What are the latest Advanced Life Support (ALS) guidelines for managing cardiac arrest in an adult patient?

Latest Advanced Life Support Guidelines for Cardiac Arrest

The 2020 International Consensus on Cardiopulmonary Resuscitation (ILCOR) provides the most current evidence-based recommendations for adult advanced life support, emphasizing high-quality CPR with minimal interruptions, early defibrillation, airway management flexibility, vasopressor administration, antiarrhythmic drugs for refractory VF/VT, and comprehensive post-resuscitation care including targeted temperature management. 1

Defibrillation Strategies for VF/Pulseless VT

Energy Levels and Timing

• If the first shock fails and your defibrillator can deliver higher energy, increase the energy for subsequent shocks 1
• Consider anticipatory charging: charge the defibrillator near the end of a compression cycle but before checking rhythm, then pause briefly to both analyze rhythm and deliver shock if indicated 1
• This minimizes peri-shock pause duration compared to the traditional method of checking rhythm first, then charging while resuming compressions 1
• Double sequential defibrillation has been reviewed but lacks strong evidence for routine recommendation 1

Airway Management During CPR

Advanced Airway vs. Bag-Mask Ventilation

• There is equipoise between using an advanced airway (endotracheal tube or supraglottic airway) versus bag-mask ventilation during cardiac arrest 1
• Either approach is acceptable based on provider skill and clinical context 1
• When choosing an advanced airway, there is also equipoise between supraglottic airways and endotracheal intubation as the initial advanced airway 1

Airway Confirmation and Oxygenation

• Confirm correct tracheal tube placement with waveform capnography 1
• Use the highest possible inspired oxygen concentration (100%) during CPR 1
• Avoid excessive ventilation rates; provide 1 breath every 6 seconds (10 breaths/minute) with continuous compressions 2

Vasopressors During Cardiac Arrest

Epinephrine Administration

• Administer epinephrine 1 mg IV/IO every 3-5 minutes during cardiac arrest 1
• For non-shockable rhythms (PEA/asystole), give epinephrine as soon as feasible 1
• For shockable rhythms (VF/pVT), give epinephrine after initial defibrillation attempts 1
• Earlier administration (within 10 minutes of resuscitation onset) may improve outcomes, though evidence quality is limited 1
• Standard-dose epinephrine (1 mg) is preferred over high-dose epinephrine (≥5 mg), as high-dose offers no survival benefit and may worsen neurological outcomes 1

Vasopressin

• Vasopressin offers no advantage over epinephrine and is not recommended as a substitute 1
• The combination of vasopressin plus epinephrine provides no benefit over epinephrine alone 1

Route of Administration

• Both intravenous and intraosseous routes are acceptable for drug delivery during cardiac arrest 1

Antiarrhythmic Drugs for Refractory VF/VT

Amiodarone and Lidocaine

• For VF/pVT unresponsive to defibrillation, administer amiodarone 300 mg IV/IO, with a second dose of 150 mg if needed 1
• Lidocaine (1-1.5 mg/kg initial dose) is an acceptable alternative if amiodarone is unavailable 1
• Both drugs may improve short-term outcomes (ROSC, survival to admission) but have not definitively improved survival to discharge with good neurological function 1

Circulatory Support During CPR

Mechanical CPR Devices

• Mechanical chest compression devices do not improve outcomes compared to high-quality manual compressions 1
• They may be considered in specific situations where manual compressions are difficult (e.g., during transport, prolonged resuscitation, or in the catheterization laboratory) 1

Extracorporeal CPR (ECPR)

• ECPR may be considered for selected patients with cardiac arrest when conventional CPR is failing, particularly in settings with established ECPR programs 1
• This applies to patients with reversible causes (e.g., acute MI, pulmonary embolism, hypothermia) who meet specific selection criteria 1
• Evidence is limited to observational studies, but ECPR may improve survival in highly selected populations 1

Physiological Monitoring During CPR

End-Tidal CO₂ (ETCO₂)

