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Advancedcardiaclifesupport(ACLS)inadults

OfficialreprintfromUpToDate
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Advancedcardiaclifesupport(ACLS)inadults
Author
CharlesNPozner,MD

SectionEditors
RonMWalls,MD,FRCPC,
FAAEM
RichardLPage,MD

DeputyEditor
JonathanGrayzel,MD,FAAEM

Alltopicsareupdatedasnewevidencebecomesavailableandourpeerreviewprocessiscomplete.
Literaturereviewcurrentthrough:Nov2015.|Thistopiclastupdated:Dec11,2015.
INTRODUCTIONThefieldofresuscitationhasbeenevolvingformorethantwocenturies[1].TheParis
AcademyofSciencerecommendedmouthtomouthventilationfordrowningvictimsin1740[2].In1891,Dr.
FriedrichMaassperformedthefirstdocumentedchestcompressionsonhumans[3].TheAmericanHeart
Association(AHA)formallyendorsedcardiopulmonaryresuscitation(CPR)in1963,andby1966,theyhad
adoptedstandardizedCPRguidelinesforinstructiontolayrescuers[2].
Advancedcardiaclifesupport(ACLS)guidelineshaveevolvedoverthepastseveraldecadesbasedona
combinationofscientificevidenceofvariablestrengthandexpertconsensus.TheAmericanHeartAssociation
(AHA)developedthemostrecentACLSguidelinesin2010usingthecomprehensivereviewofresuscitation
literatureperformedbytheInternationalLiaisonCommitteeonResuscitation(ILCOR),andthesewereupdated
in2015[48].Guidelinesarereviewedcontinuallybutareformallyreleasedeveryfiveyears,andpublishedin
thejournalsCirculationandResuscitation.
Thistopicwilldiscussthemanagementofcardiacarrhythmiasinadultsasgenerallydescribedinthemost
recentiterationoftheACLSGuidelines.Whereoursuggestionsdifferorexpanduponthepublishedguidelines,
westatethisexplicitly.Theevidencesupportingthepublishedguidelinesispresentedseparately,asare
issuesrelatedtocontroversialtreatmentsforcardiacarrestpatients,basiclifesupport(BLS),airway
management,andpostcardiacarrestmanagement.(See"Supportivedataforadvancedcardiaclifesupportin
adultswithsuddencardiacarrest"and"Therapiesofuncertainbenefitinbasicandadvancedcardiaclife
support"and"Basiclifesupport(BLS)inadults"and"Basicairwaymanagementinadults"and"Advanced
emergencyairwaymanagementinadults"and"Postcardiacarrestmanagementinadults".)
EVIDENCEBASEDGUIDELINESBecauseofthenatureofresuscitationresearch,fewrandomized
controlledtrialshavebeencompletedinhumans.ManyoftherecommendationsintheAmericanHeart
Association's2010Guidelinesforadvancedcardiaclifesupportandthe2015update(hereafterreferredtoas
theACLSGuidelines)aremadebaseduponretrospectivestudies,animalstudies,andexpertconsensus[5,7].
GuidelinerecommendationsareclassifiedaccordingtotheGRADEsystem[9].Theevidencesupportingthe
ACLSGuidelinesisreviewedindetailseparately.(See"Supportivedataforadvancedcardiaclifesupportin
adultswithsuddencardiacarrest".)
PRINCIPLESOFMANAGEMENT
ExcellentbasiclifesupportanditsimportanceExcellentcardiopulmonaryresuscitation(CPR)andearly
defibrillationfortreatablearrhythmiasremainthecornerstonesofbasicandadvancedcardiaclifesupport
(ACLS).Althoughthe2015updatefortheAmericanHeartAssociation(AHA)GuidelinesforACLS(ACLS
Guidelines)suggestseveralrevisions,includingmedicationsandmonitoring,theemphasisonexcellentCPR
anditscriticalroleinresuscitativeeffortsremainsunchanged(algorithm1andalgorithm2andfigure1)[5,7].
Weemphasizetheterm"excellentCPR"becauseanythingshortofthisstandarddoesnotachieveadequate
cerebralandcoronaryperfusion,therebycompromisingapatient'schancesforneurologicallyintactsurvival.
CPRisdiscussedindetailseparatelykeyprinciplesintheperformanceofACLSaresummarizedinthe
followingtable(table1).(See"Basiclifesupport(BLS)inadults".)
Inthepast,cliniciansfrequentlyinterruptedCPRtocheckforpulses,performtrachealintubation,orobtain
venousaccess.CurrentACLSGuidelinesstronglyrecommendthateveryeffortbemadeNOTtointerrupt
CPRotherlessvitalinterventions(eg,trachealintubationoradministrationofmedicationstotreatarrhythmias)
aremadeeitherwhileCPRisperformedor,ifarequiredinterventioncannotbeperformedwhileCPRisin
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progress,duringthebriefestpossibleadditiontothe2minuterhythmcheck(afterthecompletionofafullcycle
ofCPR).
Studiesinboththeinhospitalandprehospitalsettingsdemonstratethatchestcompressionsareoften
performedincorrectly,inconsistently,andwithexcessiveinterruption[1014].Chestcompressionsmustbeof
sufficientdepth(5to6cm,or2to2.5inches)andrate(between100and120perminute),andallowfor
completerecoilofthechestbetweencompressions,tobeeffective.
Asinglebiphasicdefibrillationremainstherecommendedtreatmentforventricularfibrillation(VF)orpulseless
ventriculartachycardia(VT).CPRshouldbeperformeduntilthedefibrillatorisreadyforimmediatedischarge
andresumedimmediatelyaftertheshockisgiven,withoutpausingtorecheckapulse[15,16].Interruptionsin
CPR(eg,forsubsequentattemptsatdefibrillationorpulsechecks)shouldoccurnomorefrequentlythanevery
2minutes,andfortheshortestpossibleduration.Keyelementsintheperformanceofmanualdefibrillationare
describedinthefollowingtable(table2).
Patientsareoftenoverventilatedduringresuscitations,whichcancompromisevenousreturnresultingin
reducedcardiacoutputandinadequatecerebralandcardiacperfusion.A30:2compressiontoventilationratio
(onecycle)isrecommendedinpatientswithoutadvancedairways.AccordingtotheACLSGuidelines,
asynchronousventilationsat8to10perminuteareadministeredifanendotrachealtubeorextraglotticairway
isinplace,whilecontinuouschestcompressionsareperformedsimultaneously[17].Webelievethat6to8
ventilationsperminutearesufficientinthelowflowstateofcardiacarrestandhelptopreventexcessive
intrathoracicpressure.
ResuscitationteammanagementTheresuscitationofasuddencardiacarrest(SCA),byitsnaturealow
frequency,highacuityevent,isoftenchaotic.Agrowingbodyofliteraturedemonstratesthatbyemployingthe
principlesofCrisisResourceManagement(CRM),adaptedfromtheaviationindustryandintroducedinto
medicalcarebyanesthesiologists,disorganizationduringresuscitationdecreasesandpatientcareimproves
[1821].AprimarygoalofCRMistoaccessthecollectiveknowledgeandexperienceoftheentireteamin
ordertoprovidethebestcarepossibleandtocompensateforoversightsorotherproblemsthatanyindividual
islikelytoexperienceduringsuchstressfulevents.TrainingintheseprinciplestoimprovethequalityofACLS
performedbyhealthcarecliniciansisfeasibleandrecommended[22].
TwoprinciplesprovidethefoundationforCRM:leadershipandcommunication[20].Resuscitationsusually
involveanumberofhealthcareprovidersfromdifferentdisciplines,sometimesfromdifferentareasofan
institution,whomaynothaveworkedtogetherpreviously.Underthesecircumstances,roleclaritycanbe
difficulttoestablish.InCRM,itisimperativethatonepersonassumestheroleofteamleader[20].This
personisresponsiblefortheglobalmanagementoftheresuscitation,including:ensuringthatallrequiredtasks
