Supportive data for advanced cardiac life support in adults with sudden cardiac arrest
- Charles N Pozner, MD
Charles N Pozner, MD
- Associate Professor of Medicine
- Harvard Medical School
- Mark S Link, MD
Mark S Link, MD
- Section Editor — Cardiac Arrhythmias
- Professor of Medicine
- Tufts Medical School
- Section Editors
- Ron M Walls, MD, FRCPC, FAAEM
Ron M Walls, MD, FRCPC, FAAEM
- Editor-in-Chief — Adult and Pediatric Emergency Medicine
- Section Editor — Adult Resuscitation
- Neskey Family Professor of Emergency Medicine
- Harvard Medical School
- Brigham and Women's Hospital
- Richard L Page, MD
Richard L Page, MD
- Section Editor — Cardiac Arrhythmias
- Chair, Department of Medicine
- University of Wisconsin, School of Medicine and Public Health
Sudden cardiac arrest (SCA) and sudden cardiac death (SCD) refer to the sudden cessation of cardiac activity with hemodynamic collapse, often due to sustained ventricular tachycardia/ventricular fibrillation. Other causes of SCA and SCD are asystole and pulseless electrical activity. These events most commonly occur in patients with structural heart disease (that may not have been previously diagnosed), particularly coronary heart disease. (See "Pathophysiology and etiology of sudden cardiac arrest".)
The event is referred to as SCA (or aborted SCD) if an intervention (eg, defibrillation) results in the return of spontaneous circulation (ROSC) and restored circulation. The event is called SCD if the patient dies. However, the use of SCD to describe both fatal and nonfatal cardiac arrest persists by convention. (See "Overview of sudden cardiac arrest and sudden cardiac death", section on 'Definitions'.)
The treatment of SCA consists of emergent resuscitation followed, in survivors, by immediate postresuscitative care and attempted long-term prevention of recurrence using pharmacologic and nonpharmacologic interventions. Over time, cardiopulmonary resuscitation (CPR) performed by bystanders has increased, and the interval between collapse and defibrillation has decreased [1,2]. Despite these improvements as well as advances in the treatment of heart disease, the outcome of patients experiencing SCA remains poor. (See "Prognosis and outcomes following sudden cardiac arrest in adults".)
In general, there are two first-line therapies of resuscitation that have been shown to be associated with improved survival: excellent chest compressions and early defibrillation. Resuscitation should focus on these two elements. This is not to say that advanced cardiac life support (ACLS) therapies should be withheld if considered and indicated; however, if a shockable rhythm has not been identified and defibrillated, and/or excellent CPR is not being performed, any other non-scientifically supported interventions should be delayed until these first-line therapies are implemented. In general, the performance of the second-line interventions (as part of ACLS) should almost never interfere with defibrillation and excellent CPR.
Another therapy that has shown a neurologically-favorable survival advantage is targeted temperature management (TTM). This is discussed in greater detail separately. (See 'Targeted temperature management' below and "Post-cardiac arrest management in adults", section on 'Targeted temperature management (TTM) and therapeutic hypothermia (TH)'.)
- Herlitz J, Andersson E, Bång A, et al. Experiences from treatment of out-of-hospital cardiac arrest during 17 years in Göteborg. Eur Heart J 2000; 21:1251.
- Rea TD, Eisenberg MS, Becker LJ, et al. Temporal trends in sudden cardiac arrest: a 25-year emergency medical services perspective. Circulation 2003; 107:2780.
- Link MS, Berkow LC, Kudenchuk PJ, et al. Part 7: Adult Advanced Cardiovascular Life Support: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2015; 132:S444.
- Winkle RA, Mead RH, Ruder MA, et al. Effect of duration of ventricular fibrillation on defibrillation efficacy in humans. Circulation 1990; 81:1477.
- De Maio VJ, Stiell IG, Wells GA, et al. Optimal defibrillation response intervals for maximum out-of-hospital cardiac arrest survival rates. Ann Emerg Med 2003; 42:242.
- Larsen MP, Eisenberg MS, Cummins RO, Hallstrom AP. Predicting survival from out-of-hospital cardiac arrest: a graphic model. Ann Emerg Med 1993; 22:1652.
- Niemann JT, Cairns CB, Sharma J, Lewis RJ. Treatment of prolonged ventricular fibrillation. Immediate countershock versus high-dose epinephrine and CPR preceding countershock. Circulation 1992; 85:281.
- Baum RS, Alvarez H 3rd, Cobb LA. Survival after resuscitation from out-of-hospital ventricular fibrillation. Circulation 1974; 50:1231.
- Callans DJ. Out-of-hospital cardiac arrest--the solution is shocking. N Engl J Med 2004; 351:632.
