alternative approaches to secure airway...
 Optimize ventilation  Place laryngeal mask • Operation using LMA, face mask
• Reposition patient airway (LMA) or other • Video laryngoscope
supraglottic (SG) device
• Oral airway / nasal airway • LMA as conduit to intubation
• Two-handed mask  If unsuccessful, • Return to spontaneous ventilation
attempt intubation using • Different blades
 Check equipment video laryngoscope
• Intubating stylet
• Using 100% O2
 Prepare for surgical airway • Fiberoptic intubation
• Capnography (prep neck, get tracheostomy kit, • Light wand
• Circuit integrity call for surgeon)
• Retrograde intubation
 Check ventilation  Re-check ventilation • Blind oral or nasal intubation


If awakening patient, consider:
• Awake intubation
Still NOT ADEQUATE
• Do procedure under regional/local
 Implement surgical airway • Cancel the case

All reasonable precautions have been taken to verify the information contained in this publication. The responsibility for the interpretation and use of the materials lies with the reader. Revised April 2017 (042417.1)
 INDEX
7 Fire
Evidence of fire (smoke, odor, flash) on patient or drapes, or in patient’s airway

START

1 Call for help and activate fire alarm

 Ask: “Who will be the crisis manager?”
2 Get fire extinguisher to have if needed
If AIRWAY fire If NON-AIRWAY fire

3 Attempt to extinguish fire 3 Attempt to extinguish fire 4 After fire extinguished

 Shut off medical gases  Maintain airway
FIRST ATTEMPT
 Disconnect ventilator  Assess patient for injury
 Avoid N2O and minimize FiO2 at site of fire, and for
 Remove endotracheal tube
 Remove drapes / all flammable inhalational injury if not
 Remove flammable material from airway materials from patient intubated
 Pour saline into airway  Extinguish burning materials with  Confirm no secondary fire
4 After fire extinguished saline or saline-soaked gauze • Check surgical field, 7
DO NOT use drapes and towels 
 Re-establish ventilation using
self-inflating bag with room air • Alcohol-based solutions
• Any liquid on or in energized electrical
5 Assess patient status
• If unable to re-establish ventilation, and devise ongoing
go to   CHKLST 6 equipment ( Laser, ESU / Bovie, management plan
anesthesia machine, etc.)
• Avoid N2O and minimize FiO 2
 If equipment fire, use fire extinguisher 6 Save involved materials/
 Confirm no secondary fire devices for review
• Check surgical field, drapes and towels
Fire PERSISTS after 1 ATTEMPT
 Assess airway for injury or foreign body  Use fire extinguisher (safe in wounds)
• Assess ETT integrity (fragments may be left in airway)
• Consider bronchoscopy Fire STILL PERSISTS
5 Assess patient status and  Evacuate patient
devise ongoing management plan  Close OR door
6 Save involved materials/devices for review  Turn OFF gas supply to room

All reasonable precautions have been taken to verify the information contained in this publication. The responsibility for the interpretation and use of the materials lies with the reader. Revised April 2017 (042417.1)
 INDEX
8
Acute massive bleeding
Hemorrhage