arecarriedoutcompetentlyincorporatingnewinformationandcoordinatingcommunicationamongallteam
membersdevelopingandimplementingmanagementstrategiesthatwillmaximizepatientoutcomeand
reassessingperformancethroughouttheresuscitation.
Theteamleadershouldavoidperformingtechnicalprocedures,asperformanceofataskinevitablyshifts
attentionfromtheprimaryleadershipresponsibilities.Incircumstanceswherestaffingislimited(eg,small
communityhospital),theteamleadermayberequiredtoperformcertaincriticalprocedures.Inthese
situations,leadershipmaybetemporarilytransferredtoanotherclinicianortheteamleadermaybeforced
temporarilytoperformbothroles,althoughthiscompromisestheabilitytoprovideproficientleadership.
InCRM,communicationisorganizedtoprovideeffectiveandefficientcare.Allpertinentcommunicationgoes
throughtheteamleaderandtheteamleadersharesimportantinformationwiththeteam.Whentheteamleader
determinestheneedtoperformatask,therequestisdirectedtoaspecificteammember,ideallybyname.
Thatteammemberverballyacknowledgestherequestandperformsthetaskor,ifunabletodoso,informsthe
teamleaderthatsomeoneelseshouldbeassigned.Specificemphasisisplacedontheassignedteammember
repeatingbackmedicationdosesanddefibrillatorenergysettingstotheteamleader.This"closedloop"
communicationleadstoamoreorderlytransferofinformationandistheappropriatestandardforall
communicationduringresuscitations.
Thoughmostdecisionsemanatefromtheteamleader,agoodteamleaderenliststhecollectivewisdomand
experienceoftheentireteamasneeded.Teammembersmustbeencouragedtospeakupiftheyhavea
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concernorafeasiblesuggestion.Effortsshouldbemadetoovercomethetendencytowithholdpotentiallylife
savingsuggestionsduetothefearofbeingincorrectorthenatureofhierarchiesthatexistinmanyhealthcare
institutions.Extraneouspersonnelnotdirectlyinvolvedwithpatientcareareaskedtoleaveinordertoreduce
noiseandtoensurethatordersfromtheleaderandfeedbackfromtheresuscitationteamcanbeheardclearly.
InitialmanagementandECGinterpretationInthe2010ACLSGuidelines,circulationassumedamore
prominentroleintheinitialmanagementofcardiacarrestandthisapproachcontinuesinthe2015update.The
"mantra"is:circulation,airway,breathing(CAB).Onceunresponsivenessisrecognized,resuscitationbegins
byaddressingcirculation(chestcompressions),followedbyairwayopening,andthenrescuebreathing.The
ACLSGuidelinesemphasizetheimportanceofexcellentlyperformed,uninterruptedchestcompressionsand
earlydefibrillation.Rescuebreathingisperformedaftertheinitiationofexcellentchestcompressionsand
definitiveairwaymanagementmaybedelayedifthereisadequaterescuebreathingwithoutanadvanced
airwayinplace.(See'Excellentbasiclifesupportanditsimportance'aboveand"Basiclifesupport(BLS)in
adults",sectionon'Recognitionofcardiacarrest'.)
Inthenoncardiacarrestsituation,theotherinitialinterventionsforACLSincludeadministeringoxygen(ifthe
patientsoxygensaturationisbelow94percent),establishingvascularaccess,placingthepatientonacardiac
andoxygensaturationmonitor,andobtaininganelectrocardiogram(ECG)[5,7].Unstablepatientsmustreceive
immediatecare,evenwhendataareincompleteorpresumptive(algorithm1andalgorithm2).Patientswith
clearevidenceofSTEMIonECGshouldbepreparedforrapidtransfertothecatheterizationlaboratory,receive
athrombolytic(ifnotcontraindicated),orbetransferredtoacenterwithPCIcapabilities.Thesedecisionsare
madebasedonlocalresourcesandprotocols.
Stablepatientsrequireanassessmentoftheirelectrocardiograminordertoprovideappropriatetreatment
consistentwithACLSguidelines.AlthoughitisbesttomakeadefinitiveinterpretationoftheECGpriorto
makingmanagementdecisions,thesettingsinwhichACLSguidelinesarecommonlyemployedrequirea
modified,empiricalapproach.Suchanapproachisguidedbythefollowingquestions:
Istherhythmfastorslow?
AretheQRScomplexeswideornarrow?
Istherhythmregularorirregular?
Theanswerstothesequestionsoftenenablethecliniciantomakeaprovisionaldiagnosisandinitiate
appropriatetherapy.
AIRWAYMANAGEMENTWHILEPERFORMINGACLSVentilationisperformedduringCPRtomaintain
adequateoxygenation.Theeliminationofcarbondioxideislessimportant,andnormalizationofpHthrough
hyperventilationisbothdangerousandunattainableuntilthereisreturnofspontaneouscirculation(ROSC).
However,duringthefirstfewminutesfollowingsuddencardiacarrest(SCA),oxygendeliverytothebrainis
limitedprimarilybyreducedbloodflow[23,24].Therefore,inadults,theperformanceofexcellentchest
compressionstakespriorityoverventilationduringtheinitialperiodofbasiclifesupport.Insettingswith
multiplerescuersorclinicians,ventilationsandchestcompressionsareperformedsimultaneously.
Theventilationrateisdeterminedbywhetherthepatientisintubated.Ifthepatientisnotintubated,the
compressiontoventilationratiois30:2.Ifthepatientisintubated,wesuggestperformingnomorethansixnon
synchronizedventilationsperminute.(See"Basiclifesupport(BLS)inadults".)
Althoughresearchhasyettoidentifythepreferredparametersforventilation(eg,respiratoryrate,tidalvolume,
inspiredoxygenconcentration),itiswidelybelievedthatalowerminuteventilationisneededforpatientsin
cardiacarrest.Therefore,lowerrespiratoryratesareused(theACLSGuidelinesrecommend10breathsper
minutewithanadvancedairwayinplacewebelieve6breathsareadequate).Inaddition,weknowthat
hyperventilationisharmful,asitleadstoincreasedintrathoracicpressure,whichdecreasesvenousreturnand
compromisescardiacoutput.Tidalvolumesofapproximately600mLdeliveredinacontrolledfashionsuchthat
chestriseoccursovernomorethanonesecondisrecommendedintheACLSGuidelines.(See"Basiclife
support(BLS)inadults",sectionon'Ventilations'.)
Takingtheseprinciplesintoaccount,theACLSGuidelinessupporttheuseofabagmaskdeviceorablindly
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placedsupraglotticairwayforventilationduringtheinitialmanagementofSCA,deferringplacementofan
endotrachealtube,unlessintubationcanbecompetentlyperformedwithoutinterruptingchestcompressionsor
onecannotventilatethepatientbyotherlessinvasivemeans.Theperformanceofbagmaskventilation(BMV)
isdescribedseparately.(See"Basicairwaymanagementinadults".)
Ablindlyinsertedsupraglotticairway(eg,laryngealmaskairway,Combitube,laryngealtube)canbeplaced
withoutinterruptingchestcompressions,providesadequateventilationinmostcases,andreducestheriskof
aspirationcomparedtobagmaskventilation.Therefore,cliniciansmayprefertoventilatewithasupraglottic
devicewhileCPRisongoing,ratherthanperformingtrachealintubation.Supraglotticairwaysandtracheal
intubationarediscussedseparately.(See"Devicesfordifficultemergencyairwaymanagementinadults",
sectionon'Extraglotticdevices'and"Directlaryngoscopyandtrachealintubationinadults".)
Advancedairwaymanagementusingasupraglotticairwayortrachealintubationmaynotbethebestapproach
formanagingcardiacarrestpatientsintheprehospitalsetting.Thisviewissupportedbyaprospective
