part 8

ISSN: 1524-4539 Copyright © 2010 American Heart Association. All rights reserved. Print ISSN: 0009-7322. Online 72514 Circulation is published by the American Heart Association. 7272 Greenville Avenue, Dallas, TX DOI: 10.1161/CIRCULATIONAHA.110.970988 2010;122;S729-S767 Circulation Daniel Davis, Elizabeth Sinz and Laurie J. Morrison Scott M. Silvers, Rod S. Passman, Roger D. White, Erik P. Hess, Wanchun Tang, Shuster, Clifton W. Callaway, Peter J. Kudenchuk, Joseph P. Ornato, Bryan McNally, Robert W. Neumar, Charles W. Otto, Mark S. Link, Steven L. Kronick, Michael Cardiovascular Care Association Guidelines for Cardiopulmonary Resuscitation and Emergency Part 8: Adult Advanced Cardiovascular Life Support: 2010 American Heart http://circ.ahajournals.org/cgi/content/full/122/18_suppl_3/S729 located on the World Wide Web at: The online version of this article, along with updated information and services, is http://www.lww.com/reprints Reprints: Information about reprints can be found online at journalpermissions@lww.com 410-528-8550. E-mail: Fax:Kluwer Health, 351 West Camden Street, Baltimore, MD 21202-2436. Phone: 410-528-4050. Permissions: Permissions & Rights Desk, Lippincott Williams & Wilkins, a division of Wolters http://circ.ahajournals.org/subscriptions/ Subscriptions: Information about subscribing to Circulation is online at by on October 22, 2010 circ.ahajournals.orgDownloaded from Part 8: Adult Advanced Cardiovascular Life Support 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Robert W. Neumar, Chair; Charles W. Otto; Mark S. Link; Steven L. Kronick; Michael Shuster; Clifton W. Callaway; Peter J. Kudenchuk; Joseph P. Ornato; Bryan McNally; Scott M. Silvers; Rod S. Passman; Roger D. White; Erik P. Hess; Wanchun Tang; Daniel Davis; Elizabeth Sinz; Laurie J. Morrison Advanced cardiovascular life support (ACLS) impacts mul-tiple key links in the chain of survival that include interventions to prevent cardiac arrest, treat cardiac arrest, and improve outcomes of patients who achieve return of spontane- ous circulation (ROSC) after cardiac arrest. ACLS interventions aimed at preventing cardiac arrest include airway management, ventilation support, and treatment of bradyarrhythmias and tachyarrhythmias. For the treatment of cardiac arrest, ACLS interventions build on the basic life support (BLS) foundation of immediate recognition and activation of the emergency response system, early CPR, and rapid defibrillation to further increase the likelihood of ROSC with drug therapy, advanced airway man- agement, and physiologic monitoring. Following ROSC, sur- vival and neurologic outcome can be improved with integrated post–cardiac arrest care. Part 8 presents the 2010 Adult ACLS Guidelines: 8.1: “Adjuncts for Airway Control and Ventilation”; 8.2: “Manage- ment of Cardiac Arrest”; and 8.3: “Management of Symptomatic Bradycardia and Tachycardia.” Post–cardiac arrest interventions are addressed in Part 9: “Post–Cardiac Arrest Care.” Key changes from the 2005 ACLS Guidelines include ● Continuous quantitative waveform capnography is rec- ommended for confirmation and monitoring of endotra- cheal tube placement. ● Cardiac arrest algorithms are simplified and redesigned to emphasize the importance of high-quality CPR (in- cluding chest compressions of adequate rate and depth, allowing complete chest recoil after each compression, minimizing interruptions in chest compressions and avoiding excessive ventilation). ● Atropine is no longer recommended for routine use in the management of pulseless electrical activity (PEA)/asystole. ● There is an increased emphasis on physiologic monitoring to optimize CPR quality and detect ROSC. ● Chronotropic drug infusions are recommended as an alter- native to pacing in symptomatic and unstable bradycardia. ● Adenosine is recommended as a safe and potentially effective therapy in the initial management of stable undifferentiated regular monomorphic wide-complex tachycardia. Part 8.1: Adjuncts for Airway Control and Ventilation Overview of Airway Management This section highlights recommendations for the support of ventilation and oxygenation during CPR and the peri-arrest period. The purpose of ventilation during CPR is to maintain adequate oxygenation and sufficient elimination of carbon dioxide. However, research has not identified the optimal tidal volume, respiratory rate, and inspired oxygen concen- tration required during resuscitation from cardiac arrest. Both ventilation and chest compressions are thought to be important for victims of prolonged ventricular fibrillation (VF) cardiac arrest and for all victims with other presenting rhythms. Because both systemic and pulmonary perfusion are substantially reduced during CPR, normal ventilation- perfusion relationships can be maintained with a minute ventilation that is much lower than normal. During CPR with an advanced