Emergency Cardiovascular Care Guidelines Research Articles

Applications of capnography in airway management outside the operating room

The capnograph is vital for patient monitoring in the operating room. Its clinical applications for airway management outside the operating room are being increasingly recognized due to its role in the Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Guidelines. Capnography can be used for the detection of respi-ratory depression during procedural sedation, verification after emergency endotracheal tube intubation, assessment of the airway and circulation during cardiopulmonary resuscitation, and continuous monitoring during patient transportation and in intensive care settings. This can be especially beneficial for pediatric patients, those who are critically ill, and patients with a difficult airway.

Part 5: Neonatal Resuscitation: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.

1. Newborn resuscitation requires anticipation and preparation by providers who train individually and as teams. 2. Most newly born infants do not require immediate cord clamping or resuscitation and can be evaluated and monitored during skin-to-skin contact with their mothers after birth. 3. Inflation and ventilation of the lungs are the priority in newly born infants who need support after birth. 4. A rise in heart rate is the most important indicator of effective ventilation and response to resuscitative interventions. 5. Pulse oximetry is used to guide oxygen therapy and meet oxygen saturation goals. 6. Chest compressions are provided if there is a poor heart rate response to ventilation after appropriate ventilation corrective steps, which preferably include endotracheal intubation. 7. The heart rate response to chest compressions and medications should be monitored electrocardiographically. 8. If the response to chest compressions is poor, it may be reasonable to provide epinephrine, preferably via the intravenous route. 9. Failure to respond to epinephrine in a newborn with history or examination consistent with blood loss may require volume expansion. 10. If all these steps of resuscitation are effectively completed and there is no heart rate response by 20 minutes, redirection of care should be discussed with the team and family. It is estimated that approximately 10% of newly born infants need help to begin breathing at birth,1–3 and approximately 1% need intensive resuscitative measures to restore cardiorespiratory function.4,5 The neonatal mortality rate in the United States and Canada has fallen from almost 20 per 1000 live births6,7 in the 1960s to the current rate of approximately 4 per 1000 live births. The inability of newly born infants to establish and sustain adequate or spontaneous respiration contributes significantly to these early deaths and to the burden of adverse neurodevelopmental outcome among survivors. Effective and timely resuscitation …

Risk of bias assessment of randomised controlled trials referenced in the 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care: a cross-sectional review

ObjectivesTo identify the risk of bias of randomised controlled trials (RCTs) referenced in the 2015 American Heart Association (AHA) guidelines update for cardiopulmonary resuscitation (CPR) and emergency cardiovascular care (ECC).DesignA...

380 Risk of Bias Assessment among Randomized Controlled Trials Referenced in the 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care: A Cross-Sectional Review

Randomized controlled trials (RCTs) provide the most reliable evidence of the impact of medical intervention, however bias can invalidate the results of RCTs. This study aimed to identify the risk of bias of randomized controlled trials (RCTs) referenced in the 2015 American Heart Association (AHA) guidelines update for cardiopulmonary resuscitation (CPR) and emergency cardiovascular care (ECC). All RCTs cited as references in the 2015 AHA guidelines update for CPR and ECC were extracted. After excluding non-human trials, crossover studies, cluster trials, etc, 2 reviewers assessed the risk of bias among RCTs included in this study. The Cochrane Collaboration’s tool for assessing the risk of bias in 6 domains (random sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome assessment, incomplete outcome data, and selective reporting) was used. A total of 166 RCTs were selected for analyses. Of these, 72.9% (121/166) had a high risk of bias for blinding of participants and personnel. Although a small proportion of the trials was at high risk of bias in the remaining 5 domains, 33.7% (56/166) had an unclear risk of bias for random sequence generation, and 45.2% (75/166) had an unclear risk of bias for blinding of outcome assessment. Additionally, among 5 domains of risk of bias excluding random sequence generation, the proportion of trials at unclear or high risk of bias in journals with a relatively high IF (≥5 and <10) and high IF (≥10) was lower than that in journals with a low IF (<5) The proportion of trials at unclear or high risk of bias was high in the 2015 AHA guidelines for CPR and ECC, especially for random sequence generation and blinding of participants/outcome assessment. This tendency was more prominent in journals with a low IF (<5). Risk of bias should be considered when interpreting and applying the CPR guidelines in the clinical setting.

