From the Guidelines
To increase Return of Spontaneous Circulation (ROSC) rates in pre-hospital cardiac arrest, focus on high-quality CPR with minimal interruptions, ensuring chest compressions are at least 2 inches deep at a rate of 100-120 compressions per minute with complete chest recoil between compressions, as recommended by the 2020 American Heart Association guidelines 1.
Key Interventions
- Ensure chest compressions are performed with a depth of at least 2 inches and a rate of 100-120 compressions per minute, allowing for complete chest recoil between compressions, which is associated with improved coronary perfusion and hemodynamics 1.
- Limit pauses to less than 10 seconds for critical interventions, such as defibrillation or airway management, to minimize interruptions in CPR.
- Early defibrillation is crucial for shockable rhythms (VF/VT); apply an AED as soon as possible, as public access defibrillation programs have been shown to increase survival rates from out-of-hospital cardiac arrest 1.
Medication Administration
- For medication administration, give epinephrine 1mg IV/IO every 3-5 minutes, with the first dose given as early as possible after CPR initiation, as part of the repetitive pattern of CPR and rhythm checks 1.
- Consider amiodarone 300mg IV/IO for persistent VF/VT after initial defibrillation attempts, as part of the advanced life support protocol.
Airway Management and Team Approach
- Secure the airway using the method with the highest provider proficiency, whether basic airway adjuncts or advanced airway techniques, to minimize interruptions in CPR and ensure adequate ventilation.
- Implement a team-based approach with clear role assignments and effective communication to ensure high-quality CPR and timely interventions.
Post-ROSC Care
- Post-ROSC, initiate targeted temperature management by preventing hyperthermia and consider cooling to 32-36°C when appropriate, to minimize secondary injury after resuscitation and improve outcomes. These interventions improve outcomes by maintaining vital organ perfusion during CPR, terminating lethal arrhythmias promptly, supporting cardiac contractility, and minimizing secondary injury after resuscitation.
From the Research
Increasing ROSC Rates Pre-Hospital on Cardiac Arrest
To increase Return of Spontaneous Circulation (ROSC) rates pre-hospital on cardiac arrest, several strategies can be considered:
- Extracorporeal Cardiopulmonary Resuscitation (ECPR): ECPR may improve outcomes for refractory out-of-hospital cardiac arrest (OHCA) 2.
- Pre-Hospital Critical Care: Post-ROSC care delivered by a pre-hospital critical care team (CCT) was associated with good neurological outcomes on hospital discharge 3.
- Advanced Cardiac Life Support (ACLS): The addition of prehospital ACLS to basic cardiac life support (BCLS) was associated with a significant increase in the rate of prehospital ROSC in all patients experiencing OHCA 4.
- Thrombolytic Therapy: Thrombolytic therapy during cardiopulmonary resuscitation (CPR) can contribute to hemodynamic stabilization and survival in patients with massive pulmonary embolism and acute myocardial infarction 5.
Key Considerations
Some key considerations for increasing ROSC rates pre-hospital on cardiac arrest include:
- Time-to-ROSC: Increasing time-to-ROSC was negatively associated with survival, and the yield of survivors per minute of resuscitation increased from commencement and started to decline in the 8th minute 2.
- Transport for ECPR: Transport for ECPR should be considered between 8 to 24 minutes of professional on-scene resuscitation, with 16 minutes balancing the risks and benefits of early and later transport 2.
- Variation in Pre-Hospital Outcomes: Substantial variation in sustained ROSC upon emergency department arrival exists across EMS agencies, suggesting opportunities to identify and improve best practices in EMS agencies to advance OHCA care 6.