Therapies of uncertain benefit in basic and advanced cardiac life support
- Charles N Pozner, MD
Charles N Pozner, MD
- Associate Professor of Medicine
- Harvard 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
- Deputy Editor
- Jonathan Grayzel, MD, FAAEM
Jonathan Grayzel, MD, FAAEM
- Senior Deputy Editor — UpToDate
- Deputy Editor — Emergency Medicine (Adult and Pediatric)
- Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Assistant Professor of Emergency Medicine
- University of Massachusetts Medical School
In 1957, electric cardioversion of nonperfusing cardiac rhythms was first described, marking the advent of a new era in resuscitation of patients with sudden cardiac arrest (SCA) . Soon thereafter, researchers described the use of mouth-to-mouth ventilation and external chest compressions [2,3]. Other important advances in the management of SCA include primary prevention, increased availability of skilled rescuers and equipment, particularly automatic defibrillators, and development of treatment protocols, namely advanced cardiac life support (ACLS).
In 2010, the American Heart Association (AHA) published its latest guidelines for emergency cardiovascular care (2010 ACLS Guidelines), and these were updated in 2015 [4-7]. These guidelines focus on the interventions most likely to improve survival from SCA, as determined by an extensive evidence-based review process.
Although some treatments are well-supported by evidence and widely recommended, controversies in the management of SCA remain. Those controversies related to the techniques and medications used in the performance of basic and advanced life support are discussed here. The performance of basic and advanced life support and the evidence supporting ACLS are reviewed separately. (See "Basic life support (BLS) in adults" and "Advanced cardiac life support (ACLS) in adults" and "Basic airway management in adults" and "Supportive data for advanced cardiac life support in adults with sudden cardiac arrest".)
INSPIRATORY IMPEDANCE THRESHOLD DEVICES
An inspiratory impedance threshold device (ITD) is designed to modulate intrathoracic pressures during passive inspiration after positive pressure ventilation in order to enhance return of blood to the heart during cardiopulmonary resuscitation (CPR). The device is a plastic appliance with a silicone diaphragm placed between the airway and the bag ventilator.
The generation of negative intrathoracic pressure during passive or active decompression of the chest wall during chest compressions increases venous return to the heart (ie, preload). Without an ITD, passive airflow into the patient's airways during either active or passive decompression of the chest wall during CPR mitigates the generation of negative intrathoracic pressures, resulting in decreased venous return (preload) [8,9]. Decreased venous return results in lower systolic blood pressures generated with active chest compressions.To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- KOUWENHOVEN WB, MILNOR WR, KNICKERBOCKER GG, CHESNUT WR. Closed chest defibrillation of the heart. Surgery 1957; 42:550.
- SAFAR P, ESCARRAGA LA, ELAM JO. A comparison of the mouth-to-mouth and mouth-to-airway methods of artificial respiration with the chest-pressure arm-lift methods. N Engl J Med 1958; 258:671.
- KOUWENHOVEN WB, JUDE JR, KNICKERBOCKER GG. Closed-chest cardiac massage. JAMA 1960; 173:1064.
- 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.
- Cave DM, Gazmuri RJ, Otto CW, et al. Part 7: CPR techniques and devices: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2010; 122:S720.
- 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.
- 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.
- Lurie KG, Coffeen P, Shultz J, et al. Improving active compression-decompression cardiopulmonary resuscitation with an inspiratory impedance valve. Circulation 1995; 91:1629.
- Plaisance P, Soleil C, Ducros L, et al. Measurement of intrathoracic pressures during basic and advanced cardiac life support which performing active compression decompression cardiopulmonary resuscitation with an inspiratory impedance threshold valve. Crit Care Med 2001; 29:A73.
- Langhelle A, Strømme T, Sunde K, et al. Inspiratory impedance threshold valve during CPR. Resuscitation 2002; 52:39.
- Plaisance P, Lurie KG, Payen D. Inspiratory impedance during active compression-decompression cardiopulmonary resuscitation: a randomized evaluation in patients in cardiac arrest. Circulation 2000; 101:989.
