Aha 2010 Adult Acls

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Part 8: Adult Advanced Cardiovascular Life Support: 2010 American HeartAssociation Guidelines for Cardiopulmonary Resuscitation and mer!ency

Cardiovascular Care

Robert W. Neumar, harles W. !tto, "ar# $. %in#, $te&en %. 'ronic#, "ichael$huster, lifton W. allaway, (eter ). 'udenchu#, )ose*h (. !rnato, +ryan "cNally,

$cott ". $il&ers, Rod $. (assman, Roger D. White, ri# (. -ess, Wanchun ang,Daniel Da&is, li/abeth $in/ and %aurie ). "orrison

Circulation 2010122$23$4D!56 10.114175R8%95!N9-9.110.0::

irculation is *ublished by the 9merican -eart 9ssociation. 22 ;reen&ille 9&enue, Dallas,

o*yright ? 2010 9merican -eart 9ssociation. 9ll rights reser&ed. (rint 5$$N6 0003@22. !nline5$$N6 1=2>3>=@

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9

Part 8: Adult Advanced Cardiovascular Life Support2010 American Heart Association Guidelines for Cardiopulmonary

Resuscitation and mer!ency Cardiovascular Care

Robert W. Neumar, hair harles W. !tto "ar# $. %in# $te&en %. 'ronic#"ichael $huster lifton W. allaway (eter ). 'udenchu# )ose*h (. !rnato +ryan "cNally

$cott ". $il&ers Rod $. (assman Roger D. White ri# (. -ess Wanchun ang

Daniel Da&is li/abeth $in/ %aurie ). "orrison

d&anced cardio&ascular life su**ort B9%$C im*acts mul3

ti*le #ey lin#s in the chain of sur&i&al that include

inter&entions to *re&ent cardiac arrest, treat cardiac arrest, and

im*ro&e outcomes of *atients who achie&e return of s*ontane3

ous circulation BR!$C after cardiac arrest. 9%$

inter&entions aimed at *re&enting cardiac arrest include airway

management, &entilation su**ort, and treatment ofbradyarrhythmias and tachyarrhythmias. For the treatment of

cardiac arrest, 9%$ inter&entions build on the basic life

su**ort B+%$C foundation of immediate recognition and

acti&ation of the emergency res*onse system, early (R, and

ra*id defibrillation to further increase the li#elihood of R!$

with drug thera*y, ad&anced airway man3 agement, and

*hysiologic monitoring. Following R!$, sur3 &i&al and

neurologic outcome can be im*ro&ed with integrated

*ostG cardiac arrest care.

(art : *resents the 2010 9dult 9%$ ;uidelines6 :.16

H9djuncts for 9irway ontrol and IentilationJ :.26 H"anage3

ment of ardiac 9rrestJ and :.@6 H"anagement of

$ym*tomatic +radycardia and achycardia.J (ostG cardiac

arrest inter&entions are addressed in (art 6 H(ostGardiac

9rrest are.J

'ey changes from the 200= 9%$ ;uidelines include

K ontinuous Luantitati&e wa&eform ca*nogra*hy is rec3

ommended for confirmation and monitoring of endotra3

cheal tube *lacement.K ardiac arrest algorithms are sim*lified and redesigned

to em*hasi/e the im*ortance of high3Luality (R Bin3

cluding chest com*ressions of adeLuate rate and de*th,

allowing com*lete chest recoil after each com*ression,

minimi/ing interru*tions in chest com*ressions anda&oiding eEcessi&e &entilationC.K 9tro*ine is no longer recommended for routine use in the

management of *ulseless electrical acti&ity B(9C7asystole.K here is an increased em*hasis on *hysiologic monitoring

to o*timi/e (R Luality and detect R!$.K hronotro*ic drug infusions are recommended as an alter3

nati&e to *acing in sym*tomatic and unstable bradycardia.

K 9denosine is recommended as a safe and *otentially

effecti&e thera*y in the initial management of stable

undifferentiated regular monomor*hic wide3com*leE

tachycardia.

Part 8"1: Ad#uncts for Air$ay Controland %entilation

&vervie$ of Air$ay 'ana!ementhis section highlights recommendations for the su**ort of

&entilation and oEygenation during (R and the *eri3arrest

*eriod. he *ur*ose of &entilation during (R is to maintain

adeLuate oEygenation and sufficient elimination of carbon

dioEide. -owe&er, research has not identified the o*timal

tidal &olume, res*iratory rate, and ins*ired oEygen concen3

tration reLuired during resuscitation from cardiac arrest.

+oth &entilation and chest com*ressions are thought to be

im*ortant for &ictims of *rolonged &entricular fibrillation

BIFC cardiac arrest and for all &ictims with other *resentingrhythms. +ecause both systemic and *ulmonary *erfusion are

substantially reduced during (R, normal &entilation3

*erfusion relationshi*s can be maintained with a minute

&entilation that is much lower than normal. During (R with

an ad&anced airway in *lace, a lower rate of rescue breathing

is needed to a&oid hy*er&entilation.

%entilation and &(y!en Administration)urin! CPRDuring low blood flow states such as (R, oEygen deli&ery to

the heart and brain is limited by blood flow rather than by

arterial oEygen content.1,2 herefore, rescue breaths are less

im*ortant than chest com*ressions during the first few minutesof resus3 citation from witnessed IF cardiac arrest and could

reduce (R efficacy due to interru*tion in chest com*ressions

and the increase in intrathoracic *ressure that accom*anies

*ositi&e3 *ressure &entilation. hus, during the first few

minutes of witnessed cardiac arrest a lone rescuer should not

interru*t chest

he 9merican -eart 9ssociation reLuests that this document be cited as follows6 Neumar RW, !tto W, %in# "$, 'ronic# $%, $huster ", allawayW, 'udenchu# (), !rnato )(, "cNally +, $il&ers $", (assman R$, White RD, -ess (, ang W, Da&is D, $in/ , "orrison %). (art :6 adult ad&ancedcardio&ascular life su**ort6 2010 9merican -eart 9ssociation ;uidelines for ardio*ulmonary Resuscitation and mergency ardio&ascular are.

Circulation. 2010122Bsu**l @C6$2 G$4.*Circulation" 2010+122,suppl -.:S/2 S//"3? 2010 9merican -eart 9ssociation, 5nc.

Ci l i i il 4l 5 66 i 5 # l )&7 10 1116C7RCLA97&AHA 110 /088
http://circ.ahajournals.org/http://circ.ahajournals.org/http://circ.ahajournals.org/


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S218 Circulation ovem4er 2; 2010

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com*ressions for &entilation. 9d&anced airway *lacement in

cardiac arrest should not delay initial (R and defibrillation for

IF cardiac arrest Blass 5, %! C.

&(y!en )urin! CPR

Oxygen Administration During CPRhe o*timal ins*ired oEygen concentration during adult (R

has not been established in human or animal studies. 5n

addition, it is un#nown whether 100M ins*ired oEygen

BF5!2 1.0C is beneficial or whether titrated oEygen is better.

9lthough *rolonged eE*osure to 100M ins*ired oEygen

BF5!2 1.0C has *otential toEicity, there is insufficient e&i3

dence to indicate that this occurs during brief *eriods of adult

(R.@G= m*irical use of 100M ins*ired oEygen during (R

o*timi/es arterial oEyhemoglobin content and in turn oEygen

deli&ery therefore, use of 100M ins*ired oEygen BF 5!2 1.0C

as soon as it becomes a&ailable is reasonable during resusci3

tation from cardiac arrest Blass 55a, %! C. "anagement of

oEygen after R!$ is discussed in (art 6 H(ost3ardiac

9rrest are.J

Passive Oxygen Delivery During CPR(ositi&e3*ressure &entilation has been a mainstay of (R but

recently has come under scrutiny because of the *otential for

increased intrathoracic *ressure to interfere with circulation

due to reduced &enous return to the heart. 5n the out3of3

hos*ital setting, *assi&e oEygen deli&ery &ia mas# with an

o*ened airway during the first 4 minutes of (R *ro&ided by

emergency medical ser&ices B"$C *ersonnel was *art of a

*rotocol of bundled care inter&entions Bincluding continuous

chest com*ressionsC that resulted in im*ro&ed sur&i&al.4G :

When *assi&e oEygen deli&ery using a fenestrated tracheal

tube B+oussignac tubeC during uninterru*ted *hysician3managed (R was com*ared with standard (R, there was

no difference in oEygenation, R!$, or sur&i&al to hos*ital

admission.,10 hest com*ressions cause air to be eE*elled

from the chest and oEygen to be drawn into the chest

*assi&ely due to the elastic recoil of the chest. 5n theory,

because &entilation reLuirements are lower than normal

during cardiac arrest, oEygen su**lied by *assi&e deli&ery is

li#ely to be sufficient for se&eral minutes after onset of

cardiac arrest with a *atent u**er airway.2 At t5is time t5ere

is insufficient evidence to support t5e removal of ventila0,>1,=2,=@

5n one case seriesassessing >0 out3of3hos*ital cardiac arrest *atients, insertion

of the laryn3 geal tube by trained *aramedics was successful

and &entila3 tion was effecti&e in :=M of *atients. >1 For @

*atients, &entilation was ineffecti&e because of cuff ru*ture

for @ other


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*atients, &entilation was ineffecti&e because of massi&e

regurgitation and as*iration before laryngeal tube *lacement.

9nother out3of3hos*ital assessment of 1= attem*ts at laryn3

geal tube *lacement re&ealed a M success rate in a

miEed *o*ulation of cardiac arrest and noncardiac arrest

*atients.>0 For healthcare *rofessionals trained in its use, the

laryngeal tube may be considered as an alternati&e to bag3

mas# &entilation Blass 55b, %! C or endotracheal intubation

for airway managementin cardiac arrest Blass 55b, %!

C.

