IV-6 Circulation December 13. 2005 There is insufficient evidence to recommend for or against arrest, and the results of 4 animal studies (loe 623-126 were the routine use of fibrinolysis for cardiac arrest. It may be neutral. There is insufficient evidence to recommend routine considered on a case-by-case basis when pulmonary embolus administration of fluids to treat cardiac arrest(Class Indeter is suspected( Class Ila). Ongoing CPR is not a contraindica minate). Fluids should be infused if hypovolemia is tion to fibrinolysis. Interventions Not Supported by Summary Outcome evidence Ideally ACLS providers will prevent pulseless arrest if they Pacing in Arrest are able to intervene in the prearrest period. If arrest occurs, Several randomized controlled trials(LOE 2)99-101 failed good ACLS begins with high-quality BLS. During resuscita- show benefit from attempted pacing for asystole. At this time tion rescuers must provide good chest compressions(ade use of pacing for patients with asystolic cardiac arrest is not quate rate and depth), allow complete recoil of the chest between compressions, and minimize interruptions in chest compressions. Rescuers should be careful to avoid provision Procainamide in VF and Pulseless vt of excessive ventilation, particularly once an advanced ai Use of procainamide in cardiac arrest is supported by 1 way is in place. Resuscitation drugs have not been shown to retrospective comparison study of 20 patients. o2Administra- increase rate of survival to hospital discharge, and none has tion of procainamide in cardiac arrest is limited by the nee the impact of early and effective CPR and prompt for slow infusion and by uncertain efficacy in emergent defibrillation. References Norepinephrine I. Barsan WG. Levy RC. Weir H. Lidocaine levels during CPR: differences Norepinephrine has been studied in only a limited fashion for ater p mph., sentral venous, and intracardiac injections. treatment of cardiac arrest. human data is limited. but it 2. Kuhn G, White BC, Swetnam RE. Mumey JF, Rydesky MF, Tintinalli JE, suggests that norepinephrine produces effects equivalent epinephrine in the initial resuscitation of cardiac arrest. 53.10 3. Emerman CL, Pinchak AC, Hancock D. Hagen JF. Effect of injection site In the only prospective human trial comparing standard-dose epinephrine, high-dose epinephrine, and high-dose norepi- 4. Banerjee S, Singhi SC, Singh S, Singh M. The intraosseous route is a nephrine, the norepinephrine was associated with no benefit editor.1994:31:1511-1520 and a trend toward worse neurologic outcome (LOe 1).53 5. Brickman KR, Krupp K, Rega P, Alexander J, Guinness M. Typing and reening of blood from intraosseous access. Ann Emerg Med. 1992: 2 Precordial Thump for VF or Pulseless VT 6. Fiser RT, Walker WM, Seibert J, McCarthy R, Fiser DH. Tibial length There are no prospective studies that evaluated the use of 1997: 13: 186-188ospective, radiographic analysi precordial(chest) thump. In 3 case series(LOE 5), 04-06 VF 7. Ummenhofer w, Frei F, Urwyler A, Drewe J. Are laboratory values in or pulseless VT was converted to a perfusing rhythm by a editable for venous blood in paediatric patients? precordial thump. In contrast, other case series documented 8. Glaeser Pw, Hellmich TR, Szewczuga D, Losek JD, Smith DS Five-yea deterioration in cardiac rhythm, such as rate acceleration of 19-1124 VT, conversion of VT to VF, or development of complete heart block or asystole following the use of the thump (lOe Pediatr Surg. 1993: 28: 158-161 Phillips K, Pollack C Jr, Robinson DJ, Rumball C, Stair T. Tiffan The precordial thump is not recommended for BLS pro viders. In light of the limited evidence in support of its 11.EI H efficacy and reports of potential harm, no recommendation reterm and full term neonates. Arch Dis Child Fetal Neonatal Ed. 1999 80:F74-F75. can be made for or against its use by AClS providers(Class 12. Howard RF, Bingham RM. Endotrack mpared with intravenous 13. Lee PL, Chung YT, Lee BY, Yeh CY, Lin SY, Chao CC. Th the endotracheal route. Ma zui xue Za Zhi. 1989- 27:35-38 14. Prengel Aw. Lindner KH, Hahnel J. Ahn Electrolyte Therapies in Arrest Rhythms ma lidocaine cos eldt KK. Endobronchial application of In-hospital and out-of-hospital studies in adult cardiac arrest of hospital cardiopulmon Resuscitation. 