Part 4: Advanced Life Support

HomeCirculationVol. 132, No. 16ₛuppl₁Part 4: Advanced Life Support Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessResearch ArticlePDF/EPUBPart 4: Advanced Life Support2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Clifton W. Callaway, Jasmeet Soar, Mayuki Aibiki, Bernd W. Böttiger, Steven C. Brooks, Charles D. Deakin, Michael W. Donnino, Saul Drajer, Walter Kloeck, Peter T. Morley, Laurie J. Morrison, Robert W. Neumar, Tonia C. Nicholson, Jerry P. Nolan, Kazuo Okada, Brian J. O'Neil, Edison F. Paiva, Michael J. Parr, Tzong-Luen Wang and Jonathan Witt Clifton W. CallawayClifton W. Callaway, Jasmeet SoarJasmeet Soar, Mayuki AibikiMayuki Aibiki, Bernd W. BöttigerBernd W. Böttiger, Steven C. BrooksSteven C. Brooks, Charles D. DeakinCharles D. Deakin, Michael W. DonninoMichael W. Donnino, Saul DrajerSaul Drajer, Walter KloeckWalter Kloeck, Peter T. MorleyPeter T. Morley, Laurie J. MorrisonLaurie J. Morrison, Robert W. NeumarRobert W. Neumar, Tonia C. NicholsonTonia C. Nicholson, Jerry P. NolanJerry P. Nolan, Kazuo OkadaKazuo Okada, Brian J. O'NeilBrian J. O'Neil, Edison F. PaivaEdison F. Paiva, Michael J. ParrMichael J. Parr, Tzong-Luen WangTzong-Luen Wang and Jonathan WittJonathan Witt and on behalf of the Advanced Life Support Chapter Collaborators Originally published20 Oct 2015https: //doi. org/10. 1161/CIR. 0000000000000273Circulation. 2015;132: S84–S145IntroductionThe International Liaison Committee on Resuscitation (ILCOR) Advanced Life Support (ALS) Task Force performed detailed systematic reviews based on the recommendations of the Institute of Medicine of the National Academies1 and using the methodological approach proposed by the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) Working Group. 2 Questions to be addressed (using the PICO population, intervention, comparator, outcome format) 3 were prioritized by ALS Task Force members (by voting). Prioritization criteria included awareness of significant new data and new controversies or questions about practice. Questions about topics no longer relevant to contemporary practice or where little new research has occurred were given lower priority. The ALS Task Force prioritized 42 PICO questions for review. With the assistance of information specialists, a detailed search for relevant articles was performed in each of 3 online databases (PubMed, Embase, and the Cochrane Library). By using detailed inclusion and exclusion criteria, articles were screened for further evaluation. The reviewers for each question created a reconciled risk of bias assessment for each of the included studies, using state-of-the-art tools: Cochrane for randomized controlled trials (RCTs), 4 Quality Assessment of Diagnostic Accuracy Studies (QUADAS) -2 for studies of diagnostic accuracy, 5 and GRADE for observational studies that inform both therapy and prognosis questions. 6GRADE evidence profile tables7 were then created to facilitate an evaluation of the evidence in support of each of the critical and important outcomes. The quality of the evidence (or confidence in the estimate of the effect) was categorized as high, moderate, low, or very low, 8 based on the study methodologies and the 5 core GRADE domains of risk of bias, inconsistency, indirectness, imprecision, and other considerations (including publication bias). 9These evidence profile tables were then used to create a written summary of evidence for each outcome (the consensus on science statements). Whenever possible, consensus-based treatment recommendations were then created. These recommendations (designated as strong or weak) were accompanied by an overall assessment of the evidence and a statement from the task force about the values, preferences, and task force insights that underlie the recommendations. Further details of the methodology that underpinned the evidence evaluation process are found in "Part 2: Evidence Evaluation and Management of Conflicts of Interest. "The task force preselected and ranked outcome measures that were used as consistently as possible for all PICO questions. Longer-term, patient-centered outcomes were considered more important than process variables and shorter-term outcomes. For most questions, we used the following hierarchy starting with the most important: long-term survival with neurologically favorable survival, long-term survival, short-term survival, and process