Causes and Prevention
Identification of the Etiology of Cardiac Arrest
The physical circumstances, history, or precipitating events may enable the rescuer to determine a noncardiac cause of the cardiorespiratory arrest. Under these circumstances the rescuer should undertake interventions based on the presumed noncardiac etiology.
Impact of Medical Emergency Teams (METs)
Introduction of a MET system for adult hospital in-patients should be considered, with special attention to details of implementation (e.g., composition and availability of the team, calling criteria, education and awareness of hospital staff, and method of activation of the team). Introduction of an early warning scoring (EWS) system for adult in-hospital patients may be considered.
Airway and Ventilation
Basic Airway Devices
Nasopharyngeal Airway
In the presence of a known or suspected basal skull fracture, an oral airway is preferred, but if this is not possible and the airway is obstructed, gentle insertion of a nasopharyngeal airway may be lifesaving (i.e., the benefits may far outweigh the risks).
Advanced Airway Devices
Tracheal Intubation Versus Ventilation With Bag-Valve Mask
There is insufficient evidence to support or refute the use of any specific technique to maintain an airway and provide ventilation in adults with cardiopulmonary arrest. Either bag-valve mask alone or in combination with tracheal intubation is acceptable for ventilation during cardiopulmonary resuscitation (CPR) by prehospital providers. Rescuers must weigh the risks and benefits of intubation versus the need to provide effective chest compressions. The intubation attempt will require interruption of chest compressions, but once an advanced airway is in place, ventilation will not require interruption (or even pausing) of chest compressions. To avoid substantial interruptions in chest compressions, providers may defer an intubation attempt until return of spontaneous circulation (ROSC). To ensure competence, healthcare systems that utilize advanced airways should address factors such as adequacy of training and experience and quality assurance. Providers must confirm tube placement and ensure that the tube is adequately secured.
Tracheal Intubation Versus the Combitube/Laryngeal Mask Airway (LMA)
It is acceptable for healthcare professionals to use the Combitube or the LMA as alternatives to the tracheal tube for airway management in cardiac arrest.
Confirming Advanced Airway Placement
Unrecognized esophageal intubation is the most serious complication of attempted tracheal intubation. Routine confirmation of correct placement of the tracheal tube should reduce this risk. There are inadequate data to identify the optimal method of confirming tube placement during cardiac arrest. All devices should be considered adjuncts to other confirmatory techniques.
Exhaled Carbon Dioxide (CO2)
Healthcare providers should recognize that evaluation of exhaled CO2 is not infallible for confirming correct placement of a tracheal tube, particularly in patients in cardiac arrest. Exhaled CO2 should be considered as just one of several independent methods for confirming tracheal tube placement. Continuous capnometry may be useful for early detection of tracheal tube dislodgment during transport.
Esophageal Detector Device (EDD)
The use of the EDD should be considered as just one of several independent methods for tracheal tube confirmation.
Strategies to Secure Advanced Airways
Securing the Tracheal Tube
Either commercially made tracheal tube holders or conventional tapes or ties should be used to secure the tracheal tube.
Strategies for Ventilation
Automatic Transport Ventilators (ATVs)
The use of a manually triggered, flow-limited resuscitator or an ATV by professional healthcare providers is reasonable for ventilation of adults with an advanced airway in place during cardiac arrest. The use of ATVs for adults without an advanced airway in place is discussed in the guideline entitled Adult Basic Life Support (see National Guideline Clearinghouse [NGC] summary of the American Heart Association guideline).
Drugs and Fluids for Cardiac Arrest
Vasopressors
Epinephrine and Vasopressin
Despite the absence of placebo-controlled trials, epinephrine has been the standard vasopressor in cardiac arrest. There is insufficient evidence to support or refute the use of vasopressin as an alternative to, or in combination with, epinephrine in any cardiac arrest rhythm.
Antiarrhythmics
Amiodarone
In light of the short-term survival benefits, amiodarone should be considered for refractory ventricular fibrillation/ventricular tachycardia (VF/VT).
Other Drugs and Fluids
Buffers
Giving sodium bicarbonate routinely during cardiac arrest and CPR (especially in out-of-hospital cardiac arrest) or after ROSC is not recommended. Sodium bicarbonate may be considered for life-threatening hyperkalemia or cardiac arrest associated with hyperkalemia, preexisting metabolic acidosis, or tricyclic antidepressant overdose.
Magnesium
Magnesium should be given for hypomagnesemia and torsades de pointes, but there is insufficient data to recommend for or against its routine use in cardiac arrest.
Fibrinolysis During CPR
Fibrinolysis should be considered in adult patients with cardiac arrest with proven or suspected pulmonary embolism. There is insufficient data to support or refute the routine use of fibrinolysis in cardiac arrest from other causes.