Out of Hospital Cardiac Arrest: A Current Review of the Literature that Informed the 2015 American Heart Association Guidelines Update.

Out-of-Hospital cardiac arrest affects over 300,000 individuals in the US per year and is the third leading cause of death for Americans. Given the extent of this public health problem, investigations are ongoing to improve upon outcomes for patients who suffer cardiac arrest. In 2015, the American Heart Association issued an update to the 2010 Cardiopulmonary and Emergency Cardiovascular Care Guidelines.1 In this manuscript, we reviewed the literature that informed the major changes to the guidelines and present a concise review of the current literature that informs how patients who suffer a cardiac arrest are cared for in the pre-hospital, emergency department and in-hospital environment. Additionally, the new AHA guideline on Maternal Resuscitation will also be described.

Trends and Outcomes of Coronary Angiography and Percutaneous Coronary Intervention After Out-of-Hospital Cardiac Arrest Associated With Ventricular Fibrillation or Pulseless Ventricular Tachycardia

The 2015 cardiopulmonary resuscitation and emergency cardiovascular care guidelines recommend performing coronary angiography in resuscitated patients after cardiac arrest with or without ST-segment elevation (STE). To assess the temporal trends, predictors, and outcomes of performing coronary angiography and percutaneous coronary intervention (PCI) in patients resuscitated after out-of-hospital cardiac arrest (OHCA) with initial rhythms of ventricular tachycardia or pulseless ventricular fibrillation (VT/VF). An observational analysis of the use of coronary angiography and PCI in 407 974 patients hospitalized after VT/VF OHCA from January 1, 2000, through December 31, 2012, from the Nationwide Inpatient Sample database. Multivariable analysis was used to assess factors associated with coronary angiography and PCI use. Data analysis was performed from December 12, 2015, to January 5, 2016. Temporal trends of coronary angiography, PCI, and survival to discharge in patients with VT/VF OHCA. Among the 407 974 patients hospitalized after VT/VF OHCA, 143 688 (35.2%) were selected to undergo coronary angiography. The mean (SD) age of the total population was 65.7 (14.9) years, 37.9% were female, and 74.1% were white, 13.4% black, 6.8% Hispanic, and 5.7% other race. Use of coronary angiography increased from 27.2% in 2000 to 43.9% in 2012 (odds ratio, 2.47; 95% CI, 2.25-2.71; P for trend < .001), and PCI increased from 9.5% in 2000 to 24.1% in 2012 (odds ratio, 4.80; 95% CI, 4.21-5.66; P for trend < .001). From 2000 to 2012, coronary angiography and PCI after VT/VF OHCA increased in patients with STE (53.7% to 87.2%, P for trend < .001, and 29.7% to 77.3%, P for trend < .001, respectively) and those without STE (19.3% to 33.9%, P for trend < .001, and 3.5% to 11.8%, P for trend < .001, respectively). There was an associated increasing trend in survival to discharge in the overall population of patients with VT/VF OHCA (46.9% to 60.1%, P for trend < .001) in those with STE (59.2% to 74.3%, P for trend < .001) or without STE (43.3% to 56.8%, P for trend < .001). Coronary angiography, PCI, and survival to discharge have increased in VT/VF OHCA survivors from event to hospitalization. However, a significant proportion of patients with VT/VF OHCA, especially those without STE, do not undergo coronary angiography and revascularization. Prospective studies are needed to determine whether this limitation has a survival effect.

Assessment of long-term impact of formal certified cardiopulmonary resuscitation training program among nurses.