airway in place, a lower rate of rescue breathing is needed to avoid hyperventilation. Ventilation and Oxygen Administration During CPR During low blood flow states such as CPR, oxygen delivery to the heart and brain is limited by blood flow rather than by arterial oxygen content.1,2 Therefore, rescue breaths are less important than chest compressions during the first few minutes of resus- citation from witnessed VF cardiac arrest and could reduce CPR efficacy due to interruption in chest compressions and the increase in intrathoracic pressure that accompanies positive- pressure ventilation. Thus, during the first few minutes of witnessed cardiac arrest a lone rescuer should not interrupt chest The American Heart Association requests that this document be cited as follows: Neumar RW, Otto CW, Link MS, Kronick SL, Shuster M, Callaway CW, Kudenchuk PJ, Ornato JP, McNally B, Silvers SM, Passman RS, White RD, Hess EP, Tang W, Davis D, Sinz E, Morrison LJ. Part 8: adult advanced cardiovascular life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122(suppl 3):S729–S767. (Circulation. 2010;122[suppl 3]:S729–S767.) © 2010 American Heart Association, Inc. Circulation is available at http://circ.ahajournals.org DOI: 10.1161/CIRCULATIONAHA.110.970988 S729 by on October 22, 2010 circ.ahajournals.orgDownloaded from compressions for ventilation. Advanced airway placement in cardiac arrest should not delay initial CPR and defibrillation for VF cardiac arrest (Class I, LOE C). Oxygen During CPR Oxygen Administration During CPR The optimal inspired oxygen concentration during adult CPR has not been established in human or animal studies. In addition, it is unknown whether 100% inspired oxygen (FIO2�1.0) is beneficial or whether titrated oxygen is better. Although prolonged exposure to 100% inspired oxygen (FIO2�1.0) has potential toxicity, there is insufficient evi- dence to indicate that this occurs during brief periods of adult CPR.3–5 Empirical use of 100% inspired oxygen during CPR optimizes arterial oxyhemoglobin content and in turn oxygen delivery; therefore, use of 100% inspired oxygen (FIO2�1.0) as soon as it becomes available is reasonable during resusci- tation from cardiac arrest (Class IIa, LOE C). Management of oxygen after ROSC is discussed in Part 9: “Post-Cardiac Arrest Care.” Passive Oxygen Delivery During CPR Positive-pressure ventilation has been a mainstay of CPR but recently has come under scrutiny because of the potential for increased intrathoracic pressure to interfere with circulation due to reduced venous return to the heart. In the out-of- hospital setting, passive oxygen delivery via mask with an opened airway during the first 6 minutes of CPR provided by emergency medical services (EMS) personnel was part of a protocol of bundled care interventions (including continuous chest compressions) that resulted in improved survival.6–8 When passive oxygen delivery using a fenestrated tracheal tube (Boussignac tube) during uninterrupted physician- managed CPR was compared with standard CPR, there was no difference in oxygenation, ROSC, or survival to hospital admission.9,10 Chest compressions cause air to be expelled from the chest and oxygen to be drawn into the chest passively due to the elastic recoil of the chest. In theory, because ventilation requirements are lower than normal during cardiac arrest, oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway.2 At this time there is insufficient evidence to support the removal of ventila- tions from CPR performed by ACLS providers. Bag-Mask Ventilation Bag-mask ventilation is an acceptable method of providing ventilation and oxygenation during CPR but is a challenging skill that requires practice for continuing competency. All healthcare providers should be familiar with the use of the bag-mask device.11,12 Use of bag-mask ventilation is not recom- mended for a lone provider. When ventilations are performed by a lone provider, mouth-to-mouth or mouth-to-mask are more efficient. When a second provider is available, bag-mask venti- lation may be used by a trained and experienced provider. But bag-mask ventilation is most effective when performed by 2 trained and experienced providers. One provider opens the airway and seals the mask to the face while the other squeezes the bag. Bag-mask ventilation is particularly helpful when placement of an advanced airway is delayed or unsuccessful. The desirable components of a bag-mask device are listed in Part 5: “Adult Basic Life Support.” The provider should use an adult (1 to 2 L) bag and the provider should deliver approximately 600 mL of tidal volume sufficient to produce chest rise over 1 second.13 This volume of ventilation is adequate for oxygenation and minimizes the risk of gastric inflation. The provider should be sure to open the airway adequately with a head tilt–chin lift, lifting the jaw against the