All reviewers were instructed to search their allocated questions broadly. Reviewers documented their search strategies to ensure reproducibility of the search. The minimum electronic databases searched included the Cochrane database for systematic reviews and the Central Register of Controlled Trials (http://www.cochrane.org/), MEDLINE (http://www.ncbi.nlm.nih.gov/PubMed/), EMBASE (www.embase.com), and the master reference library collated by the American Heart Association (AHA). To identify the largest possible number of relevant articles, reviewers were also encouraged to perform hand searches of journals, review articles, and books as appropriate.

The reviewers documented the mechanism by which studies relevant to the hypothesis were selected. Specific study inclusion and exclusion criteria and study limitations were documented. Inclusion of all relevant evidence (from animal and manikin/model studies as well as human studies) was encouraged.

The default levels of evidence used for the 2005 consensus process were not designed for the review of studies that evaluate diagnosis or prognosis. For these studies other methods of assigning levels of evidence were considered (such as those proposed by the Oxford Centre for Evidence-Based Medicine [http://www.cebm.net/]). Worksheet reviewers planning to include alternative levels of evidence were asked to define such levels clearly and to retain the default levels of evidence.

Completed worksheets were posted on the Internet for further review. The initial process involved posting the worksheet to a password-protected area of the American Heart Association Intranet (accessible to worksheet reviewers). In December 2004 the completed worksheets were posted on an Internet site that could be accessed by the public for further review and feedback before the 2005 Consensus Conference in Dallas (www.C2005.org).

Wording of science statements and treatment recommendations was refined after further review by International Liaison Committee on Resuscitation (ILCOR) member organizations and the international editorial board. This format ensured that this final document represents a truly international consensus process.

The manuscript was ultimately approved by all ILCOR member organizations and by an international editorial board. The American Heart Association (AHA) Science Advisory and Coordinating Committee and the editor of Circulation obtained peer reviews of this document before it was accepted for publication. The document is being published simultaneously in Circulation and Resuscitation, although the version in Resuscitation does not include the sections on stroke and first aid.

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.

For information about availability, see the "Availability of Companion Documents" and "Patient Resources" fields below.

Potential conflicts of interest of the editorial board are listed in Appendix 3 of the original guideline document (see "Availability of Companion Documents" field). Potential conflicts of interest of the worksheet authors are noted in the worksheets and can be accessed through the links to the worksheets contained in the original guideline document. All 380 attendees were required to complete forms in order to document their potential conflicts of interest. Most attendees were also worksheet authors. The information from the conflict of interest forms completed by all conference attendees, including worksheet authors, can also be accessed at the website http://circ.ahajournals.org/content/vol112/22_suppl/#APPENDIX. Readers of the print version can also access the statements at the American Heart Association website: www.C2005.org.

Electronic copies: Available from the American Heart Association Web site.

Print copies: Available from the American Heart Association, Public Information, 7272 Greenville Ave, Dallas, TX 75231-4596; Phone: 800-242-8721

Electronic copies: Available from the American Heart Association Web site.

Print copies: Available from the American Heart Association, Public Information, 7272 Greenville Ave, Dallas, TX 75231-4596; Phone: 800-242-8721

Copyright to the original guideline is owned by the American Heart Association, Inc. (AHA). Reproduction of the AHA Guideline without permission is prohibited. Single reprint is available by calling 800-242-8721 (US only) or writing the American Heart Association, Public Information, 7272 Greenville Ave., Dallas, TX 75231-4596. Ask for reprint No. 71-0276. To purchase additional reprints: up to 999 copies, call 800-611-6083 (US only) or fax 413-665-2671; 1000 or more copies, call 410-528-4121, fax 410-528-4264, or email kgray@lww.com. To make photocopies for personal or educational use, call the Copyright Clearance Center, 978-750-8400.

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