Download The Advanced Cardiovascular Life Support Guidelines

January 2013 • Volume 27 • Number 1
Lesson 2
The Advanced
Cardiovascular Life Support
Guidelines
Sharon E. Mace, MD, FACEP, FAAP
■Objectives
On completion of this lesson, you
should be able to:
1. Describe the treatment of
adult patients in cardiac arrest
recommended in the 2010 American
Heart Association (AHA) basic life
support guidelines.
2. Explain the appropriate management
of patients based on the AHA’s new
adult advanced cardiovascular life
support algorithms, including drug
therapy.
3. Discuss the rationale for “handsonly” cardiopulmonary resuscitation.
4. Explain the appropriate electrical
therapy for various dysrhythmias,
including ventricular fibrillation,
ventricular tachycardia, atrial
fibrillation, atrial flutter, and others.
5. Describe the key principles in
post–cardiac arrest management,
including hypothermia, titration
of supplemental oxygen (to
avoid hyperoxemia), and use of
quantitative capnography.
6. Communicate the principles of
systems of care for patients with
ST-segment elevation myocardial
infarction.
■From the EM Model
3.0 Cardiovascular Disorders
3.1 Cardiopulmonary Arrest
The cornerstone of resuscitation
in patients of any age is high-quality
cardiopulmonary resuscitation
(CPR), with an emphasis on chest
compressions. This lesson will
summarize the key points in the
American Heart Association’s
(AHA’s) guidelines for advanced
cardiovascular life support
(ACLS), including electrical
therapy, pharmacology, airway,
and postresuscitation care, while
reiterating the essentials of basic
life support (BLS) that provide the
foundation for ACLS.
Case Presentations
■ Case One
Paramedics are called to the home
of a 65-year-old woman. She had
been sitting on the porch talking
with her neighbors when she became
unresponsive. The neighbor gently
placed her on the firm surface of the
porch and found her unresponsive
with gasping respirations. One of the
neighbors began performing “handsonly” CPR, while his wife called 911.
The neighbor began chest
compressions within 10 seconds
of recognizing the arrest. His
compression rate was at least 100/
minute. He completed a complete
cycle of 30 compressions in less than
18 seconds. His compression depth
was at least 2 inches (5 mm). He
allowed for complete chest recoil after
each chest compression.
When the paramedics arrived,
the monitor defibrillator showed
ventricular fibrillation (VF), so one
shock was given at 200 J because this
was a biphasic defibrillator and the
manufacturer’s recommended dose
was unknown. Chest compressions
were continued for 2 minutes, and
an intravenous line was placed. The
monitor still indicated VF, so another
shock was given. Chest compressions
were continued for 2 minutes, during
which time 1 mg of epinephrine was
administered via the intravenous line.
The monitor rhythm was still VF,
so another shock was given. Chest
compressions were resumed, and a
300-mg IV bolus of amiodarone was
administered.
Without interrupting CPR (eg,
chest compressions), paramedics
intubated the patient on the way
to the hospital. On arrival in the
emergency department, waveform
capnography was applied and
indicated that the endotracheal (ET)
tube was in appropriate position
with good CPR/chest compressions
in progress. The monitor revealed
asystole, so epinephrine, 1 mg IV,
was given since it had been 3 minutes
since the last dose.
Reversible causes of her arrest
were considered: she was intubated
with the ET tube in good position,
on 100% Fio2, and arterial blood
gas was drawn to check for acidosis
and hypoxia. A normal saline (NS)
bolus was administered to treat
hypovolemia. The breath sounds
were equal bilaterally, and there
was no tracheal deviation or jugular
venous distention, so a tension
pneumothorax was ruled out. A
bedside echocardiogram showed
absent wall motion consistent with
11
Critical Decisions in Emergency Medicine
Critical Decisions
• How have the American Heart Association’s
(AHA’s) basic life support guidelines changed
when compared to the previous guidelines?
• What is “hands-only” CPR, and what is the
science behind this recommendation?
• What are the differences regarding the new
airway and breathing recommendations
compared to previous recommendations?