variable. In general, long-term was defined as from hospital discharge to 180 days or longer, and short-term was defined as shorter than to hospital discharge. For certain questions (eg, related to defibrillation or confirmation of tracheal tube position), process variables such as termination of fibrillation and correct tube placement were important. A few questions (eg, organ donation) required unique outcomes. The International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations (CoSTR) statements in this Part are organized in the approximate sequence of interventions for a patient: defibrillation, airway, oxygenation and ventilation, circulatory support, monitoring during cardiopulmonary resuscitation (CPR), drugs during CPR, and special circumstances. We also include statements for postresuscitation care, prognostication of neurologic outcome, and organ donation. Defibrillation Strategies for Ventricular Fibrillation (VF) or Pulseless Ventricular Tachycardia (pVT) Biphasic waveform (ALS 470) Pulsed biphasic waveform (ALS 470) First-shock energy (ALS 470) Single shock versus stacked shocks (ALS 470) Fixed versus escalating defibrillation energy levels (ALS 470) Recurrent VF (ALS 470) Airway, Oxygenation, and VentilationOxygen dose during CPR (ALS 889) Basic versus advanced airway (ALS 783) Supraglottic airways (SGAs) versus tracheal intubation (ALS 714) Confirmation of correct tracheal tube placement (ALS 469) Ventilation rate during continuous chest compressions (ALS 808) Circulatory Support During CPRImpedance threshold device (ITD) (ALS 579) Mechanical CPR devices (ALS 782) Extracorporeal CPR (ECPR) versus manual or mechanical CPR (ALS 723) Physiological Monitoring During CPREnd-tidal carbon dioxide (ETCO2) to predict outcome of cardiac arrest (ALS 459) Monitoring physiological parameters during CPR (ALS 656) Ultrasound during CPR (ALS 658) Drugs During CPREpinephrine versus placebo (ALS 788) Epinephrine versus vasopressin (ALS 659) Epinephrine versus vasopressin in combination with epinephrine (ALS 789) Standard-dose epinephrine (SDE) versus high-dose epinephrine (HDE) (ALS 778) Timing of administration of epinephrine (ALS 784) Steroids for cardiac arrest (ALS 433) Antiarrhythmic drugs for cardiac arrest (ALS 428) Cardiac Arrest in Special CircumstancesCardiac arrest during pregnancy (ALS 436) Lipid therapy for cardiac arrest (ALS 834) Opioid toxicity (ALS 441) Cardiac arrest associated with pulmonary embolism (PE) (ALS 435) Cardiac arrest during coronary catheterization (ALS 479) Postresuscitation CareOxygen dose after return of spontaneous circulation (ROSC) in adults (ALS 448) Postresuscitation ventilation strategy (ALS 571) Postresuscitation hemodynamic support (ALS 570) Postresuscitation antiarrhythmic drugs (ALS 493) Targeted temperature management (ALS 790) Timing of induced hypothermia (ALS 802) Prevention of fever after cardiac arrest (ALS 879) Postresuscitation seizure prophylaxis (ALS 431) Seizure treatment (ALS 868) Glucose control after resuscitation (ALS 580) Prognostication in comatose patients treated with hypothermic targeted temperature management (TTM) (ALS 450) Prognostication in the absence of TTM (ALS 713) Organ donation (ALS 449) The 2010 CoSTR statements10, 11 that have not been addressed in 2015 are listed under the relevant section. Summary of ALS Treatment RecommendationsThe systematic reviews showed that the quality of evidence for many ALS interventions is low or very low, and this led to predominantly weak recommendations. For some issues, despite a low quality of evidence, the values and preferences of the task force led to a strong recommendation. This was especially so when there was consensus that not doing so could lead to harm. In addition, treatment recommendations were left unchanged unless there were compelling reasons not to do so. The rationale for any change is addressed in the values, preferences, and insights that follow treatment recommendations. The most important developments and recommendations in ALS since the 2010 ILCOR review are as follows: Defibrillation strategies for VF or pVT: There were no major developments since 2010. We suggest if the first shock is not successful and the defibrillator is capable of delivering shocks of higher energy, it is reasonable to increase the energy for subsequent shocks. Airway, oxygenation, and ventilation: We suggest using the highest possible