What are the latest guidelines for cardiac arrest management?

Latest Guidelines for Cardiac Arrest Management

The 2020 American Heart Association Guidelines represent the most current comprehensive recommendations for cardiac arrest management, emphasizing high-quality CPR with compressions at 100-120/min to a depth of 5-6 cm, early defibrillation, epinephrine administration (particularly for nonshockable rhythms), and comprehensive post-cardiac arrest care including targeted temperature management for all comatose survivors. 1

High-Quality CPR: The Foundation

Compression Technique

• Push hard and fast: Compress the chest to a depth of at least 5 cm (2 inches) but avoid exceeding 6 cm (2.4 inches) in adults 1, 2
• Maintain optimal rate: Perform compressions at 100-120/min, avoiding rates below 100 or above 120 1, 2
• Hand position: Place hands on the lower half of the sternum 1
• Allow complete chest wall recoil: Avoid leaning on the chest between compressions to permit full cardiac refilling 1, 2
• Minimize interruptions: Keep total preshock and postshock pauses as short as possible, ideally maintaining a chest compression fraction of at least 60% 1
• Rotate compressors every 2 minutes or sooner if fatigued to maintain compression quality 2

Compression-to-Ventilation Ratio

• Use 30:2 ratio for adults in cardiac arrest without an advanced airway 1
• For untrained lay rescuers: Dispatchers should instruct compression-only CPR for adults with sudden cardiac arrest 1
• Compression-only CPR is a reasonable alternative to conventional CPR for adult cardiac arrest 1

Advanced Airway Management

• Once an advanced airway (endotracheal tube or supraglottic device) is placed, deliver 1 breath every 6 seconds (10 breaths/min) while continuing uninterrupted chest compressions 1, 2
• Use waveform capnography to confirm and continuously monitor endotracheal tube placement 1, 2
• Deliver each breath over approximately 1 second 1
• Avoid excessive ventilation 2

Defibrillation Strategy

Shockable Rhythms (VF/Pulseless VT)

• Early defibrillation with concurrent high-quality CPR is critical to survival 1
• For witnessed arrest when an AED is immediately available, use the defibrillator as soon as possible 1
• Single-shock strategy: Deliver one shock, then immediately resume CPR for 2 minutes before the next rhythm check 1
• Resume CPR immediately after shock delivery without a rhythm or pulse check, beginning with chest compressions 1

Energy Dosing

• Biphasic defibrillators: Use manufacturer's recommended energy dose (typically 120-200 J for first shock); if unknown, use maximum available 1
• Second and subsequent shocks should be equivalent or higher energy 1
• Monophasic defibrillators: Use 360 J 1, 2

Medication Management

Epinephrine

• Administration of epinephrine with concurrent high-quality CPR improves survival, particularly in patients with nonshockable rhythms 1
• For nonshockable rhythms (PEA/asystole): Administer epinephrine as soon as feasible 2
• For shockable rhythms (VF/pVT): Consider epinephrine after initial defibrillation attempts have failed 2
• Dosing: 1 mg IV/IO every 3-5 minutes 1, 2
• Standard-dose epinephrine (1 mg) is reasonable; high-dose epinephrine is not recommended 1

Antiarrhythmic Drugs for Refractory VF/pVT

The 2018 focused update modified previous recommendations to place amiodarone and lidocaine on equal footing 1:

• Amiodarone: First dose 300 mg IV/IO bolus, second dose 150 mg 1, 2
• Lidocaine (as alternative): First dose 1-1.5 mg/kg IV/IO, second dose 0.5-0.75 mg/kg 1, 2
• Either may be considered for VF/pVT unresponsive to CPR, defibrillation, and vasopressor therapy 1

Critical caveat: No antiarrhythmic drug has been shown to increase long-term survival or neurologically intact survival; recommendations are based on short-term outcomes like ROSC 1

Route of Administration

• Establish IV access first when possible for drug administration 2
• Consider IO access if IV attempts are unsuccessful or not feasible 1, 2
• Endotracheal drug delivery may be used for epinephrine and lidocaine only if IV/IO access cannot be established, though this is less preferred 1

Monitoring CPR Quality

Physiologic Feedback

• Waveform capnography: If ETCO₂ <10 mm Hg, attempt to improve CPR quality 1
• An abrupt sustained increase in ETCO₂ (typically ≥40 mm Hg) suggests ROSC 1
• Intra-arterial pressure monitoring: If diastolic pressure <20 mm Hg, attempt to improve CPR quality 1

Special Circumstances

Recognition of Reversible Causes

Recognition that all cardiac arrest events are not identical is critical for optimal patient outcome 1. Always consider the "H's and T's":

• Hypovolemia, Hypoxia, Hydrogen ion (acidosis), Hypo-/hyperkalemia, Hypothermia 1, 2
• Tension pneumothorax, Tamponade (cardiac), Toxins, Thrombosis (pulmonary), Thrombosis (coronary) 1, 2

Opioid-Associated Cardiac Arrest

• The opioid epidemic has resulted in an increase in opioid-associated OHCA 1
• Focus on high-quality CPR as the mainstay of care 2
• Administer naloxone along with standard care if it doesn't delay CPR 2

Drowning

• Ventilation is particularly important due to the hypoxic nature of drowning arrest 2
• Use the highest possible inspired oxygen concentration when available 2

Pregnancy

• Specialized management is necessary 1
• Consider perimortem cesarean delivery if no ROSC within 4 minutes

Post-Cardiac Arrest Care

Post-cardiac arrest care is a critical component of the Chain of Survival and demands a comprehensive, structured, multidisciplinary system 1.

Targeted Temperature Management

• Prompt initiation of targeted temperature management is necessary for all patients who do not follow commands after ROSC 1, 2
• Target temperature between 32°C and 37.5°C 2
• Avoid hyperthermia 2

Oxygenation and Ventilation

• Avoid both hypoxemia and hyperoxemia: Target oxygen saturation of 94-98% once reliably measured 2
• Avoid hypocapnia during post-ROSC care 2

Neurological Prognostication

• Accurate neurological prognostication in brain-injured cardiac arrest survivors is critically important to ensure patients with significant potential for recovery are not destined for poor outcomes due to premature care withdrawal 1
• Delay prognostication, especially in patients treated with targeted temperature management

Discharge Planning

• Recovery expectations and survivorship plans addressing treatment, surveillance, and rehabilitation need to be provided to cardiac arrest survivors and caregivers at hospital discharge 1

Systems of Care Improvements

• Implement public-access defibrillation programs in large public areas 2
• Use real-time CPR feedback devices to improve CPR quality metrics 2
• Consider extracorporeal CPR (eCPR) for select patients with cardiac arrest refractory to standard ACLS when provided within an appropriately trained system 2
• Recognize organ donation as an important outcome in systems of care development 2

Common Pitfalls to Avoid

• Do not use immobilization devices for suspected spinal injury during lay rescuer CPR; use manual spinal motion restriction instead (placing hands on either side of head) as devices may be harmful 1
• Do not routinely use passive ventilation techniques during conventional CPR, as their effectiveness is unknown 1
• Do not routinely use magnesium for VF/pVT 1
• Do not routinely use atropine for PEA or asystole 1
• Do not routinely use sodium bicarbonate during cardiac arrest 1
• Vasopressin offers no advantage as a substitute for epinephrine 1