2018 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
This Executive Summary provides an overview of the 2018 Focused Updates to the American Heart Association (AHA) Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC). This second annual AHA Guidelines Focused Update is based on the continuous evidence evaluation process launched in 2015 by the International Liaison Committee on Resuscitation (ILCOR). This process is designed to enable rapid analysis of peer-reviewed published resuscitation studies and development of International Consensus on CPR and ECC Science With Treatment Recommendations (CoSTR) statements. Ultimately, the process should shorten the interval between publication of resuscitation evidence and integration of this evidence into guidelines recommendations by ILCOR member councils, such as the AHA. This Executive Summary highlights the changes included in the 2018 AHA Guidelines Focused Updates published by the advanced cardiovascular life support (ACLS) and pediatric advanced life support (PALS) writing groups. Readers are referred to section 5.3, Medications for Arrest Rhythms, in Part 7: ACLSand section 4.7, Amiodarone and Lidocaine for Shock-Refractory VF and pVT, in Part 12: Pediatric ALS for details about this evidence as well as the recommendations.
The question prioritized for systematic review this year addressed the use of antiarrhythmic drugs for the treatment of shock-refractory ventricular fibrillation (VF) or pulseless ventricular tachycardia (pVT) during or immediately after cardiac arrest. The ILCOR Advanced Life Support Task Force and the Pediatric Task Force then analyzed, discussed, and debated the studies identified and analyzed by the systematic reviewers. These task forces developed draft CoSTR statements that were posted online for public comment on the ILCOR website (www.ilcor.org), and the final joint ILCOR CoSTR summary was published simultaneously in Circulation and Resuscitation.
When developing the AHA Guidelines Focused Updates, the AHA writing groups review the published evidence and the ILCOR consensus recommendations to determine the appropriate AHA Guidelines Focused Update recommendations in light of the structure and resources of the out-of-hospital and in-hospital resuscitation systems as well as the resources and training of lay rescuers and healthcare providers who use AHA guidelines. Each AHA ECC clinical strategy, intervention, treatment, or testing recommendation is then linked with a class of recommendation and a level of evidence, using the most recent language approved by the AHA and the American College of Cardiology. The criteria and language are shown in the Table 1.
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As in the 2015 AHA Guidelines Update for CPR and ECC, the AHA science experts emphasized that this most recent review and update did not examine the optimal sequence of adult or pediatric advanced life support interventions for VF/pVT cardiac arrest, such as ideal timing of administering a vasopressor or antiarrhythmic or the timing of medication administration in relation to CPR or shock delivery. These optimal sequences have not yet been identified. As always, the timing of recommended ACLS and PALS interventions should consider the individual patient as well as the environment of care.
The key change contained in the 2018 ACLS Guidelines Focused Update is a revised recommendation enabling consideration of lidocaine as an alternative to amiodarone for shock-refractory VF/pVT. This revision resulted in a change to the Adult Cardiac Arrest Algorithm and to the Adult Cardiac Arrest Circular Algorithm. As part of the 2018 AHA Guidelines Focused Updates, both the ACLS and PALS writing groups took the opportunity to review the text in the Adult Cardiac Arrest Algorithm and the Pediatric Cardiac Arrest Algorithm and made a small number of minor edits to minimize differences between them.
The 2018 ILCOR systematic review identified no new studies about the effect of magnesium in adults with shock-refractory VF/pVT. As a result, the ACLS writing group reaffirmed previous recommendations against the routine use of magnesium for VF/pVT cardiac arrest, but it may be considered for torsades de pointes (ie, polymorphic VT associated with a long QT interval).
There were no new studies about antiarrhythmic use in adults during the first hour after return of spontaneous circulation (ROSC). The ACLS writing group noted there was insufficient evidence to make a recommendation about the routine use of ẞ-blockers or lidocaine early after ROSC. However, the ACLS writing group did note that in the absence of contraindications, the prophylactic use of lidocaine may be considered in specific circumstances when treatment of recurrent VF/pVT might prove to be logistically challenging (such as during emergency medical services transport after ROSC).
No new published studies were identified to evaluate the association between antiarrhythmic drugs and the outcome for pediatric patients with VF/pVT cardiac arrest. After reviewing the single in-hospital study of antiarrhythmic use in pediatric cardiac arrest, the PALS writing group reaffirmed the previous recommendation that providers may administer either amiodarone or lidocaine for pediatric shock-refractory VF/pVT. No studies were identified to evaluate the effects of antiarrhythmics in children early after ROSC. There were no major treatment changes in the Pediatric Cardiac Arrest Algorithm, although minor text changes were made to reduce differences between the adult and pediatric cardiac arrest algorithms.
2017 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
The purpose of this Executive Summary is to provide an overview of the new, revised, or unchanged recommendations contained in these 2017 focused updates. This year marks the start of a continuous evidence evaluation (CEE) review of published relevant and new science related to the implementation of cardiopulmonary resuscitation (CPR) quality.
The updates align with the International Liaison Committee on Resuscitation’s (ILCOR’s) CEE review process. Updates are published when ILCOR completes a literature review based on new science. This year included a recent evidence-based review of the following adult basic life support (BLS) topics: emergency medical services (EMS)–delivered CPR, dispatch-assisted CPR, bystander CPR, chest compression–to–ventilation ratio, and CPR for cardiac arrest. A summary of the key findings and major changes highlights the use of continuous vs interrupted chest compressions by EMS providers, dispatch-assisted CPR, and the use of compression-only CPR vs CPR using chest compressions with ventilation for in-hospital and out-of-hospital settings. The adult BLS focused update also provides clarity about the descriptions of lay rescuers (eg, untrained, trained in chest compression–only CPR, trained in CPR using chest compressions and ventilation) in response to questions from the American Heart Association’s Training Network. The pediatric BLS focused update provides an evidence-based review and treatment recommendations for compression-only CPR vs CPR using chest compressions with rescue breaths for children younger than 18 years of age.
The topics reviewed here include the following:
At the request of the AHA Training Network, we have clarified the descriptions of lay rescuers as follows:
2017 (Updated): We recommend that when dispatchers’ instructions are needed, dispatchers should provide chest compression–only CPR instructions to callers for adults with suspected out-of-hospital cardiac arrest (OHCA).
