Guidelines Summary
The most recent changes from the International Guidelines from the American Heart Association (AHA) (2015) included changes to cardiopulmonary resuscitation (CPR) chest compressions, such as the following [37] :
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Quick chest compressions (100-120 per minute)
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Appropriate chest compression depth (5-6 cm)
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Full chest relaxation (complete chest recoil)
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Avoid interruption of chest compressions
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Avoid hyperventilation
Advanced Cardiac Life Support guidelines
Updated CPR and emergency cardiovascular care (ECC) guidelines were also issued in 2015 by the following organizations:
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AHA
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European Resuscitation Council (ERC)
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The International Liaison Committee on Resuscitation (ILCOR)
The following summarizes the AHA adult cardiac arrest algorithm for ventricular fibrillation (VF) or pulseless ventricular tachycardia (pVT) [38] :
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Activate emergency response system.
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Initiate cardiopulmonary resuscitation (CPR) and give oxygen when available.
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Verify patient is in ventricular fibrillation (VF) as soon as possible (ie, automated external defibrillator (AED) and quick look with paddles).
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Defibrillate once: Use a device specific recommendations (i.e., 120-200 J for biphasic waveform and 360 J for monophasic waveform); if unknown, use the maximum available.
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Resume CPR immediately without pulse check and continue for 5 cycles. One cycle of CPR equals 30 compressions and 2 breaths; 5 cycles of CPR should take roughly 2 minutes (compression rate 100 per minute). Do not check for rhythm/pulse until 5 cycles of CPR are completed.
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During CPR, minimize interruptions while securing intravenous access and performing endotracheal intubation. Once the patient is intubated, continue CPR at 100 compressions per minute without pauses for respirations, and administer respirations at 10 breaths per minute.
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Check rhythm after 2 minutes of CPR.
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Repeat a single defibrillation if still VF/pVT (pulseless ventricular tachycardia) with rhythm check. Selection of fixed versus escalating energy for subsequent shocks is based on the specific manufacturer’s instructions. For a manual defibrillator capable of escalating energies, higher energy for second and subsequent shocks may be considered.
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Resume CPR for 2 minutes immediately after defibrillation.
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Continuously repeat the cycle of (1) rhythm check, (2) defibrillation, and (3) 2 minutes of CPR
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Administer vasopressor: Give vasopressor during CPR before or after shock when intravenous or intraosseous access is available. Administer epinephrine 1 mg every 3–5 minutes.
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Administer antidysrhythmics: Give antidysrhythmic during CPR before or after shock. Administer amiodarone 300 mg IV/IO once, then consider administering an additional 150 mg once.
In addition, correct the following if necessary and/or possible:
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Hypovolemia
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Hypoxia
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Hydrogen ion (acidosis) - Consider bicarbonate therapy.
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Hyperkalemia/hypokalemia and metabolic disorders
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Hypoglycemia (Check fingerstick or administer glucose.)
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Hypothermia (Check core rectal temperature.)
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Toxins
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Tamponade, cardiac (Check with ultrasonography.)
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Tension pneumothorax (Consider needle thoracostomy.)
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Thrombosis, coronary or pulmonary - Consider thrombolytic therapy if suspected.
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Trauma
According to the AHA, if all the following are present, termination of resuscitation in out-of-hospital cardiac arrest (OHCA) may be considered [38] :
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Arrest was not witnessed by emergency medical services (EMS) personnel
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No return of spontaneous circulation (ROSC) prior to transport
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No AED shock delivered prior to transport
In addition, in intubated patients, failure to achieve an end-tidal carbon dioxide (ETCO2) above 10 mmHg by waveform capnography after 20 minutes of CPR may be considered as one component of a multimodal approach to decide when to end resuscitative efforts. However, no studies of nonintubated patients have been reviewed ETCO2 should not be used as an indication to end resuscitative efforts.
