Part 7.2: Management of Cardiac Arrest F rhythms produce pulseless cardiac arrest: ventricular effective for fluid resuscitation, drug delivery, and blood fibrillation (VF), rapid ventricular tachycardia (VT), sampling for laboratory evaluation, and is attainable in all age useless electrical activity(PEA), and asystole. Surviva groups. Providers may establish I0 access if IV access is from these arrest rhythms requires both basic life support unavailable( Class IIa). Commercially available kits can (BLS) and advanced cardiovascular life support(ACLS) facilitate IO access in adults The foundation of ACLS care is good BLS care, beginning If spontaneous circulation does not return after defibrilla with prompt high-quality bystander CPR and, for VE/pulse- tion and peripheral venous or I0 drug administration, the less VT, attempted defibrillation within minutes of collapse. provider may consider placement of a central line(unless For victims of witnessed VF arrest, prompt bystander CPr there are contraindications ). Note that central venous cathe and early defibrillation can significantly increase the chance terization is a relative (not absolute) contraindication for for survival to hospital discharge. In comparison, typical fibrinolytic therapy in patients with stroke or acute coronary ACLS therapies, such as insertion of advanced airways and syndromes of the circulation have not be If iv and io access cannot be established. some resusci- shown to increase rate of survival to hospital discharge. This tation drugs may be administered by the endotracheal route section details the general care of a patient in cardiac arrest One study in children(LOE 2), 2 5 studies in adults(LOE and provides an overview of the ACLs Pulseless Arrest 213-15; LOE 316.1), as well as multiple animal studies(LOE 6), 8-20 showed that lidocaine, 14,2I epinephrine, 2 atropine, 23 naloxone, and vasopressin20 are absorbed via the trachea. Access for Medications: Correct Priorities dministration of resuscitation drugs into the trachea, how- During cardiac arrest, basic CPR and early defibrillation are ever, results in lower blood concentrations than the same dose of primary importance, and drug administration is of second- given intravascularly. Furthermore, recent animal studies24 ary importance. Few drugs used in the treatment of cardiac suggest that the lower epinephrine concentrations achieved arrest are supported by strong evidence. After beginning CPR when the drug is delivered by the endotracheal route may and attempting defibrillation, rescuers can establish intrave- produce transient B-adrenergic effects. These effects can be nous (Tv) access, consider drug therapy, and insert an detrimental, causing hypotension, lower coronary artery per dvanced airway. fusion pressure and flow, and reduced potential for return of Central Versus Peripheral Infusions spontaneous circulation (ROSC). Thus, although Central line access is not needed in most resuscitation cheal administration of some resuscitation drugs is attempts. If IV access has not been established, the provide IV or Io drug administration is preferred because should insert a large peripheral venous catheter. Although in provide more predictable drug delivery and pharmacologic effect adults peak drug concentrations are lower and circulation times longer when drugs are administered via peripheral sites In one nonrandomized cohort study of out-of-hospital cardiac arrest in adults (loe 4)28 using a randomized control rather than central sites, the establishment of peripheral administration of atropine and epinephrine by the IV route access does not require interruption of CPR. .2 Drugs typi cally require I to 2 minutes to reach the central circulation was associated with a higher rate of rosc and survival to when given via a peripheral vein but require less time when hospital admission than administration of the drugs by the endotracheal route. Five percent of those who received Iv given via central venous access. venous route, administer the drug by bolus injection and in the group receiving drugs by the endotracheal roule ved If a resuscitation drug is administered by a peripheral drugs survived to hospital discharge, but no patient survived The optimal endotracheal dose of most drugs is unknown, follow with a 20-mL bolus of IV fluid Elevate the extremity but typically the dose given by the endotracheal route is 2 to for 10 to 20 seconds to facilitate drug delivery to the central irculation 3 21 times the recommended iv dose. In 2 CPR studies th Intraosseous(1O)cannulation provides access to a noncol- equipotent epinephrine dose given endotracheally was ap- lapsible venous plexus, enabling drug delivery similar to that proximately 3 to 10 times higher than the IV dose(LOE 52 achieved by central venous access. Two prospective(LOE 3) LOE 630). Providers should dilute the recommended dose in trials, in children and adults 5 and 6 other studies(LOE 46, 5 to 10 mL of water or normal saline and inject the drug LOE 57: LOE 710.1)documented that IO access is safe and directly into the endotracheal tube. 22 Studies with epineph- rine3I and lidocaine showed that dilution with water instead of 0.9%o saline may achieve better drug absorption (Circulation. 2005: 112: lV-58-IV-66) o 2005 American Heart Associa Arrest rhythms This special supplement to Circulation is freely available at The management of pulseless arrest is highlighted in the http://www.circulationaha.org ACLS Pulseless Arrest Algorithm(Figure). Box numbers in DOI: 10.1161/CIRCULATIONAHA 105. 