2015 (Old): Dispatchers should provide chest compression–only CPR instructions to callers for adults with suspected OHCA.
Why: The 2017 BLS International Consensus on CPR and ECC Science With Treatment Recommendations (CoSTR) summary and systematic review considered instructions for dispatch-assisted chest compression–only CPR for OHCA. No new studies were reviewed for this topic.
Why: The 2017 BLS CoSTR summary and systematic review compared bystander use of chest compression–only CPR with CPR using chest compressions and ventilation (rescue breaths).
Why: The 2017 BLS CoSTR summary and systematic review compared bystander use of chest compression–only CPR with CPR using chest compressions and ventilation (rescue breaths).
2017 (Updated): Whenever an advanced airway (tracheal tube or supraglottic device) is inserted during CPR, it may be reasonable for providers to perform continuous compressions with positive-pressure ventilation delivered without pausing chest compressions.
2017 (Unchanged): It may be reasonable for the provider to deliver 1 breath every 6 seconds (10 breaths per minute) while continuous chest compressions are being performed.
2015 (Old): When the victim has an advanced airway in place during CPR, rescuers no longer deliver cycles of 30 compressions and 2 breaths (ie, they no longer interrupt compressions to deliver 2 breaths). Instead, it may be reasonable for the provider to deliver 1 breath every 6 seconds (10 breaths per minute) while continuous chest compressions are being performed.
Why: The 2017 BLS CoSTR summary and systematic review considered the use of continuous vs interrupted chest compressions after placement of an advanced airway in the hospital setting. No new studies were reviewed for this topic.
2017 (Updated): It is reasonable for rescuers trained in CPR using chest compressions and ventilation (rescue breaths) to provide a compression-to-ventilation ratio of 30:2 for adults in cardiac arrest.
2015 (Old): It is reasonable for rescuers to provide a compression-to-ventilation ratio of 30:2 for adults in cardiac arrest.
Why: The 2017 BLS CoSTR summary and systematic review considered the compression-to-ventilation ratio for adult BLS. No new studies were reviewed for this topic.
The changes for pediatric BLS were a result of weighing the survival benefits of CPR using chest compressions with rescue breaths against chest compression–only CPR, with the conclusion that the incremental benefit of rescue breaths justified a distinct recommendation. The topics reviewed here include the following:
2017 (Updated): Chest compressions with rescue breaths should be provided for infants and children in cardiac arrest.
2015 (Old): Conventional CPR (chest compressions and rescue breaths) should be provided for pediatric cardiac arrests.
Why: Grounded in a growing evidence base since the 2015 Guidelines Update publication, the recommendation for providing CPR using chest compressions with rescue breaths to infants and children in cardiac arrest is reasonable.
2017 (Updated): If bystanders are unwilling or unable to deliver rescue breaths, we recommend that rescuers provide chest compressions for infants and children in cardiac arrest.
2015 (Old): Because compression-only CPR is effective in patients with a primary cardiac event, if rescuers are unwilling or unable to deliver breaths, we recommend that rescuers perform compression-only CPR for infants and children in cardiac arrest.
Why: In comparing the survival benefits of CPR using chest compressions with rescue breaths against the convenience of adopting alignment with the adult recommendation for chest compression–only CPR, we concluded that the incremental benefit of rescue breaths justified a different recommendation.
2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
Publication of the 2015 American Heart Association (AHA) Guidelines Update for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC) marks 49 years since the first CPR guidelines were published in 1966 by an Ad Hoc Committee on Cardiopulmonary Resuscitation established by the National Academy of Sciences of the National Research Council.1 Since that time, periodic revisions to the Guidelines have been published by the AHA in 1974,2 1980,3 1986,4 1992,5 2000,6 2005,7 2010,8 and now 2015. The 2010 AHA Guidelines for CPR and ECC provided a comprehensive review of evidence-based recommendations for resuscitation, ECC, and first aid. The 2015 AHA Guidelines Update for CPR and ECC focuses on topics with significant new science or ongoing controversy, and so serves as an update to the 2010 AHA Guidelines for CPR and ECC rather than a complete revision of the Guidelines.
The purpose of this Executive Summary is to provide an overview of the new or revised recommendations contained in the 2015 Guidelines Update. This document does not contain extensive reference citations; the reader is referred to Parts 3 through 9 for more detailed review of the scientific evidence and the recommendations on which they are based.
There have been several changes to the organization of the 2015 Guidelines Update compared with 2010. “Part 4: Systems of Care and Continuous Quality Improvement” is an important new Part that focuses on the integrated structures and processes that are necessary to create systems of care for both in-hospital and out-of-hospital resuscitation capable of measuring and improving quality and patient outcomes. This Part replaces the “CPR Overview” Part of the 2010 Guidelines.
Another new Part of the 2015 Guidelines Update is “Part 14: Education,” which focuses on evidence-based recommendations to facilitate widespread, consistent, efficient and effective implementation of the AHA Guidelines for CPR and ECC into practice. These recommendations will target resuscitation education of both lay rescuers and healthcare providers. This Part replaces the 2010 Part titled “Education, Implementation, and Teams.” The 2015 Guidelines Update does not include a separate Part on adult stroke because the content would replicate that already offered in the most recent AHA/American Stroke Association guidelines for the management of acute stroke.9,10 Finally, the 2015 Guidelines Update marks the beginning of a new era for the AHA Guidelines for CPR and ECC, because the Guidelines will transition from a 5-year cycle of periodic revisions and updates to a Web-based format that is continuously updated. The first release of the Web-based Integrated Guidelines, now available online at ECCguidelines.heart.org is based on the comprehensive 2010 Guidelines plus the 2015 Guidelines Update. Moving forward, these Guidelines will be updated by using a continuous evidence evaluation process to facilitate more rapid translation of new scientific discoveries into daily patient care.
Creation of practice guidelines is only one link in the chain of knowledge translation that starts with laboratory and clinical science and culminates in improved patient outcomes. The AHA ECC Committee has set an impact goal of doubling bystander CPR rates and doubling cardiac arrest survival by 2020. Much work will be needed across the entire spectrum of knowledge translation to reach this important goal.
