Part 5: Electrical Therapies 1v-43 pital or hospital (emergency department) setting. Given the defibrillation in pa with out-of-hospital ventricular fibrillation. recent recognition of the importance of maximizing chest JAMA.1999:281:182-1188 compressions as well as the lack of demonstrated benefit of 7. Cummins, RO. Eisenberg. MS. Hallstrom, AP, Litwin, PE Survival of ospital cardiac arrest with early initiation of cardiopulmonar pacing for asystole, withholding chest compressions to at- resuscitation. Am J Emerg Med. 1985: 3: 114-119. tempt pacing for patients with asystole is not recommended 8. Holmberg S, Holmberg M, Herlitz J, Effect of bystander cardiopulmo- ( Class Il) nary resuscitation in out-of-hospital cardiac arrest patients in Sweden. Resuscitation. 2000: 47: 59-70 pacing 9. Waalewijn RA, Tijssen JG, Koster RW. Bystander initiated actions in symptomatic bradycardia when a pulse is present. Healthcare f-hospital cardiopulmonary resuscitation: results from th providers should be prepared to initiate pacing in patients Amsterdam Resuscitation Study (ARRESUST) Resuscitation. 2001 who do not respond to atropine(or second-line drugs if these 273-279 do not delay definitive management). Immediate pacing is 10. Weaver WD, Copass MK, Bufi D, Ray r, Hallstrom AP. Cobb LA. ved neurologic recovery and survival after early defibrillation. indicated if the patient is severely symptomatic, especially Circulation. 1984: 69 943-948 hen the block is at or below the His Purkinje level. If the 11. Intemational Liaison Committee on Resuscitation. 2005 Internationa patient does not respond to transcutaneous pacing, transvenous Consensus on Cardiopulmonary Resuscitation and Emergency Cardio- pacing is needed. For further information see Part 7.3: "Man- vascular Care With Treatment Recommendations. Circulation. 2005 l2:II-1-l-136 agement of Symptomatic Bradycardia and Tachycardia. 12. Jacobs IG. Finn JC. Oxer HF. Jelinek GA CPR before defibrillation in Maintaining Devices in a State of Readiness 2005:17:39-45 User checklists have been developed to reduce equipment 13. Yu T, Weil MH, Tang w, Sun S, Louche K, Povoas H, Bisera J. Adverse outcomes of interrupted precordial compression during malfunction and operator errors. Failure to properly maintain he defibrillator or power supply is responsible for the 14. Berg RA. Sanders AB, Kern KB. Hilwig Rw. Heidenreich JW, Porter majority of reported malfunctions. Checklists are useful when ME, Ewy GA. Adverse hemodynamic designed to identify and prevent such deficiencies compressions for rescue breathing during cardiopulmonary resuscitation ntricular fibrillation cardiac arrest. Circulation. 2001: 104 Summary 15. Ken K, Hilwig R, Berb R, Sanders A, Ewy G. Importance of continuous The new recommendations for electrical therapies described chest compressions during CPR. Circulation. 2002: 105: 645-649. in this section are designed to improve survival from SCA 16. Eftestol T, Sunde K, Steen PA. Effects of interrupting precordial cor pressions on the calculated probability of defibrillation success during and life-threatening arrhythmias. For any victim of cardiac out-of-hospital cardiac arrest. Circulation. 2002: 105: 2270-2273 arrest, good CPR--push hard, push fast, allow complete chest 17. van Alem AP, Chapman FW, Lank P, Hart AA, Koster Rw. A pro- recoil,and minimize interruptions in chest compressions--is spective, randomised and blinded comparison of first shock success of essential. Some victims of vF SCA may benefit from a short monophasic and biphasic waveforms in out-of-hospital cardiac arrest Resuscitation. 