CPR2015 update: Adult Advanced Cardiovascular Life Support

1. Adult Advanced Cardiovascular Life
Support
Part 7

3. Oxygen Dose During CPR
2015 Recommendation-updated Class
When supplementary oxygen is
available, it may be reasonable to use
the maximal feasible inspired oxygen
concentration during CPR
IIb, LOE C-EO
The higher ranges of arterial Po2 during CPR were associated with
an increase in hospital admission rates. However, there was no
statistical difference in overall neurologic survival

4. Monitoring Physiologic Parameters
During CPR
2015 Recommendation—Updated Class
It may be reasonable to use physiologic
parameters (quantitative waveform
capnography, arterial relaxation diastolic
pressure, arterial pressure monitoring,
and ScVO2) when feasible to monitor and
optimize CPR quality, guide vasopressor
therapy, and detect ROSC
IIb, LOE C-EO

5. Ultrasound During Cardiac Arrest
2015 Recommendations—Updated Class
Ultrasound (cardiac or noncardiac) may be
considered during the management of
cardiac arrest, although its usefulness has
not been well established
Class IIb,
LOE C-EO

6. Ultrasound During Cardiac Arrest
2015 Recommendations—Updated Class
If a qualified sonographer is present and
use of ultrasound does not interfere
with the standard cardiac arrest
treatment protocol, then ultrasound
may be considered as an adjunct to
standard patient evaluation
IIb, LOE C-EO

8. Bag-Mask Ventilation Compared With Any
Advanced Airway During CPR
2015 Recommendations—Updated Class
Either a bag-mask device or an
advanced airway may be used for
oxygenation and ventilation during
CPR in both the inhospital and out-of-
hospital setting
IIb, LOE C-LD
For healthcare providers trained in
their use, either an SGA device or an
ETT may be used as the initial
Advanced airway during CPR
IIb, LOE C-LD

9. Clinical Assessment of Tracheal Tube Placement
2015 Recommendations—Updated Class
Continuous waveform capnography is
recommended in addition to clinical
assessment as the most reliable method
of confirming and monitoring correct
placement of an ETT
I,LOE C-LD
If continuous waveform capnometry is
not available, a nonwaveform CO2
detector, esophageal detector device, or
ultrasound used by an experienced
operator is a reasonable alternative
IIa, LOE C-LD

10. Ventilation After Advanced Airway Placement
2015 Recommendation—Updated Class
After placement of an advanced
airway, it may be reasonable for the
provider to deliver 1 breath every 6
seconds (10breaths/min) while
continuous chest compressions are
being performed
IIb, LOE C-LD

12. Defibrillation Strategies for VF or Pulseless VT:
WaveformEnergy and First-Shock Success
2015 Recommendations—Updated Class
Defibrillators (using BTE, RLB, or
monophasic waveforms) are
recommended to treat atrial and
ventricular arrhythmias
I, LOE B-NR
Using biphasic waveforms (BTE or
RLB) are preferred to monophasic
defibrillators for treatment of both
atrial and ventricular arrhythmias
IIa, LOE B-R

13. Defibrillation Strategies for VF or Pulseless VT:
Waveform Energy and First-Shock Success
2015 Recommendations—Updated Class
it is reasonable to use the manufacturer’s
recommended energy dose for the first
shock. If this is not known, defibrillation at
the maximal dose may be considered
IIb, LOE C-LD

14. Defibrillation Strategies for VF or Pulseless VT: Energy
Dose for Subsequent Shocks
2015 Recommendations—Updated Class
It is reasonable that selection of fixed
versus escalating energy for subsequent
shocks be based on the specific
manufacturer’s instructions
IIa, LOE C-LD
If using a manual defibrillator capable
of escalating energies,higher energy for
second and subsequent shocks may be
considered
IIb, LOE C-LD

15. Defibrillation Strategies for VF or Pulseless VT : Single
Shocks Versus Stacked Shocks
2015 Recommendation—Updated Class
A single-shock strategy (as opposed to
stacked shocks) is reasonable for
defibrillation
IIa, LOE B-NR