Context:Cardiopulmonary resuscitation (CPR) and emergency cardiovascular care guidelines are periodically renewed and published by the American Heart Association. Formal training programs are conducted based on these guidelines. Despite widespread training CPR is often poorly performed. Hospital educators spend a significant amount of time and money in training health professionals and maintaining basic life support (BLS) and advanced cardiac life support (ACLS) skills among them. However, very little data are available in the literature highlighting the long-term impact of these training.Aims:To evaluate the impact of formal certified CPR training program on the knowledge and skill of CPR among nurses, to identify self-reported outcomes of attempted CPR and training needs of nurses.Setting and Design:Tertiary care hospital, Prospective, repeated-measures design.Subjects and Methods:A series of certified BLS and ACLS training programs were conducted during 2010 and 2011. Written and practical performance tests were done. Final testing was undertaken 3–4 years after training. The sample included all available, willing CPR certified nurses and experience matched CPR noncertified nurses.Statistical Analysis Used:SPSS for Windows version 21.0.Results:The majority of the 206 nurses (93 CPR certified and 113 noncertified) were females. There was a statistically significant increase in mean knowledge level and overall performance before and after the formal certified CPR training program (P = 0.000). However, the mean knowledge scores were equivalent among the CPR certified and noncertified nurses, although the certified nurses scored a higher mean score (P = 0.140).Conclusions:Formal certified CPR training program increases CPR knowledge and skill. However, significant long-term effects could not be found. There is a need for regular and periodic recertification.

Does Your 911 Call Center Provide CPR Instruction

The 2010 American Heart Association Emergency Cardiovascular Care Guidelines recommend that all emergency call center dispatchers be trained to provide cardiopulmonary resuscitation (CPR) instruction for out-of-hospital cardiac arrest (Circulation 2010; 122:S685). To measure how many call centers are able to provide telephone CPR instruction, …

Part 11: Pediatric Basic Life Support and Cardiopulmonary Resuscitation Quality

Reprint: The American Heart Association requests that this document be cited as follows: Atkins DL, Berger S, Duff JP, Gonzales JC, Hunt EA, Joyner BL, Meaney PA, Niles DE, Samson RA, Schexnayder SM. Part 11: pediatric basic life support and cardiopulmonary resuscitation quality: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation . 2015;132(suppl 2):S519–S525. Reprinted with permission of the American Heart Association, Inc. This article has been published in Circulation . This 2015 American Heart Association (AHA) Guidelines Update for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC) section on pediatric basic life support (BLS) differs substantially from previous versions of the AHA Guidelines.1 This publication updates the 2010 AHA Guidelines on pediatric BLS for several key questions related to pediatric CPR. The Pediatric ILCOR Task Force reviewed the topics covered in the 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations and the 2010 council-specific guidelines for CPR and ECC (including those published by the AHA) and formulated 3 priority questions to address for the 2015 systematic reviews. In the online version of this document, live links are provided so the reader can connect directly to those systematic reviews on the International Liaison Committee on Resuscitation (ILCOR) Scientific Evidence Evaluation and Review System (SEERS) website. These links are indicated by a superscript combination of letters and numbers (eg, Peds 709). We encourage readers to use the links and review the evidence and appendices. A rigorous systematic review process was undertaken to review the relevant literature to answer those questions, resulting in the 2015 International Consensus on CPR and ECC Science With Treatment Recommendations, “Part 6: Pediatric Basic Life Support and Pediatric Advanced Life Support.”2,3 This 2015 Guidelines Update covers only those topics reviewed as …