Laryngeal Mask

Airwayhe laryngeal mas# airway *ro&ides a more secure andreliable

means of &entilation than the face mas#.=>,== 9lthough the

laryngeal mas# airway does not ensure absolute *rotection

against as*iration, studies ha&e shown that regurgitation is less

li#ely with the laryngeal mas# airway than with the bag3mas#

de&ice and that as*iration is uncommon. When com*ared with

the endotracheal tube, the laryngeal mas# airway *ro&ides

eLui&alent &entilation>,== successful &entilation during (Rhas been re*orted in 2M to M of*atients.@4,@,>>,=4G=:

+ecause insertion of the laryngeal mas# airway does not

reLuire laryngosco*y and &isuali/ation of the &ocal cords,

training in its *lacement and use is sim*ler than that for

endotracheal intubation. he laryngeal mas# airway also may

ha&e ad&antages o&er the endotracheal tube when access to

the *atient is limited,=,40 there is a *ossibility of unstable

nec# injury,41 or a**ro*riate *ositioning of the *atient for

endotracheal intubation is im*ossible.

Results from studies in anestheti/ed *atients com*aring

the laryngeal mas# airway with endotracheal intubation, as

well as additional studies com*aring it with other airways or

&entilation techniLues su**ort the use of the laryngeal mas#

airway for airway control in a &ariety of settings by nurses,

res*iratory thera*ists, and "$ *ersonnel, many of whom

had not *re&iously used this de&ice.12,@,>>,==,42G 4=

9fter successful insertion, a small *ro*ortion of *atients

cannot be &entilated with the laryngeal mas# airway.12,>>,==

With this in mind, it is im*ortant for *ro&iders to ha&e an

alternati&e strategy for airway management. (ro&iders who

insert the laryngeal mas# airway should recei&e adeLuate initial

training and then should *ractice insertion of the de&ice

regularly. $uccess rates and the occurrence of com*lications

should be monitored closely. For healthcare *rofessionals

trained in its use, the laryngeal mas# airway is an acce*tablealternati&e to bag3 mas# &entilation Blass 55a, %! +C or

endotracheal intubation Blass 55a, %! C for airway

management in cardiac arrest.

#ndotraceal

$ntu%ationhe endotracheal tube was once considered the o*timal

method of managing the airway during cardiac arrest. -ow3

e&er, intubation attem*ts by uns#illed *ro&iders can *roduce

com*lications, such as trauma to the oro*harynE, interru*tion

of com*ressions and &entilations for unacce*tably long *eri3

ods, and hy*oEemia from *rolonged intubation attem*ts or

failure to recogni/e tube mis*lacement or dis*lacement. 5t is

now clear that the incidence of com*lications is unacce*tably

high when intubation is *erformed by ineE*erienced *ro&id3

ers or monitoring of tube *lacement is inadeLuate. he

o*timal method of managing the airway during cardiac arrest

will &ary based on *ro&ider eE*erience, characteristics of the


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"$ or healthcare system, and the *atients condition.

FreLuent eE*erience or freLuent retraining is recommended

for *ro&iders who *erform endotracheal intubation Blass 5,

%! +C.@1,44 "$ systems that *erform *rehos*ital intuba3

tion should *ro&ide a *rogram of ongoing Luality im*ro&e3

ment to minimi/e com*lications Blass 55a, %! +C.

No *ros*ecti&e randomi/ed clinical trials ha&e *erformed a

direct com*arison of bag3mas# &entilation &ersus endotra3

cheal intubation in adult &ictims of cardiac arrest. !ne

*ros*ecti&e, randomi/ed controlled trial in an "$ system

with short out3of3hos*ital trans*ort inter&als4 showed no

sur&i&al ad&antage for endotracheal intubation o&er bag3mas#

&entilation in children *ro&iders in this study had limited

training and eE*erience in intubation.

he endotracheal tube #ee*s the airway *atent, *ermits

suctioning of airway secretions, enables deli&ery of a high

concentration of oEygen, *ro&ides an alternati&e route for the

administration of some drugs, facilitates deli&ery of a selected

tidal &olume, and, with use of a cuff, may *rotect the airway

from as*iration.5ndications for emergency endotracheal intubation are B1C

the inability of the *ro&ider to &entilate the unconscious

*atient adeLuately with a bag and mas# and B2C the absence

of airway *rotecti&e refleEes Bcoma or cardiac arrestC. he

*ro&ider must ha&e a**ro*riate training and eE*erience in

endotracheal intubation.

During (R *ro&iders should minimi/e the number and

duration of interru*tions in chest com*ressions, with a goal to

limit interru*tions to no more than 10 seconds. 5nterru*tions for

su*raglottic airway *lacement should not be necessary at all,

whereas interru*tions for endotracheal intubation can be mini3

mi/ed if the intubating *ro&ider is *re*ared to begin the

intubation attem*tOie, insert the laryngosco*e blade with thetube ready at handOas soon as the com*ressing *ro&ider

*auses com*ressions. om*ressions should be interru*ted only

for the time reLuired by the intubating *ro&ider to &isuali/e the

&ocal cords and insert the tube this is ideally less than 10

seconds. he com*ressing *ro&ider should be *re*ared to

resume chest com*ressions immediately after the tube is *assed

through the &ocal cords. 5f the initial intubation attem*t is

unsuccessful, a second attem*t may be reasonable, but early

consideration should be gi&en to using a su*raglottic airway.

5n retros*ecti&e studies, endotracheal intubation has been

associated with a 4M to 2=M incidence of unrecogni/ed tube

mis*lacement or dis*lacement.4: G2 his may reflect inade3

Luate initial training or lac# of eE*erience on the *art of the*ro&ider who *erformed intubation, or it may ha&e resulted

from dis*lacement of a correctly *ositioned tube when the

*atient was mo&ed. he ris# of tube mis*lacement, dis*lace3

ment, or obstruction is high,4,0 es*ecially when the *atient is

mo&ed.@ hus, e&en when the endotracheal tube is seen to

*ass through the &ocal cords and tube *osition is &erified by

chest eE*ansion and auscultation during *ositi&e3*ressure

&entilation, *ro&iders should obtain additional confirmation

of *lacement using wa&eform ca*nogra*hy or an eEhaled

!2 or eso*hageal detector de&ice BDDC.>

he *ro&ider should use both clinical assessment and

confirmation de&ices to &erify tube *lacement immediately

after insertion and again when the *atient is mo&ed.

-owe&er,


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no single confirmation techniLue is com*letely reliable.=,4

ontinuous wa&eform ca*nogra*hy is recommended in addi3

tion to clinical assessment as the most reliable method of

confirming and monitoring correct *lacement of an endotra3

cheal tube Blass 5, %! 9C.

5f wa&eform ca*nogra*hy is not a&ailable, an DD or

nonwa&eform eEhaled !2 monitor in addition to clinical

assessment is reasonable Blass 55a, %! +C. echniLues to

confirm endotracheal tube *lacement are further discussedbelow.

Clinical Assessment to Confirm Tube Placement(ro&iders should *erform a thorough assessment of endotra3

cheal tube *osition immediately after *lacement. his assess3

ment should not reLuire interru*tion of chest com*ressions.

9ssessment by *hysical eEamination consists of &isuali/ing

chest eE*ansion bilaterally and listening o&er the e*igastrium

Bbreath sounds should not be heardC and the lung fields

bilaterally Bbreath sounds should be eLual and adeLuateC. 9

de&ice should also be used to confirm correct *lacement in

the trachea Bsee belowC. 5f there is doubt about correct tube

*lacement, use the laryngosco*e to &isuali/e the tube *assingthrough the &ocal cords. 5f still in doubt, remo&e the tube and

*ro&ide bag3mas# &entilation until the tube can be re*laced.

Use of e!ices to Confirm Tube Placement(ro&iders should always use both clinical assessment and

de&ices to confirm endotracheal tube location immediately

after *lacement and throughout the resuscitation. wo studies

of *atients in cardiac arrest2, demonstrated 100M sensiti&3

ity and 100M s*ecificity for wa&eform ca*nogra*hy in

identifying correct endotracheal tube *lacement in &ictims of

cardiac arrest. -owe&er, @ studies demonstrated 4>M sensi3

ti&ity and 100M s*ecificity when wa&eform ca*nogra*hy

was first used for &ictims with *rolonged resuscitation andtrans3 *ort times.:G:0 9ll confirmation de&ices should be

consid3 ered adjuncts to other confirmation techniLues.

E"hale# C$% etectors. Detection of eEhaled !2 is one of

se&eral inde*endent methods of confirming endotracheal tube

*osition. $tudies of wa&eform ca*nogra*hy to &erify endo3

tracheal tube *osition in &ictims of cardiac arrest ha&e shown

100M sensiti&ity and 100M s*ecificity in identifying correct

endotracheal tube*lacement.2,,:1G :: ontinuous wa&eform

ca*nogra*hy is recommended in addition to clinical assess3

ment as the most reliable method of confirming and moni3

toring correct *lacement of an endotracheal tube Blass 5,

%! 9C.;i&en the sim*licity of colorimetric and nonwa&eform

eEhaled !2 detectors, these methods can be used in addition

to clinical assessment as the initial method for confirming

correct tube *lacement in a *atient in cardiac arrest when

wa&eform ca*nogra*hy is not a&ailable Blass 55a, %! +C.

-owe&er, studies of colorimetric eEhaled !2 detectors:G>

and nonwa&eform (!2 ca*nometers,:,0,= indicate that

the accuracy of these de&ices does not eEceed that of ausculta3

tion and direct &isuali/ation for confirming the tracheal *osition

of an endotracheal tube in &ictims of cardiac arrest.

When eEhaled !2 is detected B*ositi&e reading for !2C

in cardiac arrest, it is usually a reliable indicator of tube


12/68

*osition in the trachea. False3*ositi&e readings Bie, !2 is

detected but the tube is located in the eso*hagusC ha&e been

obser&ed in animals after ingestion of large amounts of

carbonated liLuids before the arrest howe&er, the wa&eform

does not continue during subseLuent breaths.4

False3negati&e readings Bdefined in this conteEt as failure

to detect !2 des*ite tube *lacement in the tracheaC may be*resent during cardiac arrest for se&eral reasons. he most

common is that blood flow and deli&ery of !2 to the lungs

is low. False3negati&e results also ha&e been re*orted in

association with *ulmonary embolus because *ulmonary

blood flow and deli&ery of !2 to the lungs are reduced. 5f

the detector is contaminated with gastric contents or acidic

drugs Beg, endotracheally administered e*ine*hrineC, a color3

imetric de&ice may dis*lay a constant color rather than

breath3to3breath color change. 5n addition, elimination and

through standard defibrillation *ads, may distinguish tracheal

from eso*hageal intubations.10@G10=

here are 2 *ublished re*orts in&ol&ing 4 *atients where

&entilation3induced changes in thoracic im*edance disa*3

*eared after eso*hageal intubation.104,10 here is little e&i3

dence for the use of thoracic im*edance in diagnosing

adeLuacy of &entilation during (R. reatment decisionsshould not be based solely on thoracic im*edance measure3

ments until further study has confirmed its utility and accu3

racy in this *o*ulation.