• What are the new pharmacology
recommendations in the ACLS protocols?
• What suggestions have been made
regarding postresuscitation care?
• What do the AHA guidelines recommend
regarding devices and CPR techniques?
• What do the AHA guidelines recommend
regarding systems of care?
• What are the new guidelines for electrical therapy?
a myocardial infarction, and her
cardiac enzymes were elevated. She
had return of spontaneous circulation
(ROSC).
■ Case Two
A 45-year-old man presents with
chest pain that began 1 hour ago.
He has no allergies and is on no
medications; his past medical history
is negative. Vital signs are blood
pressure 120/80, pulse rate 80 and
regular, respiratory rate 20, and pulse
oximetry 99% on room air. The nurse
asks if she should put the patient on
oxygen and give morphine for his
pain.
The physician asks the nurse to
get an ECG; start an intravenous
line; draw blood, including cardiac
enzymes; and place the patient on
a monitor. Supplemental oxygen is
not started because the patient has
a normal pulse oxygen saturation.
Aspirin, 325 mg, and a sublingual
nitroglycerin are ordered for his chest
pain instead of the morphine because
the physician recalls a study in a large
registry showing increased mortality
rates with morphine use. The patient’s
initial ECG is unremarkable. His
chest pain resolves, but enzymes are
positive, so the physician calls for a
cardiology consultation.
A short time later, the patient again
complains of chest pain, and he has
become pale and sweaty and is now
confused. His blood pressure is 65/35
and heart rate is 30. The monitor
shows a complete heart block. The
12
physician immediately gives atropine,
0.5 mg IV bolus, and asks the nurse
to prepare an epinephrine infusion.
The patient is still hypotensive
and bradycardic so a second dose
of atropine is given 3 minutes
after the first dose; an epinephrine
infusion is started at 5 mcg/minute,
and preparations are made for
transcutaneous pacing.
■ Case Three
A 50-year-old woman presents
with palpitations. Her past medical
history is negative. She is on no
medications and has no allergies.
Vital signs are blood pressure 130/80,
pulse rate 180, respiratory rate 16,
and pulse oxygen saturation 97% on
room air. She is placed on a monitor,
and an intravenous line is started. Her
ECG shows a wide QRS (≥12 seconds)
and indicates that her tachycardia
is regular and monomorphic, so
adenosine, 6 mg rapid IV push,
is given. Her heart rate and blood
pressure remain unchanged, so
adenosine, 12 mg rapid IV push, is
administered. There is no response,
so the physician asks the nurse to
see what antiarrhythmic infusions
are available, and a cardiology
consultation is requested. The nurse
reports that sotalol (dose 100 mg
or 1.5 mg/kg up to 100 mg over 5
minutes), procainamide (20-50 mg/
min), and amiodarone (150 mg
over 10 minutes) are immediately
available from the department’s
automated medication dispensing
system. Because of concern for heart
failure and because the patient’s QT
is prolonged, procainamide is not
given. The prolonged QT also makes
sotalol a poor choice. Amiodarone,
150 mg over 10 minutes, is given.
Unfortunately, she does not respond
but instead becomes unresponsive,
with a blood pressure of 65/35.
Synchronized cardioversion at 100
J is attempted because the patient’s
rhythm is wide-complex regular.
CRITICAL DECISION
How have the AHA’s basic life
support guidelines changed
compared to the previous
guidelines?
The 2010 American Heart
Association Guidelines for
Cardiopulmonary Resuscitation
and Emergency Cardiovascular care
stress the importance of high-quality
CPR with a focus on high-quality
chest compressions. Thus, there is a
fundamental shift from the previous
airway-breathing-chest compressions,
or A-B-C, to chest compressionsairway-breathing, C-A-B.1-5
With this new focus, there is
a change in the sequence of steps
in basic life support. The current
recommended sequence is, first
check responsiveness and breathing,
next call for help and get the
automatic external defibrillator
(AED), then check the pulse and
give chest compressions. After chest
compressions, open the airway and
give two rescue breaths, then resume
January 2013 • Volume 27 • Number 1
compressions. In the new 2010
guidelines, chest compressions come
before the two rescue breaths1-5 (Table
1, Figure 1).