The process used to generate the 2015 AHA Guidelines Update for CPR and ECC was significantly different from the process used in prior releases of the Guidelines, and marks the planned transition from a 5-year cycle of evidence review to a continuous evidence evaluation process. The AHA continues to partner with the International Liaison Committee on Resuscitation (ILCOR) in the evidence review process. However, for 2015, ILCOR prioritized topics for systematic review based on clinical significance and availability of new evidence. Each priority topic was defined as a question in PICO (population, intervention, comparator, outcome) format. Many of the topics reviewed in 2010 did not have new published evidence or controversial aspects, so they were not rereviewed in 2015. In 2015, 165 PICO questions were addressed by systematic reviews, whereas in 2010, 274 PICO questions were addressed by evidence evaluation. In addition, ILCOR adopted the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) process for evidence evaluation and expanded the opportunity for public comment. The output of the GRADE process was used to generate the 2015 International Consensus on CPR and ECC Science With Treatment Recommendations (CoSTR).11,12
The recommendations of the ILCOR 2015 CoSTR were used to inform the recommendations in the 2015 AHA Guidelines Update for CPR and ECC. The wording of these recommendations is based on the AHA classification system for evidentiary review (see “Part 2: Evidence Evaluation and Management of Conflicts of Interest”).
The 2015 AHA Guidelines Update for CPR and ECC contains 315 classified recommendations. There are 78 Class I recommendations (25%), 217 Class II recommendations (68%), and 20 Class III recommendations (7%). Overall, 3 (1%) are based on Level of Evidence (LOE) A, 50 (15%) are based on LOE B-R (randomized studies), 46 (15%) are based on LOE B-NR (nonrandomized studies), 145 (46%) are based on LOE C-LD (limited data), and 73 (23%) are based on LOE C-EO (consensus of expert opinion). These results highlight the persistent knowledge gap in resuscitation science that needs to be addressed through expanded research initiatives and funding opportunities.
As noted above, the transition from a 5-year cycle to a continuous evidence evaluation and Guidelines update process will be initiated by the 2015 online publication of the AHA Integrated Guidelines for CPR and ECC at ECCguidelines.heart.org. The initial content will be a compilation of the 2010 Guidelines and the 2015 Guidelines Update. In the future, the Scientific Evidence Evaluation and Review System (SEERS) Web-based resource will also be periodically updated with results of the ILCOR continuous evidence evaluation process at www.ilcor.org/seers.
As resuscitation practice evolves, ethical considerations must also evolve. Managing the multiple decisions associated with resuscitation is challenging from many perspectives, especially when healthcare providers are dealing with the ethics surrounding decisions to provide or withhold emergency cardiovascular interventions.
Ethical issues surrounding resuscitation are complex and vary across settings (in or out of hospital), providers (basic or advanced), patient population (neonatal, pediatric, or adult), and whether to start or when to terminate CPR. Although the ethical principles involved have not changed dramatically since the 2010 Guidelines were published, the data that inform many ethical discussions have been updated through the evidence review process. The 2015 ILCOR evidence review process and resultant 2015 Guidelines Update include several recommendations that have implications for ethical decision making in these challenging areas.
New resuscitation strategies, such as ECPR, have made the decision to discontinue cardiac arrest measures more complicated (see “Part 6: Alternative Techniques and Ancillary Devices for Cardiopulmonary Resuscitation” and “Part 7: Adult Advanced Cardiovascular Life Support”). Understanding the appropriate use, implications, and likely benefits related to such new treatments will have an impact on decision making. There is new information regarding prognostication for newborns, infants, children, and adults with cardiac arrest and/or after cardiac arrest (see “Part 13: Neonatal Resuscitation,” “Part 12: Pediatric Advanced Life Support,” and “Part 8: Post-Cardiac Arrest Care”). The increased use of targeted temperature management has led to new challenges for predicting neurologic outcomes in comatose post-cardiac arrest patients, and the latest data about the accuracy of particular tests and studies should be used to guide decisions about goals of care and limiting interventions.
With new information about the success rate for transplanted organs obtained from victims of cardiac arrest, there is ongoing discussion about the ethical implications around organ donation in an emergency setting. Some of the different view-points on important ethical concerns are summarized in “Part 3: Ethical Issues.” There is also an enhanced awareness that although children and adolescents cannot make legally binding decisions, information should be shared with them to the extent possible, using appropriate language and information for their level of development. Finally, the phrase “limitations of care” has been changed to “limitations of interventions,” and there is increasing availability of the Physician Orders for Life-Sustaining Treatment (POLST) form, a new method of legally identifying people who wish to have specific limits on interventions at the end of life, both in and out of healthcare facilities.
Almost all aspects of resuscitation, from recognition of cardio-pulmonary compromise, through cardiac arrest and resuscitation and post-ardiac arrest care, to the return to productive life, can be discussed in terms of a system or systems of care. Systems of care consist of multiple working parts that are interdependent, each having an effect on every other aspect of the care within that system. To bring about any improvement, providers must recognize the interdependency of the various parts of the system. There is also increasing recognition that out-of-hospital cardiac arrest (OHCA) and in-hospital cardiac arrest (IHCA) systems of care must function differently. “Part 4: Systems of Care and Continuous Quality Improvement” in this 2015 Guidelines Update makes a clear distinction between the two systems, noting that OHCA frequently is the result of an unexpected event with a reactive element, whereas the focus on IHCA is shifting from reactive resuscitation to prevention. New Chains of Survival are suggested for in-hospital and out-of-hospital systems of care, with relatively recent in-hospital focus on prevention of arrests. Additional emphasis should be on continuous quality improvement by identifying the problem that is limiting survival, and then by setting goals, measuring progress toward those goals, creating accountability, and having a method to effect change in order to improve outcomes.
This new Part of the AHA Guidelines for CPR and ECC summarizes the evidence reviewed in 2015 with a focus on the systems of care for both IHCA and OHCA, and it lays the framework for future efforts to improve these systems of care. A universal taxonomy of systems of care is proposed for stakeholders. There are evidence-based recommendations on how to improve these systems.
