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Therapies of uncertain benefit in basic and advanced cardiac life support

Charles N Pozner, MD
Section Editors
Richard L Page, MD
Deputy Editor
Jonathan Grayzel, MD, FAAEM


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) [1]. 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".)


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.

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Literature review current through: Nov 2017. | This topic last updated: Aug 04, 2017.
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