Postintubation Airway Management9fter inserting and confirming correct *lacement of an

endotracheal tube, the *ro&ider should record the de*th of

the tube as mar#ed at the front teeth or gums and secure it.

here is significant *otential for endotracheal tube mo&e3

detection of !2 can be drastically reduced with se&ere ment with head fleEion and eEtension10: G110 and when the

airway obstruction Beg, status asthmaticusC and *ulmonary *atient is mo&ed from one location to another.111,112

edema.@,,: For these reasons, if !2 is not detected, we

recommend that a second method be used to confirm endo3

tracheal tube *lacement, such as direct &isuali/ation or the

eso*hageal detector de&ice.

8se of !23detecting de&ices to determine the correct

*lacement of other ad&anced airways Beg, ombitube, laryn3

geal mas# airwayC has not been studied their utility will

de*end on airway design. -owe&er, effecti&e &entilation

through a su*raglottic airway de&ice should result in ca*no3

gra*h wa&eform during (R and after R!$.

Esophageal etector e!ices. he DD consists of a bulb

that is com*ressed and attached to the endotracheal tube. 5f the

tube is in the eso*hagus B*ositi&e result for an DDC, the

suction created by the DD will colla*se the lumen of the

eso*hagus or *ull the eso*hageal tissue against the ti* of the

tube, and the bulb will not re3eE*and. he DD may also

consist of a syringe that is attached to the endotracheal tube

the *ro&ider attem*ts to *ull the barrel of the syringe. 5f the

tube is in the eso*hagus, it will not be *ossible to *ull the

barrel Bas*irate airC with the syringe.

-owe&er, studies of the syringe as*iration DD, and

the self3inflating bulb DD:G:0 indicate that the accuracy

of these de&ices does not eEceed that of auscultation and

direct &isuali/ation for confirming the tracheal *osition of

an endotracheal tube in &ictims of cardiac arrest. ;i&en the

sim*licity of the DD, it can be used as the initialmethod for confirming correct tube *lacement in addition

to clinical assessment in the &ictim of cardiac arrest when

wa&eform ca*nogra*hy is not a&ailable Blass 55a, %!

+C.

he DD may yield misleading results in *atients with

morbid obesity, late *regnancy, or status asthmaticus, or

when there are co*ious endotracheal secretions,100,101because

the trachea tends to colla*se in the *resence of these condi3

tions. here is no e&idence that the DD is accurate for the

continued monitoring of endotracheal tube *lacement.

Thoracic &mpe#ance. ransthoracic im*edance is slightly but

significantly higher during ins*iration than during eEhala3tion.102 9ir is a *oor electric conductor. (reliminary studies

suggest that changes in thoracic im*edance, as measured


13/68

ontinuous monitoring of endotracheal tube *lacement

with wa&eform ca*nogra*hy is recommended as discussed

abo&e. he endotracheal tube should be secured with ta*e

or a commercial de&ice Blass 5, %! C. De&ices and ta*e

should be a**lied in a manner that a&oids com*ression of

the front and sides of the nec#, which may im*air &enous

return from the brain.

!ne out3of3hos*ital study11@ and 2 studies in an intensi&e3

care setting11>,11= indicate that bac#boards, commercial de3&ices for securing the endotracheal tube, and other strategies

*ro&ide eLui&alent methods for *re&enting inad&ertent tube

dis*lacement when com*ared with traditional methods of

securing the tube Bta*eC. hese de&ices may be considered

during *atient trans*ort Blass 55b, %! C. 9fter tube

confirmation and fiEation, obtain a chest E3ray Bwhen feasi3

bleC to confirm that the end of the endotracheal tube is

*ro*erly *ositioned abo&e the carina.

&entilation A'ter Advanced Air!ay PlacementEce*t for res*iratory rate, it is un#nown whether monitoring

&entilatory *arameters Beg, minute &entilation, *ea# *ressureC

during (R will influence outcome. -owe&er, *ositi&e3*ressure &entilation increases intrathoracic *ressure and may

reduce &enous return and cardiac out*ut, es*ecially in *a3

tients with hy*o&olemia or obstructi&e airway disease. Ien3

tilation at high res*iratory rates B 2= breaths *er minuteC is

common during resuscitation from cardiac arrest.114,11 5n

animal models, slower &entilation rates B4 to 12 breaths *er

minuteC are associated with im*ro&ed hemodynamic *aram3

eters and short3term sur&i&al.114,11:G12>

+ecause cardiac out*ut is lower than normal during

cardiac arrest, the need for &entilation is reduced. Follow3

ing *lacement of an ad&anced airway, the *ro&ider deli&3

ering &entilations should *erform 1 breath e&ery 4 to :seconds B: to 10 breaths *er minuteC without *ausing in

a**lying chest com*ressions Bunless &entilation is inade3

Luate when com*ressions are not *ausedC Blass 55b, %!

C. "onitoring res*iratory rate cou*led with real3time

feedbac# during (R may result in better com*liance with

&entilation guidelines.12=


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Automatic (ransport &entilators5n both out3of3hos*ital and in3hos*ital settings, automatic

trans*ort &entilators B9IsC can be useful for &entilation

of adult *atients in noncardiac arrest who ha&e an ad3

&anced airway in *lace Blass 55b, %! C. here are &ery

few studies e&aluating the use of 9Is attached to

ad&anced airways during ongoing resuscitati&e efforts.

During *rolonged resuscitati&e efforts the use of an 9I

B*neumatically *owered and time3 or *ressure3cycledC may

allow the "$ team to *erform other tas#s while *ro&id3

ing adeLuate &entilation and oEygenation Blass 55b, %!

C.124,12 (ro&iders should always ha&e a bag3mas# de&ice

a&ailable for bac#u*.

Suction )evices+oth *ortable and installed suction de&ices should be

a&ailable for resuscitation emergencies. (ortable units

should *ro&ide adeLuate &acuum and flow for *haryngeal

suction. he suction de&ice should be fitted with large3

bore, non#in#ing suction tubing and semirigid *haryngealti*s. $e&eral sterile suction catheters of &arious si/es

should be a&ailable for suctioning the lumen of the

ad&anced airway, along with a nonbrea#able collection

bottle and sterile water for cleaning tubes and catheters.

he installed suction unit should be *owerful enough to

*ro&ide an airflow of >0 %7min at the end of the deli&ery

tube and a &acuum of @00 mm -g when the tube is

clam*ed. he amount of suction should be adjustable for

use in children and intubated *atients.

Summary9ll basic and ad&anced healthcare *ro&iders should be able

to *ro&ide &entilation with a bag3mas# de&ice during (Ror when the *atient demonstrates cardiores*iratory com3

*romise. 9irway control with an ad&anced airway, which

may include an endotracheal tube or a su*raglottic airway

de&ice, is a fundamental 9%$ s#ill. (rolonged interru*3

tions in chest com*ressions should be a&oided during

ad&anced airway *lacement. 9ll *ro&iders should be able

to confirm and monitor correct *lacement of ad&anced

airways this #ey s#ill is reLuired to ensure the safe and

effecti&e use of these de&ices. raining, freLuency of use,

and monitoring of success and com*lications are more

im*ortant than the choice of a s*ecific ad&anced airway

de&ice for use during (R.

Part 8"2: 'ana!ement of Cardiac Arrest

&vervie$his section details the general care of a *atient in cardiac

arrest and *ro&ides an o&er&iew of the 2010 9%$ 9dult

ardiac 9rrest 9lgorithms BFigures 1 and 2C. ardiac

arrest can be caused by > rhythms6 &entricular fibrillation

BIFC, *ulseless &entricular tachycardia BIC, *ulseless

electric acti&ity B(9C, and asystole. IF re*resents disor3

gani/ed electric acti&ity, whereas *ulseless I re*resents

organi/ed electric acti&ity of the &entricular myocardium.

Neither of these rhythms generates significant forward

blood flow. (9 encom*asses a heterogeneous grou* of

organi/ed electric rhythms that are associated with either

absence of mechanical &entricular acti&ity or mechanical

&entricular acti&ity that is insufficient to generate a clini3

cally detectable *ulse. 9systole B*erha*s better described

as &entricular asystoleC re*resents absence of detectable

&entricular electric acti&ity with or without atrial electric

acti&ity.

$ur&i&al from these cardiac arrest rhythms reLuires bothbasic life su**ort B+%$C and a system of ad&anced cardio3

&ascular life su**ort B9%$C with integrated *ostG cardiac

arrest care. he foundation of successful 9%$ is high3

Luality (R, and, for IF7*ulseless I, attem*ted defibrillation

within minutes of colla*se. For &ictims of witnessed IF arrest,

early (R and ra*id defibrillation can significantly increase the

chance for sur&i&al to hos*ital discharge.12:G1@@ 5n com*arison,

other 9%$ thera*ies such as some medications and ad&anced

airways, although associated with an increased rate of R!$,

ha&e not been shown to increase the rate of sur&i&al to hos*ital

discharge.@1,@@,1@> G1@: he majority of clinical trials testing these

9%$ inter&entions, howe&er, *receded the recently renewed

em*hasis on high3Luality (R and ad&ances in *ostG cardiac

arrest care Bsee (art 6 H(ostGardiac 9rrest areJC. here3

fore, it remains to be determined if im*ro&ed rates of R!$

achie&ed with 9%$ inter&entions might better translate into

im*ro&ed long3term outcomes when combined with higher3

Luality (R and *ostG cardiac arrest inter&entions such as

thera*eutic hy*othermia and early *ercutaneous coronary

inter&ention B(5C.

he 2010 9%$ 9dult ardiac 9rrest 9lgorithms BFig3

ures 1 and 2C are *resented in the traditional boE3and3line

format and a new circular format. he 2 formats are

*ro&ided to facilitat e learning and memori/ation of the

treatment recommendations discussed below. !&erall thesealgorithms ha&e been sim*lified and redesigned to em*ha3

si/e the im*ortance of high3Luality (R that is fundamen3

tal to the management of all cardiac arrest rhythms.