START

1 Call for help and a code cart 1� Consider... DRUG DOSES and treatments
 Ask: “Who will be the crisis manager?”  Electrolyte disturbances HYPOCALCEMIA treatment
(hypocalcemia and hyperkalemia) Give calcium to replace deficit
2 Open IV fluids and (calcium chloride or calcium gluconate)
assess for adequate IV access  Uncrossmatched type O-neg blood
if crossmatched blood not available
HYPERKALEMIA treatment
3 Turn FiO2 to 100% and  Damage control surgery
turn down volatile anesthetics 1. Calcium gluconate • 30 mg/kg IV
(pack, close, resuscitate) - or -
Calcium chloride • 10 mg/kg IV
4 Call blood bank  Special patient populations
(see considerations below) 2. Insulin • 10 units regular
 Activate massive transfusion protocol
IV with 1– 2 amps
 Assign 1 person as primary contact D50W as needed
for blood bank
3. Sodium bicarbonate • 1 – 2 mEq/kg
 Order blood products (in addition if pH < 7.2 slow IV push
to PRBCs)
•  1 FFP : 1 PRBC
•  If indicated, 6 units of platelets SPECIAL PATIENT POPULATIONS
OBSTETRIC: TRAUMA: NON-SURGICAL 8
5 Request rapid infuser (or pressure bags) • Empirical administration of 1 pool of Give either...
UNCONTROLLED BLEEDING
despite massive transfusion of
6 Discuss management plan between cryoprecipitate (10 cryo units) • Antifibrinolytic tranexamic acid:
PRBC, FFP, platelets and cryo:
surgical, anesthesiology, and nursing teams • Check fibrinogen (goal is 200 mg/dL) 1000 mg IV over 10 minutes
followed by 1000 mg over the • Consider giving Recombinant
< 100 Order 2 more pools next 8 hours Factor VIIa: 40 mcg/kg IV
7 Call for surgery consultation mg/dL of cryoprecipitate –  or – – Surgical bleeding must first
8 Keep patient warm 100 – 200 Order 1 more pool • Aminocaproic acid: 4 – 5 g in
be controlled
mg/dL of cryoprecipitate 250 mL NS/RL IV over first –  use with CAUTION in
9 Send labs hour followed by a continuing patients at risk for thrombosis
CBC, PT / PTT / INR, fibrinogen, lactate, infusion of 1 g in 50 mL NS/RL –  DO NOT use
arterial blood gas, potassium, and ionized calcium IV per hour over 8 hours when PH is < 7.2

All reasonable precautions have been taken to verify the information contained in this publication. The responsibility for the interpretation and use of the materials lies with the reader. Revised April 2017 (042417.1)
 INDEX
9 Hypotension
Unexplained drop in blood pressure refractory to initial treatment

START
DRUG DOSES and treatments
1 Call for help and a code cart 7 Consider actions... Ephedrine: 5 – 25 mg IV, repeat as needed
 Ask: “Who will be the crisis manager?”  Place patient in Phenylephrine: 80 – 200 mcg IV, repeat as needed
Trendelenberg position Epinephrine: BOLUS: 4 – 8 mcg IV
2 Check...   (dilute 1 mg in 250 mL = 4 mcg/mL)
 Obtain additional IV access
 Pulse INFUSION: 0.1 – 1 mcg/kg/min IV
 Place arterial line
 Blood pressure
 Equipment 8 Consider causes...
 Heart rate Operative field Breathing
• If BRADYCARDIA, go to   CHKLST 3 • Mechanical or surgical manipulation • Increased PEEP
• Insufflation during laparoscopy • Hypoventilation
 Rhythm
• Retraction • Hypoxia  go to   CHKLST 10
• If VF / VT, go to   CHKLST 5
• Vagal stimulation • Persistent hyperventilation
• If PEA, go to   CHKLST 4
• Vascular compression • Pneumothorax

3 Run IV fluids wide open • Pulmonary edema

Unaccounted blood loss
• Blood in suction canister Circulation
4 Give vasopressors and titrate to response
• Bloody sponges • Airembolism  go to   CHKLST 1
 MILD hypotension: • Blood on the floor • Bradycardia  go to   CHKLST 3
Give ephedrine or phenylephrine

 SIGNIFICANT / REFRACTORY hypotension:
• Internal bleeding • Malignant hyperthermia  go to   CHKLST 11
• Tachycardia  go to   CHKLST 12
9
Give epinephrine bolus, consider starting Drugs / Allergy
• Bone cementing (methylmethacrylate effect)
epinephrine infusion • Anaphylaxis  go to   CHKLST 2
• Myocardial ischemia
• Recent drugs given
• Emboli (pulmonary, fat, septic, amniotic, CO2)
5 Turn FiO2 to 100% and • Dose error
• Severe sepsis
turn down volatile anesthetics • Drugs used on the field
• Tamponade
(i.e., intravascular injection of local
6 Inspect surgical field for bleeding anesthetic drugs)
•  If BLEEDING, go to   CHKLST 8 • Wrong drug