Defibrillation
AHA recommendations for defibrillation include the following [38] :
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Defibrillators (using BTE, RLB, or monophasic waveforms) to treat atrial and ventricular arrhythmias. (Class I)
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Defibrillators using biphasic waveforms (BTE or RLB) are preferred. (Class IIa)
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A single-shock strategy (as opposed to stacked shocks) for defibrillation. (Class IIa)
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The benefit of using a multimodal defibrillator in manual instead of automatic mode is uncertain. (Class IIb)
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The value of VF waveform analysis to guide management of defibrillation is uncertain. (Class IIb)
Overall, the ERC and ILCOR guidelines concur with AHA, [39, 40] but ERC includes an additional recommendation for self-adhesive defibrillation pads which are preferred over manual paddles and should always be used when they are available. [40]
Adjuncts for airway control and ventilation
The AHA guidelines provide the following recommendations for airway control and ventilation [38] :
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Advanced airway placement in cardiac arrest should not delay initial CPR and defibrillation for V) cardiac arrest. (Class I)
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If advanced airway placement will interrupt chest compressions, consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates return of spontaneous circulation. (Class IIb)
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The routine use of cricoid pressure in cardiac arrest is not recommended. (Class III)
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Either a bag-mask device or an advanced airway may be used for oxygenation and ventilation during CPR in both the in-hospital and out-of-hospital setting. (Class IIb) The choice of bag-mask device versus advanced airway insertion should be determined by the skill and experience of the provider. (Class I)
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For healthcare providers trained in their use, either an supraglottic airway (SGA) device or an endotracheal tube (ETT) may be used as the initial advanced airway during CPR. (Class IIb)
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Providers who perform endotracheal intubation should undergo frequent retraining. (Class I)
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To facilitate delivery of ventilations with a bag-mask device, oropharyngeal airways can be used in unconscious (unresponsive) patients with no cough or gag reflex and should be inserted only by trained personnel. (Class IIa)
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In the presence of known or suspected basal skull fracture or severe coagulopathy, an oral airway is preferred. (Class IIa)
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Continuous waveform capnography in addition to clinical assessment is the most reliable method of confirming and monitoring correct placement of an ETT. (Class I)
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If continuous waveform capnometry is not available, a nonwaveform CO2 detector, esophageal detector device, or ultrasound used by an experienced operator are reasonable alternatives. (Class IIa)
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After placement of an advanced airway, it is reasonable for the provider to deliver 1 breath every 6 seconds (10 breaths/min) while continuous chest compressions are performed. (Class IIb)
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Automatic transport ventilators (ATVs) can be useful for ventilation of adult patients in noncardiac arrest who have an advanced airway in place in both out-of-hospital and in-hospital settings. (Class IIb)
There are no significant differences in the recommendations from ERC or ILCOR. [39, 40]
Medication management
The 2015 AHA guidelines offers the following recommendations for the administration of drugs during cardiac arrest [38] :
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Amiodarone may be considered for ventricular fibrillation (VF) or pulseless ventricular tachycardia(pVT) that is unresponsive to CPR, defibrillation, and a vasopressor therapy; lidocaine may be considered as an alternative.(Class IIb)
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Routine use of magnesium for VF/pVT is not recommended in adult patients. (Class III)
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Inadequate evidence to support routine use of lidocaine. However, the initiation or continuation of lidocaine may be considered immediately after ROSC from cardiac arrest due to VF/pVT. (Class IIb)
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Inadequate evidence to support the routine use of a β-blocker after cardiac arrest. However, the initiation or continuation of a β-blocker may be considered after hospitalization from cardiac arrest due to VF/pVT. (Class IIb)
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Atropine during pulseless electrical activity (PEA) or asystole is unlikely to have a therapeutic benefit. (Class IIb)
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There is insufficient evidence for or against the routine initiation or continuation of other antiarrhythmic medications after ROSC from cardiac arrest.
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Standard-dose epinephrine (1 mg every 3 to 5 minutes) may be reasonable for patients in cardiac arrest. (Class IIb); high-dose epinephrine is not recommended for routine use in cardiac arrest. (Class III)
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Vasopressin has been removed from the Adult Cardiac Arrest Algorithm and offers no advantage in combination with epinephrine or as a substitute for standard-dose epinephrine. (Class IIb)
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It may be reasonable to administer epinephrine as soon as feasible after the onset of cardiac arrest due to an initial non- shockable rhythm. (Class IIb)
The 2009 American Heart Association Cardiac Arrest Survival Summit released consensus recommendations for implementation strategies to optimize the care of patients with out-of-hospital sudden cardiac arrest (OHCA). [41] These recommendations included collection of national data on OHCA and local culture changes because incomplete implementation of existing standards was seen as the limiting problem.