- Plaisance P, Soleil C, Lurie KG, et al. Use of an inspiratory impedance threshold device on a facemask and endotracheal tube to reduce intrathoracic pressures during the decompression phase of active compression-decompression cardiopulmonary resuscitation. Crit Care Med 2005; 33:990.
- Plaisance P, Lurie KG, Vicaut E, et al. Evaluation of an impedance threshold device in patients receiving active compression-decompression cardiopulmonary resuscitation for out of hospital cardiac arrest. Resuscitation 2004; 61:265.
- Aufderheide TP, Pirrallo RG, Provo TA, Lurie KG. Clinical evaluation of an inspiratory impedance threshold device during standard cardiopulmonary resuscitation in patients with out-of-hospital cardiac arrest. Crit Care Med 2005; 33:734.
- Aufderheide TP, Nichol G, Rea TD, et al. A trial of an impedance threshold device in out-of-hospital cardiac arrest. N Engl J Med 2011; 365:798.
- Westfall M, Krantz S, Mullin C, Kaufman C. Mechanical versus manual chest compressions in out-of-hospital cardiac arrest: a meta-analysis. Crit Care Med 2013; 41:1782.
- Brooks SC, Hassan N, Bigham BL, Morrison LJ. Mechanical versus manual chest compressions for cardiac arrest. Cochrane Database Syst Rev 2014; :CD007260.
- Gates S, Quinn T, Deakin CD, et al. Mechanical chest compression for out of hospital cardiac arrest: Systematic review and meta-analysis. Resuscitation 2015; 94:91.
- Bonnes JL, Brouwer MA, Navarese EP, et al. Manual Cardiopulmonary Resuscitation Versus CPR Including a Mechanical Chest Compression Device in Out-of-Hospital Cardiac Arrest: A Comprehensive Meta-analysis From Randomized and Observational Studies. Ann Emerg Med 2016; 67:349.
- Rubertsson S, Lindgren E, Smekal D, et al. Mechanical chest compressions and simultaneous defibrillation vs conventional cardiopulmonary resuscitation in out-of-hospital cardiac arrest: the LINC randomized trial. JAMA 2014; 311:53.
- Wik L, Olsen JA, Persse D, et al. Manual vs. integrated automatic load-distributing band CPR with equal survival after out of hospital cardiac arrest. The randomized CIRC trial. Resuscitation 2014; 85:741.
- Perkins GD, Lall R, Quinn T, et al. Mechanical versus manual chest compression for out-of-hospital cardiac arrest (PARAMEDIC): a pragmatic, cluster randomised controlled trial. Lancet 2015; 385:947.
- William P, Rao P, Kanakadandi UB, et al. Mechanical Cardiopulmonary Resuscitation In and On the Way to the Cardiac Catheterization Laboratory. Circ J 2016; 80:1292.
- Venturini JM, Retzer E, Estrada JR, et al. Mechanical chest compressions improve rate of return of spontaneous circulation and allow for initiation of percutaneous circulatory support during cardiac arrest in the cardiac catheterization laboratory. Resuscitation 2017; 115:56.
- Ward KR, Sullivan RJ, Zelenak RR, Summer WR. A comparison of interposed abdominal compression CPR and standard CPR by monitoring end-tidal PCO2. Ann Emerg Med 1989; 18:831.
- Babbs CF. Interposed abdominal compression CPR: a comprehensive evidence based review. Resuscitation 2003; 59:71.
- Waldman PJ, Walters BL, Grunau CF. Pancreatic injury associated with interposed abdominal compressions in pediatric cardiopulmonary resuscitation. Am J Emerg Med 1984; 2:510.
- Sack JB, Kesselbrenner MB, Jarrad A. Interposed abdominal compression-cardiopulmonary resuscitation and resuscitation outcome during asystole and electromechanical dissociation. Circulation 1992; 86:1692.
- Babbs CF. Simplified meta-analysis of clinical trials in resuscitation. Resuscitation 2003; 57:245.
- Sack JB, Kesselbrenner MB, Bregman D. Survival from in-hospital cardiac arrest with interposed abdominal counterpulsation during cardiopulmonary resuscitation. JAMA 1992; 267:379.
- Mateer JR, Stueven HA, Thompson BM, et al. Pre-hospital IAC-CPR versus standard CPR: paramedic resuscitation of cardiac arrests. Am J Emerg Med 1985; 3:143.