All reasonable precautions have been taken to verify the information contained in this publication. The responsibility for the interpretation and use of the materials lies with the reader. Revised April 2017 (042417.1)
 INDEX
10 Hypoxia
Unexplained oxygen desaturation

START

1 Call for help and a code cart 7 Consider causes...

 Ask: “Who will be the crisis manager?”  Is Airway / Breathing issue suspected?
2 Turn FiO2 to 100% at high gas flows NO airway issue suspected YES airway issue suspected
 Confirm inspired FiO2 = 100%
on gas analyzer Circulation Airway / Breathing
 Confirm presence of end-tidal CO2 and • Embolism • Aspiration
changes in capnogram morphology – Pulmonary embolus • Atelectasis

– Air embolism – Venous  go to   CHKLST 1 • Bronchospasm

3 Hand-ventilate to assess compliance
– Other emboli (fat, septic, CO2, amniotic fluid) • Hypoventilation

4 Listen to breath sounds • Heart disease • Laryngospasm

– Congestive heart failure • Obesity / positioning

5 Check... – Coronary heart disease • Pneumothorax
 Blood pressure, PIP, pulse – Myocardial ischemia • Pulmonary edema
 ET tube position – Cardiac tamponade • Right mainstem intubation
 Pulse oximeter placement – Congenital / anatomical defect • Ventilator settings,
 Circuit integrity: look for disconnection, • Severe sepsis leading to auto-peep
kinks, holes
• If hypoxia associated with hypotension, 
go to   CHKLST 9
6 Consider actions to assess possible
breathing issue... Additional DIAGNOSTIC TESTS
Drugs / Allergy
 Draw blood gas • Fiberoptic bronchoscope

 Suction (to clear secretions, mucus plug)

• Recent drugs given
• Chest xray 10
• Dose error / allergy / anaphylaxis
• Electrocardiogram
 Remove circuit and use ambu-bag
• Dyes and abnormal hemoglobin • Transesophageal echocardiogram
 Bronchoscopy (e.g., methemoglobinemia, methylene blue)

All reasonable precautions have been taken to verify the information contained in this publication. The responsibility for the interpretation and use of the materials lies with the reader. Revised April 2017 (042417.1)
 INDEX
11 Malignant Hyperthermia
In presence of triggering agent: unexpected, unexplained increase in end-tidal CO2 , unexplained tachycardia/tachypnea,
prolonged masseter muscle spasm after succinylcholine. Hyperthermia is a late sign.

START DRUG DOSES and treatments

Dantrolene • 2.5 mg/kg, repeat up to 10 mg/kg until
1 Call for help and a code cart 1� Send labs symptoms subside
 Ask: “Who will be the crisis manager?” •  Arterial blood gas • Rarely, may require up to 30 mg/kg
•  Electrolytes
2 Get Malignant Hyperthermia Kit •  Serum creatine kinase (CK)
Ryanodex® Dantrium® or Revonto®
• Reconstitute 250 mg vials • Reconstitute 20 mg vials
3 Call MH Hotline 1.800.­644.­9737 •  Serum / urine myoglobin with 5 cc sterile water each with 60 cc sterile water each
•  Coagulation profile (shake until orange/opaque) • 2.5 mg/kg = 7.5 mL/kg
4 Assign dedicated person to start • 2.5 mg/kg = 0.05 mL/kg • 70 kg patient dose = 525 mL
mixing dantrolene 1� Initiate supportive care • 70 kg patient dose = 3.5 mL
Consider cooling patient