17. Antiarrhythmic Therapy for Refractory
VF/pVT Arrest
2015 Recommendations—Updated Class
Amiodarone may be considered for VF/pVT
that is unresponsive to CPR, defibrillation, and
a vasopressor therapy
IIb, LOE B-R
Lidocaine may be considered as an alternative
to amiodarone for VF/pVT that is unresponsive
to CPR, defibrillation,and vasopressor therapy
IIb, LOE C-LD
The routine use of magnesium for VF/pVT is
not recommended in adult patients
III: No Benefit,
LOE B-R

18. Antiarrhythmic Drugs After Resuscitation
2015 Recommendations—New Class
•There is inadequate evidence to support
the routine use of lidocaine after cardiac
arrest.
•However, the initiation or continuation of
lidocaine may be considered immediately
after ROSC from cardiac arrest due to
VF/pVT
IIb, LOE C-LD

19. Antiarrhythmic Drugs After Resuscitation
2015 Recommendations—New Class
•There is inadequate evidence to support
the routine use of a β-blocker after cardiac
arrest.
•However, the initiation or continuation of
an oral or intravenous β-blocker may be
considered early after hospitalization from
cardiac arrest due to VF/pVT
IIb, LOE C-LD

21. Standard-Dose Epinephrine
2015 Recommendation—Updated Class
Standard-dose epinephrine (1 mg every
3 to 5 minutes) may be reasonable for
patients in cardiac arrest
IIb, LOE B-R

22. Standard Dose Epinephrine Versus High-Dose
Epinephrine
2015 Recommendation—New Class
High-dose epinephrine is not
recommended for routine use in
cardiac arrest
III: No Benefit,
LOE B-R

23. Epinephrine Versus Vasopressin
2015 Recommendation—Updated Class
Vasopressin offers no advantage as a
substitute for epinephrine in cardiac
arrest
IIb, LOE B-R
•The removal of vasopressin has been noted in the
Adult Cardiac Arrest Algorithm

24. Epinephrine Versus Vasopressin in Combination
With Epinephrine
2015 Recommendation—New Class
Vasopressin in combination with
epinephrine offers no advantage as a
substitute for standard-dose
epinephrine in cardiac arrest
IIb, LOE B-R

25. Timing of Administration of Epinephrine
2015 Recommendations—Updated Class
It may be reasonable to administer
epinephrine as soon as feasible after
the onset of cardiac arrest due to an
initial nonshockable rhythm
IIb, LOE C-LD

26. Steroids
2015 Recommendations—New Class
•In IHCA, the combination of intra-arrest
vasopressin, epinephrine, and
methylprednisolone and post-arrest
hydrocortisone may be considered;
•However, further studies are needed
before recommending the routine use of
this therapeutic strategy
IIb,
LOE C-LD

27. Steroids
2015 Recommendations—New Class
For patients with OHCA, use of steroids
during CPR is of uncertain benefit
IIb, LOE C-
LD

28. Prognostication During CPR:
End-Tidal CO2
2015 Recommendations—New Class
In intubated patients, failure to achieve an
ETCO2 > 10 mmHg by waveform
capnography after 20 minutes of CPR may
be considered as one component of a
multimodal approach to decide when to
end resuscitative efforts, but it should not
be used in isolation
IIb,LOE C-
LD

29. Prognostication During CPR:
End-Tidal CO2
2015 Recommendations—New Class
In nonintubated patients, a specific
ETCO2 cutoff value at any time during
CPR should not be used as an indication
to end resuscitative efforts
III: Harm,
LOE C-EO

30. Overview of Extracorporeal CPR
2015 Recommendation—New Class
There is insufficient evidence to
recommend the routine use of ECPR for
patients with cardiac arrest. In settings
where it can be rapidly implemented,
ECPR may be considered for select cardiac
arrest patients for whom the suspected
etiology of the cardiac arrest is potentially
reversible during a limited period of
mechanical cardiorespiratory support
IIb,
LOE C-LD

32. Post–Cardiac Arrest Care
Part 8

34. Acute Cardiovascular Interventions
2015 Recommendations—Updated Class
Coronary angiography should be
performed emergently (rather than later
in the hospital stay or not at all) for OHCA
patients with suspected cardiac etiology
of arrest and ST elevation on ECG
I, LOE B-NR

