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Chapter 24: Cardiac Resuscitation

Brit Long; Alex Koyfman; Anantharaman Venkataraman; Swee Han Han; Marcus E. H. Ong; Kenneth B. K. Tan

Content Update

March 7, 2017

Cardiac resuscitation is a rapidly changing clinical science. Recommendations of the November 2015 AHA-ACLS updates1 are provided in this chapter and are augmented by the most current resuscitation research literature. To summarize:

CHEST COMPRESSIONS

  • The recommended chest compression rate is 100-120 per minute, updated from 100 per minute.

  • Chest compression depth should be 5-6 cm, not more than 6 cm. Chest compression ratio should be > 60 and as close to 90 as possible.

  • There does not appear to be an advantage to asynchronous or interpolated breaths as long as the highest possible compression ratio is maintained.

  • The compression to breath ratio is 30:2. If adjunctive or definitive airway is in place, provide 10 breaths per minute.

DEFIBRILLATION

  • Early defibrillation is the most effective modality for return of spontaneous circulation (ROSC).

DRUGS

  • Amiodarone or lignocaine (lidocaine) may not provide added benefit to defibrillation.

  • Vasopressin has been removed from the ACLS algorithm.

  • Routine use of beta blockers after cardiac arrest is not recommended, with benefits for ROSC only demonstrated through animal studies and case reports.

  • Steroids may provide some benefit when bundled with vasopressin and epinephrine in in-hospital cardiac arrest, though routine use is not recommended.

OXYGENATION AND CAPNOGRAPHY

  • Provide 100% FiO2 during cardiac arrest, with oxygen saturation titrated to greater than 94% post ROSC.

  • End tidal CO2 can be used to monitor for ROSC. Low end tidal CO2 (less than 10 mm Hg) after 20 minutes is associated with low likelihood of survival.

ECMO

  • ECMO or ECPR can be considered in patients with refractory cardiac arrest who have not responded to conventional CPR, where it can be rapidly implemented with suspicion of reversible cause of cardiac arrest.

POST ROSC CARE

  • Emergency percutaneous coronary intervention is recommended for patients with ST elevation on ECG and for hemodynamically or electrically unstable patients with no ST elevation but suspected cardiovascular cause.

  • Targeted temperature management between 32-36oC for comatose patients with ROSC for at least 24 hours is recommended.

SOCIAL MEDIA AND EDUCATION

  • Use of social media technologies that summon rescuers in close proximity to a victim of out-of-hospital cardiac arrest may be reasonable. Audiovisual devices can be used to educate providers and improve CPR quality.

INTRODUCTION AND EPIDEMIOLOGY

Every year, approximately 6.8 to 8.5 million persons throughout the world2 sustain cardiac arrest. About 70% of cardiac arrests occur out of hospital. The proportion of cardiac arrest patients who are treated varies from about 54.6% (United States) to about 28.3% (Asia). The proportions with ventricular fibrillation (VF) and survival vary from 11% and 2%, respectively, in Asia, to 28% and 6% in North America, 35% and 9% in Europe, and 40% and 11% in Australia.3 About half of cardiac arrest victims are <65 years old.

Ventricular tachyarrhythmias are the initiating event in about 80% of patients with out-of-hospital primary cardiac arrest. During ambulatory electrocardiogram (ECG) monitoring of 157 ...

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