Part 10: Special Circumstances of Resuscitation

This Part of the 2015 American Heart Association (AHA) Guidelines Update for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC) addresses cardiac arrest in situations that require special treatments or procedures other than those provided during basic life support (BLS) and advanced cardiovascular life support (ACLS). This Part summarizes recommendations for the management of resuscitation in several critical situations, including cardiac arrest associated with pregnancy (Part 10.1), pulmonary embolism (PE) (10.2), and opioid-associated resuscitative emergencies, with or without cardiac arrest (10.3). Part 10.4 provides recommendations on intravenous lipid emulsion (ILE) therapy, an emerging therapy for cardiac arrest due to drug intoxication. Finally, updated guidance for the management of cardiac arrest during percutaneous coronary intervention (PCI) is presented in Part 10.5. A table of all recommendations made in this 2015 Guidelines Update as well as those made in the 2010 Guidelines is contained in the Appendix. The special situations of resuscitation section (Part 12) of the 2010 AHA Guidelines for CPR and ECC 1 covered 15 distinct topic areas. The following topics were last updated in 2010: Additional information about drowning is presented in Part 5 of this publication, “Adult Basic Life Support and Cardiopulmonary Resuscitation Quality.” The recommendations in this 2015 Guidelines Update are based on an extensive evidence review process that was begun by the International Liaison Committee on Resuscitation (ILCOR) with the publication of the ILCOR 2010 International Consensus on CPR and ECC Science With Treatment …

Code blue: overcoming the fear.

Code blue: overcoming the fear.

Impact of Percutaneous Coronary Intervention Performance Reporting on Cardiac Resuscitation Centers

Patients who experience out-of-hospital cardiac arrest (OHCA) have high mortality rates. Acute coronary occlusions and high-risk coronary obstructive disease are common in this population, especially in patients with ventricular tachycardia or ventricular fibrillation (VF) as the presenting cardiac arrest (CA) rhythm. In one recent series, 32% of patients with OHCA and sustained return of spontaneous circulation (ROSC) had ST-segment elevation on their first documented ECG.1 The vast majority of patients are unable to give a history of prearrest symptoms on hospital arrival because they are comatose. The “2010 American Heart Association (AHA) Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC)” state that “appropriate treatment of ACS or STEMI, including PCI, should be initiated regardless of coma (Class I, LOE B)” and “coma and the use of induced hypothermia are not contraindications or reasons to delay PCI.”2 The 2010 AHA Guidelines for CPR and ECC also state that “PCI after ROSC in subjects with arrest of presumed cardiac etiology may be reasonable, even in the absence of a clearly defined STEMI (Class IIb, LOE B).” Quality postarrest care was thought to make such a significant contribution to overall survival after CA that the AHA added a fifth link to the Chain of Survival to emphasize the importance of care after resuscitation treatments. The AHA recently issued a policy statement calling for the establishment of regional systems of care to manage OHCA patients.3 The proposed model is patterned after similar successful major trauma, ST-segment elevation myocardial infarction (STEMI), and stroke programs. The policy statement recommends a comprehensive, regionalized approach to postresuscitation care that includes therapeutic hypothermia, multidisciplinary goal-directed management of critical physiological functions (ie, organ perfusion, ventilation, metabolic management), and early coronary angiography/percutaneous coronary intervention (PCI) when indicated. The AHA policy statement defines 2 levels of cardiac …

Are you up to date on the latest emergency cardiovascular care guidelines?

In Brief The American Heart Association has made several changes to its guidelines and standard algorithms for basic life support, advanced cardiovascular life support, and pediatric advanced life support. This article provides an overview of the newest additions and deletions so you're up to date on the most recent advances in emergency cardiovascular care.

Working together, nurses can make a difference in resuscitation outcomes: An update on the American Heart Association's 2010 guidelines for cardiopulmonary resuscitation and emergency cardiovascular care

The International Liaison Committee on Resuscitation (ILCOR) was formed in 1992 to provide a forum for resuscitation organizations worldwide. According to its mission, ILCOR provides a mechanism by which international science and knowledge that are relevant to cardiopulmonary resuscitation (CPR) and emergency cardiovascular care (ECC) can be identified, reviewed, and evaluated. Every 5 years, based on a rigorous review of the published, peer-reviewed science, ILCOR develops a consensus on resuscitation science and carries that forward into internationally agreed-on treatment recommendations. As part of the 2010 evidence-evaluation process, ILCOR published an updated consensus on science and treatment recommendations (CoSTR). Based on the CoSTR, the American Heart Association (AHA) developed and disseminated guidelines for ECC and CPR. Nursing has unique responsibilities in the chain of survival. This article reviews the major elements of AHA's 2010 guidelines and discusses the critical role that nurses play in the development, dissemination, and implementation of resuscitation science. By making the connection in resuscitation science, nurses can help to save more lives.