2003: 58: 17-24 period of CPR before attempted defibrillation. Whenever 18. Wik L, Kramer-Johansen J, Myklebust H, Sorebo H, Svensson L. defibrillation is attempted, rescuers must coordinate good Fellows B, Steen PA. Quality of cardiopulmonary resuscitation during CPR with defibrillation to minimize interruptions in chest out-of-hospital cardiac arrest. JAMA. 2005: 293: 299-304. compressions and to ensure immediate resumption of chest 19. Abella BS, Alvarado JP, Myklebust H, Edelson DP, Barry A, OHearn N, Vanden Hoek TL, Becker LB. Quality of cardiopulmonary resusci- compressions after shock delivery. The high first-shock est. jan efficacy of newer biphasic defibrillators led to the recommen- 20. Bain AC. Swerdlow CD, Love C]. Ellenbogen KA, Deering TF. Brewer dation of single shocks plus immediate CPR instead of JE, Augostini RS, Tchou PJ. Multicenter study of principles-based 3-shock sequences that were formerly recommended to treat aveforms for external defibrillation. Ann Emerg Med. 2001: 37: 5-12. 21. Poole JE, White RD, Kanz KG, Hengstenberg F, Jarrard GT, Robinson VE. Further data is needed to refine recommendations for use JC, Santana V, McKenas DK, Rich N. Rosas S, Merritt S. Magnotto L, of electrical therapies, particularly for the use of biphase allagher JV Ill, Gliner BE. Jorgenson DB, Morgan CB. Dillon SM, Kronmal RA, Bardy GH. Low-energy impedance-compensating biphasic waveforms terminate ventricular fibrillation at high rates in victims of out-of-hospital cardiac arrest. LIFE Investigators. JCar- References liovasc Electrophysiol. 1997; 8: 1373-1385 1. Larsen MP, Eisenberg Ms, Cummins RO, Hallstrom AP. Predicting 22. White RD, Blackwell TH, Russell JK, Snyder DE, Jorgenson DB survival from out-of-hospital cardiac arrest: a graphic model. Ann Emerg Transthoracic impedance not affect defibrillation. resuscitation Med.1993:22:1652-1658. 2. Valenzuela TD, Roe DJ, Cretin S, Spaite DW. Larsen MP. Estimating non-escalating biphasic waveform defibrillator. Resuscitation. 2005: 64: survival model. Circulation. 1997- 96: 3308-3313. 23. Mittal S, Ayati S, Stein KM, Knight BP, Morady F, Schwartzman D 3. Swor RA, Jackson RE, Cynar M, Sadler E, Basse E, Boji B, Rivera- Cavlovich D, Platia EV. Calkins H. Tchou PJ. Miller JM. wharton JM Rivera e, Maher A, Grubb w, Jacobson R, et al. Bystander CPR, ung R, Slotwiner DJ, Markowitz SM, Lerman BB. Comparison of a entricular fibrillation, and survival in witnessed. unmonitored out-of novel rectilinear biphasic waveform with a damped sine wave hospital cardiac arrest. Ann Emerg Med. 1995: 25: 780-784 monophasic waveform for transthoracic ventricular defibrillation. ZOLL 4. Holmberg M, Holmberg S. Herlitz J Incidence duration and survival of J Am Coll Cardiol. 199 ventricular fibrillation in out-of-hospital cardiac arrest patients in 24. Schneider T Martens PR. Paschen H. Kuisma M, Wolcke B, Gliner BE, Sweden. Resuscitation. 2000: 44-7-17 Russell JK Weaver WD, Bossaert L, Chamberlain D. Multicenter 5. Wik L, Hansen TB. Fylling F, Steen T, Vaagenes P, Auestad BH, Steen andomized, controlled trial of 150-J biphasic sho mpared with ve basic cardiopulmonary resuscitate 200to 360-J monophasic shocks in the resuscitation of out-of-hospital patients with out-of-hospital ventricular fibrillation: a randomize cardiac arrest victims. Circulation. 2000: 102: 1780-1787 aL.JAMA.2003:289:1389-1395 25. Hess EP, White RD. Ventricular fibrillation is not pre 6. Cobb LA, Fahrenbruch CE, Walsh TR, Copass MK, Olsufka M, Breskin compression during post-shock organized rhythms in M, Hallstrom AP. Influence of cardiopulmonary resuscitation prior to cardiac arrest. Resuscitation 2005: 66: 7-11pital or hospital (emergency department) setting. Given the recent recognition of the importance of maximizing chest compressions as well as the lack of demonstrated benefit of pacing for asystole, withholding chest compressions to at￾tempt pacing for patients