In a randomized trial, social media was used by dispatchers to notify nearby potential rescuers of a possible cardiac arrest. Although few patients ultimately received CPR from volunteers dispatched by the notification system, there was a higher rate of bystander-initiated CPR (62% versus 48% in the control group).13
Given the low risk of harm and the potential benefit of such notifications, it may be reasonable for communities to incorporate, where available, social media technologies that summon rescuers who are willing and able to perform CPR and are in close proximity to a suspected victim of OHCA. (Class IIb, LOE B-R)
Specialized cardiac arrest centers can provide comprehensive care to patients after resuscitation from cardiac arrest. These specialized centers have been proposed, and new evidence suggests that a regionalized approach to OHCA resuscitation may be considered that includes the use of cardiac resuscitation centers.
A variety of early warning scores are available to help identify adult and pediatric patients at risk for deterioration. Medical emergency teams or rapid response teams have been developed to help respond to patients who are deteriorating. Use of scoring systems to identify these patients and creation of teams to respond to those scores or other indicators of deterioration may be considered, particularly on general care wards for adults and for children with high-risk illnesses, and may help reduce the incidence of cardiac arrest.
Evidence regarding the use of public access defibrillation was reviewed, and the use of automated external defibrillators (AEDs) by laypersons continues to improve survival from OHCA. We continue to recommend implementation of public access defibrillation programs for treatment of patients with OHCA in communities who have persons at risk for cardiac arrest.
The 2010 Guidelines were most notable for the reorientation of the universal sequence from A-B-C (Airway, Breathing, Compressions) to C-A-B (Compressions, Airway, Breathing) to minimize time to initiation of chest compressions. Since 2010, the importance of high-quality chest compressions has been reemphasized, and targets for compression rate and depth have been further refined by relevant evidence. For the untrained lay rescuer, dispatchers play a key role in the recognition of abnormal breathing or agonal gasps as signs of cardiac arrest, with recommendations for chest compression-only CPR.
This section presents the updated recommendations for the 2015 adult basic life support (BLS) guidelines for lay rescuers and healthcare providers. Key changes and continued points of emphasis in this 2015 Guidelines Update include the following: The crucial links in the adult Chain of Survival for OHCA are unchanged from 2010; however, there is increased emphasis on the rapid identification of potential cardiac arrest by dispatchers, with immediate provision of CPR instructions to the caller. These Guidelines take into consideration the ubiquitous presence of mobile phones that can allow the rescuer to activate the emergency response system without leaving the victim’s side. For healthcare providers, these recommendations allow flexibility for activation of the emergency response to better match the provider’s clinical setting. More data are available indicating that high-quality CPR improves survival from cardiac arrest. Components of high-quality CPR include
Recommendations are made for a simultaneous, choreographed approach to performance of chest compressions, airway management, rescue breathing, rhythm detection, and shock delivery (if indicated) by an integrated team of highly trained rescuers in applicable settings.
Many studies have documented that the most common errors of resuscitation are inadequate compression rate and depth; both errors may reduce survival. New to this 2015 Guidelines Update are upper limits of recommended compression rate based on preliminary data suggesting that excessive rate may be associated with lower rate of return of spontaneous circulation (ROSC). In addition, an upper limit of compression depth is introduced based on a report associating increased non-life-threatening injuries with excessive compression depth.
In adult victims of cardiac arrest, it is reasonable for rescuers to perform chest compressions at a rate of 100/min to 120/min. (Class IIa, LOE C-LD)
During manual CPR, rescuers should perform chest compressions to a depth of at least 2 inches or 5 cm for an average adult, while avoiding excessive chest compression depths (greater than 2.4 inches or 6 cm). (Class I, LOE C-LD)
In adult cardiac arrest, total preshock and postshock pauses in chest compressions should be as short as possible. (Class I, LOE C-LD)
In adult cardiac arrest with an unprotected airway, it may be reasonable to perform CPR with the goal of a chest compression fraction as high as possible, with a target of at least 60%. (Class IIb, LOE C-LD)
For patients with known or suspected opioid overdose who have a definite pulse but no normal breathing or only gasping (ie, a respiratory arrest), in addition to providing standard BLS care, it is reasonable for appropriately trained BLS healthcare providers to administer IM or IN naloxone. (Class IIa, LOE C-LD)
It is reasonable to provide opioid overdose response education with or without naloxone distribution to persons at risk for opioid overdose (or those living with or in frequent contact with such persons). (Class IIa, LOE C-LD)
For witnessed OHCA with a shockable rhythm, it may be reasonable for EMS systems with priority-based, multitiered response to delay positive-pressure ventilation by using a strategy of up to 3 cycles of 200 continuous compressions with passive oxygen insufflation and airway adjuncts. (Class IIb, LOE C-LD)
We do not recommend the routine use of passive ventilation techniques during conventional CPR for adults. (Class IIb, LOE C-LD)
However, in EMS systems that use bundles of care involving continuous chest compressions, the use of passive ventilation techniques may be considered as part of that bundle. (Class IIb, LOE C-LD)
It is recommended that emergency dispatchers determine if a patient is unresponsive with abnormal breathing after acquiring the requisite information to determine the location of the event. (Class I, LOE C-LD)
If the patient is unresponsive with abnormal or absent breathing, it is reasonable for the emergency dispatcher to assume that the patient is in cardiac arrest. (Class IIa, LOE C-LD)
Dispatchers should be educated to identify unresponsiveness with abnormal breathing and agonal gasps across a range of clinical presentations and descriptions. (Class I, LOE C-LD)
We recommend that dispatchers should provide chest compression-only CPR instructions to callers for adults with suspected OHCA. (Class I, LOE C-LD)
It is reasonable for healthcare providers to provide chest compressions and ventilation for all adult patients in cardiac arrest, from either a cardiac or noncardiac cause. (Class IIa, LOE C-LD)
When the victim has an advanced airway in place during CPR, rescuers no longer deliver cycles of 30 compressions and 2 breaths (ie, they no longer interrupt compressions to deliver 2 breaths). Instead, it may be reasonable for the provider to deliver 1 breath every 6 seconds (10 breaths per minute) while continuous chest compressions are being performed. (Class IIb, LOE C-LD)
There is insufficient evidence to recommend the use of artifact-filtering algorithms for analysis of ECG rhythm during CPR. Their use may be considered as part of a research protocol or if an EMS system, hospital, or other entity has already incorporated ECG artifact-filtering algorithms in its resuscitation protocols. (Class IIb, LOE C-EO)
It may be reasonable to use audiovisual feedback devices during CPR for real-time optimization of CPR performance. (Class IIb, LOE B-R)
For victims with suspected spinal injury, rescuers should initially use manual spinal motion restriction (eg, placing 1 hand on either side of the patient’s head to hold it still) rather than immobilization devices, because use of immobilization devices by lay rescuers may be harmful. (Class III: Harm, LOE C-LD)
High-quality conventional CPR (manual chest compressions with rescue breaths) generates about 25% to 33% of normal cardiac output and oxygen delivery. A variety of alternatives and adjuncts to conventional CPR have been developed with the aim of enhancing coronary and cerebral perfusion during resuscitation from cardiac arrest. Since the 2010 AHA Guidelines for CPR and ECC were published, a number of clinical trials have provided new data regarding the effectiveness of these alternatives. Compared with conventional CPR, many of these techniques and devices require specialized equipment and training. Some have been tested in only highly selected subgroups of cardiac arrest patients; this selection must be noted when rescuers or healthcare systems consider implementation of the devices.