Impact of the 2005 American Heart Association Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Guidelines on Out-of-Hospital Cardiac Arrest Survival

Objective. To describe changes in out-of-hospital cardiac arrest (OOHCA) survival before and after the release of the 2005 American Heart Association (AHA) guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiovascular care (ECC). Methods. Data were extracted from an OOHCA registry for 1,681 adult cases of cardiac arrest treated by one emergency medical services (EMS) system between April 1, 2004, and December 31, 2007, in a large city (2005 population 730,657). The primary endpoint was survival to hospital discharge. A convenience sample of 69 electronic electrocardiogram (ECG) recordings was reviewed to assess CPR quality parameters using impedance waveform analysis during corresponding time periods. Intervention. Implementation of the 2005 AHA guidelines for CPR and ECC in spring 2006. Results. The annual treated OOHCA incidence rate was 68/100,000; and the treated ventricular fibrillation (VF) incidence rate was 15/100,000. Bystanders performed CPR in 28% of cases. Public automated external defibrillator (AED) use was < 2% over the entire study, and few patients received hypothermia therapy. Unadjusted OOHCA survival rates were significantly higher in the postguidelines period at 9.4% (n = 1,021) than in the preguidelines period at 6.1% (n = 660), despite similarities in all major predictors of outcome (odds ratio [OR] 1.6; 95% confidence interval [CI] 1.1 to 2.4). Bystander-witnessed OOHCA survival for victims in VF on EMS arrival was 19 of 78 (24%) in the preguidelines period versus 34 of 112 (30%) in the postguidelines period (OR 1.4; 95% CI 0.7 to 2.6). CPR quality measures showed significant improvement in the postguidelines period. The mean no-flow fraction in the preguidelines group was 0.46 and dropped to 0.34 in the postguidelines group, a difference of 0.12 (95% CI 0.05 to 0.19). Multivariate regression analysis adjusting for significant predictors of survival showed that OOHCA in the postguidelines period was associated with 1.8 greater odds of survival than in the preguidelines period (95% CI 1.2 to 2.7). Conclusion. In this large city, substantial improvement occurred in overall OOHCA survival rates following the implementation of the 2005 AHA guidelines for CPR and ECC. These changes were associated with improvements in the quality of CPR.

Update on cardiopulmonary resuscitation and emergency cardiovascular care guidelines

The key changes included in the 2005 cardiopulmonary resuscitation (CPR) and emergency cardiac care (ECC) guidelines are reviewed. Advances since publication of the current guidelines are also discussed. The 2005 CPR and ECC guidelines include several key changes from the previous version published in 2000. The new guidelines place an increased emphasis on chest compressions and recommend a compression:ventilation (C:V) ratio of 30:2. Current knowledge on defibrillation has also been incorporated by recommending that Emergency Medical Service (EMS) rescuers give two minutes of CPR before defibrillation when the response interval is greater than four to five minutes and EMS responders did not witness the arrest. Another major change is the recommendation for a single shock to be administered followed immediately by CPR with no check of the cardiac rhythm until two minutes of CPR has been performed postdefibrillation. The 2005 guidelines recommend that an automated external defibrillator should be implemented in public locations where there is a relatively high likelihood of witnessed cardiac arrest. In addition, the most recent guidelines highlight the shift from primary-rhythm-based therapies and resuscitation to a focus on neurologic outcomes. Several evidence-based changes were included in the 2005 CPR and ECC guidelines, including a C:V ratio of 30:2 and mitigation of hands-off time, early defibrillation, administration of a single shock versus a three-shock sequence, use of public-access defibrillators, and a shift from primary-rhythm-based therapies to a focus on neurologic outcomes.