inspired oxygen concentration during CPR. There was equipoise between the choice of an advanced airway or a bag-mask device for airway management during CPR, and the choice between a SGA or tracheal tube as the initial advanced airway during CPR. The role of waveform capnography during ALS was emphasized, including its use to confirm and to continuously monitor the position of a tracheal tube during CPR. Circulatory support during CPR: We recommend against the routine use of the ITD in addition to conventional CPR but could not achieve consensus for or against the use of the ITD when used together with active compression-decompression (ACD) CPR. We suggest against the routine use of automated mechanical chest compression devices but suggest they are a reasonable alternative to use in situations where sustained high-quality manual chest compressions are impractical or compromise provider safety. We suggest ECPR is a reasonable rescue therapy for select patients with cardiac arrest when initial conventional CPR is failing in settings where this can be implemented. Physiological monitoring during CPR: Physiological measurement in addition to clinical signs and electrocardiographic monitoring has the potential to help guide interventions during ALS. We have not made a recommendation for any particular physiological measure to guide CPR, because the available evidence would make any estimate of effect speculative. We recommend against using ETCO2 cutoff values alone as a mortality predictor or for the decision to stop a resuscitation attempt. We suggest that if cardiac ultrasound can be performed without interfering with standard advanced cardiovascular life support (ACLS) protocol, it may be considered as an additional diagnostic tool to identify potentially reversible causes. Drugs during CPR: We suggest SDE (defined as 1 mg) be administered to patients in cardiac arrest after considering the observed benefit in short-term outcomes (ROSC and admission to hospital) and our uncertainty about the benefit or harm on survival to discharge and neurologic outcome. Our statement is not intended to change current practice until there are high-quality data on long-term outcomes. We suggest the use of amiodarone in adult patients with refractory VF/pVT to improve rates of ROSC. Our statement is not intended to change current practice until there are high-quality data on long-term outcomes. Cardiac arrest in special circumstances: The systematic review found very-low-quality evidence for specific interventions for ALS in the pregnant woman. We suggest delivery of the fetus by perimortem cesarean delivery for women in cardiac arrest in the second half of pregnancy. The lack of comparative studies led to the task force being unable to make any evidence-based treatment recommendation about the use of intravenous (IV) lipid emulsion to treat toxin-induced cardiac arrest. We recommend the use of naloxone by IV, intramuscular, subcutaneous, intraosseous (IO), or intranasal routes in respiratory arrest associated with opioid toxicity but make no recommendation regarding the modification of standard ALS in opioid-induced cardiac arrest. Postresuscitation care: We recommend avoiding hypoxia in adults with ROSC after cardiac arrest. We suggest avoiding hyperoxia in adults with ROSC after cardiac arrest. We suggest the use of 100% inspired oxygen until the arterial oxygen saturation or the partial pressure of arterial oxygen can be measured reliably in adults with ROSC after cardiac arrest. We suggest maintaining Paco2 within a normal physiological range as part of a post-ROSC bundle of care. We suggest hemodynamic goals (eg, mean arterial pressure MAP, systolic blood pressure SBP) be considered during postresuscitation care and as part of any bundle of postresuscitation interventions. We recommend selecting and maintaining a constant target temperature between 32°C and 36°C for those patients in whom temperature control is used. We recommend TTM as opposed to no TTM for adults with out-of-hospital cardiac arrest (OHCA) with an initial shockable rhythm who remain unresponsive after ROSC. We suggest TTM as opposed to no TTM for adults with OHCA with an initial nonshockable rhythm who remain unresponsive after ROSC. We suggest TTM as opposed to no TTM for adults with in-hospital cardiac arrest (IHCA) with any initial rhythm who remain unresponsive after ROSC. We suggest