2000: 47 (LOE 23-16: LOE 37; LOE 78)and animal studies ( lOe 6)119-l22 showed no increase in the rate of RoSC when ne in patients with severe cardiac disease. magnesium was routinely given during CPR. Administration Ann Intern Med. 2000: 132: 800-80 of magnesium can be considered for treatment of torsades de pointes( Class Ila-see above), but it is not effective for treatment of cardiac arrest from other causes 18. Brown LK. Diamond J. The ue to coronary art neal vs intravenous use. Proc West Routine Administration of Iv Fluids During endotracheal epinephrin Cardiac arrest of routine luin published human studies evaluating the effect 20. Wenzel V, Lindner KH, Prengel AW, Lurie KG, Strohmenger HU Endo- There were administration during normovolemic cardiac ation in pigs. Anesthesiology. 1997; 86: 1375-138There is insufficient evidence to recommend for or against the routine use of fibrinolysis for cardiac arrest. It may be considered on a case-by-case basis when pulmonary embolus is suspected (Class IIa). Ongoing CPR is not a contraindica￾tion to fibrinolysis. Interventions Not Supported by Outcome Evidence Pacing in Arrest Several randomized controlled trials (LOE 2)99–101 failed to show benefit from attempted pacing for asystole. At this time use of pacing for patients with asystolic cardiac arrest is not recommended. Procainamide in VF and Pulseless VT Use of procainamide in cardiac arrest is supported by 1 retrospective comparison study of 20 patients.102 Administra￾tion of procainamide in cardiac arrest is limited by the need for slow infusion and by uncertain efficacy in emergent circumstances. Norepinephrine Norepinephrine has been studied in only a limited fashion for treatment of cardiac arrest. Human data is limited, but it suggests that norepinephrine produces effects equivalent to epinephrine in the initial resuscitation of cardiac arrest.53,103 In the only prospective human trial comparing standard-dose epinephrine, high-dose epinephrine, and high-dose norepi￾nephrine, the norepinephrine was associated with no benefit and a trend toward worse neurologic outcome (LOE 1).53 Precordial Thump for VF or Pulseless VT There are no prospective studies that evaluated the use of precordial (chest) thump. In 3 case series (LOE 5),104–106 VF or pulseless VT was converted to a perfusing rhythm by a precordial thump. In contrast, other case series documented deterioration in cardiac rhythm, such as rate acceleration of VT, conversion of VT to VF, or development of complete heart block or asystole following the use of the thump (LOE 5105,107–111; LOE 6112). The precordial thump is not recommended for BLS pro￾viders. In light of the limited evidence in support of its efficacy and reports of potential harm, no recommendation can be made for or against its use by ACLS providers (Class Indeterminate). Electrolyte Therapies in Arrest Rhythms Magnesium In-hospital and out-of-hospital studies in adult cardiac arrest (LOE 2113–116; LOE 3117; LOE 7118) and animal studies (LOE 6)119–122 showed no increase in the rate of ROSC when magnesium was routinely given during CPR. Administration of magnesium can be considered for treatment of torsades de pointes (Class IIa—see above), but it is not effective for treatment of cardiac arrest from other causes. Routine Administration of IV Fluids During Cardiac Arrest There were no published human studies evaluating the effect of routine fluid administration during normovolemic cardiac arrest, and the results of 4 animal studies (LOE 6)123–126 were neutral. There is insufficient evidence to recommend routine administration of fluids to treat cardiac arrest (Class Indeter￾minate). Fluids should be infused if hypovolemia is suspected. Summary Ideally ACLS providers will prevent pulseless arrest if they are able to intervene in the prearrest period. If arrest occurs, good ACLS begins with high-quality BLS. During