(eriodic *auses in (R should be as brief as *ossible and

only as necessary to assess rhythm, shoc# IF7I, *erform

a *ulse chec# when an organi/ed rhythm is detected, or

*lace an ad&anced airway. "onitoring and o*timi/ing

Luality of (R on the basis of either mechanical *arame3

ters Bchest com*ression rate and de*th, adeLuacy of

relaEation, and minimi/ation of *ausesC or, when feasible,

*hysiologic *arameters B*artial *ressure of end3tidal !2P(!2Q, arterial *ressure during the relaEation *hase of

chest com*ressions, or central &enous oEygen saturation

P$c&!2QC are encouraged Bsee H"onitoring During (RJ

belowC. 5n the absence of an ad&anced airway, a synchro3

ni/ed com*ressionG&entilation ratio of @062 is recom3

mended at a com*ression rate of at least 100 *er minute.

9fter *lacement of a su*raglottic airway or an endotra3

cheal tube, the *ro&ider *erforming chest com*ressions

should deli&er at least 100 com*ressions *er minute

continuously without *auses for &entilation. he *ro&ider

deli&ering &entilations should gi&e 1 breath e&ery 4 to :

seconds B: to 10 breaths *er minuteC and should be

*articularly careful to a&oid deli&ering an eEcessi&e num3

ber of &entilations Bsee (art :.16 H9djuncts for 9irwayontrol and IentilationJC.


15/68

Figure 1.ACLS Cardiac Arrest Algorithm.

5n addition to high3Luality (R, the only rhythm3s*ecific

thera*y *ro&en to increase sur&i&al to hos*ital discharge is

defibrillation of IF7*ulseless I. herefore, this inter&entionis included as an integral *art of the (R cycle when the

rhythm chec# re&eals IF7*ulseless I. !ther 9%$ inter3

&entions during cardiac arrest may be associated with an

increased rate of R!$ but ha&e not yet been *ro&en toincrease sur&i&al to hos*ital discharge. herefore, they are


16/68

Figure 2.ACLS Cardiac Arrest Circular Algorithm.

recommended as considerations and should be *erformed

without com*romising Luality of (R or timely defibril3lation. 5n other words, &ascular access, drug deli&ery, and

ad&anced airway *lacement should not cause significant

interru*tions in chest com*ression or delay defibrillation.

here is insufficient e&idence to recommend a s*ecific

timing or seLuence BorderC of drug administration and

ad&anced airway *lacement during cardiac arrest. 5n most

cases the timing and seLuence of these secondary inter3

&entions will de*end on the number of *ro&iders *artici3

*ating in the resuscitation and their s#ill le&els. iming

and seLuence will also be affected by whether &ascular

access has been established or an ad&anced airway *laced

before cardiac arrest.

8nderstanding the im*ortance of diagnosing and treating

the underlying cause is fundamental to management of all

cardiac arrest rhythms. During management of cardiac arrest

the *ro&ider should consider the -s and s to identify and

treat any factor that may ha&e caused the arrest or may be

com*licating the resuscitati&e effort Bable 1C.

5t is common for the arrest rhythm to e&ol&e during the

course of resuscitation. 5n such cases management should

shift smoothly to the a**ro*riate rhythm3based strategy. 5n

*articular , *ro&iders should be *re*ared to deli&er a timely

shoc# when a *atient who *resented with asystole or (9

is found to be in IF7*ulseless I during a rhythm chec#.

here is no e&idence that the resuscitation strategy for anew cardiac arrest rhythm should necessarily be altered

based on the characteristics of the *re&ious rhythm. "ed3

ications administered during resuscitation should be mon3itored and total doses tabulated to a&oid *otential toEicity.

5f the *atient achie&es R!$, it is im*ortant to begin

*ostG cardiac arres t care immediately to a&oid rearrest and

o*timi/e the *atients chance of long3term sur&i&al with

good neurologic function Bsee (art C. Finally, the reality is

that the majority of resuscitati&e efforts do not result in

R!$. riteria for ending unsuccessful resuscitati&e ef3

forts are addressed briefly below Bsee HWhen $hould

Resuscitati&e fforts $to*JC and in more detail in (art @6

Hthics.J

R5yt5m


17/68


18/68

in manual instead of automatic mode during cardiac arrest is

uncertain Blass 55b, %! C.

CP) *efore efibrillationDuring treatment of IF7*ulseless I healthcare *ro&iders

must ensure that coordination between (R and shoc#

deli&ery is efficient. When IF is *resent for more than a

few minutes, the myocardium is de*leted of oEygen and

metabolic substrates. 9 brief *eriod of chest com*ressions

can deli&er oEygen and energy substrates and HunloadJ the

&olume3o&erloaded right &entricle, increasing the li#eli3

hood that a *erfusing rhythm will return after shoc#

deli&ery.1>1

(erforming (R while a defibrillator is readied for use is

strongly recommended for all *atients in cardiac arrest Blass

5, %! +C. 9nalyses of IF wa&eform characteristics *redic3

ti&e of shoc# success ha&e documented that the shorter the

time inter&al between the last chest com*ression and shoc#

deli&ery, the more li#ely the shoc# will be successful. 1>1 9

reduction of e&en a few seconds in the inter&al from *ausing

com*ressions to shoc# deli&ery can increase the *robability

of shoc# success.1>2

he &alue of intentionally delaying defibrillation to *erform

(R is less clear. !ne randomi/ed controlled trial BRC1>@

and one clinical trial1>> in&ol&ing adults with out3of3hos*ital

cardiac arrest not witnessed by "$ *ersonnel showed that

sur&i&al was im*ro&ed by a *eriod of (R *erformed before

the first defibrillation shoc# when the "$ res*onse inter&al

was > to

= minutes. +ut 2 Rs1>=,1>4 demonstrated no im*ro&ement in

R!$ or sur&i&al to hos*ital discharge in *atients with out3of3

hos*ital IF or *ulseless I who recei&ed (R from "$

*ersonnel for 1.= to @ minutes before defibrillation, regardless

of "$ res*onse inter&al. 9t this time the benefit of delaying

defibrillation to *erform (R before defibrillation is unclearBlass 55b, %! +C.

(+ 'a!eform Analysis to Pre#ict efibrillation ,uccess

Retros*ecti&e analysis of IF wa&eforms in multi*le clinical

studies suggests that it is *ossible to *redict the success of

defibrillation from the fibrillation wa&eform with &arying

reliability.1>1,1>G144 No *ros*ecti&e human studies ha&e s*e3

cifically e&aluated whether treatment altered by *redicting

success of defibrillation can im*ro&e successful defibrilla3

tion, rate of R!$, or sur&i&al from cardiac arrest. he &alue

of IF wa&eform analysis to guide management of defibril3

lation in adults with in3hos*ital and out3of3hos*ital cardiac

arrest is uncertain Blass 55b, %! C.

Drug (erapy in &)*Pulseless

&(When IF7*ulseless I *ersists after at least 1 shoc# and a

23minute (R *eriod, a &aso*ressor can be gi&en with the

*rimary goal of increasing myocardial blood flow during

(R and achie&ing R!$ Bsee H"edications for 9rrest

RhythmsJ below for dosingC Blass 55b, %! 9C. he *ea#

effect of an intra&enous B5IC7intraosseous B5!C &aso*ressor

gi&en as a bolus dose during (R is delayed for at least 1 to

2 minutes. he o*timal timing of &aso*ressor administration

during the 23minute *eriod of uninterru*ted (R has not

been established. 5f a shoc# fails to generate a *erfusingrhythm, then gi&ing a &aso*ressor soon after the shoc# will

o*timi/e


19/68

the *otential im*act of increased myocardial blood flow

before the neEt shoc#. -owe&er, if a shoc# results in a

*erfusing rhythm, a bolus dose of &aso*ressor at any time

during the subseLuent 23minute *eriod of (R Bbefore

rhythm chec#C could theoretically ha&e detrimental effects on

cardio&ascular stability. his may be a&oided by using

*hysiologic monitoring such as Luantitati&e wa&eform ca*3

nogra*hy, intra3arterial *ressure monitoring, and continuous

central &enous oEygen saturation monitoring to detect R!$

during chest com*ressions.@,14G1 -owe&er, adding an ad3

ditional *ause for rhythm and *ulse chec# after shoc#

deli&ery but before &aso*ressor thera*y will decrease myo3

cardial *erfusion during the critical *ostshoc# *eriod and

could reduce the chance of achie&ing R!$.

9miodarone is the first3line antiarrhythmic agent gi&en

during cardiac arrest because it has been clinically demon3

strated to im*ro&e the rate of R!$ and hos*ital admission

in adults with refractory IF7*ulseless I. 9miodarone may

be considered when IF7I is unres*onsi&e to (R,

defibrilla3 tion, and &aso*ressor thera*y Blass 55b, %! 9C.5f amiod3 arone is una&ailable, lidocaine may be considered,

but in clinical studies lidocaine has not been demonstrated to

im*ro&e rates of R!$ and hos*ital admission com*ared

with amiodarone Blass 55b, %! +C. "agnesium sulfate

should be considered only for torsades de *ointes associated

with a long S inter&al Blass 55b, %! +C.