5 Request chilled IV saline if temperature > 38.5°C: Bicarbonate • 1 – 2 mEq/kg, slow IV push
6 Turn off volatile anesthetics and • STOP cooling if (for suspected metabolic acidosis)
transition to non-­triggering anesthetics temperature < 38°C
•  DO NOT delay treatment to change circuit • Lavage open body cavities HYPERKALEMIA treatment
or CO2 absorber • Nasogastric lavage Calcium gluconate • 30 mg/kg
with cold water - or -
7 Turn FiO2 to 100% • Apply ice externally Calcium chloride • 10 mg/kg IV

8 Hyperventilate patient at flows of • Infuse cold saline intravenously Insulin • 10 units regular IV
10 L / min or more Place Foley catheter, • 1 – 2 amps D50W

monitor urine output
9 Terminate procedure, if possible TRIGGERING AGENTS
Call ICU
 • Inhalational anesthetics • Succinylcholine
1� Give dantrolene
1� Give bicarbonate for suspected DIFFERENTIAL diagnosis  (consider when using high doses of dantrolene without resolution of symptoms)
metabolic acidosis (maintain pH > 7.2) Cardiorespiratory Iatrogenic Neurologic Toxicology
• Hypoventilation • Exogenous CO2 source • Meningitis • Radiologic contrast neurotoxicity
1� Treat hyperkalemia, if suspected • Sepsis (e.g., laparoscopy) • Intracranial bleed • Anticholinergic syndrome

Endocrine • Overwarming • Hypoxic • Cocaine, amphetamine, 11

1� Treat dysrhythmias, if present • Neuroleptic Malignant encephalopathy salicylate toxicity
• Thyrotoxicosis
•  Standard antiarrhythmics are acceptable; Syndrome • Traumatic brain injury • Alcohol withdrawal
DO NOT use calcium channel blockers • Pheochromocytoma

All reasonable precautions have been taken to verify the information contained in this publication. The responsibility for the interpretation and use of the materials lies with the reader. Revised April 2017 (042417.1)
 INDEX
12 Tachycardia – Unstable
Persistent tachycardia with hypotension, ischemic chest pain, altered mental status or shock

START BIPHASIC CARDIOVERSION energy levels

CONDITION ENERGY LEVEL (progression)
1 Call for help and a code cart Narrow complex, regular 50 J    100 J    150 J    200 J
 Ask: “Who will be the crisis manager?”
Narrow complex, irregular 120 J    150 J    200 J
2 Turn FiO2 to 100% and turn down volatile anesthetics Wide complex, regular 100 J    150 J    200 J
3 Analyze rhythm Wide complex, irregular Treat as VF:  go to  CHKLST 5
• If wide complex, irregular: treat as VF, go to  CHKLST 5
• Otherwise: prepare for cardioversion Critical CHANGES
If cardioversion needed and impossible to synchronize shock,
4 Prepare for immediate synchronized cardioversion use high-energy unsynchronized shocks
1. Sedate all conscious patients unless deteriorating rapidly
Defribrillation doses:
2. Turn monitor/defibrillator ON, set to defibrillator mode
Biphasic: Follow manufacturer recommendation;
3. Place electrodes on chest if unknown use highest setting
4. Engage synchronization mode
Monophasic: 360J
5. Look for mark/spike on the R-wave indicating synchronization mode
6. Adjust if necessary until SYNC markers seen with each R-wave If cardiac arrest, go to:
 CHKLST 5 Cardiac Arrest – VF/VT
5 Cardiovert at appropriate energy level  CHKLST 4 Cardiac Arrest – Asystole / PEA
1. Determine appropriate energy level using Biphasic Cardioversion table at right;
begin with lowest energy level and progress as needed
During RESUSCITATION
2. Select energy level
Airway: Assess and secure
3. Press charge button
Circulation: • Confirm adequate IV or IO access
4. Press and hold shock button
• Consider IV fluids wide open
5. Check monitor; if tachycardia persists, increase energy level
6. Engage synchronization mode after delivery of each shock

6 Consider expert consultation

12
All reasonable precautions have been taken to verify the information contained in this publication. The responsibility for the interpretation and use of the materials lies with the reader. Revised April 2017 (042417.1)