The use of mechanical piston devices may be considered in specific settings where the delivery of high-quality manual compressions may be challenging or dangerous for the provider (eg, limited rescuers available, prolonged CPR, during hypothermic cardiac arrest, in a moving ambulance, in the angiography suite, during preparation for extracorporeal CPR [ECPR]), provided that rescuers strictly limit interruptions in CPR during deployment and removal of the devices. (Class IIb, LOE C-EO)
The major changes in the 2015 advanced cardiovascular life support (ACLS) guidelines include recommendations regarding prognostication during CPR based on end-tidal carbon dioxide measurements, use of vasopressin during resuscitation, timing of epinephrine administration stratified by shockable or nonshockable rhythms, and the possibility of bundling steroids, vasopressin, and epinephrine administration for treatment of IHCA. In addition, vasopressin has been removed from the pulseless arrest algorithm. Recommendations regarding physiologic monitoring of CPR were reviewed, although there is little new evidence.
In IHCA, the combination of intra-arrest vasopressin, epinephrine, and methylprednisolone and post-arrest hydrocortisone as described by Mentzelopoulos et al 16 may be considered; however, further studies are needed before recommending the routine use of this therapeutic strategy.
When ROSC is not rapidly achieved after cardiac arrest, several options exist to provide prolonged circulatory support. These options include mechanical CPR devices, and use of endovascular ventricular assist devices, intra-aortic balloon counterpulsation, and ECPR have all been described. The role of these modalities, alone or in combination, is not well understood. (For additional information, see, “Part 6: Alternative Techniques and Ancillary Devices for Cardiopulmonary Resuscitation”)
Post–cardiac arrest care research has advanced significantly over the past decade. Multiple studies and trials detail the heterogeneity of patients and the spectrum of pathophysiology after cardiac arrest. Post–cardiac arrest care should be titrated based on arrest etiology, comorbid disease, and illness severity. Thus, the 2015 Guidelines Update integrates available data to help experienced clinicians make the complex set of therapeutic decisions required for these patients. The central principles of postarrest care are (1) to identify and treat the underlying etiology of the cardiac arrest, (2) to mitigate ischemia-reperfusion injury and prevent secondary organ injury, and (3) to make accurate estimates of prognosis to guide the clinical team and to inform the family when selecting goals of continued care.
Early coronary angiography and coronary intervention are recommended for patients with ST elevation as well as for patients without ST elevation, when an acute coronary event is suspected. The decision to perform coronary angiography should not include consideration of neurologic status, because of the unreliability of early prognostic signs. Targeted temperature management is still recommended for at least 24 hours in comatose patients after cardiac arrest, but clinicians may choose a target temperature from the wider range of 32°C to 36°C. Estimating the prognosis of patients after cardiac arrest is best accomplished by using multiple modalities of testing: clinical examination, neurophysiological testing, and imaging.
One of the most common causes of cardiac arrest outside of the hospital is acute coronary occlusion. Quickly identifying and treating this cause is associated with better survival and better functional recovery. Therefore, coronary angiography should be performed emergently (rather than later in the hospital stay or not at all) for OHCA patients with suspected cardiac etiology of arrest and ST elevation on ECG. Emergency coronary angiography is reasonable for select (eg, electrically or hemodynamically unstable) adults who are without ST elevation on ECG but are comatose after OHCA of suspected cardiac origin. Emergency coronary angiography is also reasonable for post–cardiac arrest patients for whom coronary angiography is indicated, regardless of whether the patient is comatose or awake.
A high-quality randomized controlled trial did not identify any superiority of targeted temperature management at 36°C compared with management at 33°C. Excellent outcomes are possible when patients are actively managed at either temperature. All comatose (ie, lack of meaningful response to verbal commands) adult patients with ROSC after cardiac arrest should have targeted temperature management, with providers selecting and maintaining a constant temperature between 32°C and 36°C for at least 24 hours after achieving target temperature. It is also reasonable to actively prevent fever in comatose patients after targeted temperature management.
The 2015 Guidelines Update newly limits recommendations for the evaluation and management of acute coronary syndromes (ACS) to the care rendered during the prehospital and emergency department phases of care only, and specifically does not address management of patients after emergency department disposition. Within this scope, several important components of care can be classified as diagnostic interventions in ACS, therapeutic interventions in ACS, reperfusion decisions in ST-segment elevation myocardial infarction (STEMI), and hospital reperfusion decisions after ROSC. Diagnosis is focused on ECG acquisition and interpretation and the rapid identification of patients with chest pain who are safe for discharge from the emergency department. Therapeutic interventions focus on prehospital adenosine diphosphate receptor antagonists in STEMI, prehospital anticoagulation, and the use of supplementary oxygen. Reperfusion decisions include when and where to use fibrinolysis versus percutaneous coronary intervention (PCI) and when post-ROSC patients may benefit from having access to PCI.
A well-organized approach to STEMI care still requires integration of community, EMS, physician, and hospital resources in a bundled STEMI system of care. Two studies published since the 2010 evidence review confirm the importance of acquiring a 12-lead ECG for patients with possible ACS as early as possible in the prehospital setting. These studies reaffirmed previous recommendations that when STEMI is diagnosed in the prehospital setting, prearrival notification of the hospital and/or prehospital activation of the catheterization laboratory should occur without delay. These updated recommendations place new emphasis on obtaining a prehospital ECG and on both the necessity for and the timing of receiving hospital notification.