- Lindner KH, Pfenninger EG, Lurie KG, et al. Effects of active compression-decompression resuscitation on myocardial and cerebral blood flow in pigs. Circulation 1993; 88:1254.
- Tucker KJ, Redberg RF, Schiller NB, Cohen TJ. Active compression-decompression resuscitation: analysis of transmitral flow and left ventricular volume by transesophageal echocardiography in humans. Cardiopulmonary Resuscitation Working Group. J Am Coll Cardiol 1993; 22:1485.
- Cohen TJ, Goldner BG, Maccaro PC, et al. A comparison of active compression-decompression cardiopulmonary resuscitation with standard cardiopulmonary resuscitation for cardiac arrests occurring in the hospital. N Engl J Med 1993; 329:1918.
- Lafuente-Lafuente C, Melero-Bascones M. Active chest compression-decompression for cardiopulmonary resuscitation. Cochrane Database Syst Rev 2013; :CD002751.
- Aufderheide TP, Frascone RJ, Wayne MA, et al. Standard cardiopulmonary resuscitation versus active compression-decompression cardiopulmonary resuscitation with augmentation of negative intrathoracic pressure for out-of-hospital cardiac arrest: a randomised trial. Lancet 2011; 377:301.
- Paris PM, Stewart RD, Kaplan RM, Whipkey R. Transcutaneous pacing for bradyasystolic cardiac arrests in prehospital care. Ann Emerg Med 1985; 14:320.
- Dalsey WC, Syverud SA, Hedges JR. Emergency department use of transcutaneous pacing for cardiac arrests. Crit Care Med 1985; 13:399.
- Hedges JR, Syverud SA, Dalsey WC, et al. Prehospital trial of emergency transcutaneous cardiac pacing. Circulation 1987; 76:1337.
- Rosenthal E, Thomas N, Quinn E, et al. Transcutaneous pacing for cardiac emergencies. Pacing Clin Electrophysiol 1988; 11:2160.
- 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.
- Sherbino J, Verbeek PR, MacDonald RD, et al. Prehospital transcutaneous cardiac pacing for symptomatic bradycardia or bradyasystolic cardiac arrest: a systematic review. Resuscitation 2006; 70:193.
- Sakamoto T, Morimura N, Nagao K, et al. Extracorporeal cardiopulmonary resuscitation versus conventional cardiopulmonary resuscitation in adults with out-of-hospital cardiac arrest: a prospective observational study. Resuscitation 2014; 85:762.
- Chen YS, Lin JW, Yu HY, et al. Cardiopulmonary resuscitation with assisted extracorporeal life-support versus conventional cardiopulmonary resuscitation in adults with in-hospital cardiac arrest: an observational study and propensity analysis. Lancet 2008; 372:554.
- Chillcott S, Stahovich M, Earnhardt C, Dembitsky W. Portable rapid response extracorporeal life support: a center's 20-year experience with a registered nurse-run program. Crit Care Nurs Q 2008; 31:211.
- Younger JG, Schreiner RJ, Swaniker F, et al. Extracorporeal resuscitation of cardiac arrest. Acad Emerg Med 1999; 6:700.
- Siao FY, Chiu CC, Chiu CW, et al. Managing cardiac arrest with refractory ventricular fibrillation in the emergency department: Conventional cardiopulmonary resuscitation versus extracorporeal cardiopulmonary resuscitation. Resuscitation 2015; 92:70.
- Richardson AS, Schmidt M, Bailey M, et al. ECMO Cardio-Pulmonary Resuscitation (ECPR), trends in survival from an international multicentre cohort study over 12-years. Resuscitation 2017; 112:34.
- Huang SC, Wu ET, Chen YS, et al. Extracorporeal membrane oxygenation rescue for cardiopulmonary resuscitation in pediatric patients. Crit Care Med 2008; 36:1607.
- Debaty G, Babaz V, Durand M, et al. Prognostic factors for extracorporeal cardiopulmonary resuscitation recipients following out-of-hospital refractory cardiac arrest. A systematic review and meta-analysis. Resuscitation 2017; 112:1.