observationalnationwideJapanesestudyinvolving649,359patientswithsuddenoutofhospitalcardiacarrest
[25].Inthisstudy,therateofsurvivalwithafavorableneurologicoutcomewassignificantlyloweramongthose
managedwithadvancedairwaytechniquescomparedwithbagmaskventilation(1.1versus2.9percentodds
ratio[OR]0.38,95%CI0.360.39).Higherratesofsurvivalwithafavorableneurologicoutcomepersisted
acrossallanalyzedsubgroups,includingadjustmentsforinitialrhythm,returnofspontaneouscirculation,
bystanderCPR,andadditionaltreatments.Althoughthisstudyhaslimitationsduetoitsobservational
approachandwasperformedinasinglecountryandsomaynotbegeneralizabletoallsettings,itssizeand
consistentfindingsacrossallsubgroupanalysessupportitsconclusions.
Otherevidencesupportingamorebasicapproachtoairwaymanagementduringresuscitationofcardiacarrest
includesaretrospectivereviewofregistrydatainvolving10,691cardiacarrestpatients,whichreportedthat
patientsmanagedintheprehospitalsettingwithbagmaskventilationhadsignificantlyhigherratesof
neurologicallyintactsurvivaltohospitaldischargethanpatientsmanagedwitheitherasupraglotticairwayor
intubation(18.6versus5.2percentand5.4percent,respectively)[26].However,randomizedtrialsofairway
managementinthesettingofcardiacarrestarelackingandsomeobservationalstudieshavereacheddifferent
conclusions[27].
Ifadvancedairwaymanagementistobeperformedatallinprehospitalcardiacarrestpatients,itmustbedone
bycompetentproviders,requirelessthan10secondstocompletewithoutinterruptionofexcellentchest
compressions,andbeusedonlyafterallothermoreessentialresuscitativemaneuvershavebeeninitiated.
Onceperformed,rescuersmustavoidhyperventilation.Inaddition,unlessadequateBMVcannotbeperformed,
placementofanadvancedairwayshouldbeattemptedonlyduringactivechestcompressionsordeferredto
the2minuteinterval(afteracompletecycleofCPR)whendefibrillationorpatientreassessmentisperformed.
TheACLSGuidelinesincludethefollowingadditionalrecommendationsaboutairwaymanagementduringthe
performanceofACLS[23]:
Althoughevidenceislacking,itisreasonabletoprovide100percentoxygenduringCPR.Inpatientswho
aresuccessfullyresuscitated(ie,spontaneouscirculationreturns),itisimportanttoavoidhyperoxiawhile
maintainingoxygensaturationabove94percent.(See"Postcardiacarrestmanagementinadults",
sectionon'Mechanicalventilation'.)
Cricoidpressureiscontroversialandisnolongerroutinelyrecommendedduringintubation.Itmaybe
usefulforpreventinggastricinsufflationduringbagmaskventilation.Theseissuesarediscussed
separately.(See"Rapidsequenceintubationinadults",sectionon'Protection(cricoidpressure)and
positioning'.)
Oropharyngealandnasopharyngealairwayscanbeusefuladjuncts.Weencouragetheirusewhen
performingbagmaskventilation.(See"Basicairwaymanagementinadults",sectionon'Airway
adjuncts'.)
Continuouswaveformcapnography(performedinadditiontoclinicalassessment)isrecommendedfor
bothconfirmingandmonitoringcorrecttrachealtubeplacement,andformonitoringthequalityofCPRand
thereturnofspontaneouscirculation.Ifwaveformcapnographyisnotavailable,anonwaveformCO2
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detectormaybeused,inadditiontoclinicalassessment.(See"Carbondioxidemonitoring
(capnography)",sectionon'Clinicalapplicationsforintubatedpatients'.)
MANAGEMENTOFSPECIFICARRHYTHMIAS
Suddencardiacarrest
VentricularfibrillationandpulselessventriculartachycardiaVentricularfibrillation(VF)andpulseless
ventriculartachycardia(VT)arenonperfusingrhythmsemanatingfromtheventricles,forwhichearlyrhythm
identificationanddefibrillation,arethemainstaysoftreatment.ThemostrecentversionoftheAHAalgorithm
forthemanagementofcardiacarrestcanbeaccessedhere(AHAcardiacarrestalgorithm)(algorithm2and
figure1).Excellentcardiopulmonaryresuscitation(CPR)isperformeduntiltherescuerisreadytoperformearly
defibrillationandiscontinueduntiladequatespontaneouscirculationisachieved.Treatableunderlyingcauses
shouldbeidentifiedandmanagedasquicklyaspossible(table3)[8,23].
Beginperformingexcellentchestcompressionsassoonassuddencardiacarrest(SCA)isrecognizedand
continuewhilethedefibrillatorisbeingattached.Ifadefibrillatorisnotimmediatelyavailable,continueCPR
untiloneisobtained.Assoonasadefibrillatorisavailable,attachittothepatient(figure2)andchargeitwhile
continuingCPR,thenstopcompressionstoassesstherhythmanddefibrillateifappropriate(eg,VFor
pulselessVTispresent).Ifasystoleorpulselesselectricalactivity(PEA)ispresent,continueCPR.Resume
CPRimmediatelyafteranyshockisgiven.(See"Supportivedataforadvancedcardiaclifesupportinadults
withsuddencardiacarrest",sectionon'VFandpulselessVT'.)
Inthecaseofawitnessedcardiacarrest,performdefibrillationasquicklyaspossible.Decreasedtimeto
defibrillationimprovesthelikelihoodofsuccessfulconversiontoaperfusingrhythmandofpatientsurvival.
Biphasicdefibrillatorsarerecommendedbecauseoftheirincreasedefficacyatlowerenergylevels[2830].The
ACLSGuidelinesrecommendthatwhenemployingabiphasicdefibrillatorcliniciansusetheinitialdoseof
energyrecommendedbythemanufacturer(120to200J).Ifthisdoseisnotknown,themaximaldosemaybe
used.WesuggestafirstdefibrillationatmaximalenergyforVForpulselessVT.
TheACLSGuidelinesrecommendtheresumptionofCPRimmediatelyafterdefibrillationwithoutrecheckingfor
apulse.CPRshouldnotbeinterruptedtoassesstherhythm,andrhythmchecksandadditionalshocksshould
beperformednomorefrequentlythanevery2minutes.(See"Basiclifesupport(BLS)inadults",sectionon
'Phasesofresuscitation'and"Basiclifesupport(BLS)inadults",sectionon'Defibrillation'.)
IfVForpulselessVTpersistsafteratleastoneattemptatdefibrillationand2minutesofCPR,give
epinephrine(1mgIVevery3to5minutes)whileCPRisperformedcontinuously.Inthe2015ACLSupdate,
vasopressinwasremovedfromthetreatmentalgorithmforcardiacarrest.
Somestudyresultshaveraiseddoubtsaboutthebenefitofepinephrine[31,32].Otherresearcherstheorizethat
highconcentrationsofcirculatingcatecholaminesmaybeharmfulinpatientswhoexperienceareturnof
spontaneouscirculation(ROSC),andthatlowerdosesofepinephrineorlongerdosingintervalsmaybeprudent
whentreatingVForpulselessVT[31,33,34].However,pendingmoreconclusivedataoraformalchangein
ACLSprotocols,wesuggestgivingepinephrineinaccordancewiththeexistingGuidelines.(See"Supportive
dataforadvancedcardiaclifesupportinadultswithsuddencardiacarrest",sectionon'VForVTarrestand
vasopressors'.)
EvidencesuggeststhatantiarrhythmicdrugsprovidelittlesurvivalbenefitinrefractoryVForpulselessVT.
Nevertheless,thecurrentACLSGuidelinesstatethattheymaybeusedincertainsituations.Thetimingof
antiarrhythmicuseisnotspecified.Wesuggestthatantiarrhythmicdrugsbeconsideredafterasecond
unsuccessfuldefibrillationattemptinanticipationofathirdshock.
Amiodarone(300mgIVwitharepeatdoseof150mgIVasindicated)maybeadministeredinVFor
pulselessVTunresponsivetodefibrillation,CPR,andepinephrine.