mask and holding the mask against the face, creating a tight seal. During CPR give 2 breaths (each 1 second) during a brief (about 3 to 4 seconds) pause after every 30 chest compressions. Bag-mask ventilation can produce gastric inflation with complications, including regurgitation, aspiration, and pneu- monia. Gastric inflation can elevate the diaphragm, restrict lung movement, and decrease respiratory system compliance.14–16 Airway Adjuncts Cricoid Pressure Cricoid pressure in nonarrest patients may offer some measure of protection to the airway from aspiration and gastric insuffla- tion during bag-mask ventilation.17–20 However, it also may impede ventilation and interfere with placement of a supraglottic airway or intubation.21–27 The role of cricoid pressure during out-of-hospital cardiac arrest and in-hospital cardiac arrest has not been studied. If cricoid pressure is used in special circum- stances during cardiac arrest, the pressure should be adjusted, relaxed, or released if it impedes ventilation or advanced airway placement. The routine use of cricoid pressure in cardiac arrest is not recommended (Class III, LOE C). Oropharyngeal Airways Although studies have not specifically considered the use of oropharyngeal airways in patients with cardiac arrest, airways may aid in the delivery of adequate ventilation with a bag-mask device by preventing the tongue from occluding the airway. Incorrect insertion of an oropharyngeal airway can displace the tongue into the hypopharynx, causing airway obstruction. To facilitate delivery of ventilations with a bag-mask device, oropharyngeal airways can be used in unconscious (unresponsive) patients with no cough or gag reflex and should be inserted only by persons trained in their use (Class IIa, LOE C). Nasopharyngeal Airways Nasopharyngeal airways are useful in patients with airway obstruction or those at risk for developing airway obstruction, particularly when conditions such as a clenched jaw prevent placement of an oral airway. Nasopharyngeal airways are better tolerated than oral airways in patients who are not deeply unconscious. Airway bleeding can occur in up to 30% of patients following insertion of a nasopharyngeal airway.28 Two case reports of inadvertent intracranial placement of a nasopharyngeal airway in patients with basilar skull frac- tures29,30 suggest that nasopharyngeal airways should be used with caution in patients with severe craniofacial injury. As with all adjunctive equipment, safe use of the nasopha- ryngeal airway requires adequate training, practice, and retraining. No studies have specifically examined the use of S730 Circulation November 2, 2010 by on October 22, 2010 circ.ahajournals.orgDownloaded from nasopharyngeal airways in cardiac arrest patients. To facili- tate delivery of ventilations with a bag-mask device, the nasopharyngeal airway can be used in patients with an obstructed airway. In the presence of known or suspected basal skull fracture or severe coagulopathy, an oral airway is preferred (Class IIa, LOE C). Advanced Airways Ventilation with a bag and mask or with a bag through an advanced airway (eg, endotracheal tube or supraglottic air- way) is acceptable during CPR. All healthcare providers should be trained in delivering effective oxygenation and ventilation with a bag and mask. Because there are times when ventilation with a bag-mask device is inadequate, ideally ACLS providers also should be trained and experi- enced in insertion of an advanced airway. Providers must be aware of the risks and benefits of insertion of an advanced airway during a resuscitation at- tempt. Such risks are affected by the patient’s condition and the provider’s expertise in airway control. There are no studies directly addressing the timing of advanced airway placement and outcome during resuscitation from cardiac arrest. Although insertion of an endotracheal tube can be accomplished during ongoing chest compressions, intubation frequently is associated with interruption of compressions for many seconds. Placement of a supraglottic airway is a reasonable alternative to endotracheal intubation and can be done successfully without interrupting chest compressions. The provider should weigh the need for minimally inter- rupted compressions against the need for insertion of an endotracheal tube or supraglottic airway. There is inadequate evidence to define the optimal timing of advanced airway placement in relation to other interventions during resuscita- tion from cardiac arrest. In a registry study of 25 006 in-hospital cardiac arrests, earlier time to invasive airway (�5 minutes) was not associated with improved ROSC but was associated with improved 24-hour survival.31 In an urban out-of-hospital setting, intubation that was achieved in �12 minutes was associated with better survival than intubation achieved in �13 minutes.32 In out-of-hospital