Science Behind the New
Guidelines: C-A-B versus A-B-C
The rationale for the new BLS
guidelines includes the fact that the
overwhelming number of cardiac
arrests occur in adults and the highest
cardiac arrest survival rates in all
patients occur with a witnessed arrest
and with ventricular fibrillation (VF)
or pulseless ventricular tachycardia
(VT) as the initial rhythm. Chest
compressions and early defibrillation
are the key initial elements of BLS
in these patients. The goal of C-A-B
is to begin chest compression as
soon as possible. With A-B-C, chest
compressions not only occur later
in the BLS sequence but also are
frequently delayed further while
the rescuer attends to the airway
(retrieving a barrier device or other
airway/ventilation equipment and
while opening the airway and giving
rescue breaths).
However, even with the change
to C-A-B, there should only be
a minimal delay in ventilation:
specifically, the time needed to
deliver the first cycle of 30 chest
compressions for one rescuer (about
18 seconds).
Unfortunately, most out-of-hospital
cardiac arrest victims do not receive
any bystander CPR. Several factors
may contribute to this low rate of
bystander CPR. Chest compressions
are easier to perform than opening
the airway and delivering rescue
breaths. Starting with the easier
procedures (eg, chest compressions
instead of airway) may encourage
more bystanders to initiate CPR.
CRITICAL DECISION
What is “hands-only” CPR, and
what is the science behind this
recommendation?
For those who are not trained
in CPR, the new guidelines allow
the untrained bystander to provide
“hands-only” (or “compressiononly”) CPR for the adult with sudden
collapse.6,7 The bystander rescuer
should continue hands-only CPR
until an AED is ready for use or until
other rescuers can assume care of the
collapsed victim. If the trained lay
rescuer can perform rescue breathing,
the ratio remains 30 compressions to
two breaths (the same as in the 2005
guidelines).
Science Behind the New “HandsOnly” CPR
There are several reasons for
“hands-only” CPR. Survival rates for
cardiac arrest from a cardiac etiology
are similar whether “hands-only”
CPR or CPR with compressions and
rescue breaths is done. “Hands-only”
CPR is easier for an untrained rescuer
to perform. It is also easier for an
emergency medical dispatcher to
provide instructions for “hands-only”
CPR. If the rescuer is hesitant about
starting CPR because of a concern
about potential transmission of an
infection or potential contact with
secretions or vomitus, hands-only
CPR should allay this fear. It should
be noted, however, that if the trained
rescuer is able, he/she should perform
both compressions and ventilations.
Chest Compressions
The new parameters for adult chest
compressions are: depth at least 2
inches (5 cm) (the 2005 compression
depth for adults was 1½ to 2 inches)
and compression rate “at least 100/
minute” (compared with the previous
of “about 100/minute”).
The goal is to “push hard and
push fast” and to begin compressions
within 10 seconds of recognizing the
arrest. The 2010 recommendation is
that chest compressions should be
completed in less than 18 seconds;
the 2005 guidelines recommended
they be done in less than 23 seconds.
Deeper and faster compressions
are essential in order to generate
the pressure needed to perfuse the
coronary and cerebral arteries.
Table 1.
Summary of 2010 BLS recommendations
Order of CPR
CPR sequence
“Look-listen-feel”
Check for breathing
Ratio for 1-rescuer
CPR for all patients
Initiation of CPR
Compression depths (adults)
Compression rate (adults)
Chest compressions completed
2010 Guidelines
Chest compressions first
Chest compressions-airway-breathing
(C-A-B)
Omitted as a distinct step in BLS
2005 Guidelines
Airway first
Airway-breathing-circulation (A-B-C)
Part of step 1, occurs when rescuer
checks for responsiveness
30 compressions:2 breaths
“Look-listen-feel” occurred after
opening airway
Occurs after opening airway; is a
separate, distinct step
30 compressions:2 breaths
Within 10 seconds of recognition of
arrest
At least 2 inches (5 cm)
At least 100/minute
Within 18 seconds
1½ to 2 inches
About 100/minute
Within 23 seconds
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Critical Decisions in Emergency Medicine
Figure 1.