- Mahle WT, Forbess JM, Kirshbom PM, et al. Cost-utility analysis of salvage cardiac extracorporeal membrane oxygenation in children. J Thorac Cardiovasc Surg 2005; 129:1084.
- Silfvast T. Cause of death in unsuccessful prehospital resuscitation. J Intern Med 1991; 229:331.
- Spaulding CM, Joly LM, Rosenberg A, et al. Immediate coronary angiography in survivors of out-of-hospital cardiac arrest. N Engl J Med 1997; 336:1629.
- Böttiger BW, Bode C, Kern S, et al. Efficacy and safety of thrombolytic therapy after initially unsuccessful cardiopulmonary resuscitation: a prospective clinical trial. Lancet 2001; 357:1583.
- Böttiger BW, Arntz HR, Chamberlain DA, et al. Thrombolysis during resuscitation for out-of-hospital cardiac arrest. N Engl J Med 2008; 359:2651.
- Abu-Laban RB, Christenson JM, Innes GD, et al. Tissue plasminogen activator in cardiac arrest with pulseless electrical activity. N Engl J Med 2002; 346:1522.
- Stadlbauer KH, Krismer AC, Arntz HR, et al. Effects of thrombolysis during out-of-hospital cardiopulmonary resuscitation. Am J Cardiol 2006; 97:305.
- Lederer W, Lichtenberger C, Pechlaner C, et al. Long-term survival and neurological outcome of patients who received recombinant tissue plasminogen activator during out-of-hospital cardiac arrest. Resuscitation 2004; 61:123.
- Standards for cardiopulmonary resuscitation (CPR) and emergency cardiac care (ECC). I. Introduction. JAMA 1974; 227:Suppl:837.
- Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Part 6: advanced cardiovascular life support: section 6: pharmacology II: agents to optimize cardiac output and blood pressure. The American Heart Association in collaboration with the International Liaison Committee on Resuscitation. Circulation 2000; 102:I129.
- Aufderheide TP, Martin DR, Olson DW, et al. Prehospital bicarbonate use in cardiac arrest: a 3-year experience. Am J Emerg Med 1992; 10:4.
- Vukmir RB, Katz L, Sodium Bicarbonate Study Group. Sodium bicarbonate improves outcome in prolonged prehospital cardiac arrest. Am J Emerg Med 2006; 24:156.
- Dybvik T, Strand T, Steen PA. Buffer therapy during out-of-hospital cardiopulmonary resuscitation. Resuscitation 1995; 29:89.
- Craddock L, Miller B, Clifton G, et al. Resuscitation from prolonged cardiac arrest with high-dose intravenous magnesium sulfate. J Emerg Med 1991; 9:469.
- Miller B, Craddock L, Hoffenberg S, et al. Pilot study of intravenous magnesium sulfate in refractory cardiac arrest: safety data and recommendations for future studies. Resuscitation 1995; 30:3.
- Fatovich DM, Prentice DA, Dobb GJ. Magnesium in cardiac arrest (the magic trial). Resuscitation 1997; 35:237.
- Allegra J, Lavery R, Cody R, et al. Magnesium sulfate in the treatment of refractory ventricular fibrillation in the prehospital setting. Resuscitation 2001; 49:245.
- Mentzelopoulos SD, Malachias S, Chamos C, et al. Vasopressin, steroids, and epinephrine and neurologically favorable survival after in-hospital cardiac arrest: a randomized clinical trial. JAMA 2013; 310:270.
- INSPIRATORY IMPEDANCE THRESHOLD DEVICES
- AUTOMATIC COMPRESSION DEVICES
- PERFORMANCE OF INTERPOSED ABDOMINAL COMPRESSION CPR
- ACTIVE COMPRESSION-DECOMPRESSION CPR
- USE OF TRANSCUTANEOUS PACING IN ASYSTOLE
- EXTRACORPOREAL OXYGENATION
- FIBRINOLYSIS IN CARDIAC ARREST
- Sodium bicarbonate therapy
- - Recommendation
- Amiodarone versus lidocaine in refractory VF/VT
- - Recommendation
- Magnesium sulfate in cardiac arrest
- - Recommendation
- Vasopressin, glucocorticoid, and epinephrine