Lidocaine(1to1.5mg/kgIV,then0.5to0.75mg/kgevery5to10minutes)maybeusedifamiodaroneis
unavailable.
Magnesiumsulfate(2gIV,followedbyamaintenanceinfusion)maybeusedtotreatpolymorphic
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ventriculartachycardiaconsistentwithtorsadedepointes,butisnotrecommendedforroutineusein
adultcardiacarrestpatients.(See'Irregularwidecomplex'below.)
RefractoryVForpulselessVTmaybecausedbyanacutecoronarysyndrome(ACS),inwhichcase
percutaneouscoronaryinterventioncanbeperformedifthepatientissuccessfullyresuscitatedandthe
procedureisfeasible.NotethatfollowingcardiacarresttheECGmaybeinsensitiveforACScardiology
consultationisneededforpatientswithreturnofspontaneouscirculation(ROSC)[4].CausesotherthanACS
canleadtoSCA(table3).
Insummary,theROSCinVFandpulselessVThingesonearlydefibrillationandexcellentCPR.Although,the
ACLSGuidelinesadvocatetheappropriateuseofadvancedairwaymanagementandtreatmentwithspecific
medications,theseinterventionshavenotbeenshowntoimprovesurvivalinSCA.Therefore,such
interventionsmustneverbeinitiatedattheexpenseofperformingexcellentCPRandearlydefibrillation.
AsystoleandpulselesselectricalactivityAsystoleisdefinedasacompleteabsenceofdemonstrable
electricalandmechanicalcardiacactivity.Pulselesselectricalactivity(PEA)isdefinedasanyoneofa
heterogeneousgroupoforganizedelectrocardiographicrhythmswithoutsufficientmechanicalcontractionofthe
hearttoproduceapalpablepulseormeasurablebloodpressure.Bydefinition,asystoleandPEAarenon
perfusingrhythmsrequiringtheinitiationofexcellentCPRimmediatelywheneitherispresent.Themostrecent
versionoftheAHAalgorithmforthemanagementofcardiacarrestcanbeaccessedhere(AHAcardiacarrest
algorithm)(algorithm2).
IntheACLSGuidelines,asystoleandPEAareaddressedtogetherbecausesuccessfulmanagementforboth
dependsonexcellentCPR,vasopressortreatment(ie,epinephrine),andrapidreversalofunderlyingcauses,
suchashypoxia,hyperkalemia,poisoning,andhemorrhage[8,23].Asystolemaybetheresultofaprimaryor
secondarycardiacconductionabnormality,possiblyfromendstagetissuehypoxiaandmetabolicacidosis,or,
rarely,theresultofexcessivevagalstimulation.Itiscrucialtoidentifyandtreatpotentialsecondarycausesof
asystoleorPEAasrapidlyaspossible.Somecauses(eg,tensionpneumothorax,cardiactamponade)resultin
ineffectiveCPR.Donothesitatetoperforminvasiveprocedurestotreatsuspectedsecondarycausesifthe
patientisreceivingCPR,thereislittlechancetheinterventionwillmakethesituationworse.The
accompanyingtablesdescribeimportantsecondarycausesofcardiacarrest(table3).
AfterinitiatingCPR,treatreversiblecausesasappropriateandadministerepinephrine(1mgIVevery3to5
minutes).Vasopressinwasremovedfromthetreatmentalgorithminthe2015update.AswithVFand
pulselessVT,evidencesupportingthebenefitofepinephrineinpatientswithasystoleorPEAislimitedand
furtherstudyisneeded.NeitherasystolenorPEArespondstodefibrillation.Atropineisnolonger
recommendedforthetreatmentofasystoleorPEA.Cardiacpacingisineffectiveforcardiacarrestandnot
recommended.(See"Supportivedataforadvancedcardiaclifesupportinadultswithsuddencardiacarrest".)
Insummary,treatmentforasystoleandPEAconsistsofearlyidentificationandtreatmentofreversiblecauses
andexcellentCPRwithepinephrineadministrationuntileitherROSCorashockablerhythmoccurs.
MonitoringTheACLSGuidelinesencouragetheuseofclinicalandphysiologicmonitoringtooptimize
theperformanceofCPRandtodetectthereturnofspontaneouscirculation(ROSC)[5].Assessmentand
immediatefeedbackaboutimportantclinicalparameters,suchastherateanddepthofchestcompressions,
adequacyofchestrecoilbetweencompressions,andrateandforceofventilations,canimproveCPR.End
tidalcarbondioxide(EtCO2)measurementsfromcontinuouswaveformcapnography(usingnasalsamplingif
performingbagmaskventilation(BMV)ortrachealtubesamplinginintubatedpatients)accuratelyreflect
cardiacoutputandcerebralperfusionpressure,andthereforethequalityofCPR.Sudden,sustainedincreases
inEtCO2duringCPRindicateaROSCwhiledecreasingEtCO2duringCPRmayindicateinadequate
compressions.Exceptfortheinitialpulsechecktodeterminepulselessness,theneedforcheckingapulse
duringresuscitationisobviatedbytheuseofEtCO2whichenablesdeterminationofbothROSCandCPR
quality.(See"Carbondioxidemonitoring(capnography)",sectionon'EffectivenessofCPR'and"Carbon
dioxidemonitoring(capnography)",sectionon'Returnofspontaneouscirculation'.)
DatafromotherphysiologicmonitorsislesslikelytobeavailableinpatientswithSCA,butmeasurements
obtainedfromarterialandcentralvenouscathetersprovideusefulfeedbackaboutthequalityofCPRand
ROSC[23].Measurementsofarterialrelaxationprovideareasonableapproximationofcoronaryperfusion
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pressure.DuringCPR,areasonablegoalistomaintainthearterialrelaxation(or"diastole")pressureabove20
mmHg.Centralvenousoxygensaturation(SCVO2)providesinformationaboutoxygendeliveryandcardiac
output.DuringCPR,areasonablegoalistomaintainSCVO2above30percent.
BradycardiaBradycardiaisdefinedconservativelyasaheartratebelow60beatsperminute,but
symptomaticbradycardiagenerallyentailsratesbelow50beatsperminute.TheACLSGuidelinesrecommend
thatcliniciansnotinterveneunlessthepatientexhibitsevidenceofinadequatetissueperfusionthoughtto
resultfromtheslowheartrate[8,23].ThemostrecentversionoftheAHAalgorithmforthemanagementof
bradycardiacanbeaccessedhere(AHAcardiacarrestalgorithm)(algorithm3).Signsandsymptomsof
inadequateperfusionincludehypotension,alteredmentalstatus,signsofshock,ongoingischemicchestpain,
andevidenceofacutepulmonaryedema.Hypoxemiaisacommoncauseofbradycardialookforsignsof
laboredbreathing(eg,increasedrespiratoryrate,retractions,paradoxicalabdominalbreathing)andlowoxygen
saturation.Mildsymptomsmaynotwarranttreatmentotherthansupplementaloxygen.
Ifanysignificantsymptomsarepresentinthesettingofbradycardia,administeratropine(ifeasilydone)and
immediatelypreparetotreatthepatientwithtranscutaneouspacingoraninfusionofachronotropicagent
(dopamineorepinephrine).Donotdelaytreatmentwithtranscutaneouspacingorachronotropicagentinorder
togiveatropine.
Theinitialdoseofatropineis0.5mgIV.Thisdosemayberepeatedevery3to5minutestoatotaldoseof3
mg.Donotgiveatropineifthereisevidenceofahighdegree(seconddegree[Mobitz]typeIIorthirddegree)
atrioventricular(AV)block[35].AtropineexertsitsantibradycardiaceffectsattheAVnodeandisunlikelytobe
effectiveifaconductionblockexistsatorbelowtheBundleofHis,orintransplantedhearts,whichlackvagal
innervation.Atropinemaybeharmfulinthesettingofcardiacischemia.(See"Seconddegreeatrioventricular
block:MobitztypeII"and"Thirddegree(complete)atrioventricularblock".)
Beforeusingtranscutaneouspacing,assesswhetherthepatientcanperceivethepainassociatedwiththis
procedureandifsoprovideappropriatesedationandanalgesiawheneverpossible.Infusionsofdopamineare