Adult cardiac arrest algorithm. From: 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(18 Suppl 3):S736. Used with permission from the American Heart Association.
14
January 2013 • Volume 27 • Number 1
CRITICAL DECISION
What are the differences regarding
the new airway and breathing
recommendations compared to the
previous recommendations?
With the prior BLS guidelines,
airway and breathing came before
chest compressions; now this is
reversed. Previously, “look, listen, and
feel” was a distinct step in the BLS
sequence that occurred after opening
the airway. Now “look, listen, and
feel” is deleted as a step in BLS and
instead has become part of step 1.
Step 1 is to check breathing when you
check responsiveness as a part of the
first action in the BLS sequence.1-4
With the advanced airway
protocols, cricoid pressure (Sellick
maneuver) is an option and is no
longer mandatory and end-tidal
carbon dioxide monitoring is
recommended in adults not only
to confirm appropriate ET tube
placement but also to monitor CPR
quality and detect ROSC.8,9
for this.8-10 Aspiration can occur
even if the Sellick maneuver is
used. It is difficult to teach and to
learn the correct application of the
Sellick maneuver. Indeed, studies
have shown that cricoid pressure
is frequently misapplied even by
trained health care providers.10 There
have been multiple reports of cricoid
pressure actually impeding passage of
the ET tube during intubation.10
Science Behind the Guidelines:
Airway
Cricoid pressure during
intubation/ventilation is no longer
routine.8,9 There are many reasons
Table 2.
Electrical therapy
Synchronized Cardioversion
Atrial fibrillation (initial)
Atrial flutter (initial)
Ventricular tachycardia
stable monomorphic (initial)
Defibrillation (unsynchronized shock)
Sequence:
Dose:
Ventricular fibrillation (VF) or pulseless
ventricular tachycardia
Pediatric defibrillation
Ventricular fibrillation (for in-hospital
monitored patients with sudden cardiac
arrest)
AEDs
Chain of survival
Use in hospitals
Infants
Defibrillation with implantable
cardioverter-defibrillator
AED pad placement
2010 Guidelines
2005 Guidelines
200 J monophasic
120 – 200 J biphasic
50 J (monophasic or biphasic)
100 J (monophasic or biphasic)
100 – 200 J monophasic
1-shock sequence
Escalating doses for second and
subsequent shocks
200 J (monophasic)
Biphasic (use manufacturers
recommended energy dose, 120 – 200 J)
2-4 J/kg initial
≥4 J/kg subsequent
(consider higher doses)
Maximum is 10 J/kg or adult dose
For inhospital sudden cardiac arrest, in
monitored patients the time from VF to
shock delivery should be <3 minutes
3-shock sequence
Fixed doses for second and subsequent
shocks
Integration of AEDs into chain of survival
for public places
Consider use of AEDs in hospitals
May be used in infants if manual
defibrillator is not available
Consider plading pads or paddles directly
over implanted device so pad or paddle
placement does not delay defibrillation
May use any of four pad positions:
anterolateral (sternal-apical) is
reasonable default, anteroposterior,
anterior left infrascapular, anterior right
infrascapular
2 J/kg initial
4 J/kg subsequent (monophasic or
biphasic)
No recommendations
Position the pad at least 1 inch (2.5 cm)
away from the device
1 position, anterolateral (sternal-apical)
15
Critical Decisions in Emergency Medicine
CRITICAL DECISION
What are the new guidelines for
electrical therapy?
There are many changes to the
recommendations for electrical
therapy11 (Table 2). There is now a
1-shock instead of a 3-shock protocol
for unsynchronized shocks for
defibrillation, and escalating energy
doses are recommended for the
second and subsequent shocks. The
2005 guidelines called for fixed doses
for the second and subsequent shocks.