Prehospital 12-lead ECG should be acquired early for patients with possible ACS. (Class I, LOE B-NR)
Prehospital notification of the receiving hospital (if fibrinolysis is the likely reperfusion strategy) and/or prehospital activation of the catheterization laboratory should occur for all patients with a recognized STEMI on prehospital ECG. (Class I, LOE B-NR)
Because the rate of false-negative results of 12-lead ECGs may be unacceptably high, a computer reading of the ECG should not be a sole means to diagnose STEMI, but may be used in conjunction with physician or trained provider interpretation. New studies examining the accuracy of ECG interpretation by trained nonphysicians have prompted a revision of the recommendation to explicitly permit trained nonphysicians to interpret ECGs for the presence of STEMI.
We recommend that computer-assisted ECG interpretation may be used in conjunction with physician or trained provider interpretation to recognize STEMI . (Class IIb, LOE C-LD)
While transmission of the prehospital ECG to the ED physician may improve positive predictive value (PPV) and therapeutic decision-making regarding adult patients with suspected STEMI, if transmission is not performed, it may be reasonable for trained nonphysician ECG interpretation to be used as the basis for decision-making, including activation of the catheterization laboratory, administration of fibrinolysis, and selection of destination hospital. (Class IIa, LOE B-NR)
High-sensitivity cardiac troponin is now widely available. The 2015 CoSTR review examined whether a negative troponin test could reliably exclude a diagnosis of ACS in patients who did not have signs of STEMI on ECG. For emergency department patients with a presenting complaint consistent with ACS, high-sensitivity cardiac troponin T (hs-cTnT) and cardiac troponin I (cTnI) measured at 0 and 2 hours should not be interpreted in isolation (without performing clinical risk stratification) to exclude the diagnosis of ACS. In contrast, high-sensitivity cardiac troponin I (hs-cTnI), cTnI, or cardiac troponin T (cTnT) may be used in conjunction with a number of clinical scoring systems to identify patients at low risk for 30-day major adverse cardiac events (MACE) who may be safely discharged from the emergency department.
We recommend that hs-cTnI measurements that are less than the 99th percentile, measured at 0 and 2 hours, may be used together with low-risk stratification (TIMI score of 0 or 1 or low risk per Vancouver rule) to predict a less than 1% chance of 30-day MACE. (Class IIa, LOE B-NR)
We recommend that negative cTnI or cTnT measurements at 0 and between 3 and 6 hours may be used together with very low-risk stratification (TIMI score of 0, low-risk score per Vancouver rule, North American Chest Pain score of 0 and age less than 50 years, or low-risk HEART score) to predict a less than 1% chance of 30-day MACE. (Class IIa, LOE B-NR)
New recommendations have been made regarding several therapeutic interventions in ACS. New data from a case-control study that compared heparin and aspirin administered in the prehospital to the hospital setting found blood flow rates to be higher in infarct-related arteries when heparin and aspirin are administered in the prehospital setting. Because of the logistical difficulties in introducing heparin to EMS systems that do not currently use this drug and the limitations in interpreting data from a single study, initiation of adenosine diphosphate (ADP) inhibition may be reasonable in either the prehospital or the hospital setting in patients with suspected STEMI who intend to undergo primary PCI.
We recommend that EMS systems that do not currently administer heparin to suspected STEMI patients do not add this treatment, whereas those that do administer it may continue their current practice. (Class IIb, LOE B-NR)
In suspected STEMI patients for whom there is a planned PCI reperfusion strategy, administration of unfractionated heparin (UFH) can occur either in the prehospital or in-hospital setting. (Class IIb, LOE B-NR)
Supplementary oxygen has been routinely administered to patients with suspected ACS for years. Despite this tradition, the usefulness of supplementary oxygen therapy has not been established in normoxemic patients.
The usefulness of supplementary oxygen therapy has not been established in normoxic patients. In the prehospital, ED, and hospital settings, the withholding of supplementary oxygen therapy in normoxic patients with suspected or confirmed acute coronary syndrome may be considered. (Class IIb, LOE C-LD)
Timely restoration of blood flow to ischemic myocardium in acute STEMI remains the highest treatment priority. While the Class of Recommendation regarding reperfusion strategies remains unchanged from 2010, the choice between fibrinolysis and PCI has been reexamined to focus on clinical circumstances, system capabilities, and timing, and the recommendations have been updated accordingly. The anticipated time to PCI has been newly examined in 2015, and new time-dependent recommendations regarding the most effective reperfusion strategy are made. In STEMI patients, when long delays to primary PCI are anticipated (more than 120 minutes), a strategy of immediate fibrinolysis followed by routine early angiography (within 3 to 24 hours) and PCI, if indicated, is reasonable. It is acknowledged that fibrinolysis becomes significantly less effective at more than 6 hours after symptom onset, and thus a longer delay to primary PCI is acceptable in patients at more than 6 hours after symptom onset. To facilitate ideal treatment, systems of care must factor information about hospital capabilities into EMS destination decisions and interfaculty transfers.
In adult patients presenting with STEMI in the ED of a non-PCI-capable hospital, we recommend immediate transfer without fibrinolysis from the initial facility to a PCI center instead of immediate fibrinolysis at the initial hospital with transfer only for ischemia-driven PCI. (Class I, LOE B-R)
When STEMI patients cannot be transferred to a PCI-capable hospital in a timely manner, fibrinolytic therapy with routine transfer for angiography may be an acceptable alternative to immediate transfer to PCI. (Class IIb, LOE C-LD)
When fibrinolytic therapy is administered to a STEMI patient in a non–PCI-capable hospital, it may be reasonable to transport all postfibrinolysis patients for early routine angiography in the first 3 to 6 hours and up to 24 hours rather than transport postfibrinolysis patients only when they require ischemia-guided angiography. (Class IIb, LOE B-R)
“Part 10: Special Circumstances of Resuscitation” presents new guidelines for the prevention and management of resuscitation emergencies related to opioid toxicity, and for the role of intravenous lipid emulsion (ILE) therapy for treatment of cardiac arrest due to drug overdose. Updated guidelines for the management of cardiac arrest occurring during the second half of pregnancy, cardiac arrest caused by pulmonary embolism, and cardiac arrest occurring during PCI are included.