Alternative Routes for Drug Delivery
Drugs Given via the Tracheal Tube
If intravenous (IV) access is delayed or cannot be achieved, intraosseous (IO) access should be considered. Give drugs via the tracheal tube if intravascular (IV or IO) access is delayed or cannot be achieved. There are no benefits from endobronchial injection compared with injection of the drug directly into the tracheal tube. Dilution with water instead of 0.9% saline may achieve better drug absorption.
Monitoring and Assisting the Circulation
Monitoring CPR Performance
End-Tidal CO2 Monitoring to Guide Therapy During Cardiac Arrest
End-tidal CO2 monitoring is a safe and effective noninvasive indicator of cardiac output during CPR and may be an early indicator of ROSC in intubated patients.
Arterial Blood Gas Monitoring During Cardiac Arrest
Arterial blood gas monitoring during cardiac arrest enables estimation of the degree of hypoxemia and the adequacy of ventilation during CPR but is not a reliable indicator of the extent of tissue acidosis.
Coronary Perfusion Pressure (CPP) to Guide Resuscitation
Coronary perfusion pressure can guide therapy during cardiac arrest. In an intensive care facility the availability of direct arterial and central venous pressure monitoring makes calculation of CPP potentially useful. Outside the intensive care facility the technical difficulties of invasive monitoring of central arterial and venous pressure make it difficult to calculate CPP routinely during cardiac arrest.
Techniques and Devices to Assist Circulation During Cardiac Arrest
Transcutaneous Pacing for Asystole
Pacing is not recommended for patients in asystolic cardiac arrest.
CPR Prompt Devices
CPR prompt devices may improve CPR performance. See also "Interdisciplinary topics" in the "Availability of Companion Documents" field.
Open-Chest CPR
Open-chest CPR should be considered for patients with cardiac arrest in the early postoperative phase after cardiothoracic surgery or when the chest or abdomen is already open.
Periarrest Arrhythmias
Narrow-Complex Tachycardia
There are 4 options for the treatment of narrow-complex tachycardia in the periarrest setting: electrical conversion, physical maneuvers, pharmacologic conversion, or rate control. The choice depends on the stability of the patient and the rhythm. In a hemodynamically unstable patient, narrow-complex tachycardia is best treated with electrical cardioversion.
Drug Therapy for Atrial Fibrillation
Magnesium, diltiazem, or beta-blockers may be used for rate control in patients with atrial fibrillation with a rapid ventricular response. Amiodarone, ibutilide, propafenone, flecainide, digoxin, clonidine, or magnesium may be used for rhythm control in patients with atrial fibrillation.
Drug Therapy for Regular Narrow-Complex Tachycardia
Stable narrow-complex tachycardia (excluding atrial fibrillation or atrial flutter) should be treated first with vagal maneuvers (avoiding carotid sinus massage in the elderly); these will terminate about 20% of paroxysmal supraventricular tachycardias (PSVTs). If vagal maneuvers are not used or if they fail, give adenosine.
A calcium channel blocker (verapamil or diltiazem) infusion or amiodarone may be used as a second-line treatment for the 10% to 15% of patients who do not respond to adenosine. In unstable PSVT, electrical cardioversion is the treatment of choice; IV rapid bolus adenosine can be tried if electrical cardioversion is not immediately available.
Broad-Complex Tachycardia
The stability of the patient determines the choice of treatment for wide-complex (broad-complex) tachycardia. In unstable wide-complex tachycardia electrical cardioversion is the treatment of choice.
Drug Therapy for Stable Ventricular Tachycardia
Amiodarone, procainamide, and sotalol are effective in terminating stable sustained VT.
Drug Therapy for Polymorphic Ventricular Tachycardia
For hemodynamically stable polymorphic VT, where electrical therapy is not desirable or is ineffective, treatment with amiodarone may be effective.
Therapy for Torsades de Pointes
Magnesium, isoproterenol, and ventricular pacing can be used to treat torsades de pointes.
Bradycardia
In the periarrest setting the rescuer should seek and treat reversible causes of bradycardia. In the absence of reversible causes, atropine remains the first-line drug for acute symptomatic bradycardia. Failure to respond to atropine will usually necessitate transcutaneous pacing, although second-line drug therapy with dopamine, epinephrine, isoproterenol, or theophylline may be successful. Fist pacing may be attempted pending the arrival of an electrical pacing unit.
Drug Therapy for Symptomatic Bradycardia
For symptomatic bradycardia, give atropine 0.5 to 1 mg IV, repeated every 3 to 5 minutes, to a total of 3 mg. Be prepared to initiate transcutaneous pacing quickly in patients who do not respond to atropine (or second-line drugs if these do not delay definitive management). Pacing is also recommended for severely symptomatic patients, especially when the block is at or below the His-Purkinje level. Second-line drugs for symptomatic bradycardia include dopamine, epinephrine, isoproterenol, and theophylline. Consider IV glucagon if beta-blockers or calcium channel blockers are a potential cause of the bradycardia. Atropine should not be used in patients with cardiac transplants.
Fist Pacing in Cardiac Arrest
Fist pacing may be considered in hemodynamically unstable bradyarrhythmias until an electrical pacemaker (transcutaneous or transvenous) is available.