with asystole is not recommended (Class III). Transcutaneous pacing is recommended for treatment of symptomatic bradycardia when a pulse is present. Healthcare providers should be prepared to initiate pacing in patients who do not respond to atropine (or second-line drugs if these do not delay definitive management). Immediate pacing is indicated if the patient is severely symptomatic, especially when the block is at or below the His Purkinje level. If the patient does not respond to transcutaneous pacing, transvenous pacing is needed. For further information see Part 7.3: “Man￾agement of Symptomatic Bradycardia and Tachycardia.” Maintaining Devices in a State of Readiness User checklists have been developed to reduce equipment malfunction and operator errors. Failure to properly maintain the defibrillator or power supply is responsible for the majority of reported malfunctions. Checklists are useful when designed to identify and prevent such deficiencies. Summary The new recommendations for electrical therapies described in this section are designed to improve survival from SCA and life-threatening arrhythmias. For any victim of cardiac arrest, good CPR—push hard, push fast, allow complete chest recoil, and minimize interruptions in chest compressions—is essential. Some victims of VF SCA may benefit from a short period of CPR before attempted defibrillation. Whenever defibrillation is attempted, rescuers must coordinate good CPR with defibrillation to minimize interruptions in chest compressions and to ensure immediate resumption of chest compressions after shock delivery. The high first-shock efficacy of newer biphasic defibrillators led to the recommen￾dation of single shocks plus immediate CPR instead of 3-shock sequences that were formerly recommended to treat VF. Further data is needed to refine recommendations for use of electrical therapies, particularly for the use of biphasic waveforms. References 1. Larsen MP, Eisenberg MS, Cummins RO, Hallstrom AP. Predicting survival from out-of-hospital cardiac arrest: a graphic model. Ann Emerg Med. 1993;22:1652–1658. 2. Valenzuela TD, Roe DJ, Cretin S, Spaite DW, Larsen MP. Estimating effectiveness of cardiac arrest interventions: a logistic regression survival model. Circulation. 1997;96:3308–3313. 3. Swor RA, Jackson RE, Cynar M, Sadler E, Basse E, Boji B, Rivera￾Rivera EJ, Maher A, Grubb W, Jacobson R, et al. Bystander CPR, ventricular fibrillation, and survival in witnessed, unmonitored out-of￾hospital cardiac arrest. Ann Emerg Med. 1995;25:780–784. 4. Holmberg M, Holmberg S, Herlitz J. Incidence, duration and survival of ventricular fibrillation in out-of-hospital cardiac arrest patients in Sweden. Resuscitation. 2000;44:7–17. 5. Wik L, Hansen TB, Fylling F, Steen T, Vaagenes P, Auestad BH, Steen PA. Delaying defibrillation to give basic cardiopulmonary resuscitation to patients with out-of-hospital ventricular fibrillation: a randomized trial. JAMA. 2003;289:1389–1395. 6. Cobb LA, Fahrenbruch CE, Walsh TR, Copass MK, Olsufka M, Breskin M, Hallstrom AP. Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillation. JAMA. 1999;281:1182–1188. 7. Cummins, RO, Eisenberg, MS, Hallstrom, AP, Litwin, PE. Survival of out-of-hospital cardiac arrest with early initiation of cardiopulmonary resuscitation. Am J Emerg Med. 1985;3:114–119. 8. Holmberg S, Holmberg M, Herlitz J, Effect of bystander cardiopulmo￾nary resuscitation in out-of-hospital cardiac arrest patients in Sweden. Resuscitation. 2000; 47:59–70. 9. Waalewijn RA, Tijssen JG, Koster RW. Bystander initiated actions in out-of-hospital cardiopulmonary resuscitation: results from the Amsterdam Resuscitation Study (ARRESUST). Resuscitation. 2001;50: 273–279. 