In synchronized cardioversion,
the initial dose for patients in atrial
fibrillation now depends on whether
the defibrillator is monophasic (200
J) or biphasic (120-200 J); for atrial
flutter the recommended initial dose
is 50 J, and for stable monomorphic
VT the recommended dose is 100
J. For VF, the defibrillation dose
now depends on the defibrillator
manufacturer’s recommended
dose and on whether the device is
monophasic (200 J) or biphasic (120200 J).
For pediatric defibrillation, higher
doses are in the current guidelines.
Previously, 2 J/kg was the initial
recommended dose, with 4 J/kg
recommended for subsequent doses,
whether the device was monophasic
or biphasic. The new guidelines are
2 to 4 J/kg for the initial dose, and 4
J/kg or more for subsequent doses,
with higher doses considered with
a maximum of 10 J/kg or the adult
dose.
For defibrillation in a patient
who has an automated implantable
cardioverter defibrillator (AICD), the
prior guidelines suggested positioning
the pad at least 1 inch (2.5 cm) away
from the device. In order to try to
prevent any delay in beginning chest
compressions, it is now acceptable to
place pads or paddles directly over
implanted devices.
There are changes to guidelines
for AED use, as well. AEDs should be
integrated into the chain of survival
in public places. Their use should
be considered in hospitals. AEDs
can now be used in infants (age <1
year) if a manual defibrillator is not
available. There are four acceptable
pad positions now, instead of just
one: anterolateral, anteroposterior,
anterior-left infrascapular, and
anterior-right infrascapular (Table 2).
CRITICAL DECISION
What are the new pharmacology
recommendations for the ACLS
protocols?
The 2010 guidelines list fewer
indications than in the past for
the use of lidocaine, magnesium,
calcium, bicarbonate, and atropine8,9
(Table 3). Atropine is no longer
recommended for routine use
in pulseless electrical activity/
asystole, but it is still included in the
bradycardia algorithm. Lidocaine and
magnesium are no longer routinely
recommended for use in VF/pulseless
VT. Magnesium is indicated with
documented hypomagnesemia and
torsade de pointes. Neither calcium
nor bicarbonate is recommended for
routine use in cardiac arrest except
under certain circumstances. Calcium
is indicated for hypocalcemia,
hyperkalemia, hypermagnesemia,
and calcium channel blocker
overdose. Sodium bicarbonate can
be used for hyperkalemia or sodium
Table 3.
Pharmacology and adult ACLS algorithms: 2010 Guidelines
Rhythm
VT cardiac arrest (Figure 1)
Drug
Epinephrine
Amiodarone
Vasopressin
Pulseless electrical activity
(PEA) asystole
Epinephrine
Bradycardia (Figure 3)
Tachycardia (stable, regular
rhythm) (Figure 2)
Stable wide QRS tachycardia
(Figure 2)
Vasopressin
Atropine
Dopamine infusion
Epinephrine infusion
Adenosine
Amiodarone
Procainamide
Sotalol
16
Dose
1 mg IV/IO every 3-5 min
300 mg IV/IO first dose; 150 mg IV/IO second dose
40 units IV/IO (can replace first or second dose of
epinephrine)
1 mg IV/IO every 3-5 min
40 units, can replace first or second dose of epinephrine
0.5 mg bolus IV, repeated every 3 minutes (maximum 3 mg)
2-10 mcg/kg/min
2-10 mcg/min
6 mg rapid IV push followed with normal saline flush,
second dose 12 mg if needed
150 mg IV over 10 minutes, repeat as needed if VT recurs,
follow by maintenance infusion of 1 mg/min for first 6
hours)
20-50 mg/kg until arrhythmia suppressed, hypotension
ensues, QRS duration increases >50%, or maximum dose of
17 mg/kg given
Avoid if prolonged QT or CHF, maintenance infusion 1-4
mg/min
100 mg (1.5 mg/kg) over 5 minutes; avoid if prolonged QT
January 2013 • Volume 27 • Number 1
channel blocker toxicity. There is
also a caution not to routinely use
amiodarone and procainamide
simultaneously.