Cardiac Arrest in Special Circumstances
Environmental
Hypothermia
For hypothermic patients with a perfusing rhythm and without a preceding cardiac arrest, consider active (noninvasive) external warming (with heating blankets, forced air, and warmed infusion). Severely hypothermic patients in cardiac arrest may benefit from invasive warming (cardiopulmonary bypass or extracorporeal circulation).
Drowning
Victims of submersion should be removed from the water and resuscitated by the fastest means available. Only victims with risk factors (history of diving, water slide use, trauma, alcohol) or clinical signs of injury or focal neurologic signs should be treated as having a potential spinal cord injury, with stabilization of the cervical and thoracic spine.
Pregnancy
Etiology of Cardiac Arrest in Pregnancy
Rescuers should try to identify common and reversible causes of cardiac arrest in pregnancy during resuscitation attempts. The use of abdominal ultrasound by a skilled operator should be considered in detecting pregnancy and possible causes of cardiac arrest in pregnancy, but this should not delay other treatments.
Resuscitation Technique for Pregnancy
If initial resuscitative efforts fail, caesarean delivery of the fetus (hysterotomy) should be performed within 5 minutes of onset of cardiac arrest in pregnancy to improve maternal or fetal survival. A left lateral tilt of 15 degrees is required to relieve inferior vena caval compression in the majority of pregnant women. The energy levels used for defibrillation in adults are appropriate for use in pregnancy.
Asthma
Defibrillation in Asthma
If initial attempts at defibrillation fail for the patient with asthma and VF, higher shock energies should be considered.
Ventilation in Asthma
There are insufficient data to support or refute the use of helium-oxygen mixtures in asthma-related cardiac arrest. Compression of the chest wall or a period of apnea may relieve gas trapping if dynamic hyperinflation occurs. In asthma-related cardiac arrest the patient's trachea should be intubated early to facilitate ventilation and minimize the risk of gastric inflation.
Drug Overdose and Poisoning
Sodium Bicarbonate for Poisoning and Electrolyte Disturbances
Sodium bicarbonate is recommended for the treatment of tricyclic antidepressant-induced arrhythmia or hypotension. Although no study has investigated the optimal target pH with bicarbonate therapy, a pH of 7.45 to 7.55 has been commonly accepted and seems reasonable.
Postresuscitation Care
Ventilation
Control of Arterial Carbon Dioxide
There are no data to support the targeting of a specific partial pressure of arterial carbon dioxide (PaCO2) after resuscitation from cardiac arrest. Data extrapolated from patients with brain injury, however, imply that ventilation to normocarbia is appropriate. Routine hyperventilation may be detrimental and should be avoided.
Temperature Control
Therapeutic Hypothermia
Unconscious adult patients with spontaneous circulation after out-of-hospital cardiac arrest should be cooled to 32 degrees C to 34 degrees C for 12 to 24 hours when the initial rhythm was VF. Cooling to 32 degrees C to 34 degrees C for 12 to 24 hours may be considered for unconscious adult patients with spontaneous circulation after out-of-hospital cardiac arrest from any other rhythm or cardiac arrest in hospital.
Prevention and Treatment of Hyperthermia
Hyperthermia should be avoided after cardiac arrest.
Seizure Control and Sedation
Prevention and Control of Seizures
Seizures increase the oxygen requirements of the brain and can cause life-threatening arrhythmias and respiratory arrest; therefore, seizures following cardiac arrest should be treated promptly and effectively. Maintenance therapy should be started after the first event once potential precipitating causes (e.g., intracranial hemorrhage, electrolyte imbalance) are excluded.
Other Supportive Therapies
Blood Glucose Control
Providers should monitor blood glucose frequently after cardiac arrest and should treat hyperglycemia with insulin but avoid hypoglycemia.
Prophylactic Antiarrhythmic Therapy
Giving prophylactic antiarrhythmics to patients who have survived cardiac arrest, irrespective of etiology, can neither be recommended nor rejected. It may be reasonable, however, to continue an infusion of an antiarrhythmic drug that successfully restored a stable rhythm during resuscitation.
Prognostication
Prognostication During Cardiac Arrest
Predictive Value of Neurologic Examination
Relying on the neurologic exam during cardiac arrest to predict outcome is not recommended and should not be used.
Prognostication After Resuscitation
Predictive Value of Neuron-Specific Enolase (NSE) and Protein S-100b
No laboratory analyses (NSE, S-100b, base deficit, glucose, or soluble P-selectin) provide reliable prediction of the outcome after cardiac arrest.
Somatosensory-Evoked Potential
Median nerve somatosensory-evoked potentials measured 72 hours after cardiac arrest can be used to predict a fatal outcome in patients with hypoxic-anoxic coma.
Electroencephalogram (EEG)
The use of the EEG performed a minimum of 24 to 48 hours after a cardiac arrest can help define the prognosis in patients with grade I, IV, and V EEGs.