dosedat2to10mcg/kgperminute,whileepinephrineisgivenat2to10mcgperminute.Eachistitratedto
thepatient'sresponse.(See"Proceduralsedationinadults".)
Ifneithertranscutaneouspacingnorinfusionofachronotropicagentresolvesthepatient'ssymptoms,prepare
fortransvenouspacingandobtainexpertconsultationifavailable.Patientsrequiringtranscutaneousor
transvenouspacingalsorequirecardiologyconsultation,andadmissionforevaluationforpermanent
pacemakerplacement.
Commontoxicologiccausesofsymptomaticbradycardiaincludesupratherapeuticlevelsofbetablockers,
calciumchannelblockers,andDigoxin.Thesepoisoningsarediscussedseparately.(See"Betablocker
poisoning"and"Calciumchannelblockerpoisoning"and"Digitalis(cardiacglycoside)poisoning".)
Tachycardia
ApproachTachycardiaisdefinedasaheartrateabove100beatsperminute,butsymptomatic
tachycardiagenerallyinvolvesratesover150beatsperminute,unlessunderlyingventriculardysfunctionexists
[8,23].Managementoftachyarrhythmiasisgovernedbythepresenceofclinicalsymptomsandsignscaused
bytherapidheartrate.ThemostrecentversionoftheAHAalgorithmforthemanagementoftachycardiacan
beaccessedhere(AHAcardiacarrestalgorithm)(algorithm4).
Thefundamentalapproachisasfollows:Firstdetermineifthepatientisunstable(eg,manifestsongoing
ischemicchestpain,acutementalstatuschanges,hypotension,signsofshock,orevidenceofacute
pulmonaryedema).Hypoxemiaisacommoncauseoftachycardialookforsignsoflaboredbreathing(eg,
increasedrespiratoryrate,retractions,paradoxicalabdominalbreathing)andlowoxygensaturation.
Ifinstabilityispresentandappearsrelatedtothetachycardia,treatimmediatelywithsynchronized
cardioversion,unlesstherhythmissinustachycardia[36].Somecasesofsupraventriculartachycardiamay
respondtoimmediatetreatmentwithabolusofadenosine(6to12mgIV)withouttheneedofcardioversion.
Wheneverpossible,assesswhetherthepatientcanperceivethepainassociatedwithcardioversion,andifso
provideappropriatesedationandanalgesia.(See"Proceduralsedationinadults".)
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Inthestablepatient,usetheelectrocardiogram(ECG)todeterminethenatureofthearrhythmia.Intheurgent
settingsinwhichACLSalgorithmsaremostoftenemployed,specificrhythmidentificationmaynotbe
possible.Nevertheless,byperforminganorderlyreviewoftheECG,onecandetermineappropriate
management.Threequestionsprovidethebasisforassessingtheelectrocardiograminthissetting:
Isthepatientinasinusrhythm?
IstheQRScomplexwideornarrow?
Istherhythmregularorirregular?
Moredetailedapproachestorhythmdeterminationintachycardiaarediscussedseparately.(See"Clinical
manifestations,diagnosis,andevaluationofnarrowQRScomplextachycardias"and"Approachtothe
diagnosisofwideQRScomplextachycardias"and"Overviewoftheacutemanagementoftachyarrhythmias".)
RegularnarrowcomplexSinustachycardiaandsupraventriculartachycardiaarethemajorcausesofa
regularnarrowcomplexarrhythmia[8,23].Sinustachycardiaisacommonresponsetofever,anemia,shock,
sepsis,pain,heartfailure,oranyotherphysiologicstress.Nomedicationisneededtotreatsinustachycardia
careisfocusedontreatingtheunderlyingcause.(See"Sinustachycardia:Evaluationandmanagement".)
Supraventriculartachycardia(SVT)isaregulartachycardiamostoftencausedbyareentrantmechanism
withintheconductionsystem(algorithm4).TheQRSintervalisusuallynarrowbutcanbelongerthan120ms
ifabundlebranchblock(ie,SVTwithaberrancyorfixedbundlebranchblock)ispresent.Vagalmaneuvers,
whichmayblockconductionthroughtheAVnodeandresultininterruptionofthereentrantcircuit,maybe
employedonappropriatepatientswhileothertherapiesareprepared.Vagalmaneuversalone(eg,Valsalva,
carotidsinusmassage),convertupto25percentofSVTstosinusrhythm,whileValsalvafollowed
immediatelybysupinerepositioningwithapassivelegraisehasbeenshowntobeevenmoreeffective.SVT
refractorytovagalmaneuversistreatedwithadenosine[37,38].(See"Overviewoftheacutemanagementof
tachyarrhythmias"and"Clinicalmanifestations,diagnosis,andevaluationofnarrowQRScomplex
tachycardias"and"Reentryandthedevelopmentofcardiacarrhythmias"and"Vagalmaneuvers".)
Becauseofitsextremelyshorthalflife,adenosine(6to12mgIV)isinjectedasrapidlyaspossibleintoalarge
proximalvein,followedimmediatelybya20mLsalineflushandelevationoftheextremitytoensurethedrug
entersthecentralcirculationbeforeitismetabolized.Ifthefirstdoseofadenosinedoesnotconvertthe
rhythm,asecondandthirddoseof12mgIVmaybegiven.Largerdoses(eg,18mgIV)maybeneededin
patientstakingtheophyllineortheobromine,orwhoconsumelargeamountsofcaffeinesmallerdoses(eg,3
mgIV)shouldbegiventopatientstakingdipyridamoleorcarbamazepine,thosewithtransplantedhearts,or
wheninjectingviaacentralvein.
Priortoinjection,warnthepatientabouttransientsideeffectsfromadenosine,includingchestdiscomfort,
dyspnea,andflushing,andgivereassurancethattheseeffectsareverybrief.PerformcontinuousECG
recordingduringadministration.IfadenosinefailstoconverttheSVT,considerotheretiologiesforthisrhythm,
includingatrialflutteroranonreentrantSVT,whichmaybecomeapparentontheECGwhenAVnodal
conductionisslowed.
Ifconversionattemptsfail,initiateratecontrolwitheitheranintravenousnondihydropyridinecalciumchannel
blockerorabetablocker.Agentstochoosefrominclude:diltiazem,verapamil,andanumberofbetablockers,
includingmetoprolol,atenolol,esmolol,andlabetalol.(See"Controlofventricularrateinatrialfibrillation:
Pharmacologictherapy",sectionon'Pharmacologictreatment'.)
IrregularnarrowcomplexIrregularnarrowcomplextachycardiasmaybecausedbyatrialfibrillation,
atrialflutterwithvariableatrioventricular(AV)nodalconduction,multifocalatrialtachycardia(MAT),orsinus
tachycardiawithfrequentprematureatrialbeats(algorithm4).Ofthese,atrialfibrillationismostcommon
[8,23].
Theinitialgoaloftreatmentinstablepatientsistocontroltheheartrateusingeitheranondihydropyridine
calciumchannelblocker(diltiazem15to20mgIVover2minutes,repeatat20to25mgIVafter15minutes,or
verapamil2.5to5mgIVover2minutesfollowedby5to10mgIVevery15to30minutes)orabetablocker
(eg,metoprolol5mgIVfor3dosesevery2to5minutesthenupto200mgPOevery12hours).The
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managementofatrialfibrillationandSVTisdiscussedindetailseparately.(See"Overviewofatrialfibrillation"
and"Rhythmcontrolversusratecontrolinatrialfibrillation"and"Controlofventricularrateinatrialfibrillation:
Pharmacologictherapy"and"Clinicalmanifestations,diagnosis,andevaluationofnarrowQRScomplex
tachycardias"and"Multifocalatrialtachycardia".)
Calciumchannelblockersandbetablockersmaycauseorworsenhypotension.Patientsshouldbeclosely
monitoredwhilethedrugisgiven,andpatientsatgreaterriskofdevelopingseverehypotension(eg,elders)
oftenrequireloadingdosesthatarebelowtheusualrange.Combinationtherapywithabetablockerand
calciumchannelblockerincreasestheriskofsevereheartblock.