that if TTM is used, duration should be at least 24 hours. We recommend against routine use of prehospital cooling with rapid infusion of large volumes of cold IV fluid immediately after ROSC. We suggest prevention and treatment of fever in persistently comatose adults after completion of TTM between 32°C and 36°C. We suggest against routine seizure prophylaxis in post–cardiac arrest patients. We recommend the treatment of seizures in post–cardiac arrest patients. We suggest no modification of standard glucose management protocols for adults with ROSC after cardiac arrest. Comatose patients treated with TTM: We suggest against the use of clinical criteria alone before 72 hours after ROSC to estimate prognosis. We suggest prolonging the observation of clinical signs when interference from residual sedation or paralysis is suspected, so that the possibility of incorrectly predicting poor outcome is minimized. We recommend that the earliest time to prognosticate a poor neurologic outcome is 72 hours after ROSC, and should be extended longer if the residual effect of sedation and/or paralysis confounds the clinical examination. We suggest that multiple modalities of testing (clinical exam, neurophysiological measures, imaging, or blood markers) be used to estimate prognosis instead of relying on single tests or findings. We recommend that all patients who have restoration of circulation after CPR and who subsequently progress to death be evaluated for organ donation. Defibrillation Strategies for VF or pVTThe task force restricted its review to new studies since the 2010 CoSTR12, 13 and topics not reviewed in 2010. There are no major differences between the recommendations made in 2015 and those made in 2010. The PICO questions have been grouped into (1) waveforms, (2) first-shock energy, (3) single shock versus 3 shocks, (4) fixed versus escalating energy levels, and (5) refibrillation. In reviewing these, shock success is usually defined as termination of VF 5 seconds after the shock. Consensus on science and treatment recommendations for the use of automated external defibrillators can be found in "Part 3: Adult Basic Life Support and Automated External Defibrillation, " and for infants or children requiring defibrillation in "Part 6: Pediatric Basic Life Support and Pediatric Advanced Life Support. "Biphasic Waveform (ALS 470) Among adults who are in VF or pVT in any setting (P), does any specific defibrillation strategy, such as biphasic waveform (I), compared with standard management (or other defibrillation strategy), such as monophasic waveform (C), change survival with favorable neurologic/functional outcome at discharge, 30 days, 60 days, 180 days, and/or 1 year; survival only at discharge, 30 days, 60 days, 180 days, and/or 1 year; ROSC; termination of arrhythmia (O)? IntroductionAll newly manufactured defibrillators currently deliver shocks using biphasic waveforms. Although it has not been shown conclusively in randomized clinical studies that biphasic defibrillators save more lives than monophasic defibrillators, biphasic defibrillators achieve higher first-shock success rates at lower energy levels and appear to cause less postshock myocardial dysfunction. 12, 13Consensus on ScienceNo new randomized trials of biphasic waveforms since 2010 were identified. Treatment RecommendationWe recommend that a biphasic waveform (biphasic truncated exponential BTE or rectilinear-biphasic RLB) is used for both atrial and ventricular arrhythmias in preference to a monophasic waveform (strong recommendation, very-low-quality evidence). In the absence of biphasic defibrillators, monophasic defibrillators are acceptable. Values, Preferences, and Task Force InsightsIn making this strong recommendation, we place a high value on the reported higher first-shock success rate for termination of fibrillation with a biphasic waveform, the potential for less postshock myocardial dysfunction, and the existing 2010 CoSTR. 