• Use waveform capnography to confirm and monitor endotracheal tube placement 1
• ETCO₂ values can help assess CPR quality and predict ROSC 1
• Persistently low ETCO₂ (<10 mmHg) after 20 minutes of CPR may indicate poor prognosis, though should not be used as the sole criterion for terminating resuscitation 1

Point-of-Care Ultrasound

• Ultrasound may be used during cardiac arrest to identify reversible causes (e.g., cardiac tamponade, pulmonary embolism, hypovolemia) 1
• Minimize interruptions to chest compressions when performing ultrasound examinations 1

Post-Resuscitation Care

Oxygenation and Ventilation After ROSC

• Target arterial oxygen saturation of 92-98% after ROSC; avoid both hypoxemia and hyperoxemia 1, 2
• Use low tidal volume ventilation (6-8 mL/kg predicted body weight) 2
• Target normocapnia (PaCO₂ 35-45 mmHg); avoid hyperventilation 1, 2

Targeted Temperature Management (TTM)

• Maintain constant temperature between 32°C and 36°C for at least 24 hours in comatose patients after ROSC 1
• Actively prevent fever (temperature >37.7°C) for at least 72 hours after ROSC 1
• The optimal target temperature within this range remains uncertain, but consistency is key 1

Hemodynamic Support

• Optimize hemodynamics to maintain adequate perfusion pressure 1
• Consider early coronary angiography for patients with suspected cardiac etiology, particularly those with ST-elevation on post-ROSC ECG 1

Seizure Management

• Treat clinical seizures promptly with antiepileptic medications 1
• Prophylactic antiepileptic drugs are not routinely recommended 1
• Consider continuous EEG monitoring in comatose patients to detect non-convulsive seizures 1

Sedation Post-ROSC

• Use titrated, light-to-moderate sedation with opioid analgesia (fentanyl or remifentanil) as the foundation 2
• Add short-acting sedatives (propofol, dexmedetomidine) only if analgesia alone is insufficient 2
• Avoid or minimize neuromuscular blocking agents; use only for short intervals when absolutely necessary 2

Prognostication in Comatose Patients

Timing and Multimodal Approach

• Delay prognostication until at least 72 hours after ROSC (or after rewarming if TTM used) to avoid premature withdrawal of life-sustaining therapy 1
• Use a multimodal approach combining clinical examination, neurophysiological tests (EEG, somatosensory evoked potentials), blood biomarkers (neuron-specific enolase), and brain imaging (CT, MRI) 1
• No single test is sufficiently reliable in isolation 1

Clinical Examination

• Absent pupillary and corneal reflexes at ≥72 hours post-arrest are associated with poor prognosis but should not be used alone 1
• Myoclonus within 48 hours does not reliably predict poor outcome 1

Special Circumstances

Cardiac Arrest in Pregnancy

• Perform manual left uterine displacement to relieve aortocaval compression 1
• Prepare for perimortem cesarean delivery if ROSC is not achieved within 4 minutes of arrest onset (delivery by 5 minutes) 1
• Use standard ACLS medications and defibrillation energies 1

Cardiac Arrest Associated with Pulmonary Embolism

• Consider thrombolytic therapy for cardiac arrest with suspected or confirmed pulmonary embolism 1
• ECPR or surgical embolectomy may be considered in refractory cases with appropriate resources 1

Opioid-Associated Cardiac Arrest

• Administer naloxone for suspected opioid toxicity, but do not delay standard ACLS interventions 1
• Higher doses (2-10 mg IV/IO) may be needed for synthetic opioids 1

Key Pitfalls to Avoid

• Do not interrupt chest compressions for prolonged periods; limit pauses to <10 seconds for rhythm checks and defibrillation 1
• Do not hyperventilate; excessive ventilation increases intrathoracic pressure, decreases venous return, and worsens outcomes 1, 2
• Do not use high-dose epinephrine; it does not improve survival and may worsen neurological outcomes 1
• Do not rely on a single prognostic indicator when determining neurological prognosis; always use multimodal assessment 1
• Do not prematurely withdraw life support; wait at least 72 hours after ROSC and rewarming before making prognostic decisions 1