What are the current emergency guidelines for managing cardiac arrest, ischemic stroke, and severe trauma?

From the Guidelines

Current emergency management of cardiac arrest, ischemic stroke, and severe trauma prioritizes immediate intervention to maximize survival and minimize disability, with protocols including high-quality CPR, early defibrillation, rapid assessment and treatment with intravenous and intra-arterial therapies, and hemorrhage control. For cardiac arrest, immediate high-quality CPR should be initiated with 30 compressions to 2 breaths at a rate of 100-120 compressions per minute and a depth of 2-2.4 inches, as recommended by the 2020 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care 1. Early defibrillation is crucial for shockable rhythms (ventricular fibrillation/pulseless ventricular tachycardia), with epinephrine 1mg IV/IO administered every 3-5 minutes. Advanced airway management and identification of reversible causes (the "H's and T's") should follow, as outlined in the 2019 American Heart Association focused update on advanced cardiovascular life support 1.

For ischemic stroke, rapid assessment using tools like FAST (Face, Arms, Speech, Time) is essential, followed by immediate CT imaging, as recommended by the 2018 guidelines for the early management of patients with acute ischemic stroke 1. If eligible, intravenous alteplase (0.9 mg/kg, maximum 90mg, with 10% as bolus and remainder over 60 minutes) should be administered within 4.5 hours of symptom onset. Endovascular thrombectomy is indicated for large vessel occlusions within 24 hours of symptom onset.

For severe trauma, the ABCDE approach (Airway, Breathing, Circulation, Disability, Exposure) guides initial assessment, with hemorrhage control being paramount, as emphasized in the 2020 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care 1. Tourniquets should be applied for extremity bleeding and pelvic binders for suspected pelvic fractures. Permissive hypotension (systolic BP 80-90 mmHg) may be appropriate until definitive hemorrhage control. Tranexamic acid 1g IV over 10 minutes, followed by 1g over 8 hours, should be given within 3 hours of injury for patients with significant bleeding.

Key considerations in emergency management include:

• Rapid intervention to prevent cardiac tissue death, brain tissue loss, and irreversible shock
• Adherence to established protocols and guidelines, such as those from the American Heart Association
• Identification and management of reversible causes of cardiac arrest, stroke, and trauma
• Use of evidence-based therapies, including intravenous and intra-arterial treatments, and medications like epinephrine and tranexamic acid.

From the Research

Emergency Guidelines for Managing Cardiac Arrest

• The current guidelines for managing cardiac arrest recommend the use of epinephrine as the primary drug administered during cardiopulmonary resuscitation (CPR) to reverse cardiac arrest 2.
• However, recent studies have questioned the overall benefit of epinephrine for patients, with some suggesting that it may increase short-term survival but have no benefit or even harm for long-term survival and functional recovery 2, 3.
• The use of vasopressors, such as epinephrine and vasopressin, has been shown to improve short-term survival outcomes, but no long-term survival benefit has been demonstrated 3.
• The pharmacologic management of cardiac arrest is widely debated, but recent studies have begun to clarify the effectiveness of various medications, including epinephrine, vasopressin, and antiarrhythmic medications 4.

Emergency Guidelines for Managing Ischemic Stroke

• Cardiac arrest is a devastating complication of acute ischemic stroke, with an overall incidence of 3.9% 5.
• Independent predictors of cardiac arrest in patients with acute ischemic stroke include older age, greater stroke severity, preadmission dependence, and a history of diabetes, myocardial infarction, congestive heart failure, and atrial fibrillation 5.
• Patients with cardiac arrest after ischemic stroke have higher disability at discharge and a markedly increased 30-day mortality of 82.1% compared with 9.3% without cardiac arrest 5.

Emergency Guidelines for Managing Severe Trauma

• There are no specific studies provided on the emergency guidelines for managing severe trauma.
• However, the use of vasopressors and other medications may be relevant in the management of severe trauma, particularly in cases where cardiac arrest occurs 3, 4.

Current Recommendations

• The current recommendations for managing cardiac arrest, ischemic stroke, and severe trauma emphasize the importance of prompt and effective treatment, including the use of epinephrine and other vasopressors, as well as antiarrhythmic medications and other medications as needed 2, 3, 4.
• The American Heart Association and other organizations provide guidelines for the management of cardiac arrest and other emergency conditions, which should be followed by healthcare professionals 2, 3, 4.