Previously recommend only for
suspected regular narrow complex
reentry supraventricular tachycardia,
adenosine is now recommended for
the initial diagnosis and treatment
of stable, undifferentiated regular
monomorphic wide complex
tachycardia. However, adenosine
should not be used for irregular widecomplex tachycardia because it can
precipitate VF (Figure 2).
The 2010 guidelines allow
chronotropic drug infusions as an
alternative to pacing. The previous
guidelines recommended that they
be given only after atropine and if
transcutaneous pacing failed (Figure 3).
CRITICAL DECISION
What suggestions have been made
regarding postresuscitation care?
Post–cardiac arrest care requires
a “comprehensive, structured,
integrated, multidisciplinary system
of care that includes cardiopulmonary
and neurologic support.” Favorable
outcomes have been reported with
percutaneous coronary interventions
(PCI) in adult patients resuscitated
from cardiac arrest.12,13 Thus, cardiac
catheterization should be considered
in post–cardiac arrest protocols,
and coma is not a contraindication.
Coronary angiography may be
indicated after ROSC in patients
whose arrest is likely due to
ischemic cardiac disease, even in
Pearls
• Use out-of-hospital 12-lead ECGs to reduce time
to reperfusion with fibrinolytic therapy.
• Use a 1-shock instead of a 3-shock sequence for ventricular fibrillation (VF).
• Use escalating instead of fixed doses for the second and subsequent shocks.
• Omit atropine from the advanced cardiovascular life
support (ACLS) cardiac arrest algorithm.
• Use morphine with caution in patients with unstable angina/non-STEMI.
• Use quantitative waveform capnography for monitoring CPR quality
and detecting ROSC based on end-tidal carbon dioxide values.
• Include AEDs in the adult chain-of-survival system for
public places, and consider their use in the hospital.
Pitfalls
• Failing to provide high-quality, basic CPR, especially high-quality
chest compressions, which are the foundation for ACLS.
• Focusing on ventilation instead of high-quality chest compressions.
• Relying on drugs and devices while minimizing the
importance of chest compressions and BLS measures.
• Failing to titrate the use of supplemental oxygen in postresuscitation care.
• Failing to use morphine with caution and using morphine as a
first-line drug (instead of nitrates) for patients with ACS.
• Failing to implement comprehensive care for patients after cardiac
arrest with STEMI or suspected ACS, which may include PCI.
• Failing to institute systems of care for patients with STEMI
in order to improve outcome for STEMI patients.
the absence of a STEMI because
the ECG can be insensitive or even
misleading following cardiac arrest.
Recommendations new to the 2010
guidelines are to transfer patients
to a facility with a comprehensive
post–cardiac arrest treatment system
of care, identify/treat reversible causes
including acute coronary syndrome
(which may include PCI), control
temperature to optimize neurologic
recovery, and anticipate, treat, and
prevent multiple organ dysfunction
(which includes avoiding excessive
ventilation and hyperoxia and
considering hypothermia).
CRITICAL DECISION
What do the AHA guidelines
recommend regarding devices and
techniques?
The precordial thump may be
used for patients with witnessed,
monitored, unstable VT if a
defibrillator is not immediately ready
for use14 (Table 4).
Continuous waveform
capnography should be used for
intubated patients in the periarrest
period and is useful for confirming
ET tube placement in adults,
monitoring CPR quality, and detecting
ROSC in adults based on end-tidal
carbon dioxide.
CPR techniques have been
designed to increase perfusion
during resuscitation from cardiac
arrest and to increase survival.
In certain situations when used
by well-trained providers, some
alternative CPR techniques may
improve hemodynamics/short-term
survival, but not long-term survival.6
Furthermore, these alternative
CPR techniques generally require
additional equipment, training, and
personnel and often can only be
used in a specific setting.6 “To date,
no CPR device has consistently been
shown to be superior to standard
conventional (manual) CPR for outof-hospital BLS, and no device other
than a defibrillator has consistently
improved long-term survival for outof-hospital cardiac arrest.”6
17
Critical Decisions in Emergency Medicine
Table 4.