35. Acute Cardiovascular Interventions
2015 Recommendations—Updated Class
Emergency coronary angiography is
reasonable for select (eg, electrically or
hemodynamically unstable) adult
patients who are comatose after OHCA of
suspected cardiac origin but without ST
elevation on ECG
IIa, LOE B-
NR

36. Acute Cardiovascular Interventions
2015 Recommendations—Updated Class
Coronary angiography is reasonable in
post–cardiac arrest patients for whom
coronary angiography is indicated
regardless of whether the patient is
comatose or awake
IIa,
LOE C-LD

37. Hemodynamic Goals
2015 Recommendation—New Class
Avoiding and immediately correcting
hypotension (systolic blood pressure less
than 90 mm Hg, MAP less than 65 mm
Hg) during postresuscitation care may be
reasonable
IIb,
LOE C-LD

39. Induced Hypothermia
2015 Recommendations—Updated Class
Recommend that comatose (ie, lack of
meaningful response to verbal
commands) adult patients with ROSC
after cardiac arrest have TTM
•Class I, LOE B-R for
VF/pVT OHCA
•Class I, LOE C-EO
for non-VF/pVT
Recommend selecting and maintaining
a constant temperature between 32C
and 36C during TTM
Class I, LOE B-R
It is reasonable that TTM be maintained
for at least 24 hours after achieving
target temperature
Class IIa, LOE C-
EO

40. Hypothermia in the Prehospital Setting
2015 Recommendation—New Class
We recommend against the routine
prehospital cooling of patients after ROSC
with rapid infusion of cold intravenous
fluids
Classs III: No
benefit, LOE
A

41. Avoidance of Hyperthermia
2015 Recommendation—New Class
It may be reasonable to actively
prevent fever in comatose patients
after TTM
IIb, LOE C-LD

43. Seizure Management
2015 Recommendations—Updated Class
An EEG for the diagnosis of seizure
should be promptly performed and
interpreted, and then should be
monitored frequently or continuously
in comatose patients after ROSC
I, LOE C-LD
The same anticonvulsant regimens for
the treatment of status epilepticus
caused by other etiologies may be
considered after cardiac arrest
IIb, LOE C-LD

45. Ventilation
2015 Recommendation—Updated Class
Maintaining the PaCo2 within a normal
physiological range, taking into account
any temperature correction, may be
reasonable
IIb, LOE B-NR

46. Oxygenation
2015 Recommendations—New and Updated Class
To avoid hypoxia in adults with ROSC after
cardiac arrest, it is reasonable to use the highest
available oxygen concentration until the arterial
oxyhemoglobin saturation or the partial pressure
of arterial oxygen can be measured
IIa, LOE
C-EO

47. Oxygenation
2015 Recommendations—New and Updated Class
When resources are available to titrate the
Fio2 and to monitor O2sat, it is reasonable to
decrease the Fio2 when oxyhemoglobin
saturation is 100%, provided O2sat can be
maintained at 94% or greater
IIa, LOE
C-LD

49. Glucose Control
2015 Recommendation—Updated Class
The benefit of any specific target range of
glucose managementis uncertain in adults
with ROSC after cardiac arrest
IIb, LOE B-R

51. Timing of Outcome Prediction
2015 Recommendations—New and Updated Class
The earliest time for prognostication using clinical
examination in patients treated with TTM, where
sedation or paralysis could be a confounder, may
be 72 hours after return to normothermia
IIb, LOE
C-EO

52. Timing of Outcome Prediction
2015 Recommendations—New and Updated Class
Recommend the earliest time to prognosticate
a poor neurologic outcome using clinical
examination in patients not treated with TTM is
72 hours after cardiac arrest
I, LOE B-
NR
This time until prognostication can be even
longer than 72 hours after cardiac arrest if the
residual effect of sedation or paralysis
confounds the clinical examination
IIa, LOE C-
LD

53. Clinical Examination Findings That Predict Outcome
2015 Recommendations—New and Updated Class
In comatose patients who are not treated with
TTM, the absence of pupillary reflex to light at 72
hours or more after cardiac arrest is a reasonable
exam finding with which to predict poor
neurologic outcome
IIa,
LOE B-
NR

