Arrest Documentation Quick Reference · Cardiac Arrest Report Guide Documenting Vitals and Patient’s ECG Rhythm (every 2 minutes) Vitals and Patient’s ECG Rhythm during a full

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Arrest Documentation Quick Reference When documenting cardiac arrest care, the following items should be documented at applicable times and

listed intervals.

Each attempt at an intervention must be listed individually as successful or unsuccessful. (Except Chest Compressions)

✓ Intervention to Document Location/Power

Tool Interval

Initial Vitals (Including 0 pulse, resp, b/p) Vitals Tool DO NOT USE CPR VITALS TOOL

Vitals (Including 0 pulse, resp, b/p, and ETCO2) CPR Vitals Tool every 2 minutes after initial

ECG Rhythm CPR Vitals Tool Initial & every 2 minutes

Chest Compressions (Manual, w/ Feedback

Device, or w/ Mechanical Device) Procedures Tool Start/Re-Start & Stop (Rosc or Termination)

DO NOT document changes in Compressor

Oxygen (BVM) Medications Tool Time O2 was connected

Oral Airway Procedures Tool Time inserted or attempted

Nasal Airways Procedures Tool

Vascular Access Attempts (IV or IO) IV/IO Tool Time of attempt

Normal Saline (Total mL infused) Medications Tool End of call or arrival at destination

Epinephrine Medications Tool Initial & every 3-5 mins

Amiodarone (VT/VF only) Medications Tool Initial & 5 min if VF/VT persists

Defibrillation (VF/VT Only) Monitor Tool Time(s) shock delivered

Advanced Airway Attempts (ETT or Supraglottic)

Airway-suc (or) Airway-Unsuc

Time of attempt. Use appropriate tool for successful or

unsuccessful.

Blood Glucose Check Vitals Tool Time glucose is checked

Any other medications Medications Tool Document time administered

Assessments Assessment Tool

Time Performed: - Lung Sounds - Pupil - Pertinent findings / Trauma

Use of AutoVent Procedures Tool Time AutoVent was connected to Pt

ROSC Documentation Considerations

CPR Stop - ROSC Procedures Tool Time of ROSC

Full set of vitals Vitals Tool DO NOT USE CPR VITALS TOOL

12-Lead ECG Monitor Tool

Nor-Epi (if applicable) Medications Tool Time drip started

2nd site Vascular Access Attempts (IV or IO) IV/IO Tool Time of vascular access attempt

Pacing (if applicable) Monitor Tool Time pacer started



Cardiac Arrest Report Guide

Documenting Vitals and Patient’s ECG Rhythm (every 2 minutes)

Vitals and Patient’s ECG Rhythm during a full arrest are documented every two minutes during CPR.

INITIAL VITALS, use the normal Vitals & ECG Power Tools to document (even if the patient is in cardiac arrest.)

While Pt is in arrest, use the “CPR Vitals” power tool

Upon ROSC, use the normal vitals & ECG power tools.

Use the “CPR Vitals” Power Tool to simplify documentation.

INITIAL VITALS

CPR VITALS

q. 2 minutes



Document the following within the power tool:

Heart rate and respiratory rate defaulted to 0 (zero).

o If the heart rate is not zero because you are providing CPR to an infant with a pulse less than 60, document the

actual pt’s pulse.

Document the measured EtCO2



Document the patient’s ECG rhythm.

o If the patient is in PEA select the underlying patient rhythm along with the “PEA” button.

o The field of ECG Rhythm can have more than one field selected

o E.g.: Patient is in “Idioventricular Rhythm” with no pulse, select both Idioventricular and PEA buttons.

ROSC and non-arrest vitals should be documented via normal power tools.

ECG Rhytms when the Pt has a pulse must be documented per standard documentation practices.



Documenting Defibrillation

Document every time that the patient was defibrillated during the cardiac arrest event.

Select the “Monitor” Power Tool from the right column.

Select the crew member that performed the defibrillation and time of the event.

Select “Defibrillation” as your “Event Type”.

Fill in the “Energy” of the defibraillation. (joules setting of the device)

Fill in “1” for “Toatl Number of Shocks Delivered.” (Each defibrillation or intervention must be documented individually)

Select the “Type of Shock” delievered by your monitor.



Documenting Chest Compressions

CPR (chest compressions) is to be documented as a procedure only at the following benchmarks:

o Anytime chest compressions are started (or restarted for re-arresting patients)

o When the method of delivering compressions changes (e.g.: switching from manual to mechanical device*)

o When chest compressions are discontinued. (ROSC or field termination of resuscitation.)

DO NOT document every time compressors change (q. 2 minutes).

*Mechanical CPR device means an automated device to deliver chest compressions.



Options for discontinuing CPR may be quickly found by typing in “cpr dis” into the search window.

If CPR is performed with the ResQPOD in place, use the appropriate procedure.

If CPR is performed with a Feedback Device in place, use the appropriate procedure.



Documenting Advanced Airways (King, Orotracheal, Nasal, Surgical)

Select appropriate Advanced Airway Power Tool from the right column, based upon the outcome of the procedure

Remember to complete the “Crew Member” field in the upper right.

Choose the correct “Airway” procedure from the list of procedures.

o The list is pre-selected to only have those procedures that are allowed by the system

Choose the appropriate blade size if a lyrgnascope was used for intubation.



Complete all remaining fields in the power tool, including those fields under the “Airway Confirmation” section.



Documenting Medications Select “Meds” Power Tool from the right column.

Properly document all of the medications adminsitered during the cardiac arrest incident.

Common items that are forgotten and not documented are as follows:

o Oxygen

o Normal Saline (Total ammount given)

Documents

Arrest Documentation Quick Reference · Cardiac Arrest Report Guide Documenting Vitals and Patient’s ECG Rhythm (every 2 minutes) Vitals and Patient’s ECG Rhythm during a full