12, 13 The task force acknowledges that many emergency medical services (EMS) systems and hospitals around the world continue to use older monophasic devices. Pulsed Biphasic Waveform (ALS 470) Among adults who are in VF or pVT in any setting (P), does any specific defibrillation strategy, such as pulsed biphasic waveform (I), compared with standard management (or other defibrillation strategy) (C), change survival with favorable neurologic/functional outcome at discharge, 30 days, 60 days, 180 days, and/or 1 year; survival only at discharge, 30 days, 60 days, 180 days, and/or 1 year; ROSC; termination of arrhythmia (O)? IntroductionThe pulsed biphasic waveform that is used in clinical practice had not previously been reviewed in 2010. The single published study14 of this waveform used a non–impedance compensated waveform (ie, the current delivered is not adjusted for the impedance of the chest), whereas the waveform in clinical use is an impedance-compensated waveform (ie, the current delivered is adjusted for the impedance of the chest). Consensus on ScienceFor the critical outcome of survival to hospital discharge, very-low-quality evidence (downgraded for very serious risk of bias and serious indirectness) from 1 cohort study (ie, no control group) 14 with a total of 104 patients that used a 130 J-130 J-180 J pulsed biphasic waveform protocol documented a survival rate of 9. 8%. This compares with a weighted average BTE survival rate of 33. 1% at 150 to the important outcome of termination of the very-low-quality evidence (downgraded for very serious risk of bias and serious indirectness) from 1 cohort study14 with a total of 104 patients documented first-shock termination rates at 130 J of with a pulsed biphasic waveform, with BTE waveforms average at 150 to RecommendationWe recommend following the for first and subsequent shock energy levels for the pulsed biphasic waveform (strong recommendation, very-low-quality Preferences, and Task Force InsightsIn making this strong recommendation, we have a high value on following the in the absence of high-quality data to suggest The available very-low-quality data the of a non–impedance compensated pulsed biphasic waveform do not with other biphasic waveforms. In addition, no clinical studies to the of this waveform in its current impedance-compensated (ALS 470) Among adults who are in VF or pVT in any setting (P), does any specific defibrillation strategy, such as specific first-shock energy (I), compared with standard management (or other defibrillation strategy), such as a first-shock energy (C), change survival with favorable neurologic/functional outcome at discharge, 30 days, 60 days, 180 days, and/or 1 year; survival only at discharge, 30 days, 60 days, 180 days, and/or 1 year; ROSC; termination of arrhythmia it was that it was reasonable to at a energy of 150 to J for a BTE waveform, and no lower than J for an waveform for defibrillation of VF/pVT cardiac that the evidence was on ScienceFor the important outcome of termination of evidence (downgraded for and risk of bias, from a from an and a cohort study showed a first-shock success rate of of and of when using a J initial shock with an recommend an initial biphasic shock energy of 150 J or for BTE waveforms, and J or for waveforms (strong recommendation, very-low-quality evidence). a monophasic defibrillator is used, we recommend an initial monophasic shock energy of J (strong recommendation, very-low-quality Preferences, and Task Force InsightsIn making strong the was to and that evidence for the first-shock energy was We also considered that monophasic defibrillators are no longer they are used in many (ALS 470) Among adults who are in VF or pVT in any setting (P), does any specific defibrillation strategy, such as a single shock (I), compared with standard management (or other defibrillation strategy), such as 3 stacked shocks (C), change survival with favorable neurologic/functional outcome at discharge, 30 days, 60 days, 180 days, and/or 1 year; survival only at discharge, 30 days, 60 days, 180 days, and/or 1 year; ROSC; termination of arrhythmia it was that when defibrillation was a single shock should be with of chest compressions after the This recommendation was made for (1) in an to to chest and (2) because it was that with the of biphasic shocks, if a biphasic shock to a further of chest compressions could be was that there was no clinical evidence to support outcomes from this on ScienceFor the critical outcome of survival to 1 we have evidence (downgraded for serious risk of bias and serious indirectness) from 1 OHCA patients no in single versus 3 stacked shocks confidence the critical outcome of survival to hospital discharge, we have evidence (downgraded for serious risk of bias and serious indirectness) from 1 OHCA patients no in single versus 3 stacked shocks the