Diltiazemissuggestedinmostinstancesforthemanagementofacuteatrialfibrillationwithrapidventricular
response.Betablockersmayalsobeusedandmaybepreferredinthesettingofanacutecoronarysyndrome.
Betablockersaremoreeffectiveforchronicratecontrol.Foratrialfibrillationassociatedwithhypotension,
amiodaronemaybeused(150mgIVover10minutes,followedby1mg/mindripforsixhours,andthen0.5
mg/min),butthepossibilityofconversiontosinusrhythmmustbeconsidered[39].Foratrialfibrillation
associatedwithacuteheartfailure,amiodaroneordigoxinmaybeusedforratecontrol.TreatmentofMAT
includescorrectionofpossibleprecipitants,suchashypokalemiaandhypomagnesemia.TheACLSGuidelines
recommendconsultationwithacardiologistforthesearrhythmias.
CardioversionofstablepatientswithirregularnarrowcomplextachycardiasshouldNOTbeundertakenwithout
consideringtheriskofembolicstroke.Ifthedurationofatrialfibrillationisknowntobelessthan48hours,the
riskofembolicstrokeislow,andtheclinicianmayconsiderelectricalorchemicalcardioversion[40].Anumber
ofmedicationscanbeusedforchemicalcardioversionandthebestdrugvariesaccordingtoclinical
circumstance.Thequestionsofwhetherchemicalcardioversionisappropriateandwhichagenttoselectare
reviewedseparately.
RegularwidecomplexAregular,widecomplextachycardiaisgenerallyventricularinetiology
(algorithm4).Aberrantlyconductedsupraventriculartachycardiasmayalsobeseen.Becausedifferentiation
betweenventriculartachycardia(VT)andSVTwithaberrancycanbedifficult,assumeVTispresent.Treat
clinicallystableundifferentiatedwidecomplextachycardiawithantiarrhythmicsorelectivesynchronized
cardioversion[8,23].
Incasesofregular,widecomplextachycardiawithamonomorphicQRScomplex,adenosinemaybeusedfor
diagnosisandtreatment.DoNOTgiveadenosinetopatientswhoareunstableormanifestwidecomplex
tachycardiawithanirregularrhythmorapolymorphicQRScomplex.Adenosineisunlikelytoaffectventricular
tachycardiabutislikelytosloworconvertSVTwithaberrancy.DosingisidenticaltothatusedforSVT.(See
'Regularnarrowcomplex'above.)
Otherantiarrhythmicsthatmaybeusedtotreatstablepatientswithregular,widecomplextachycardiainclude
procainamide(20mg/minIV),amiodarone(150mgIVgivenover10minutes,repeatedasneededtoatotalof
2.2gIVoverthefirst24hours),andsotalol(100mgIVover5minutes).Aprocainamideinfusioncontinues
untilthearrhythmiaissuppressed,thepatientbecomeshypotensive,theQRSwidens50percentbeyond
baseline,oramaximumdoseof17mg/kgisadministered.Procainamideandsotalolshouldbeavoidedin
patientswithaprolongedQTinterval.Ifthewidecomplextachycardiapersists,inspiteofpharmacologic
therapy,electivecardioversionmaybeneeded.TheACLSGuidelinesrecommendexpertconsultationforall
patientswithwidecomplextachycardia.
SVTwithaberrancy,ifDEFINITIVELYidentified(eg,oldECGdemonstratesbundlebranchblock),maybe
treatedinthesamemannerasnarrowcomplexSVT,withvagalmaneuvers,adenosine,orratecontrol.(See
'Irregularnarrowcomplex'above.)
IrregularwidecomplexAwidecomplex,irregulartachycardiamaybeatrialfibrillationwithpreexcitation
(eg,WolfParkinsonWhitesyndrome),atrialfibrillationwithaberrancy(bundlebranchblock),orpolymorphic
ventriculartachycardia(VT)/torsadesdepointes(algorithm4)[8,23].Useofatrioventricular(AV)nodalblockers
inwidecomplex,irregulartachycardiaofunclearetiologymayprecipitateventricularfibrillation(VF)andpatient
death,andiscontraindicated.Suchmedicationsincludebetablockers,calciumchannelblockers,digoxin,and
adenosine.Toavoidinappropriateandpossiblydangeroustreatment,theACLSGuidelinessuggestassuming
thatanywidecomplex,irregulartachycardiaiscausedbypreexcitedatrialfibrillation.
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Patientswithawidecomplex,irregulartachycardiacausedbypreexcitedatrialfibrillationusuallymanifest
extremelyfastheartrates(generallyover200beatsperminute)andrequireimmediateelectriccardioversion.In
caseswhereelectriccardioversionisineffectiveorunfeasible,oratrialfibrillationrecurs,antiarrhythmictherapy
withprocainamide,amiodarone,orsotalolmaybegiven.TheACLSGuidelinesrecommendexpertconsultation
forallpatientswithwidecomplextachycardia.Dosingforantiarrhythmicmedicationsisdescribedabove.(See
'Regularwidecomplex'above.)
TreatpolymorphicVTwithemergentdefibrillation.InterventionstopreventrecurrentpolymorphicVTinclude
correctingunderlyingelectrolyteabnormalities(eg,hypokalemia,hypomagnesemia)and,ifaprolongedQT
intervalisobservedorthoughttoexist,stoppingallmedicationsthatincreasetheQTinterval.Magnesium
sulfate(2gIV,followedbyamaintenanceinfusion)canbegiventopreventpolymorphicVTassociatedwith
familialoracquiredprolongedQTsyndrome[41].
AclinicallystablepatientwithatrialfibrillationandawideQRSintervalKNOWNtostemfromapreexisting
bundlebranchblock(ie,oldECGdemonstratespreexistingblock)maybetreatedinthesamemannerasa
narrowcomplexatrialfibrillation.
AlternativemethodsformedicationadministrationWheneverpossible,ACLSmedicationsshouldbe
givenintravenously.WhenIVaccesscannotbeestablished,intraosseous(IO)linesaresafe,effective,and
canbeplacedefficiently[8,23].MedicationdosesforIOadministrationareidenticaltothoseforIVtherapy.If
neitherIVnorIOaccesscanbeestablished,somemedicationsmaybegivenviathetrachealtube.(See
"Intraosseousinfusion".)
Multiplestudieshavedemonstratedthatlidocaine,epinephrine,atropine,vasopressin,andnaloxoneare
absorbedviathetrachea[23]however,theserumdrugconcentrationsachievedusingthisrouteare
unpredictable.Ifthepatientalreadyhasperipheral,intraosseous,orcentralvenousaccess,thesearealways
thepreferredroutesfordrugadministration.Whenunabletoobtainsuchaccessexpeditiously,onemayuse
theendotrachealtubewhileattemptingtoestablishvascularorintraosseousaccess.Atnopointshould
excellentCPRbeinterruptedtoobtainvascularaccess.
Dosesfortrachealadministrationare2to2.5timesthestandardIVdosesandmedicationsshouldbedilutedin
5to10mLofsterilewaterornormalsalinebeforeinjectiondownthetrachealtube.
POSTRESUSCITATIONCARETheACLSGuidelinesrecommendacombinationofgoaloriented
interventionsprovidedbyanexperiencedmultidisciplinaryteamforallcardiacarrestpatientswithreturnof
spontaneouscirculation[8,23,42].Importantobjectivesforsuchcareinclude:
Optimizingcardiopulmonaryfunctionandperfusionofvitalorgans
Managingacutecoronarysyndromes
Implementingstrategiestopreventandmanageorgansystemdysfunctionandinjury
Managementofthepostcardiacarrestpatientisreviewedseparately.(See"Postcardiacarrestmanagement
inadults".)
TERMINATIONOFRESUSCITATIVEEFFORTSDeterminingwhentostopresuscitationeffortsincardiac
arrestpatientsisdifficult,andlittledataexisttoguidedecisionmaking.Factorsassociatedwithpoorandgood
outcomesarediscussedindetailseparately.(See"Prognosisandoutcomesfollowingsuddencardiacarrestin
adults".)
Physiciansurveydataandclinicalpracticeguidelinessuggestthatfactorsinfluencingthedecisiontostop
resuscitativeeffortsinclude[4347]:

Durationofresuscitativeeffort>30minuteswithoutasustainedperfusingrhythm
Initialelectrocardiographicrhythmofasystole
Prolongedintervalbetweenestimatedtimeofarrestandinitiationofresuscitation
Patientageandseverityofcomorbiddisease
Absentbrainstemreflexes

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Normothermia
Moreobjectiveendpointsofresuscitationhavebeenproposed.Ofthese,thebestpredictorofoutcomemaybe
theendtidalcarbondioxide(EtCO2)levelfollowing20minutesofresuscitation[4850].EtCO2valuesarea
functionofCO2productionandvenousreturntotherightheartandpulmonarycirculation.AverylowEtCO2
(<10mmHg)followingprolongedresuscitation(>20minutes)isasignofabsentcirculationandastrong
predictorofacutemortality[4850].ItiscrucialtonotethatlowEtCO2levelsmayalsobecausedbya
misplaced(esophageal)endotrachealtube,andthispossibilityneedstobeexcludedbeforethedecisionis
madetoterminateresuscitativeefforts.(See"Carbondioxidemonitoring(capnography)".)
Resuscitationintheemergencydepartmentdoesnotappeartobesuperiortofieldresuscitationbyemergency
medicalservices(EMS)personnel.Therefore,EMSpersonnelshouldnotberequiredtotransportallvictimsof
suddencardiacarresttothehospital,iffurtherresuscitationisdeemedfutile[51,52].
Large,retrospectivecohortstudieshaveassessedcriteria(BLSandALS)fortheprehospitalterminationof
resuscitativeeffortsincardiacarrest,initiallydescribedintheOPALSstudy[53,54].BothBLSandALScriteria
demonstratedhighspecificityforidentifyingoutofhospitalcardiacarrestpatientswithlittleornochanceof
survival.Studiesofanotherclinicaldecisionrulesuggestthatittooaccuratelypredictssurvivalandwould
reduceunnecessarytransportssubstantiallyifimplemented[51,55].
Accordingtoasystematicreviewof12smalltrials,mostofwhichstudiedconveniencesamplesofpatients
withsuddencardiacarrest(n=568),bedsideechocardiographymaybehelpfulforassessingprognosis[56].In
thisreview,thepooledsensitivityandspecificityofechocardiographytopredictthereturnofspontaneous
circulation(ROSC)were91.6and80percentrespectively(95%CIforsensitivity84.6to96.1%95%CIfor
specificity76.1to83.6%).Ofthe190patientsfoundtohavecardiacwallmotion,98(51.6percent)achieved
ROSC,whereasonly9(2.4percent)ofthe378withoutcardiacwallmotiondidso.Limitationsoftheindividual
studiespreventedtheauthorsfromassessingsurvivaltodischargeorsurvivalwithgoodneurologicfunction.
Theauthorsofthisreviewemphasizethatechocardiographyresultsshouldnotbethesolebasisfor
terminatingresuscitativeeffortsbutmayserveasanadjuncttoclinicalassessment.Bedside
echocardiographymustneverinterferewithresuscitationefforts,andshouldnotinterruptordelayresumptionof
CPR,exceptincaseswheretheultrasoundisbeingobtainedstrictlytoconfirmabsenceofwallmotionwhena
decisiontoterminateresuscitativeeffortsisimminent.
INFORMATIONFORPATIENTSUpToDateofferstwotypesofpatienteducationmaterials,"TheBasics"
and"BeyondtheBasics."TheBasicspatienteducationpiecesarewritteninplainlanguage,atthe5thto6th
gradereadinglevel,andtheyanswerthefourorfivekeyquestionsapatientmighthaveaboutagiven
condition.Thesearticlesarebestforpatientswhowantageneraloverviewandwhoprefershort,easytoread
materials.BeyondtheBasicspatienteducationpiecesarelonger,moresophisticated,andmoredetailed.
Thesearticlesarewrittenatthe10thto12thgradereadinglevelandarebestforpatientswhowantindepth
informationandarecomfortablewithsomemedicaljargon.
Herearethepatienteducationarticlesthatarerelevanttothistopic.Weencourageyoutoprintoremailthese
topicstoyourpatients.(Youcanalsolocatepatienteducationarticlesonavarietyofsubjectsbysearchingon
"patientinfo"andthekeyword(s)ofinterest.)
Basicstopic(see"Patientinformation:Ventricularfibrillation(TheBasics)")
SUMMARYANDRECOMMENDATIONS
Cardiopulmonaryresuscitation(CPR)andearlydefibrillationfortreatablearrhythmiasremainthe
cornerstonesofbasicandadvancedcardiaclifesupport(ACLS).Excellentchestcompressionswithout
interruptionarethekeytosuccessfulCPR(table1).(See'Excellentbasiclifesupportanditsimportance'
above.)
TheperformanceofteamsprovidingACLSimproveswhenthereisasingledesignatedleaderwhoasks
forandacceptshelpfulsuggestionsfrommembersoftheteam,andwhentheteampracticesclear,
closedloopcommunication.(See'Resuscitationteammanagement'above.)
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BeginproperlyperformedCPRimmediatelyforanypatientwithsuspectedcardiacarrest.Otherinitial
interventionsforACLSincludeadministeringoxygenwhenneeded,establishingintravenousaccess,
placingthepatientonacardiacandoxygensaturationmonitor,andobtaininganelectrocardiogram
(ECG).(See'InitialmanagementandECGinterpretation'above.)
Inadults,properlyperformedchestcompressionstakepriorityoverventilationduringtheinitialperiodof
basiclifesupport.Whenventilatingthepatientincardiacarrest,give100percentoxygen,uselow
respiratoryrates(approximately6breathsperminute),andavoidhyperventilation,whichisharmful.(See
'AirwaymanagementwhileperformingACLS'above.)
ForthepurposesofACLS,ECGinterpretationisguidedbythreequestions:
Istherhythmfastorslow?
AretheQRScomplexeswideornarrow?
Istherhythmregularorirregular?
ThebasicapproachandimportantaspectsofmanagementforeacharrhythmiacoveredbytheACLS
Guidelinesarediscussedinthetextandsummarizedintheaccompanyingalgorithms(see'Management
ofspecificarrhythmias'above):
Cardiacarrest(ventricularfibrillationpulselessventriculartachycardiaasystolepulseless
electricalactivity):(algorithm2andfigure1)
Bradycardiawithpulse:(algorithm3)
Tachycardiawithpulse:(algorithm4)
UseofUpToDateissubjecttotheSubscriptionandLicenseAgreement.
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30. SchwarzB,BowdleTA,JettGK,etal.Biphasicshockscomparedwithmonophasicdampedsinewave
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43. MohrM,BahrJ,SchmidJ,etal.Thedecisiontoterminateresuscitativeefforts:resultsofa
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46. BaileyED,WydroGC,ConeDC.Terminationofresuscitationintheprehospitalsettingforadultpatients
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47. HorstedTI,RasmussenLS,LippertFK,NielsenSL.Outcomeofoutofhospitalcardiacarrestwhydo
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48. LevineRL,WayneMA,MillerCC.Endtidalcarbondioxideandoutcomeofoutofhospitalcardiacarrest.
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49. GrmecS,KlemenP.Doestheendtidalcarbondioxide(EtCO2)concentrationhaveprognosticvalue
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50. AhrensT,SchallomL,BettorfK,etal.Endtidalcarbondioxidemeasurementsasaprognosticindicator
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GRAPHICS
AdultBLSalgorithmforhealthcareproviders