urban and rural settings, patients intu- bated during resuscitation had a better survival rate than patients who were not intubated,33 whereas in an in-hospital setting, patients who required intubation during CPR had a worse survival rate.34 A recent study8 found that delayed endotracheal intubation combined with passive oxygen deliv- ery and minimally interrupted chest compressions was asso- ciated with improved neurologically intact survival after out-of-hospital cardiac arrest in patients with adult witnessed VF/pulseless VT. If advanced airway placement will interrupt chest compressions, providers may consider deferring inser- tion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC (Class IIb, LOE C). For a patient with perfusing rhythm who requires intuba- tion, pulse oximetry and electrocardiographic (ECG) status should be monitored continuously during airway placement. Intubation attempts should be interrupted to provide oxygen- ation and ventilation as needed. To use advanced airways effectively, healthcare providers must maintain their knowledge and skills through frequent practice. It may be helpful for providers to master one primary method of airway control. Providers should have a second (backup) strategy for airway management and venti- lation if they are unable to establish the first-choice airway adjunct. Bag-mask ventilation may serve as that backup strategy. Once an advanced airway is inserted, providers should immediately perform a thorough assessment to ensure that it is properly positioned. This assessment should not interrupt chest compressions. Assessment by physical examination consists of visualizing chest expansion bilaterally and listen- ing over the epigastrium (breath sounds should not be heard) and the lung fields bilaterally (breath sounds should be equal and adequate). A device also should be used to confirm correct placement (see the section “Endotracheal Intubation” below). Continuous waveform capnography is recommended in addition to clinical assessment as the most reliable method of confirming and monitoring correct placement of an endotra- cheal tube (Class I, LOE A). Providers should observe a persistent capnographic waveform with ventilation to confirm and monitor endotracheal tube placement in the field, in the transport vehicle, on arrival at the hospital, and after any patient transfer to reduce the risk of unrecognized tube misplacement or displacement. The use of capnography to confirm and monitor correct placement of supraglottic airways has not been studied, and its utility will depend on airway design. However, effective ventilation through a supraglottic airway device should result in a capnograph waveform during CPR and after ROSC. Once an advanced airway is in place, the 2 providers should no longer deliver cycles of CPR (ie, compressions interrupted by pauses for ventilation) unless ventilation is inadequate when compressions are not paused. Instead the compressing provider should give continuous chest compres- sions at a rate of at least 100 per minute, without pauses for ventilation. The provider delivering ventilation should pro- vide 1 breath every 6 to 8 seconds (8 to 10 breaths per minute). Providers should avoid delivering an excessive ventilation rate because doing so can compromise venous return and cardiac output during CPR. The 2 providers should change compressor and ventilator roles approximately every 2 minutes to prevent compressor fatigue and deterioration in quality and rate of chest compressions. When multiple providers are present, they should rotate the compressor role about every 2 minutes. Supraglottic Airways Supraglottic airways are devices designed to maintain an open airway and facilitate ventilation. Unlike endotracheal intubation, intubation with a supraglottic airway does not require visualiza- tion of the glottis, so both initial training and maintenance of skills are easier. Also, because direct visualization is not neces- sary, a supraglottic airway is inserted without interrupting compressions. Supraglottic airways that have been studied in cardiac arrest are the laryngeal mask airway (LMA), the esophageal-tracheal tube (Combitube) and the laryngeal tube Neumar et al Part 8: Adult Advanced Cardiovascular Life Support S731 by on October 22, 2010 circ.ahajournals.orgDownloaded from (Laryngeal Tube or King LT). When prehospital providers are trained in the use of advanced supraglottic airways such as the esophageal-tracheal tube, laryngeal tube, and the laryngeal mask airway, they appear to be able to use these devices safely and can provide ventilation that is as effective as that provided with a bag and mask or an endotracheal tube.12,35–41 Advanced airway interventions are technically compli- cated. Failure can occur; thus maintenance of skills through frequent experience or practice is essential.42 It is important to remem