(reating Potentially Reversi%le Causes o'&)*Pulseless &(he im*ortance of diagnosing and treating the underlying

cause of IF7*ulseless I is fundamental to the management

of all cardiac arrest rhythms. 9s always, the *ro&ider should

recall the -s and s to identify a factor that may ha&e

caused the arrest or may be com*licating the resuscitati&e

effort Bsee able 1 and (art 126 H$*ecial Resuscitation

$ituationsJC. 5n the case of refractory IF7*ulseless I, acute

coronary ischemia or myocardial infarction should be con3

sidered as a *otential etiology. Re*erfusion strategies such as

coronary angiogra*hy and (5 during (R or emergency

cardio*ulmonary by*ass ha&e been demonstrated to be fea3

sible in a number of case studies and case series but ha&e not

been e&aluated for their effecti&eness in Rs.1: G1: Fibrino3

lytic thera*y administered during (R for acute coronary

occlusion has not been shown to im*ro&e outcome.1::

ROSC A'ter &)*Pulseless &(5f the *atient has R!$, *ostG cardiac arrest care should be

started B(art C. !f *articular im*ortance are treatment of

hy*oEemia and hy*otension, early diagnosis and treatment of

$3ele&ation myocardial infarction B$"5C Blass 5, %!

+C and thera*eutic hy*othermia in comatose *atients Blass 5,

%! +C.

PA6AsystoleWhen a rhythm chec# by an 9D re&eals a nonshoc#able

rhythm, (R should be resumed immediately, beginning with

chest com*ressions, and should continue for 2 minutes before

the rhythm chec# is re*eated. When a rhythm chec# using a

manual defibrillator or cardiac monitor re&eals an organi+ed

rytm, a *ulse chec# is *erformed. 5f a *ulse is detected,

*ostG cardiac arrest care should be initiated immediately Bsee

(art C. 5f the rhythm is asystole or the *ulse is absent Beg,

(9C, (R should be resumed immediately, beginning with

chest com*ressions, and should continue for 2 minutes before

the rhythm chec# is re*eated. he *ro&ider *erforming chest

com*ressions should switch e&ery 2 minutes. (R Luality

should be monitored on the basis of mechanical or *hysio3logic *arameters Bsee H"onitoring During (RJ belowC.

Drug (erapy 'or P#A*Asystole9 &aso*ressor can be gi&en as soon as feasible with the

*rimary goal of increasing myocardial and cerebral blood

flow during (R and achie&ing R!$ Bsee HIaso*ressorsJ

below for dosingC Blass 55b, %! 9C. 9&ailable e&idence

suggests that the routine use of atro*ine during (9 or

asystole is unli#ely to ha&e a thera*eutic benefit Blass 55b,

%! +C. For this reason atro*ine has been remo&ed from the

cardiac arrest algorithm.

(reating Potentially Reversi%le Causes o' P#A*Asystole

(9 is often caused by re&ersible conditions and can betreated successfully if those conditions are identified andcorrected. During each 23minute *eriod of (R the *ro&ider

should recall the -s and s to identify factors that may ha&e

caused the arrest or may be com*licating the resuscitati&e

effort Bsee able 1 and (art 126 H$*ecial Resuscitation

$ituationsJC. ;i&en the *otential association of (9 with

hy*oEemia, *lacement of an ad&anced airway is theoretically

more im*ortant than during IF7*ulseless I and might be

necessary to achie&e adeLuate oEygenation or &entilation.

(9 caused by se&ere &olume loss or se*sis will *otentially

benefit from administration of em*irical 5I75! crystalloid. 9

*atient with (9 caused by se&ere blood loss will *otentially

benefit from a blood transfusion. When *ulmonary embolismis *resumed or #nown to be the cause of cardiac arrest,

em*irical fibrinolytic thera*y can be considered Blass 55a,

%! + see (art 12C. Finally, if tension *neumothoraE is

clinically sus*ected as the cause of (9, initial management

includes needle decom*ression. 5f a&ailable, echocardiogra3

*hy can be used to guide management of (9 because it

*ro&ides useful information about intra&ascular &olume status

Bassessing &entricular &olumeC, cardiac tam*onade, mass

lesions Btumor, clotC, left &entricular contractility, and re3

gional wall motion.1: $ee (art 12 for management of

toEicological causes of cardiac arrest.

9systole is commonly the end3stage rhythm that follows

*rolonged IF or (9, and for this reason the *rognosis isgenerally much worse.

ROSC A'ter P#A*Asystole5f the *atient has R!$, *ostG cardiac arrest care shouldbe

initiated Bsee (art C. !f *articular im*ortance is treatment of

hy*oEemia and hy*otension and early diagnosis and treat3

ment of the underlying cause of cardiac arrest. hera*eutic

hy*othermia may be considered when the *atient is comatose

Blass 55b, %! C.

'onitorin! )urin! CPR

,ecanical Parameters(R Luality can be im*ro&ed by using a number of


20/68

non*hysi3

ologic techniLues that hel* the *ro&ider adhere to recom3


21/68

mended (R *arameters such as rate and de*th of com*res3

sion and rate of &entilation. he most sim*le are auditory or

&isual metronomes to guide *ro&iders in *erforming the

recommended rate of chest com*ressions or &entilations.

"ore so*histicated de&ices actually monitor chest com*res3

sion rate, de*th, relaEation, and *auses in real time and

*ro&ide &isual and auditory feedbac#. When recorded, this

information can also be useful in *ro&iding feedbac# to the

entire team of *ro&iders after the resuscitation has ended.

his ty*e of (R Luality monitoring is discussed in more

detail in (art =6 H9dult +asic %ife $u**ortJ and (art 146

Hducation, 5m*lementation and eams.J

Pysiologic Parameters5n humans cardiac arrest is the most critically ill condition,

yet it is ty*ically monitored by rhythm assessment using

selected electocardiogra*hic B;C leads and *ulse chec#s

as the only *hysiologic *arameters to guide thera*y.

9nimal and human studies indicate that monitoring of

(!2, coronary *erfusion *ressure B((C, and central

&enous oEygen saturation B$c&!2C *ro&ides &aluable infor3mation on both the *atients condition and res*onse to

*ressed as a *artial *ressure in mm -g B(!2C. +ecause

!2 is a trace gas in atmos*heric air, !2 detected by

ca*nogra*hy in eEhaled air is *roduced in the body and

deli&ered to the lungs by circulating blood. 8nder normal

conditions (!2 is in the range of @= to >0 mm -g.

During untreated cardiac arrest !2 continues to be

*roduced in the body, but there is no !2 deli&ery to thelungs. 8nder these conditions (!2 will a**roach /ero

with continued &entilation. With initiation of (R, cardiac

out*ut is the major determinant of !2 deli&ery to the

lungs. 5f &entilation is relati&ely constant, (!2 corre3

lates well with cardiac out*ut during (R. he correlation

between (!2 and cardiac out*ut during (R can be

transiently altered by gi&ing 5I sodium bicarbonate.20:

his is eE*lained by the fact that the bicarbonate is

con&erted to water and !2, causing a transient increase in

deli&ery of !2 to the lungs. herefore, a transient rise in

(!2 after sodium bicarbonate thera*y is eE*ected and

should not be misinter*reted as an im*ro&ement in Luality

of (R or a sign of R!$. 9nimal and human studies ha&ealso shown that (!2 correlates with (( and cerebral

thera*y. "ost im*ortantly, (!2, ((, and $c&!2 corre3*erfusion *ressure during (R.20,210 he correlation of

late with cardiac out*ut and myocardial blood flow during

(R, and threshold &alues below which R!$ is rarely

achie&ed ha&e been re*orted.14:,10 G1= Furthermore, an

abru*t increase in any of these *arameters is a sensiti&e

indicator of R!$ that can be monitored without interru*ting

chest com*ressions.1,@,14G1=,1,14 G201 9lthough no clinical

study has eEamined whether titrating resuscitati&e efforts to

these or other *hysiologic *arameters im*ro&es outcome, it is

reasonable to consider using these *arameters when feasible

to o*timi/e chest com*ressions and guide &aso*ressor ther3

a*y during cardiac arrest Blass 55b, %! C.

Pulselinicians freLuently try to *al*ate arterial *ulses during chest

com*ressions to assess the effecti&eness of com*ressions. No

studies ha&e shown the &alidity or clinical utility of chec#ing

*ulses during ongoing (R. +ecause there are no &al&es in the

inferior &ena ca&a, retrograde blood flow into the &enous

system

(!2 with (( during (R can be altered by &aso*res3

sor thera*y, es*ecially at high doses Bie, 1 mg of

e*ine*hrineC.211G21> Iaso*ressors cause increased after3

load, which will increase blood *ressure and myocardial

blood flow during (R but will also decrease cardiac

out*ut. herefore, a small decrease in (!2 after &aso3

*ressor thera*y may occur but should not be misinter*reted

as a decrease in (R Luality.

(ersistently low (!2 &alues B 10 mm -gC during

(R in intubated *atients suggest that R!$ is

unli#ely.11,1@,1>,10,11,21=,214 $imilar data using Luantita3ti&e monitoring of (!2 are not a&ailable for *atients with

a su*raglottic airway or those recei&ing bag3mas# &entilation

during (R. !ne study using colorimetic end3tidal !2detection in nonintubated *atients during (R found that low

end3tidal !2 was not a reliable *redictor of failure to

achie&e R!$.21 9n air lea# during bag3mas# &entilation or

&entilation with a su*raglottic airway could result in lower

may *roduce femoral &ein *ulsations.202 hus, *al*ation of a

*ulse in the femoral triangle may indicate &enous rather thanmeasured (!2 &alues. 9lthough a (!2 &alue of

arterial blood flow. arotid *ulsations during (R do not

indicate the efficacy of myocardial or cerebral *erfusion during

(R. (al*ation of a *ulse when chest com*ressions are *ausedis a reliable indicator of R!$ but is *otentially less sensiti&e

than other *hysiologic measures discussed below.