If the fundus height is at or above the level of the umbilicus, manual LUD can be beneficial in relieving aortocaval compression during chest compressions. (Class IIa, LOE C-LD)
In situations such as nonsurvivable maternal trauma or prolonged pulselessness, in which maternal resuscitative efforts are obviously futile, there is no reason to delay performing PMCD. (Class I, LOE C-LD)
PMCD should be considered at 4 minutes after onset of maternal cardiac arrest or resuscitative efforts (for the unwitnessed arrest) if there is no ROSC. (Class IIa, LOE C-EO)
The 2015 Guidelines Update for pediatric BLS concentrated on modifications in the algorithms for lone- and 2-rescuer CPR, initial actions of rescuers, and CPR quality process measures. Algorithms for 1- and 2-person healthcare provider CPR have been separated to better guide rescuers through the initial stages of resuscitation. In an era where handheld cellular telephones with speakers are common, this technology can allow a single rescuer to activate the emergency response system while beginning CPR. Healthcare providers should perform an assessment of breathing and pulse check simultaneously, to minimize delays in starting CPR if the child is unresponsive with no breathing or only gasping.
The 3 major CPR process characteristics that were evaluated included C-A-B (Compressions, Airway, Breathing) versus A-B-C (Airway, Breathing, Compressions), compression-only CPR, and compression depth and rate. No major changes were made for the 2015 Guidelines Update; however, new concepts in CPR delivery were examined for children.
Because of the limited amount and quality of the data, it may be reasonable to maintain the sequence from the 2010 Guidelines by initiating CPR with C-A-B over A-B-C sequence. (Class IIb, LOE C-EO)
Conventional CPR (chest compressions and rescue breaths) should be provided for pediatric cardiac arrests. (Class I, LOE B-NR)
However, because compression-only CPR is effective in patients with a primary cardiac event, if rescuers are unwilling or unable to deliver breaths, we recommend rescuers perform compression-only CPR for infants and children in cardiac arrest. (Class I, LOE B-NR)
Conventional CPR (chest compressions and rescue breaths) is a Class I recommendation. (LOE B-NR)
The following are the most important changes and reinforcements to recommendations made in the 2010 Guidelines:
There is new evidence that when treating pediatric septic shock in specific settings, the use of restricted volume of isotonic crystalloid leads to improved survival, contrasting with the long-standing belief that all patients benefit from aggressive volume resuscitation. New guidelines suggest a cautious approach to fluid resuscitation, with frequent patient reassessment, to better tailor fluid therapy and supportive care to children with febrile illness.
“Part 13: Neonatal Resuscitation” presents new guidelines for resuscitation of primarily newly born infants transitioning from intrauterine to extrauterine life. The recommendations are also applicable to neonates who have completed newborn transition and require resuscitation during the first weeks after birth.
Much of the neonatal resuscitation guidelines remains unchanged from 2010, but there is increasing focus on umbilical cord management, maintaining a normal temperature after birth, accurate determination of heart rate, optimizing oxygen use during resuscitation, and de-emphasis of routine suctioning for meconium in nonvigorous newborns. The etiology of neonatal arrest is almost always asphyxia, and therefore, establishing effective ventilation remains the most critical step.
Umbilical cord management: The 2015 Guidelines Update includes for the first time recommendations regarding umbilical cord management. Until recently, it was common practice to clamp the umbilical cord immediately after birth to facilitate rapid transfer of the baby to the pediatric provider for stabilization. A significant issue with the available evidence is that the published studies enrolled very few babies who were considered to need resuscitation.
Delayed cord clamping for longer than 30 seconds is reasonable for both term and preterm infants who do not require resuscitation at birth. (Class IIa, LOE C-LD)
Assessment of heart rate: Immediately after birth, assessment of the newborn’s heart rate is used to evaluate the effectiveness of spontaneous respiratory effort and determine the need for subsequent interventions. An increase in the newborn’s heart rate is considered the most sensitive indicator of a successful response to resuscitation interventions. Therefore, identifying a rapid, reliable, and accurate method to measure the newborn’s heart rate is critically important.
During resuscitation of term and preterm newborns, the use of 3-lead ECG for the rapid and accurate measurement of the newborn’s heart rate may be reasonable. (Class IIb, LOE C-LD)
Maintaining normal temperature of the newborn after birth:
Management of the meconium stained infant: For more than a decade, vigorous infants born through meconium stained amniotic fluid have been treated no differently than if they had been born through clear fluid. However, there remained a long standing practice to intubate and suction infants born through meconium stained amniotic fluid who have poor muscle tone and inadequate breathing efforts at birth.
Oxygen use for preterm infants in the delivery room: Since the release of the 2010 AHA Guidelines for CPR and ECC, additional randomized trials have been published that examine the use of oxygen during resuscitation and stabilization of preterm newborns. These additional publications have allowed an increase from Class IIb to a Class I recommendation.
Resuscitation of preterm newborns of less than 35 weeks of gestation should be initiated with low oxygen (21% to 30%), and the oxygen concentration should be titrated to achieve preductal oxygen saturation approximating the interquartile range measured in healthy term infants after vaginal birth at sea level.19 (Class I, LOE B-R)
Oxygen use during neonatal cardiac compressions: The evidence for optimal oxygen use during neonatal cardiac compressions was not reviewed for the 2010 Guidelines. Unfortunately, there are no clinical studies to inform the neonatal guidelines, but the available animal evidence demonstrated no obvious advantage of 100% oxygen over air. However, by the time resuscitation of a newborn includes cardiac compressions, the steps of trying to improve the heart rate via effective ventilation with low concentrations of oxygen should have already been tried. Thus, the 2015 Guidelines Task Force thought it was reasonable to increase the supplementary oxygen concentration during cardiac compressions and then subsequently wean the oxygen as soon as the heart rate recovers (see “Part 13: Neonatal Resuscitation” in the 2015 Web-based Integrated Guidelines).
Structure of educational programs to teach neonatal resuscitation: Currently, neonatal resuscitation training that includes simulation and debriefing is recommended at 2-year intervals.
Umbilical cord management for newborns needing resuscitation: As noted previously, the risks and benefits of delayed cord clamping for newborns who need resuscitation after birth remains unknown because such infants have thus far been excluded from the majority of trials. Concern remains that delay in establishing ventilation may be harmful. Further study is strongly endorsed.