166557 the text refer to the numbered boxes in the algorithm IV-58Part 7.2: Management of Cardiac Arrest Four rhythms produce pulseless cardiac arrest: ventricular fibrillation (VF), rapid ventricular tachycardia (VT), pulseless electrical activity (PEA), and asystole. Survival from these arrest rhythms requires both basic life support (BLS) and advanced cardiovascular life support (ACLS). The foundation of ACLS care is good BLS care, beginning with prompt high-quality bystander CPR and, for VF/pulse￾less VT, attempted defibrillation within minutes of collapse. For victims of witnessed VF arrest, prompt bystander CPR and early defibrillation can significantly increase the chance for survival to hospital discharge. In comparison, typical ACLS therapies, such as insertion of advanced airways and pharmacologic support of the circulation, have not been shown to increase rate of survival to hospital discharge. This section details the general care of a patient in cardiac arrest and provides an overview of the ACLS Pulseless Arrest Algorithm. Access for Medications: Correct Priorities During cardiac arrest, basic CPR and early defibrillation are of primary importance, and drug administration is of second￾ary importance. Few drugs used in the treatment of cardiac arrest are supported by strong evidence. After beginning CPR and attempting defibrillation, rescuers can establish intrave￾nous (IV) access, consider drug therapy, and insert an advanced airway. Central Versus Peripheral Infusions Central line access is not needed in most resuscitation attempts. If IV access has not been established, the provider should insert a large peripheral venous catheter. Although in adults peak drug concentrations are lower and circulation times longer when drugs are administered via peripheral sites rather than central sites, the establishment of peripheral access does not require interruption of CPR.1,2 Drugs typi￾cally require 1 to 2 minutes to reach the central circulation when given via a peripheral vein but require less time when given via central venous access. If a resuscitation drug is administered by a peripheral venous route, administer the drug by bolus injection and follow with a 20-mL bolus of IV fluid. Elevate the extremity for 10 to 20 seconds to facilitate drug delivery to the central circulation.3 Intraosseous (IO) cannulation provides access to a noncol￾lapsible venous plexus, enabling drug delivery similar to that achieved by central venous access. Two prospective (LOE 3) trials, in children4 and adults,5 and 6 other studies (LOE 46; LOE 57–9; LOE 710,11) documented that IO access is safe and effective for fluid resuscitation, drug delivery, and blood sampling for laboratory evaluation, and is attainable in all age groups. Providers may establish IO access if IV access is unavailable (Class IIa). Commercially available kits can facilitate IO access in adults. If spontaneous circulation does not return after defibrilla￾tion and peripheral venous or IO drug administration, the provider may consider placement of a central line (unless there are contraindications). Note that central venous cathe￾terization is a relative (not absolute) contraindication for fibrinolytic therapy in patients with stroke or acute coronary syndromes. If IV and IO access cannot be established, some resusci￾tation drugs may be administered by the endotracheal route. One study in children (LOE 2),12 5 studies in adults (LOE 213–15; LOE 316,17), as well as multiple animal studies (LOE 6),18–20 showed that lidocaine,14,21 epinephrine,22 atropine,23 naloxone, and vasopressin20 are absorbed via the trachea. Administration of resuscitation drugs into the trachea, how￾ever, results in lower blood concentrations than the same dose given intravascularly. Furthermore, recent animal studies24–27 suggest that the lower epinephrine concentrations achieved when the drug is delivered by the endotracheal route may produce transient
-adrenergic effects. These effects can be detrimental, causing hypotension, lower coronary artery per￾fusion pressure and flow, and reduced potential for return of spontaneous circulation (ROSC). Thus, although endotra￾cheal administration of some resuscitation drugs is possible, IV or IO drug administration is preferred because it will provide more predictable drug delivery and pharmacologic effect. In one nonrandomized cohort study of out-of-hospital cardiac arrest in adults (LOE 4)28 using a randomized control, administration of atropine and epinephrine by the IV route was associated with a higher rate of ROSC and survival to hospital admission than administration of the drugs by the endotracheal route. Five percent of those who received IV drugs survived to hospital discharge, but no patient survived in the group receiving drugs by the endotracheal route. The optimal endotracheal dose of most drugs is unknown, but typically the dose given by the endotracheal route is 2 to 21⁄2 times the recommended IV dose. In 2 CPR studies the equipotent epinephrine dose given endotracheally was ap￾proximately 3 to 10 times higher than the IV dose (LOE 529; LOE 630). Providers should dilute the recommended dose in 5 to 10 mL of water or normal saline and inject the drug directly into the endotracheal tube.22 Studies with epineph￾rine31 and lidocaine17 showed that dilution with water instead of 0.9% saline may achieve better drug absorption. Arrest Rhythms The management of pulseless arrest is highlighted in the ACLS Pulseless Arrest Algorithm (Figure). Box numbers in the text refer to the numbered boxes in the algorithm. (Circulation. 2005;112:IV-58-IV-66.) © 2005 American Heart Association. This special supplement to Circulation is freely available at http://www.circulationaha.org DOI: 10.1161/CIRCULATIONAHA.105.166557 IV-58