-ealthcare *ro&iders also may ta#e too long to chec# for a

10 mm -g in intubated *atients indicates that cardiac

out*ut is inadeLuate to achie&e R!$, a s*ecific target

(!2 &alue that o*timi/es the chance of R!$ has not

been established. "onitoring (!2 trends during (R

has the *otential to guide indi&idual o*timi/ation of

com*ression de*th and rate and to detect fatigue in the

*ro&ider *erforming com*ressions.201,21:,21 5n addition, an

abru*t sustained in3*ulse20@,20> and ha&e difficulty determining if a *ulse is

crease in (!2 during (R is an indicator of*resent or absent.20@G20= here is no e&idence, howe&er, that

chec#ing for breathing, coughing, or mo&ement is su*erior

for detection of circulation.204 +ecause delays in chest com3

*ressions should be minimi/ed, the healthcare *ro&ider

should ta#e no more than 10 seconds to chec# for a *ulse,

and

R!$.1,1,14,1:G201 herefore, it is reasonable to consider

using Luantitati&e wa&eform ca*nogra*hy in intubated *a3

tients to monitor (R Luality, o*timi/e chest com*ressions,

and detect R!$ during chest com*ressions or when rhythm

chec# re&eals an organi/ed rhythm Blass 55b, %! C. 5f

if it is not felt within that time *eriod chest com*ressions

should be started.20=,20

(!2 is 10 mm -g, it is reasonable to consider trying to

#nd-(idal CO2

nd3tidal !2 is the concentration of carbon dioEide ineEhaled air at the end of eE*iration. 5t is ty*ically eE3


22/68

im*ro&e (R Luality by o*timi/ing chest com*ression *a3

rameters Blass 55b, %! C. 5f (!2 abru*tly increases to

a normal &alue B@= to >0 mm -gC, it is reasonable to consider

that this is an indicator of R!$ Blass 55a, %! +C. he


23/68

&alue of using Luantitati&e wa&eform ca*nogra*hy in nonin3

tubated *atients to monitor and o*timi/e (R Luality and

detect R!$ is uncertain Blass 55b, %! C.

Coronary Per'usion Pressure and Arterial

Relaxation Pressure

(( Bcoronary *erfusion *ressure aortic relaEationPHdiastolicJQ *ressure minus right atrial relaEation PHdia3

stolicJQ *ressureC during (R correlates with both

myocardial blood flow and R!$.14:,12,220 RelaEation *ressure

during (R is the trough of the *ressure wa&eform during the

relaEation *hase of chest com*ressions and is analogous to

diastolic *ressure when the heart is beating. 5ncreased ((

correlates with im*ro&ed 2>3hour sur&i&al rates in animal

studies1@ and is associated with im*ro&ed myocardial blood

flow and R!$ in animal studies of e*ine*hrine, &aso*ressin,

and angiotensin 55.1@G1= 5n one human study R!$ did not

occur unless a ((

1= mm -g was achie&ed during (R.14: -owe&er,

monitoring of (( during (R is rarely a&ailable clinically

because measurement and calculation reLuire simultaneous

recording of aortic and central &enous *ressure.

9 reasonable surrogate for (( during (R is arterial

relaEation BHdiastolicJC *ressure, which can be measured

using a radial, brachial, or femoral artery catheter. hese

closely a**roEimate aortic relaEation *ressures during (R

in humans.211,221 he same study that identified a ((

threshold of 1= mm -g for R!$ also re*orted that R!$

was not achie&ed if aortic relaEation HdiastolicJ *ressure

did not eEceed 1 mm -g during (R.14: 9 s*ecific target

arterial relaEation *ressure that o*timi/es the chance of

R!$ has not been established. 5t is reasonable to considerusing arterial relaEation HdiastolicJ *ressure to monitor

(R Luality, o*timi/e chest com*ressions, and guide

&aso*ressor thera*y. Blass 55b, %! C. 5f the arterial

relaEation HdiastolicJ *ressure is 20 mm -g, i t is

reasonable to consider trying to im*ro&e Luality of (R by

o*timi/ing chest com*ression *arameters or gi&ing a

&aso*ressor or both Blass 55b, %! C. 9rterial *ressure

monitoring can also be used to detect R!$ during chest

com*ressions or when a rhythm chec# re&eals an organi/ed

rhythm Blass 55b, %! C.

Central &enous Oxygen SaturationWhen oEygen consum*tion, arterial oEygen saturation

B$a!2C, and hemoglobin are constant, changes in $c& !2reflect changes in oEygen deli&ery by means of changes in

cardiac out*ut. $c&!2 can be measured continuously using

oEimetric ti**ed central &enous catheters *laced in the

su*erior &ena ca&a. $c&!2 &alues normally range from 40M

to:0M. During cardiac arrest and (R these &alues range from

2=M to @=M, indicating the inadeLuacy of blood flow

*roduced during (R. 5n one clinical study the failure to

achie&e $c&!2 of @0M during (R was associated with

failure to achie&e R!$.14 $c&!2

also hel*s to ra*idly detect

R!$ without interru*ting chest com*ressions to chec#

rhythm and *ulse. When a&ailable, continuous $c&!2 moni3

toring is a *otentially useful indicator of cardiac out*ut and


24/68

oEygen deli&ery during (R. herefore, when in *lace

before cardiac arrest, it is reasonable to consider using

continuous $c&!2 measurement to monitor Luality of

(R, o*timi/e chest com*ressions, and detect R!$ during

chest com*res3 sions or when rhythm chec# re&eals an

organi/ed rhythm Blass 55b, %! C. 5f $c&!2 is @0M, it is

reasonable to consider trying to im*ro&e the Luality of (R

by o*timi/ing chest com*ression *arameters Blass 55b,

%! C.

Pulse OximetryDuring cardiac arrest, *ulse oEimetry ty*ically does not

*ro&ide a reliable signal because *ulsatile blood flow is

inadeLuate in *eri*heral tissue beds. +ut the *resence of a

*lethysmogra*h wa&eform on *ulse oEimetry is *otentially

&aluable in detecting R!$, and *ulse oEimetry is useful to

ensure a**ro*riate oEygenation after R!$.

Arterial .lood /ases9rterial blood gas monitoring during (R is not a reliable

indicator of the se&erity of tissue hy*oEemia, hy*ercarbia

Band therefore adeLuacy of &entilation during (RC, or tissueacidosis.222 Routine measurement of arterial blood gases

during (R has uncertain &alue Blass 55b, %! C.

#cocardiograpyNo studies s*ecifically eEamine the im*act of echocardiog3

ra*hy on *atient outcomes in cardiac arrest. -owe&er, a

number of studies suggest that transthoracic and transeso*h3

ageal echocardiogra*hy ha&e *otential utility in diagnosing

treatable causes of cardiac arrest such as cardiac tam*onade,

*ulmonary embolism, ischemia, and aortic dissection.22@G22

5n addition, @ *ros*ecti&e studies22: G2@0 found that absence of

cardiac motion on sonogra*hy during resuscitation of *atients

in cardiac arrest was highly *redicti&e of inability to achie&eR!$6 of the @>1 *atients from the @ studies, 21: had no

detectable cardiac acti&ity and only 2 of these had R!$ Bno

data on sur&i&al3to3hos*ital discharge were re*ortedC. rans3

thoracic or transeso*hageal echocardiogra*hy may be con3

sidered to diagnose treatable causes of cardiac arrest and

guide treatment decisions Blass 55b, %! C.

Access for Parenteral 'edications )urin!

Cardiac Arrest

(iming o' $&*$O AccessDuring cardiac arrest, *ro&ision of high3Luality (R and

ra*id defibrillation are of *rimary im*ortance and drugadministration is of secondary im*ortance. 9fter beginning

(R and attem*ting defibrillation for identified IF or *ulse3

less I, *ro&iders can establish 5I or 5! access. his should

be *erformed without interru*ting chest com*ressions. he

*rimary *ur*ose of 5I75! access during cardiac arrest is to

*ro&ide drug thera*y. wo clinical studies1@>,1@4 re*orted data

suggesting worsened sur&i&al for e&ery minute that antiar3

rhythmic drug deli&ery was delayed Bmeasured from time of

dis*atchC. -owe&er, this finding was *otentially biased by a

concomitant delay in onset of other 9%$ inter&entions. 5n

one study1@4 the inter&al from first shoc# to administration of

an antiarrhythmic drug was a significant *redictor ofsur&i&al.


25/68

!ne animal study2@1 re*orted lower (( when deli&ery of a

&aso*ressor was delayed. ime to drug administration was

also a *redictor of R!$ in a retros*ecti&e analysis of swine

cardiac arrest.2@2 hus, although time to drug treatment

a**ears to ha&e im*ortance, there is insufficient e&idence to

s*ecify eEact time *arameters or the *recise seLuence with

which drugs should be administered during cardiac arrest.

Periperal $& Drug Delivery5f a resuscitation drug is administered by a *eri*heral &enous

route, it should be administered by bolus injection and

followed with a 203m% bolus of 5I fluid to facilitate the drug

flow from the eEtremity into the central circulation.2@@ +riefly

ele&ating the eEtremity during and after drug administration

theoretically may also recruit the benefit of gra&ity to

facilitate deli&ery to the central circulation but has not been

systematically studied.

$O Drug Delivery5! cannulation *ro&ides access to a noncolla*sible &enous

*leEus, enabling drug deli&ery similar to that achie&ed by

*eri*heral &enous access at com*arable doses. wo *ros*ec3

ti&e trials in children2@> and adults2@= and 4 other studies2@4 G

2>2 suggest that 5! access can be established efficiently is

safe and effecti&e for fluid resuscitation, drug deli&ery, and

blood sam*ling for laboratory e&aluation and is attainable in

all age grou*s. -owe&er, many of these studies were con3

ducted during normal *erfusion states or hy*o&olemic shoc#

or in animal models of cardiac arrest. 9lthough &irtually all

9%$ drugs ha&e been gi&en intraosseously in the clinical

setting without #nown ill effects, there is little information on

the efficacy and effecti&eness of such administration inclinical cardiac arrest during ongoing (R. 5t is reasonable

for *ro&iders to establish 5! access if 5I access is not readily

a&ailable Blass 55a, %! C. ommercially a&ailable #its

can facilitate 5! access in adults.