AED:automatedexternaldefibrillatorALS:advancedlifesupportBLS:basiclifesupport.
*Theboxesborderedwithdashedlinesareperformedbyhealthcareprovidersandnotbylayrescuers.
Reprintedwithpermission.AdultBasicLifeSupport:2010.AmericanHeartAssociationGuidelinesfor
CardiopulmonaryResuscitationandEmergencyCardiovascularCare.2010AmericanHeart
Association,Inc.
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Adultcardiacarrestalgorithm:2010ACLSguidelines

CPR:cardiopulmonaryresuscitationET:endotrachealtubeEtCO2:endtidalcarbondioxideIO:
intraosseousIV:intravenousPEA:pulselesselectricalactivityVF:ventricularfibrillationVT:ventricular
tachycardia.
Reprintedwithpermission.AdultAdvancedCardiovascularLifeSupport:2010.AmericanHeartAssociation
GuidelinesforCardiopulmonaryResuscitationandEmergencyCardiovascularCare.2010American
HeartAssociation,Inc.
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ACLScardiacarrestcircularfigure

ReprintedwithpermissionAdultAdvancedCardiovascularLifeSupport:2010.AmericanHeartAssociation
GuidelinesforCardiopulmonaryResuscitationandEmergencyCardiovascularCare.2010AmericanHeart
Association,Inc.
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KeyprinciplesintheperformanceofACLS
ExcellentCPRiscrucial.
Excellentchestcompressionsmustbeperformedthroughouttheresuscitationwithout
interruption,usingpropertiming(100compressionsperminute)andforce(5cmdepth),
andallowingforcompletechestrecoil.
Donotstopcompressionsuntilthedefibrillatorisfullycharged.
AnythingshortofexcellentCPRdoesnotachieveadequatecerebralandcoronaryperfusion.
Excellentchestcompressionstakepriorityoverventilation.Ifasecondrescuerispresent,
ventilationsmustbeperformedusingpropertiming(6to8breathsperminuteinthe
intubatedpatientratioof30compressionsto2ventilationsifnotintubated)andforce
(eachbreathdeliveredoverafull1to2seconds)avoidhyperventilation.
DefibrillateVFandpulselessVTasrapidlyaspossible.
Rapidlyidentifyandtreatcausesofnonshockablearrest(PEA,asystole).
Importantcausesincludethe5H'sand5T's:Hypoxia,Hypovolemia,Hydrogenions
(acidosis),Hyper/Hypokalemia,HypothermiaTensionpneumothorax,Tamponadecardiac,
Toxins,Thrombosiscoronary(MI),Thrombosispulmonary(PE).
Ifreversiblecausesarenotcorrectedrapidly,thepatienthaslittlechanceofsurvival.
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Manualdefibrillationperformancebundle
1. Attachandchargethedefibrillatorwhilecontinuingexcellentchestcompressions.
2. Stopcompressionsandassessrhythm(shouldtakenomorethan5seconds).
3. IfVForVTispresent,delivershockifnonshockablerhythmispresent,resumeexcellent
CPR.
4. ResumeexcellentchestcompressionsandCPRimmediatelyaftertheshockisdelivered.
Criticalpoint:Interruptionsinexcellentchestcompressionsmustbekepttoaminimum:Do
NOTstopcompressionswhiledefibrillatorischarged.
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Treatableconditionsassociatedwithcardiacarrest
Condition

Commonassociatedclinicalsettings

Acidosis

Diabetes,diarrhea,drugoverdose,renaldysfunction,sepsis,shock

Anemia

Gastrointestinalbleeding,nutritionaldeficiencies,recenttrauma

Cardiac
tamponade

Postcardiacsurgery,malignancy,postmyocardialinfarction,pericarditis,
trauma

Hyperkalemia

Drugoverdose,renaldysfunction,hemolysis,excessivepotassiumintake,
rhabdomyolysis,majorsofttissueinjury,tumorlysissyndrome

Hypokalemia*

Alcoholabuse,diabetesmellitus,diuretics,drugoverdose,profound
gastrointestinallosses

Hypothermia

Alcoholintoxication,significantburns,drowning,drugoverdose,elderpatient,
endocrinedisease,environmentalexposure,spinalcorddisease,trauma

Hypovolemia

Significantburns,diabetes,gastrointestinallosses,hemorrhage,malignancy,
sepsis,trauma

Hypoxia

Upperairwayobstruction,hypoventilation(CNSdysfunction,neuromuscular
disease),pulmonarydisease

Myocardial
infarction

Cardiacarrest

Poisoning

Historyofalcoholordrugabuse,alteredmentalstatus,classictoxidrome(eg,
sympathomimetic),occupationalexposure,psychiatricdisease

Pulmonary
embolism

Immobilizedpatient,recentsurgicalprocedure(eg,orthopedic),peripartum,
riskfactorsforthromboembolicdisease,recenttrauma,presentation
consistentwithacutepulmonaryembolism

Tension
pneumothorax

Centralvenouscatheter,mechanicalventilation,pulmonarydisease(eg,
asthma,chronicobstructivepulmonarydisease),thoracentesis,thoracic
trauma

*Hypomagnesemiashouldbeassumedinthesettingofhypokalemia,andbothshouldbetreated.
Adaptedfrom:EisenbergMS,MengertTJ.Cardiacresuscitation.NEnglJMed2001344:1304.
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Optionsforhandsfreepacemaker/defibrillatorpad
positioning

Positioningoptionsforhandsfreepacemaker/defibrillatorpadsshowing
anterior/lateralpositioning(left)andanterior/posteriorpositioning(right).
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Adultbradycardiaalgorithm(withpulse):2010ACLS
guidelines

ECG:electrocardiogramIV:intravenousmcg:microgram.
Reprintedwithpermission.AdultAdvancedCardiovascularLifeSupport:2010.
AmericanHeartAssociationGuidelinesforCardiopulmonaryResuscitationand
EmergencyCardiovascularCare.2010AmericanHeartAssociation,Inc.
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Adulttachycardiaalgorithm(withpulse):2010ACLSguidelines

CHF:congestiveheartfailureECG:electrocardiogramIV:intravenousJ:joulesNS:normal
(isotonic)salineVT:ventriculartachycardia.
Reprintedwithpermission.AdultAdvancedCardiovascularLifeSupport:2010.AmericanHeart
AssociationGuidelinesforCardiopulmonaryResuscitationandEmergencyCardiovascularCare.
2010AmericanHeartAssociation,Inc.
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Disclosures
Disclosures:CharlesNPozner,MDNothingtodisclose.RonMWalls,MD,FRCPC,FAAEMOtherFinancialInterest:Airway
ManagementEducationCenter[Healthcareprovidereducationandresources(CookMelkerUniversalCricothyrotomykit,theDifficult
Airwaycourse)].RichardLPage,MDNothingtodisclose.JonathanGrayzel,MD,FAAEMNothingtodisclose.
Contributordisclosuresarereviewedforconflictsofinterestbytheeditorialgroup.Whenfound,theseareaddressedbyvetting
throughamultilevelreviewprocess,andthroughrequirementsforreferencestobeprovidedtosupportthecontent.Appropriately
referencedcontentisrequiredofallauthorsandmustconformtoUpToDatestandardsofevidence.
Conflictofinterestpolicy

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