critical outcome of survival to hospital we have very-low-quality evidence (downgraded for serious risk of bias and serious indirectness) from 1 OHCA patients no in single versus 3 stacked shocks the critical outcome of ROSC, we have evidence (downgraded for serious risk of bias and serious indirectness) from 1 OHCA patients no in single versus 3 stacked shocks the important outcome of of VF we have evidence (downgraded for serious risk of bias, serious indirectness, and serious from 1 OHCA patients no in single versus 3 stacked shocks RecommendationWe recommend a strategy when defibrillation is required (strong recommendation, Preferences, and Task Force InsightsIn making this strong recommendation, the task force has a value on not current practice and in chest compressions that studies since 2010 have not shown that any specific shock strategy is of benefit for any survival There is no evidence that a strategy is of benefit for ROSC or of VF compared with 3 stacked shocks, but in of the evidence that outcome is by to chest we continue to recommend single The task force is that there are some (eg, VF cardiac arrest with defibrillator immediately when 3 rapid stacked shocks could be (ALS 470) Among adults who are in VF or pVT in any setting (P), does any specific defibrillation strategy, such as fixed shock energy (I), compared with standard management (or other defibrillation strategy), such as escalating shock energy (C), change survival with favorable neurologic/functional outcome at discharge, 30 days, 60 days, 180 days, and/or 1 year; survival only at discharge, 30 days, 60 days, 180 days, and/or 1 year; ROSC; termination of arrhythmia we that for second and subsequent biphasic shocks, the initial energy was but that it was reasonable to increase the energy when possible (ie, with manual on ScienceFor the critical outcome of survival with favorable neurologic outcome at hospital discharge, we very-low-quality evidence (downgraded for serious risk of bias, serious imprecision, and serious indirectness) from 1 OHCA patients no benefit of strategy the other the critical outcome of survival to hospital discharge, we have very-low-quality evidence (downgraded for serious risk of bias, serious imprecision, and serious indirectness) from 1 OHCA patients no benefit of strategy the other the critical outcome of ROSC, we have very-low-quality evidence (downgraded for serious risk of bias, serious imprecision, and serious indirectness) from 1 OHCA patients no benefit of strategy the other RecommendationWe suggest if the first shock is not successful and the defibrillator is capable of delivering shocks of higher energy, it is reasonable to increase the energy for subsequent shocks recommendation, very-low-quality Preferences, and Task Force InsightsIn making this recommendation, we have considered that an escalating shock energy may the risk of ALS We also this to be in with current where shock energy if initial defibrillation and the defibrillator is capable of delivering a higher shock VF (ALS 470) Among adults who are in VF or pVT in any setting (P), does any specific defibrillation strategy (I), compared with standard management (or other defibrillation strategy) (C), improve termination of is and in the of patients after initial first-shock termination of was not addressed in 2010 from refractory defined as fibrillation that after 1 or more shocks, of fibrillation is usually defined as of VF during a documented cardiac after initial termination of VF the under the care of the on ScienceFor the important outcome of termination of evidence (downgraded for serious risk of from observational with a total of of initial fibrillation showed termination rates of subsequent were unchanged when using fixed or 150 J shocks, and observational (downgraded for with a total of of initial fibrillation showed termination rates of when using J shocks, unless an energy was RecommendationWe suggest an escalating defibrillation energy protocol to recommendation, Preferences, and Task Force InsightsIn making this weak recommendation, we considered the lack of studies myocardial from biphasic waveforms, making it reasonable to defibrillation energy levels when delivering shocks for if the energy dose delivered by the defibrillator can be is from current studies of VF are more to defibrillation and a higher energy or a fixed energy is that defibrillation is of the few