Central $& Drug Deliveryhe a**ro*riately trained *ro&ider may consider *lacement

of a central line Binternal jugular or subcla&ianC during

cardiac arrest, unless there are contraindications Blass 55b,

%! C. he *rimary ad&antage of a central line is that *ea#

drug concentrations are higher and drug circulation times

shorter com*ared with drugs administered through a *eri*h3eral 5I catheter.2>@G2>= 5n addition, a central line eEtending

into the su*erior &ena ca&a can be used to monitor $c&!2 and

estimate (( during (R, both of which are *redicti&e of

R!$.14:,14 -owe&er, central line *lacement can interru*t

(R. entral &enous catheteri/ation is a relati&e Bbut not

absoluteC contraindication for fibrinolytic thera*y in *atients

with acute coronary syndromes.

#ndotraceal Drug Delivery!ne study in children,2>4 = studies in adults,2>G2=1 and

multi*le animal studies2=2G2=> ha&e shown that lido3

caine,2>:,2==

e*ine*hrine,2=4

atro*ine,2=

naloEone, and &aso3*ressin2=> are absorbed &ia the trachea. here are no data

regarding endotracheal administration of amiodarone. 9d3

ministration of resuscitation drugs into the trachea results in

lower blood concentrations than when the same dose is gi&en

intra&ascularly. Furthermore, the results of recent animal

studies2=:,2= suggest that the lower e*ine*hrine concentra3

tions achie&ed when the drug is deli&ered endotracheally may

*roduce transient 3adrenergic effects, resulting in &asodila3tion. hese effects can be detrimental, causing hy*otension,

lower (( and flow, and reduced *otential for R!$. hus,

although endotracheal administration of some resuscitation

drugs is *ossible, 5I or 5! drug administration is *referred

because it will *ro&ide more *redictable drug deli&ery and

*harmacologic effect.

5n one nonrandomi/ed cohort study of out3of3hos*ital

cardiac arrest in adults240 using a randomi/ed control, 5I

administration of atro*ine and e*ine*hrine was associated

with a higher rate of R!$ and sur&i&al to hos*ital

admission than administration by the endotracheal route. Fi&e

*ercent of those who recei&ed 5I drugs sur&i&ed to hos*ital

discharge, but no *atient sur&i&ed in the grou* recei&ing

drugs by the endotracheal route.

5f 5I or 5! access cannot be established, e*ine*hrine,

&aso*ressin, and lidocaine may be administered by the

endotracheal route during cardiac arrest Blass 55b, %! +C.

he o*timal endotracheal dose of most drugs is un#nown, but

ty*ically the dose gi&en by the endotracheal route is 2 to 21T2

times the recommended 5I dose. 5n 2 animal (R studies the

eLui*otent e*ine*hrine dose gi&en endotracheally was a*3

*roEimately @ to 10 times higher than the 5I dose.241,242

(ro&iders should dilute the recommended dose in = to 10 m%

of sterile water or normal saline and inject the drug directly

into the endotracheal tube.2=4

$tudies with e*ine*hrine24@

andlidocaine2=1 showed that dilution with sterile water instead of

0.M saline may achie&e better drug absor*tion.

Advanced Air$ayhere is inadeLuate e&idence to define the o*timal timing of

ad&anced airway *lacement in relation to other inter&entions

during resuscitation from cardiac arrest. here are no *ro3

s*ecti&e studies that directly address the relationshi* between

timing or ty*e of ad&anced airway *lacement during (R

and outcomes. 5n an urban out3of3hos*ital setting,

intubation in

12 minutes has been associated with a better rate of

sur&i&al than intubation in 1@ minutes.@2 5n a registry

study of

2= 004 in3hos*ital cardiac arrests, earlier time to ad&anced

airway B = minutesC was not associated with increased

R!$ but was associated with im*ro&ed 2>3hour sur&i&al.@1

5n out3of3hos*ital urban and rural settings, *atients intubated

during resuscitation had better sur&i&al rates than *atients

who were not intubated.@@ 5n an in3hos*ital setting *atients

reLuiring intubation during (R had worse sur&i&al rates.@> 9

recent study: found that delayed endotracheal intubation

combined with *assi&e oEygen deli&ery and minimally inter3

ru*ted chest com*ressions was associated with im*ro&ed

neurologically intact sur&i&al after out3of3hos*ital cardiacarrest in *atients with witnessed IF7I.


26/68

9d&antages of ad&anced airway *lacement include elimi3

nation of the need for *auses in chest com*ressions for


27/68


28/68

rates of R!$ with 9%$ medications to be translated into

increased long3term sur&i&al remains to be determined.

%asopressorso date no *lacebo3controlled trials ha&e shown that admin3

istration of any &aso*ressor agent at any stage during man3

agement of IF, *ulseless I, (9, or asystole increases the

rate of neurologically intact sur&i&al to hos*ital discharge.

here is e&idence, howe&er, that the use of &aso*ressoragents is associated with an increased rate of R!$.

#pineprin

e*ine*hrine hydrochloride *roduces beneficial effects in

*atients during cardiac arrest, *rimarily because of its

3adrenergic rece*tor3stimulating Bie, &asoconstrictorC *ro*3

erties.24> he 3adrenergic effects of e*ine*hrine can increase

(( and cerebral *erfusion *ressure during (R. 24= he

&alue and safety of the 3adrenergic effects of e*ine*hrine

are contro&ersial because they may increase myocardial

wor# and reduce subendocardial *erfusion.244

here are no Rs that adeLuately com*are e*ine*hrinewith *lacebo in treatment of and outcomes related to out3of3

hos*ital cardiac arrest. 9 retros*ecti&e study24 com*ared

e*ine*hrine to no e*ine*hrine for sustained IF and (97

asystole and found im*ro&ed R!$ with e*ine*hrine but no

difference in sur&i&al between the treatment grou*s. 9

meta3analysis and other studies ha&e found im*ro&ed R!$,

but none ha&e demonstrated a sur&i&al benefit of high3dose

e*ine*hrine &ersus standard3dose e*ine*hrine in cardiac

arrest.1@=,24:G22

5t is reasonable to consider administering a 1 mg dose of

5I75! e*ine*hrine e&ery @ to = minutes during adult cardiac

arrest Blass 55b, %! 9C. -igher doses may be indicated to

treat s*ecific *roblems, such as a 3bloc#er or calcium

channel bloc#er o&erdose. -igher doses can also be consid3

ered if guided by hemodynamic monitoring such as arterial

relaEation HdiastolicJ *ressure or ((. 5f 5I75! access is

delayed or cannot be established, e*ine*hrine may be gi&en

endotracheally at a dose of 2 to 2.= mg.

&asopressinIaso*ressin is a nonadrenergic *eri*heral &asoconstrictor

that also causes coronary and renal &asoconstriction.2@

hree Rs and a meta3analysis of the trials2> G2 dem3

onstrated no difference in outcomes BR!$, sur&i&al to

discharge, or neurologic outcomeC with &aso*ressin B>0units 5IC &ersus e*ine*hrine B1 mgC as a first3line &aso3

*ressor in cardiac arrest. wo Rs2:,2 demonstrated no

difference in outcomes BR!$, sur&i&al to discharge, or

neurologicC when com*aring e*ine*hrine in combination

with &aso*ressin &ersus e*ine*hrine alone in cardiac

arrest. !ne R found that re*eated doses of &aso*ressin

during cardiac arrest did not im*ro&e sur&i&al rates com3

*ared with re*eated doses of e*ine*hrine.2:0

+ecause the effects of &aso*ressin ha&e not been shown to

differ from those of e*ine*hrine in cardiac arrest, 1 dose of

&aso*ressin >0 units 5I75! may re*lace either the first or

second dose of e*ine*hrine in the treatment of cardiac arrest

Blass 55b, %! 9C.


29/68

Oter &asopressorshere are no alternati&e &aso*ressors Bnore*ine*hrine,

*henyle*hrineC with *ro&en sur&i&al benefit com*ared

with e*ine*hrine.24:,2:1,2:2

Antiarr5yt5mics

here is no e&idence that any antiarrhythmic drug gi&en

routinely during human cardiac arrest increases sur&i&al to

hos*ital discharge. 9miodarone, howe&er, has been shown to

increase short3term sur&i&al to hos*ital admission when

com*ared with *lacebo or lidocaine.

Amiodarone5I amiodarone affects sodium, *otassium, and calcium chan3

nels and has 3 and 3adrenergic bloc#ing *ro*erties. 5t can

be considered for treatment of IF or *ulseless I unres*on3

si&e to shoc# deli&ery, (R, and a &aso*ressor. 5n blinded

randomi/ed controlled clinical trials in adults with refractory

IF7*ulseless I in the out3of3hos*ital setting,1@>,1@4 *ara3medic administration of amiodarone B@00 mg1@> or = mg7#g1@4C

im*ro&ed hos*ital admission rates when com*ared with

administration of *lacebo1@> or 1.= mg7#g of lidocaine.1@4

9dditional studies2:@G2: documented consistent im*ro&ement

in termination of arrhythmias when amiodarone was gi&en to

humans or animals with IF or hemodynamically unstable

I. 9 higher incidence of bradycardia and hy*otension was

re*orted for amiodarone in one out3of3hos*ital study.1@> 9

canine study2:: noted that administration of a &asoconstrictor

before amiodarone *re&ented hy*otension. he ad&erse he3

modynamic effects of the 5I formulation of amiodarone are

attributed to &asoacti&e sol&ents B*olysorbate :0 and ben/ylalcoholC. When administered in the absence of these sol&ents,

an analysis of the combined data of > *ros*ecti&e clinical

trials of *atients with I Bsome hemodynamically unstableC

showed that amiodarone *roduced no more hy*otension than

lidocaine.2:4 9 formulation of 5I amiodarone without these

&asoacti&e sol&ents was a**ro&ed for use in the 8nited

$tates. 9miodarone may be considered for IF or *ulseless

I unres*onsi&e to (R, defibrillation, and a &aso*ressor

ther3 a*y Blass 55b, %! +C. 9n initial dose of @00 mg

5I75! can be followed by 1 dose of 1=0 mg 5I75!.

9lthough anecdot3 ally administered 5! without #nown

ad&erse effects, there islimited eE*erience with amiodarone gi&en by this route.