CPR techniques and devices
Continuous waveform capnography
Precordial thump
CPR devices
impedance threshold device
Load-distributing band CPR (auto-pulse)
New 2010 Guidelines
Recommended for intubated patients in peri-arrest period
In adults, confirms ET tube placement, detects ROSC, and
monitors CPR quality
Consider if: witnessed, monitored unstable VT if defibrillator is
not immediately ready for use
Improved ROSC/short-term survival but no improvement in
long-term survival
No improvement in 4-hour survival
Worse neurologic outcome when used
Figure 2.
Adult tachycardia algorithm. From: 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(18 Suppl 3):S751. Used with permission from the American Heart Association.
18
January 2013 • Volume 27 • Number 1
CRITICAL DECISIONS
What do the AHA guidelines
recommend regarding systems of
care?
Optimal management of
STEMI care requires integration of
community, EMS, physician, and
hospital resources in a well-organized,
coordinated, system-wide approach
to care.
Components of such a systemic
approach to care can involve public
awareness/education regarding
the symptoms of acute coronary
syndrome (ACS), dispatch
instructions, EMS protocols, out-ofhospital 12-lead ECGs, emergency
department and hospital programs,
and intrafacility systems of care and
interfacility transfer agreements,
where appropriate. Out-of-hospital
ECGs can reduce the time to PCI and
streamline triage to specific hospitals
when PCI is the therapy of choice.
Positive outcomes have occurred in
adults resuscitated from cardiac arrest
who have undergone PCI. Emergency
angiography with revascularization of
the infarct-related artery in patients
with out-of-hospital cardiac arrest is
one of the 2010 recommendations.
The following should be noted:
1) the ECG may be insensitive or
misleading after cardiac arrest,
2) coronary angiography after
ROSC in patients with arrest of
presumed cardiac etiology may be
reasonable, even in the absence of
a clearly defined STEMI, and 3)
coma is frequently seen after outof-hospital cardiac arrest and is not
a contraindication to immediate
angiography and PCI.
artery is recommended in patients
with out-of-hospital cardiac arrest
from VF.
A stent was placed in the cardiac
catheterization lab, and the patient
woke up after the procedure, did well,
and was discharged home 4 days
later, neurologically intact.
■ Case Two
The 45-year-old patient with
complete heart block was sent to
the cardiac ICU. A pacemaker was
inserted. The patient did well and
was sent home 3 days later with the
diagnosis of complete heart block,
status post-pacemaker placement, and
non-STEMI.
■ Case Three
After the synchronized
cardioversion, the tachycardic patient
with a widened QRS awakened.
Her heart rate was 84, and blood
pressure was 130/80; she was
responding appropriately to verbal
stimuli. The cardiologist arrived
and noted that the patient had been
scheduled for a cardiac ablation in 2
weeks for recurrent supraventricular
tachycardia. She was admitted to the
cardiac ICU, and a successful ablation
was done. She was discharged home
in sinus rhythm 1 day later.
Summary
Although airway and breathing
are still important, the emphasis
in the 2010 AHA guidelines is on
Figure 3.
Adult bradycardia algorithm. From: 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(18 Suppl 3):S749. Used with permission from the
American Heart Association.
Case Resolutions
■ Case One
In the case of the woman who
had a witnessed arrest and received
immediate by-stander CPR,
although she was comatose and
had a nondiagnostic ECG, she was
taken to the cardiac catheterization
laboratory for emergent angiography.
According to the ACLS guidelines,
emergent angiography with prompt
revascularization of the infarct-related
19
Critical Decisions in Emergency Medicine
high-quality CPR—especially highquality chest compressions. A major
change is from airway-breathingchest compressions (A-B-C) to chest
compressions-airway-breathing
(C-A-B); chest compressions should
be started before attention to airway
and breathing. Recommendations for
electrical therapy have been modified
and include a 1-shock protocol versus
3-shock sequence for VF. Some of
the changes in pharmacology include
elimination of atropine from the PEA/
asystole algorithm and elimination of
lidocaine from the VF/pulseless VT
algorithm. There are also new sections
on post–cardiac arrest care and stroke
care that focus on organized systems
of care with a goal of improving
functional outcome.
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