Wearable Cardioverter-Defibrillator Therapy
The 2016 AHA recommendations for wearable cardioverter-defibrillator therapy (WCD) are summarized below. [42]
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A WCD is reasonable when there is a clear indication for an implanted/permanent device accompanied by a transient contraindication or interruption in ICD care (ie, infection) (Class IIa; level of evidence: C).
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A WCD is reasonable as a bridge to more definitive therapy such as cardiac transplantation. (Class IIa; level of evidence: C)
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A WCD may be reasonable when there is concern about a heightened risk of SCD that may resolve over time or with treatment of left ventricular dysfunction. (Class IIb; level of evidence: C)
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A WCD may be appropriate as bridging therapy in situations associated with increased risk of death in which ICDs have been shown to reduce SCD but not overall survival. (Class IIb; level of evidence: C)
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A WCD should not be used when nonarrhythmic risk is expected to significantly exceed arrhythmic risk, particularly in patients who are not expected to survive >6 months. (Class III)
Sudden Unexplained Cardiac Death
In its 2013 expert consensus statement on inherited primary arrhythmia syndromes, the Heart Rhythm Society/European Heart Rhythm Association/Asia Pacific Heart Rhythm Society (HRS/EHRA/APHRS) recommended that an unexplained sudden death occurring in anyone over 1 year old is called “sudden unexplained death syndrome” (SUDS) and a SUDS death with negative pathological and toxicologic findings should be called "sudden arrhythmic death syndrome" (SADS). Additional recommendations are summarized below. [43]
Evaluation
Personal/familyhistory and circumstances of the sudden death, along with blood and/or tissue for molecular autopsy, should be collected in all cases of sudden unexplained death in infancy (SUDI). (Class I)
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Assessment by an expert cardiac pathologist to rule out the presence of microscopic indicators of structural heart (Class I)
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An arrhythmia syndrome–focused molecular autopsy/postmortem genetic testing can be useful (Class IIa)
Follow-up screening of first-degree relatives
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First-degree relatives should undergo genetic testing whenever a pathogenic mutation in a gene associated with increased risk of sudden death is identified by molecular autopsy of a sudden unexpected death syndrome (SUDS) victim. (Class I)
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Evaluation should be done with resting electrocardiography (ECG) with high right ventricular leads, exercise stress testing, and echocardiology. Assessment of obligate carriers and those with a history of arrhythmias or syncope should be prioritized. (Class I)
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Follow-up clinical assessment in young family members who may manifest symptoms and/or signs of the disease at an older age and in all family members whenever additional SUDS or SUDI events occur. (Class I)
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Evaluation with ambulatory and signal-averaged ECGs, cardiac magnetic resonance imaging (MRI) and provacative testing with Class Ic anitarrhythic drugs may be useful. (Class IIa)
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Consider evaluation of first-degree relatives with epinephrine infusion. (Class IIb)
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Sudden Cardiac Death. Interplay of various risk factors that can lead to sudden cardiac death.
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Sudden Cardiac Death. Plots of mortality rates (deaths per 1000 persons) for ischemic heart disease occurring out of the hospital or in the emergency department (top) and occurring in the hospital (bottom) by age, sex, and race in 40 states during 1985.
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Sudden Cardiac Death. Figure a: Neurologic outcome stratified by initial cardiac arrest score. Neurologic recovery is defined as discharged to home and able to care for self. Figure b: Overall survival stratified by initial cardiac arrest score.
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Sudden Cardiac Death. Epsilon wave in a patient with arrhythmogenic right ventricular dysplasia.
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Sudden Cardiac Death. Ventricular fibrillation appeared during rapid atrial fibrillation in a patient with Wolff-Parkinson-White syndrome.
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Sudden Cardiac Death. Complex arrhythmias such as ventricular tachycardia/ventricular fibrillation (VT/V)F are the result of an imbalance between important components that control the rhythm. Reprinted with permission from Nova Science Publishers, Inc (Dudley SC, Kocheril AG, Sovari AA, Eds. Ventricular Arrhythmia: From Principles to Patients, Part of the Cardiology Research and Clinical Developments Series. Nova Science Publishers. New York, 2013).