0idocaine9 retros*ecti&e re&iew2: demonstrated an association

between im*ro&ed hos*ital admission rates and use of

lidocaine Bcom*ared with standard treatmentC in *atients

with out3of3hos*ital IF cardiac arrest. +ut there is inade3

Luate e&idence to recommend the use of lidocaine in

*atients who ha&e refractory I7IF, defined as I7IF not

terminated by defibrillation or that continues to recur after

defibrillation during out3of3hos*ital cardiac arrest or in3

hos*ital cardiac arrest.

%idocaine is an alternati&e antiarrhythmic of long3standing

and wides*read familiarity with fewer immediate side effects


30/68

than may be encountered with other antiarrhythmics. %ido3

caine, howe&er, has no *ro&en short3 or long3term efficacy in

cardiac arrest. %idocaine may be considered if amiodarone is

not a&ailable Blass 55b, %! +C. he initial dose is 1 to 1.=

mg7#g 5I. 5f IF7*ulseless I *ersists, additional doses of 0.=

to 0.= mg7#g 5I *ush may be administered at =3 to

103minute inter&als to a maEimum dose of @ mg7#g.

,agnesium Sul'atewo obser&ational studies20,21 showed that 5I magnesium

sulfate can facilitate termination of torsades de *ointes

Birregular7*olymor*hic I associated with *rolonged S

inter&alC. "agnesium sulfate is not li#ely to be effecti&e in

terminating irregular7*olymor*hic I in *atients with a

normal S inter&al.21

9 number of doses of magnesium sulfate ha&e been used

clinically, and an o*timal dosing regimen has not been

established. When IF7*ulseless I cardiac arrest is associ3

ated with torsades de *ointes, *ro&iders may administer an

5I75! bolus of magnesium sulfate at a dose of 1 to 2 g

diluted in 10 m% D=W Blass 55b, %! C. $ee (art :.@6

H"anage3 ment of $ym*tomatic +radycardia andachycardiaJ for additional information about management

of torsades de *ointes not associated with cardiac arrest.

hree Rs22G2> did not identify a significant benefit

from use of magnesium com*ared with *lacebo among

*atients with IF arrest in the *rehos*ital, intensi&e care unit,

and emergency de*artment setting, res*ecti&ely. hus, rou3

tine administration of magnesium sulfate in cardiac arrest is

not recommended Blass 555, %! 9C unless torsades de

*ointes is *resent.

7nterventions ot Recommended for Routine se)urin! Cardiac Arrest

Atropine9tro*ine sulfate re&erses cholinergic3mediated decreases in

heart rate and atrio&entricular nodal conduction. No *ros*ec3

ti&e controlled clinical trials ha&e eEamined the use of

atro*ine in asystole or bradycardic (9 cardiac arrest.

%ower3le&el clinical studies *ro&ide conflicting e&idence of

the benefit of routine use of atro*ine in cardiac arrest.@>,2=G@0>

here is no e&idence that atro*ine has detrimental effects

during bradycardic or asystolic cardiac arrest. 9&ailable

e&idence suggests that routine use of atro*ine during (9 or

asystole is unli#ely to ha&e a thera*eutic benefit Blass 55b,

%! +C. For this reason atro*ine has been remo&ed from the

cardiac arrest algorithm.

Sodium .icar%onateissue acidosis and resulting acidemia during cardiac arrest

and resuscitation are dynamic *rocesses resulting from no

blood flow during arrest and low blood flow during (R.

hese *rocesses are affected by the duration of cardiac arrest,

le&el of blood flow, and arterial oEygen content during (R.

Restoration of oEygen content with a**ro*riate &entilation

with oEygen, su**ort of some tissue *erfusion and some

cardiac out*ut with high3Luality chest com*ressions, then

ra*id R!$ are the mainstays of restoring acid3base balance

during cardiac arrest.


31/68

wo studies demonstrated@0=,@04 increased R!$, hos3

*ital admission, and sur&i&al to hos*ital discharge associ3

ated with use of bicarbonate. -owe&er, the majority of

studies showed no benefit@0G@0 or found a relationshi*

with *oor outcome.@0>,@10G@12

here are few data to su**ort thera*y with buffers during

cardiac arrest. here is no e&idence that bicarbonate im*ro&esthe li#elihood of defibrillation or sur&i&al rates in animals

with IF cardiac arrest. 9 wide &ariety of ad&erse effects ha&e

been lin#ed to administration of bicarbonate during cardiac

arrest. +icarbonate may com*romise (( by reducing sys3

temic &ascular resistance.@1@ 5t can create eEtracellular al#a3

losis that will shift the oEyhemoglobin saturation cur&e and

inhibit oEygen release. 5t can *roduce hy*ernatremia and

therefore hy*erosmolarity. 5t *roduces eEcess !2, which

freely diffuses into myocardial and cerebral cells and may

*aradoEically contribute to intracellular acidosis.@1> 5t can

eEacerbate central &enous acidosis and may inacti&ate simul3

taneously administered catecholamines.

5n some s*ecial resuscitation situations, such as *reeEisting

metabolic acidosis, hy*er#alemia, or tricyclic antide*ressant

o&erdose, bicarbonate can be beneficial Bsee (art 126

Hardiac 9rrest in $*ecial $ituationsJC. -owe&er, routine use

of sodium bicarbonate is not recommended for *atients in

cardiac arrest Blass 555, %! +C. When bicarbonate is used

for s*ecial situations, an initial dose of 1 mL7#g is ty*ical.

Whene&er *ossible, bicarbonate thera*y should be guided by

the bicarbonate concentration or calculated base deficit ob3

tained from blood gas analysis or laboratory measurement. o

minimi/e the ris# of iatrogenically induced al#alosis, *ro&id3

ers should not attem*t com*lete correction of the calculated

base deficit. !ther nonG!23generating buffers such as car3

bicarb, -9", or tribonate ha&e shown *otential for mini3

mi/ing some ad&erse effects of sodium bicarbonate, including

!2 generation, hy*erosmolarity, hy*ernatremia, hy*oglyce3

mia, intracellular acidosis, myocardial acidosis, and Ho&er3

shootJ al#alosis.@1=G@1 +ut clinical eE*erience is greatly

limited and outcome studies are lac#ing.

Calcium$tudies of calcium during cardiac arrest ha&e found &ariable

results on R!$, and no trial has found a beneficial effect on

sur&i&al either in or out of hos*ital.@01,@0>,@1: G@2@ Routine

administration of calcium for treatment of in3hos*ital andout3of3hos*ital cardiac arrest is not recommended Blass 555,

%! +C.

)i%rinolysisFibrinolytic thera*y was *ro*osed for use during cardiac

arrest to treat both coronary thrombosis Bacute coronary

syndromeC with *resumably com*lete occlusion of a *roEi3

mal coronary artery and major life3threatening *ulmonary

embolism. !ngoing (R is not an absolute contraindication

to fibrinolysis. 5nitial studies were *romising@2> G@@0 and sug3

gested benefit from fibrinolytic thera*y in the treatment of

&ictims of cardio*ulmonary arrest unres*onsi&e to standardthera*y. +ut 2 large clinical trials1::,@@1 failed to show any

im*ro&ement in outcome with fibrinolytic thera*y during

(R. !ne of these showed an increased ris# of intracranial

bleeding associated with the routine use of fibrinolytics

during cardiac arrest.1::

Fibrinolytic thera*y should not be routinely used in cardiac

arrest Blass 555, %! +C. When *ulmonary embolism is

*resumed or #nown to be the cause of cardiac arrest,em*irical fibrinolytic thera*y can be considered Blass 55a,

%! + see (art 12C.

$& )luidsNo *ublished human study directly com*ares the outcome of

routine 5I fluid administration to no fluid administration

during (R. "ost human and animal studies of fluid infusion

during (R did not ha&e a control grou*,@@2G@>@ and 2 animal

studies showed that normothermic fluid infusion during (R

caused a decrease in ((.@>> G@>4 5n addition to normothermic

fluid, hy*ertonic and chilled fluids ha&e been studied in

animal and small human studies without a sur&i&al bene3fit.@@2,@@>,@@4 G@@:,@>1G@>@ 5f cardiac arrest is associated with

eEtreme &olume losses, hy*o&olemic arrest should be sus3

*ected. hese *atients *resent with signs of circulatory shoc#

ad&ancing to (9. 5n these settings intra&ascular &olume

should be *rom*tly restored.

Pacin!lectric *acing is generally not effecti&e in cardiac arrest, and

no studies ha&e obser&ed a sur&i&al benefit from *acing in

cardiac arrest.@>G@=0 Eisting e&idence suggests that *acing

by transcutaneous, trans&enous, or transmyocardial means in

cardiac arrest does not im*ro&e the li#elihood of R!$ orsur&i&al outcome regardless of the timing of *acing admin3

istration Bearly or delayed in established asystoleC, location of

arrest Bin3hos*ital or out3of3hos*italC, or *rimary cardiac

rhythm Basystole, (9C targeted for treatment. lectric *ac3

ing is not recommended for routine use in cardiac arrest

Blass 555, %! +C.

Precordial 95umphe *otential utility of *recordial thum* in cardiac arrest has

not been well studied. When hemodynamically unstable

&entricular tachyarrhythmias were induced during electro3

*hysiological testing, initial administration of a *recordialthum* a**eared to be safe but rarely effecti&e in terminating

&entricular arrhythmias.@=1 5n a *ros*ecti&e obser&ational

study of *atients with out3of3hos*ital cardiac arrest, *rec3

ordial thum* was associated with R!$ when administered

*rom*tly to *atients with res*onder3witnessed asystolic ar3

rest. When administered for IF7I or (9 arrest it was

ineffecti&e but resulted in no a**arent harm.@=2 5n @ case

series@=@G@== IF or *ulseless I was con&erted to a *erfusing

rhythm by a *recordial thum*. on&ersely, other case series

documented deterioration in cardiac rhythm, such as rate

acceleration of I, con&ersion of I to IF, or de&elo*ment

of com*lete 9I bloc# or asystole following thethum*.@=>,@=4G@41


32/68

he *recordial thum* may be considered for termination

of witnessed monitored unstable &entricular tachyarrhyth3

mias when a defibrillator is not immediately r

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Aha 2010 Adult Acls