Sayta giriş  Hesab

AHA 2016: ACLS - advanced cardiac life support: Defibrillation, Medications and ECR

  • Defibrillation
    • indications
      • defibrillators recommended for atrial and ventricular arrhythmias associated with cardiac arrest (AHA Class I, Level B-NR)
      • perform CPR while defibrillator is being readied (AHA Class I, Level B)
    • biphasic waveform
      • preferred over monophasic waveform for both atrial and ventricular arrhythmias due to increased success in arrhythmia termination (AHA Class IIa, Level B-R)
      • biphasic defibrillation might decrease failure to terminate arrhythmia on first shock but may not improve return of spontaneous circulation compared to monophasic defibrillation in patients with out-of-hospital cardiac arrest (level 2 [mid-level] evidence)
  • Epinephrine
    • standard dose (1 mg every 3-5 minutes) may be reasonable (AHA Class IIb, Level B-R)
    • high dose (0.1-0.2 mg/kg) not recommended for routine use (AHA Class III, Level B-R)
    • standard-dose epinephrine appears to increase return of spontaneous circulation but might decrease survival and neurological outcomes (level 2 [mid-level] evidence)
    • repeated high doses of epinephrine may not improve survival to hospital discharge in patients with out-of-hospital cardiac arrest (level 2 [mid-level] evidence)
    • timing of epinephrine administration
      • for initial nonshockable rhythm, it may be reasonable to give epinephrine as soon as possible after onset of cardiac arrest (AHA Class IIb, Level C-LD)
      • longer time to first epinephrine treatment since arrest associated with decreased survival to hospital discharge in patients with in-hospital cardiac arrest and nonshockable rhythms (level 2 [mid-level] evidence)
  • Vasopressin
    • offers no advantage either as substitute for or in combination with standard-dose epinephrine in cardiac arrest (AHA Class IIb, Level B-R)
    • vasopressin does not appear more effective than epinephrine in patients with in-hospital or out-of-hospital cardiac arrest (level 2 [mid-level] evidence)
    • combination vasopressin plus epinephrine is not more effective than epinephrine alone during advanced cardiovascular life support for out-of-hospital cardiac arrest (level 1 [likely reliable] evidence)
  • Steroids
    • for in-hospital cardiac arrest
      • no evidence for routine use of steroids alone
      • combination of vasopressin, epinephrine, and methylprednisolone during cardiac arrest and hydrocortisone after cardiac arrest may be considered, but additional evidence needed before recommending for routine use (AHA Class IIb, Level C-LD)
      • addition of vasopressin and steroids to epinephrine during resuscitation may increase survival to discharge with favorable neurologic outcomes in adults with in-hospital cardiac arrest (level 2 [mid-level] evidence)
    • for out-of-hospital cardiac arrest, steroids during cardiopulmonary resuscitation is of uncertain benefit (AHA Class IIb, Level C-LD)
  • Antiarrhythmics not shown to improve survival or neurologic outcome
    • for patients with ventricular fibrillation or polymorphic ventricular tachycardia who do not respond to CPR, defibrillation, and vasopressor therapy
      • amiodarone may be considered (AHA Class IIb, Level B-R)
      • lidocaine may be considered as alternative to amiodarone (AHA Class IIb, Level C-LD)
  • Extracorporal CPR (ECPR) - insufficient evidence to recommended the routine use of ECPR for patients with cardiac arrest, but ECPR may be considered in patients with suspected cardiac etiology that is potentially reversible during limited period of extracorporeal membrane oxygenation (ECMO) if it can be rapidly implemented (AHA Class IIb, Level C-LD)
  • Monitoring and improving CPR quality - no study has evaluated if titrating resuscitative efforts to physiological parameters during CPR improves outcomes, but physiological parameters may be reasonable to monitor and optimize CPR quality, guide vasopressor therapy, and detect return of spontaneous circulation (AHA Class IIb, Level C-EO)
  • Stopping resuscitative efforts
    • end-tidal carbon dioxide
      • for intubated patients, failure to achieve end-tidal carbon dioxide > 10 mm Hg on waveform capnography after 20 minutes of CPR may be considered as 1 component (but not the only component) of a multimodal approach to deciding to stop resuscitative efforts (AHA Class IIb, Level C-LD)
      • end-tidal carbon dioxide < 10 mm Hg after 20 minutes of ACLS may help predict death in patients with no pulse who are intubated (level 2 [mid-level] evidence)
      • for nonintubated patients, end-tidal carbon dioxide should not be used as an indication to end resuscitative efforts (AHA Class III, Level C-EO)
    • decision rule for in-hospital cardiac arrest using combination of pulselessness for 10 minutes after start of CPR, presence of initial cardiac rhythm that is neither ventricular tachycardia or ventricular fibrillation, and unwitnessed cardiac arrest identifies patients for whom resuscitation may be discontinued (level 1 [likely reliable] evidence)

REFERRENCES.

  • 1. 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 Nov 3;132(18 Suppl 2):S444-64
  •  2. 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 Nov 2;122(18 Suppl 3):S729-67 full-text