- Thompson RJ, McCullough PA, Kahn JK, O'Neill WW. Prediction of death and neurologic outcome in the emergency department in out-of-hospital cardiac arrest survivors. Am J Cardiol 1998; 81:17.
- Eftestøl T, Sunde K, Steen PA. Effects of interrupting precordial compressions on the calculated probability of defibrillation success during out-of-hospital cardiac arrest. Circulation 2002; 105:2270.
- Eftestol T, Sunde K, Ole Aase S, et al. Predicting outcome of defibrillation by spectral characterization and nonparametric classification of ventricular fibrillation in patients with out-of-hospital cardiac arrest. Circulation 2000; 102:1523.
- Eftestøl T, Wik L, Sunde K, Steen PA. Effects of cardiopulmonary resuscitation on predictors of ventricular fibrillation defibrillation success during out-of-hospital cardiac arrest. Circulation 2004; 110:10.
- Christenson J, Andrusiek D, Everson-Stewart S, et al. Chest compression fraction determines survival in patients with out-of-hospital ventricular fibrillation. Circulation 2009; 120:1241.
- Yu T, Weil MH, Tang W, et al. Adverse outcomes of interrupted precordial compression during automated defibrillation. Circulation 2002; 106:368.
- Cobb LA, Fahrenbruch CE, Walsh TR, et al. Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillation. JAMA 1999; 281:1182.
- Wik L, Hansen TB, Fylling F, et al. Delaying defibrillation to give basic cardiopulmonary resuscitation to patients with out-of-hospital ventricular fibrillation: a randomized trial. JAMA 2003; 289:1389.
- Baker PW, Conway J, Cotton C, et al. Defibrillation or cardiopulmonary resuscitation first for patients with out-of-hospital cardiac arrests found by paramedics to be in ventricular fibrillation? A randomised control trial. Resuscitation 2008; 79:424.
- Jacobs IG, Finn JC, Oxer HF, Jelinek GA. CPR before defibrillation in out-of-hospital cardiac arrest: a randomized trial. Emerg Med Australas 2005; 17:39.
- Stiell IG, Nichol G, Leroux BG, et al. Early versus later rhythm analysis in patients with out-of-hospital cardiac arrest. N Engl J Med 2011; 365:787.
- Neumar RW, Otto CW, Link MS, et al. Part 8: adult advanced cardiovascular life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2010; 122:S729.
- Field JM, Hazinski MF, Sayre MR, et al. Part 1: executive summary: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2010; 122:S640.
- Neumar RW, Shuster M, Callaway CW, et al. Part 1: Executive Summary: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2015; 132:S315.
- Jacobs IG, Finn JC, Jelinek GA, et al. Effect of adrenaline on survival in out-of-hospital cardiac arrest: A randomised double-blind placebo-controlled trial. Resuscitation 2011; 82:1138.
- Hagihara A, Hasegawa M, Abe T, et al. Prehospital epinephrine use and survival among patients with out-of-hospital cardiac arrest. JAMA 2012; 307:1161.
- Dumas F, Bougouin W, Geri G, et al. Is epinephrine during cardiac arrest associated with worse outcomes in resuscitated patients? J Am Coll Cardiol 2014; 64:2360.
- Andersen LW, Kurth T, Chase M, et al. Early administration of epinephrine (adrenaline) in patients with cardiac arrest with initial shockable rhythm in hospital: propensity score matched analysis. BMJ 2016; 353:i1577.
- Lindner KH, Dirks B, Strohmenger HU, et al. Randomised comparison of epinephrine and vasopressin in patients with out-of-hospital ventricular fibrillation. Lancet 1997; 349:535.
- Stiell IG, Hébert PC, Wells GA, et al. Vasopressin versus epinephrine for inhospital cardiac arrest: a randomised controlled trial. Lancet 2001; 358:105.
- Wenzel V, Krismer AC, Arntz HR, et al. A comparison of vasopressin and epinephrine for out-of-hospital cardiopulmonary resuscitation. N Engl J Med 2004; 350:105.
- Aung K, Htay T. Vasopressin for cardiac arrest: a systematic review and meta-analysis. Arch Intern Med 2005; 165:17.
- Gueugniaud PY, David JS, Chanzy E, et al. Vasopressin and epinephrine vs. epinephrine alone in cardiopulmonary resuscitation. N Engl J Med 2008; 359:21.
- Grmec S, Lah K, Tusek-Bunc K. Difference in end-tidal CO2 between asphyxia cardiac arrest and ventricular fibrillation/pulseless ventricular tachycardia cardiac arrest in the prehospital setting. Crit Care 2003; 7:R139.