resuscita￾tion rescuers must provide good chest compressions (ade￾quate rate and depth), allow complete recoil of the chest between compressions, and minimize interruptions in chest compressions. Rescuers should be careful to avoid provision of excessive ventilation, particularly once an advanced air￾way is in place. Resuscitation drugs have not been shown to increase rate of survival to hospital discharge, and none has the impact of early and effective CPR and prompt defibrillation. References 1. Barsan WG, Levy RC, Weir H. Lidocaine levels during CPR: differences after peripheral venous, central venous, and intracardiac injections. Ann Emerg Med. 1981;10:73–78. 2. Kuhn GJ, White BC, Swetnam RE, Mumey JF, Rydesky MF, Tintinalli JE, Krome RL, Hoehner PJ. Peripheral vs central circulation times during CPR: a pilot study. Ann Emerg Med. 1981;10:417–419. 3. Emerman CL, Pinchak AC, Hancock D, Hagen JF. Effect of injection site on circulation times during cardiac arrest. Crit Care Med. 1988;16: 1138–1141. 4. Banerjee S, Singhi SC, Singh S, Singh M. The intraosseous route is a suitable alternative to intravenous route for fluid resuscitation in severely dehydrated children. Indian Pediatr. 1994;31:1511–1520. 5. Brickman KR, Krupp K, Rega P, Alexander J, Guinness M. Typing and screening of blood from intraosseous access. Ann Emerg Med. 1992;21: 414–417. 6. Fiser RT, Walker WM, Seibert JJ, McCarthy R, Fiser DH. Tibial length following intraosseous infusion: a prospective, radiographic analysis. Pediatr Emerg Care. 1997;13:186–188. 7. Ummenhofer W, Frei FJ, Urwyler A, Drewe J. Are laboratory values in bone marrow aspirate predictable for venous blood in paediatric patients? Resuscitation. 1994;27:123–128. 8. Glaeser PW, Hellmich TR, Szewczuga D, Losek JD, Smith DS. Five-year experience in prehospital intraosseous infusions in children and adults. Ann Emerg Med. 1993;22:1119–1124. 9. Guy J, Haley K, Zuspan SJ. Use of intraosseous infusion in the pediatric trauma patient. J Pediatr Surg. 1993;28:158–161. 10. Macnab A, Christenson J, Findlay J, Horwood B, Johnson D, Jones L, Phillips K, Pollack C Jr, Robinson DJ, Rumball C, Stair T, Tiffany B, Whelan M. A new system for sternal intraosseous infusion in adults. Prehosp Emerg Care. 2000;4:173–177. 11. Ellemunter H, Simma B, Trawoger R, Maurer H. Intraosseous lines in preterm and full term neonates. Arch Dis Child Fetal Neonatal Ed. 1999; 80:F74–F75. 12. Howard RF, Bingham RM. Endotracheal compared with intravenous administration of atropine. Arch Dis Child. 1990;65:449–450. 13. Lee PL, Chung YT, Lee BY, Yeh CY, Lin SY, Chao CC. The optimal dose of atropine via the endotracheal route. Ma Zui Xue Za Zhi. 1989;27:35–38. 14. Prengel AW, Lindner KH, Hahnel J, Ahnefeld FW. Endotracheal and endobronchial lidocaine administration: effects on plasma lidocaine con￾centration and blood gases. Crit Care Med. 1991;19:911–915. 15. Schmidbauer S, Kneifel HA, Hallfeldt KK. Endobronchial application of high dose epinephrine in out of hospital cardiopulmonary resuscitation. Resuscitation. 2000;47:89. 16. Raymondos K, Panning B, Leuwer M, Brechelt G, Korte T, Niehaus M, Tebbenjohanns J, Piepenbrock S. Absorption and hemodynamic effects of airway administration of adrenaline in patients with severe cardiac disease. Ann Intern Med. 2000;132:800–803. 17. Hahnel JH, Lindner KH, Schurmann C, Prengel A, Ahnefeld FW. Plasma lidocaine levels and PaO2 with endobronchial administration: dilution with normal saline or distilled water? Ann Emerg Med. 1990;19:1314–1317. 18. Brown LK, Diamond J. The efficacy of lidocaine in ventricular fibrillation due to coronary artery ligation: endotracheal vs intravenous use. Proc West Pharmacol Soc. 1982;25:43–45. 19. Jasani MS, Nadkarni VM, Finkelstein MS, Hofmann WT, Salzman SK. Inspiratory-cycle instillation of endotracheal epinephrine in porcine arrest. Acad Emerg Med. 1994;1:340–345. 20. Wenzel V, Lindner KH, Prengel AW, Lurie KG, Strohmenger HU. Endo￾bronchial vasopressin improves survival during cardiopulmonary resusci￾tation in pigs. Anesthesiology. 1997;86:1375–1381. IV-64 Circulation December 13, 2005