The prohibition on shocking apparent asystole: a history and critique of the argument

A recommendation against shocking asystole has been part of the American Heart Association's Emergency Cardiovascular Care (ECC) Guidelines since 1992. The principal rationale offered then for the prohibition on shocking apparent asystole (PSAA) has since been refuted and has gradually been dropped, but the recommendation itself remains in the 2005 Guidelines. The PSAA now rests mainly on the lack of solid evidence of a survival benefit—a curious criterion given the lack of such evidence for most ECC treatment recommendations. “Occult” ventricular fibrillation and problems with distinguishing between fine ventricular fibrillation and asystole may lead to delays and omissions of potentially lifesaving shocks. No studies on the subject have been conducted since the PSAA first appeared. Removal of the PSAA from the ECC Guidelines is warranted to reopen research on this topic and support the goal of early defibrillation.

Hands-Only (Compression-Only) Cardiopulmonary Resuscitation: A Call to Action for Bystander Response to Adults Who Experience Out-of-Hospital Sudden Cardiac Arrest

Hands-Only (Compression-Only) Cardiopulmonary Resuscitation: A Call to Action for Bystander Response to Adults Who Experience Out-of-Hospital Sudden Cardiac Arrest

Feasibility of correlating the pulse check with focused point-of-care echocardiography during pediatric cardiac arrest: A case series

Rapidly determining whether an unresponsive child is in cardiac arrest or in shock, and requiring cardiopulmonary resuscitation can be problematic. The pulse check in children has been shown to be unreliable, not only for laypersons, but also for healthcare providers. The recommendation for checking the pulse in unresponsive children has been eliminated for laypersons in the latest edition of the Emergency Cardiovascular Care guidelines. Thus the decision to initiate cardiopulmonary resuscitation in children, with the goal of delivering effective chest compressions, can be fraught with uncertainty. Despite the use of pediatric advanced life support guidelines developed by the American Heart Association and the American Academy of Pediatrics, management and decision making during resuscitation of children in cardiac arrest can be challenging. Outcomes for out-of-hospital pediatric cardiac arrest remain poor. The decision to end resuscitation in children, often an emotionally charged situation, can also be particularly difficult for physicians. Information from focused point-of-care echocardiography that allows for correlation with the presence or absence of a pulse and real time assessment of resuscitation may help direct and optimize the delivery of resuscitative interventions. We report our preliminary clinical observations of using focused point-of-care echocardiography to correlate with the pulse check during resuscitation in a series of pediatric cardiac arrests.

Reducing Barriers for Implementation of Bystander-Initiated Cardiopulmonary Resuscitation

Sudden cardiac arrest (SCA) is a leading cause of death in the United States and Canada. In the United States, each year ≈330 000 people die of coronary heart disease out of the hospital or in emergency departments. Of these, >150 000 SCAs occur out of the hospital.1,2 Despite the development of electrical defibrillation and the more recent implementation of lay rescuer defibrillation programs, the vast majority of these victims do not leave the hospital alive. In studies over the past 15 years, only 1.4% of patients with out-of-hospital arrest in Los Angeles, Calif, survived to hospital discharge3; in Chicago, Ill, the number was 2%,4 and in Detroit, Mich, it was <1%.5 Conversely, a few municipalities such as Seattle, Wash, report much higher survival rates from SCA—more than 15% in 1 study6—which suggests that survival rates need not remain so low. Recent work in Europe and elsewhere has confirmed that a higher survival-to-hospital discharge rate is indeed a realistic goal, with survival rates as high as 9% reported in Amsterdam7 and 21% in Maribor, Slovenia.8 The American Heart Association (AHA) uses 4 links in the “chain of survival” to illustrate the time-sensitive actions required for victims of SCA: (1) early recognition of the emergency and activation of emergency medical services (EMS), (2) early bystander cardiopulmonary resuscitation (CPR), (3) early delivery of shock(s) from a defibrillator if indicated, and (4) early advanced life support and postresuscitation care. Immediate bystander recognition of the emergency and EMS activation are critical. In many communities, however, these actions may be followed by significant delays, because the time interval from activation of EMS to arrival of these medical personnel may be 7 to 8 minutes or longer.4 Therefore, initial care in the first critical minutes after …