Chapter 24: Cardiac Resuscitation

INTRODUCTION

Cardiac resuscitation is a rapidly changing clinical science. Recommendations of the 2015 American Heart Association Advanced Cardiac Life Support updates¹ are provided in this chapter and are augmented by the most current resuscitation research literature. These recommendations are similar to the recent 2017 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Summary.² The guidelines are summarized as follows.

CHEST COMPRESSIONS

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

• Chest compression depth should be 5 to 6 cm, not >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 an 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 lidocaine (lignocaine) may not provide added benefit to defibrillation.

• Vasopressin has been removed from the Advanced Cardiac Life Support algorithm.

• Routine use of β-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, although routine use is not recommended.

OXYGENATION AND CAPNOGRAPHY

• Provide 100% fraction of inspired oxygen (Fio₂) during cardiac arrest, with oxygen saturation titrated to >94% after ROSC.

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

EXTRACORPOREAL MEMBRANE OXYGENATION

• Extracorporeal membrane oxygenation (ECMO) or extracorporeal CPR 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-segment elevation on ECG and for hemodynamically or electrically unstable patients with no ST-segment elevation but suspected cardiovascular cause.

• Targeted temperature management between 32°C and 36°C 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.

EPIDEMIOLOGY

Every year, approximately 6.8 to 8.5 million persons throughout the world³ sustain cardiac arrest. About 70% ...