54. Clinical Examination Findings That Predict Outcome
2015 Recommendations—New and Updated Class
In comatose patients who are treated with TTM,
the absence of pupillary reflex to light at 72
hours or more after cardiac arrest is useful to
predict poor neurologic outcome
I, LOE B-
NR

55. Clinical Examination Findings That Predict Outcome
2015 Recommendations—New and Updated Class
Recommend that, given their unacceptable
FPRs, the findings of either absent motor
movements or extensor posturing should not
be used alone for predicting a poor neurologic
outcome
III: Harm,
LOE B-NR
The motor examination may be a reasonable
means to identify the population who need
further prognostic testing to predict poor
outcome
IIb, LOE B-
NR

56. Clinical Examination Findings That Predict Outcome
2015 Recommendations—New and Updated Class
Recommend that the presence of myoclonus,
which is distinct from status myoclonus, should
not be used to predict poor neurologic
outcomes because of the high FPR
Class III,
Harm,
LOE B-
NR

57. Clinical Examination Findings That Predict Outcome
2015 Recommendations—New and Updated Class
In combination with other diagnostic tests at
72 or more hours after cardiac arrest, the
presence of status myoclonus during the first
72 to 120 hours after cardiac arrest is a
reasonable finding to help predict poor
neurologic outcomes
IIa, LOE
B-NR

58. EEG Findings to Predict Outcome
2015 Recommendations—Updated Class
In comatose post–cardiac arrest patients
who are treated with TTM, it may be
reasonable to consider persistent
absence of EEG reactivity to external
stimuli at 72 hours after cardiac arrest,
and persistent burst suppression on EEG
after rewarming, to predict a poor
outcome
IIb, LOE B-
NR

59. EEG Findings to Predict Outcome
2015 Recommendations—Updated Class
Intractable and persistent (>72 hours)
status epilepticus in the absence of EEG
reactivity to external stimuli may be
reasonable to predict poor outcome
IIb, LOE
B-NR

60. EEG Findings to Predict Outcome
2015 Recommendations—Updated Class
In comatose post–cardiac arrest patients
who are not treated with TTM, it may be
reasonable to consider the presence
of burst suppression on EEG at 72 hours or
more after cardiac arrest, in combination
with other predictors, to predict a poor
neurologic outcome
IIb, LOE B-
NR

61. Evoked Potentials to Predict Outcome
2015 Recommendations—Updated Class
In patients who are comatose after
resuscitation from cardiac arrest regardless
of treatment with TTM, it is reasonable to
consider bilateral absence of the N20 SSEP
wave 24 to 72 hours after cardiac arrest or
after rewarming a predictor of poor
outcome
IIa, LOE
B-NR

62. Imaging Tests to Predict Outcome
2015 Recommendations—New Class
In patients who are comatose after
resuscitation from cardiac arrest and not
treated with TTM, it may be reasonable to
use the presence of a marked reduction of
the GWR on brain CT obtained within 2
hours after cardiac arrest to predict poor
outcome
IIb, LOE B-
NR

63. Imaging Tests to Predict Outcome
2015 Recommendations—New Class
It may be reasonable to consider extensive
restriction of diffusion on brain MRI at 2 to
6 days after cardiac arrest in combination
with other established predictors to
predict a poor neurologic outcome
IIb, LOE B-
NR

64. Blood Markers to Predict Outcome
2015 Recommendations—Updated Class
Given the possibility of high FPRs, blood
levels of NSE and S-100B should not be
used alone to predict a poor neurologic
outcome
III: Harm,
LOE C-LD

65. Blood Markers to Predict Outcome
2015 Recommendations—Updated Class
When performed with other prognostic tests
at 72 hours or more after cardiac arrest, it
may be reasonable to consider high serum
values of NSE at 48 to 72 hours after cardiac
arrest to support the prognosis of a poor
neurologic outcome
IIb, LOE B-
NR
Especially if repeated sampling reveals
persistently high values
IIb, LOE C-
LD

67. Organ Donation
2015 Recommendations—Updated and New Class
We recommend that all patients who are
resuscitated from cardiac arrest but who
subsequently progress to death or brain death
be evaluated for organ donation
I, LOE
B-NR