- Grmec S, Klemen P. Does the end-tidal carbon dioxide (EtCO2) concentration have prognostic value during out-of-hospital cardiac arrest? Eur J Emerg Med 2001; 8:263.
- Kolar M, Krizmaric M, Klemen P, Grmec S. Partial pressure of end-tidal carbon dioxide successful predicts cardiopulmonary resuscitation in the field: a prospective observational study. Crit Care 2008; 12:R115.
- Dorian P, Cass D, Schwartz B, et al. Amiodarone as compared with lidocaine for shock-resistant ventricular fibrillation. N Engl J Med 2002; 346:884.
- Kudenchuk PJ, Cobb LA, Copass MK, et al. Amiodarone for resuscitation after out-of-hospital cardiac arrest due to ventricular fibrillation. N Engl J Med 1999; 341:871.
- Scheinman MM, Levine JH, Cannom DS, et al. Dose-ranging study of intravenous amiodarone in patients with life-threatening ventricular tachyarrhythmias. The Intravenous Amiodarone Multicenter Investigators Group. Circulation 1995; 92:3264.
- Kowey PR, Levine JH, Herre JM, et al. Randomized, double-blind comparison of intravenous amiodarone and bretylium in the treatment of patients with recurrent, hemodynamically destabilizing ventricular tachycardia or fibrillation. The Intravenous Amiodarone Multicenter Investigators Group. Circulation 1995; 92:3255.
- Kudenchuk PJ, Brown SP, Daya M, et al. Amiodarone, Lidocaine, or Placebo in Out-of-Hospital Cardiac Arrest. N Engl J Med 2016; 374:1711.
- Joglar JA, Page RL. Out-of-Hospital Cardiac Arrest--Are Drugs Ever the Answer? N Engl J Med 2016; 374:1781.
- Tzivoni D, Banai S, Schuger C, et al. Treatment of torsade de pointes with magnesium sulfate. Circulation 1988; 77:392.
- Nielsen N, Wetterslev J, Cronberg T, et al. Targeted temperature management at 33°C versus 36°C after cardiac arrest. N Engl J Med 2013; 369:2197.
- Kudenchuk PJ, Redshaw JD, Stubbs BA, et al. Impact of changes in resuscitation practice on survival and neurological outcome after out-of-hospital cardiac arrest resulting from nonshockable arrhythmias. Circulation 2012; 125:1787.
- Survey of Survivors After Out-of-hospital Cardiac Arrest in KANTO Area, Japan (SOS-KANTO) Study Group. Atropine sulfate for patients with out-of-hospital cardiac arrest due to asystole and pulseless electrical activity. Circ J 2011; 75:580.
- Hedges JR, Syverud SA, Dalsey WC, et al. Prehospital trial of emergency transcutaneous cardiac pacing. Circulation 1987; 76:1337.
- Barthell E, Troiano P, Olson D, et al. Prehospital external cardiac pacing: a prospective, controlled clinical trial. Ann Emerg Med 1988; 17:1221.
- Cummins RO, Graves JR, Larsen MP, et al. Out-of-hospital transcutaneous pacing by emergency medical technicians in patients with asystolic cardiac arrest. N Engl J Med 1993; 328:1377.
- Ornato JP, Peberdy MA. The mystery of bradyasystole during cardiac arrest. Ann Emerg Med 1996; 27:576.
- Quan L, Graves JR, Kinder DR, et al. Transcutaneous cardiac pacing in the treatment of out-of-hospital pediatric cardiac arrests. Ann Emerg Med 1992; 21:905.
- Brown CG, Martin DR, Pepe PE, et al. A comparison of standard-dose and high-dose epinephrine in cardiac arrest outside the hospital. The Multicenter High-Dose Epinephrine Study Group. N Engl J Med 1992; 327:1051.
- Gueugniaud PY, Mols P, Goldstein P, et al. A comparison of repeated high doses and repeated standard doses of epinephrine for cardiac arrest outside the hospital. European Epinephrine Study Group. N Engl J Med 1998; 339:1595.
- VF AND PULSELESS VT
- - Timing
- - Defibrillatory waveforms
- VF or VT arrest and vasopressors
- Antiarrhythmic drugs
- - Amiodarone
- - Lidocaine
- - Comparison of amiodarone and lidocaine
- - Magnesium sulfate
- Targeted temperature management
- PULSELESS ELECTRICAL ACTIVITY
- PEA and vasopressors
- PEA and atropine
- Asystole and vasopressors
- - Epinephrine
- - Vasopressin
- Asystole and atropine
- INEFFECTIVE THERAPIES
- SUMMARY AND RECOMMENDATIONS