10. Weaver WD, Copass MK, Bufi D, Ray R, Hallstrom AP, Cobb LA. Improved neurologic recovery and survival after early defibrillation. Circulation. 1984;69:943–948. 11. International Liaison Committee on Resuscitation. 2005 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardio￾vascular Care With Treatment Recommendations. Circulation. 2005; 112:III-1–III-136. 12. Jacobs IG, Finn JC, Oxer HF, Jelinek GA. CPR before defibrillation in out-of-hospital cardiac arrest: a randomized trial. Emerg Med Australas. 2005;17:39–45. 13. Yu T, Weil MH, Tang W, Sun S, Klouche K, Povoas H, Bisera J. Adverse outcomes of interrupted precordial compression during automated defibrillation. Circulation. 2002;106:368–372. 14. Berg RA, Sanders AB, Kern KB, Hilwig RW, Heidenreich JW, Porter ME, Ewy GA. Adverse hemodynamic effects of interrupting chest compressions for rescue breathing during cardiopulmonary resuscitation for ventricular fibrillation cardiac arrest. Circulation. 2001;104: 2465–2470. 15. Kern K, Hilwig R, Berb R, Sanders A, Ewy G. Importance of continuous chest compressions during CPR. Circulation. 2002;105:645–649. 16. Eftestol T, Sunde K, Steen PA. Effects of interrupting precordial com￾pressions on the calculated probability of defibrillation success during out-of-hospital cardiac arrest. Circulation. 2002;105:2270–2273. 17. van Alem AP, Chapman FW, Lank P, Hart AA, Koster RW. A pro￾spective, randomised and blinded comparison of first shock success of monophasic and biphasic waveforms in out-of-hospital cardiac arrest. Resuscitation. 2003;58:17–24. 18. Wik L, Kramer-Johansen J, Myklebust H, Sorebo H, Svensson L, Fellows B, Steen PA. Quality of cardiopulmonary resuscitation during out-of-hospital cardiac arrest. JAMA. 2005;293:299–304. 19. Abella BS, Alvarado JP, Myklebust H, Edelson DP, Barry A, O’Hearn N, Vanden Hoek TL, Becker LB. Quality of cardiopulmonary resusci￾tation during in-hospital cardiac arrest. JAMA. 2005;293:305–310. 20. Bain AC, Swerdlow CD, Love CJ, Ellenbogen KA, Deering TF, Brewer JE, Augostini RS, Tchou PJ. Multicenter study of principles-based waveforms for external defibrillation. Ann Emerg Med. 2001;37:5–12. 21. Poole JE, White RD, Kanz KG, Hengstenberg F, Jarrard GT, Robinson JC, Santana V, McKenas DK, Rich N, Rosas S, Merritt S, Magnotto L, Gallagher JV III, Gliner BE, Jorgenson DB, Morgan CB, Dillon SM, Kronmal RA, Bardy GH. Low-energy impedance-compensating biphasic waveforms terminate ventricular fibrillation at high rates in victims of out-of-hospital cardiac arrest. LIFE Investigators. J Car￾diovasc Electrophysiol. 1997;8:1373–1385. 22. White RD, Blackwell TH, Russell JK, Snyder DE, Jorgenson DB. Transthoracic impedance does not affect defibrillation, resuscitation or survival in patients with out-of-hospital cardiac arrest treated with a non-escalating biphasic waveform defibrillator. Resuscitation. 2005;64: 63–69. 23. Mittal S, Ayati S, Stein KM, Knight BP, Morady F, Schwartzman D, Cavlovich D, Platia EV, Calkins H, Tchou PJ, Miller JM, Wharton JM, Sung RJ, Slotwiner DJ, Markowitz SM, Lerman BB. Comparison of a novel rectilinear biphasic waveform with a damped sine wave monophasic waveform for transthoracic ventricular defibrillation. ZOLL Investigators. J Am Coll Cardiol. 1999;34:1595–1601. 24. Schneider T, Martens PR, Paschen H, Kuisma M, Wolcke B, Gliner BE, Russell JK, Weaver WD, Bossaert L, Chamberlain D. Multicenter, randomized, controlled trial of 150-J biphasic shocks compared with 200- to 360-J monophasic shocks in the resuscitation of out-of-hospital cardiac arrest victims. Circulation. 2000;102:1780–1787. 25. Hess EP, White RD. Ventricular fibrillation is not provoked by chest compression during post-shock organized rhythms in out-of-hospital cardiac arrest. Resuscitation 2005;66:7–11. Part 5: Electrical Therapies IV-43