Utility of a sustained inflation during the initial breaths after birth: Several recent animal studies suggested that a longer sustained inflation may be beneficial for establishing functional residual capacity during transition from a fluid-filled to an air-filled lung after birth. Some clinicians have suggested applying this technique for transition of human newborns.
Determination of heart rate: Neonatal resuscitation success has classically been determined by detecting an increase in heart rate through auscultation. Heart rate also determines the need for changing interventions and escalating care. However, recent evidence demonstrates that auscultation of heart rate is inaccurate, and pulse oximetry takes several minutes to achieve a signal and also may be inaccurate during the early minutes after birth. Use of ECG in the delivery room has been suggested as a possible alternative.
There remains strikingly low survival rates for both OHCA and IHCA despite scientific advances in the care of cardiac arrest victims. The Formula for Survival suggests that cardiac arrest survival is influenced by high-quality science, education of lay providers and healthcare professionals, and a well-functioning Chain of Survival.20 Considerable opportunities exist for education to close the gap between actual and desired performance of lay providers and healthcare teams. For lay providers, this includes proficient CPR and AED skills and the self-efficacy to use them, along with immediate support such as dispatch-guided CPR. For healthcare providers, the goals remain to recognize and respond to patients at risk of cardiac arrest, deliver high-quality CPR whenever CPR is required, and improve the entire resuscitation process through improved teamwork. Additionally, there needs to be a feedback loop focused on continuous quality improvement that can help the system improve as well as identify needs for targeted learning/performance improvement. Optimizing the knowledge translation of what is known from the science of resuscitation to the victim’s bedside is a key step to potentially saving many more lives.
Evidence-based instructional design is essential to improve training of providers and ultimately improve resuscitation performance and patient outcomes. The quality of rescuer performance depends on learners integrating, retaining, and applying the cognitive, behavioral, and psychomotor skills required to successfully perform resuscitation. “Part 14: Education” provides an overview of the educational principles that the AHA has implemented to maximize learning from its educational programs. It is important to note that the systematic reviews from which the Guidelines were derived assigned a hierarchy of outcomes for educational studies that considered patient-related outcomes as critical and outcomes in educational settings as important.
The key recommendations based on the systematic reviews include the following:
Use of a CPR feedback device is recommended to learn the psychomotor skill of CPR. Devices that provide feedback on performance are preferred to devices that provide only prompts (such as a metronome). Instructors are not accurate at assessment of CPR quality by visual inspection, so an adjunctive tool is necessary to provide accurate guidance to learners developing these critical psychomotor skills. Improved manikins that better reflect patient characteristics may prove important for future training. Use of CPR quality feedback devices during CPR is reviewed in the Adult BLS and CPR Quality Part, “Part 5: Adult Basic Life Support and CPR Quality.”
“Part 15: First Aid” reaffirms the definition of first aid as the helping behaviors and initial care provided for an acute illness or injury. The provision of first aid has been expanded to include any person, from layperson to professional healthcare provider, in a setting where first aid is needed. Goals and competencies are now provided to give guidance and perspective beyond specific skills. While a basic tenet of first aid is the delivery of care using minimal or no equipment, it is increasingly recognized that in some cases first aid providers may have access to various adjuncts, such as commercial tourniquets, glucometers, epinephrine autoinjectors, or oxygen. The use of any such equipment mandates training, practice, and, in some cases, medical or regulatory oversight related to use and maintenance of that equipment.
Although there is a growing body of observational studies performed in the first aid setting, most recommendations set forth in “Part 15: First Aid” continue to be extrapolated from prehospital- and hospital-based studies. One important new development relates to the ability of a first aid provider to recognize the signs and symptoms of acute stroke. “Part 15: First Aid” describes the various stroke assessment systems that are available to first aid providers, and lists their sensitivities and specificities in identifying stroke based on included components. This new recommendation for use of a stroke assessment system complements previous recommendations for early stroke management by improving the recognition of stroke signs and symptoms at the first step of emergency care—first aid—thus potentially reducing the interval from symptom onset to definitive care.
The use of a stroke assessment system by first aid providers is recommended. (Class I, LOE B-NR)
Glucose tablets, if available, should be used to reverse hypoglycemia in a patient who is able to take these orally. (Class I, LOE B-R)
We recommend that first aid education be universally available. (Class I, LOE C-EO)
When a person with anaphylaxis does not respond to the initial dose, and arrival of advanced care will exceed 5 to 10 minutes, a repeat dose may be considered. (Class IIb, LOE C-LD)
The 2015 AHA Guidelines Update for CPR and ECC incorporated the evidence from the systematic reviews completed as part of the 2015 International Consensus on CPR and ECC Science With Treatment Recommendations. This 2015 AHA Guidelines Update marks the transition from periodic review and publication of new science-based recommendation to a more continuous process of evidence evaluation and guideline optimization designed to more rapidly translate new science into resuscitation practice that will save more lives. The Appendix to this Part contains a list of all recommendations published in the 2015 Update and, in addition, lists the recommendations from the 2010 AHA Guidelines for CPR and ECC. The 2015 recommendations were made consistent with the new AHA Classification System for describing the risk:benefit ratio for each Class and the Levels of Evidence supporting them. (Please see Table 1, in “Part 2: Evidence Evaluation and Management of Conflicts of Interest.”)
Survival from both IHCA and OHCA has increased over the past decade, but there is still tremendous potential for improvement. It is clear that successful resuscitation depends on coordinated systems of care that start with prompt rescuer actions, require delivery of high-quality CPR, and continue through optimized ACLS and post–cardiac arrest care. Systems that monitor and report quality-of-care metrics and patient-centered outcomes will have the greatest opportunity through quality improvement to save the most lives.
Robert W. Neumar; Michael Shuster; Clifton W. Callaway; Lana M. Gent; Dianne L. Atkins; Farhan Bhanji; Steven C. Brooks; Allan R. de Caen; Michael W. Donnino; Jose Maria Ferrer; Russell E. Griffin; Monica E. Kleinman; Steven L. Kronick; Eric J. Lavonas; Mark S. Link; Mary E. Mancini; Laurie J. Morrison; Robert E. O’Connor; Ricardo A. Samson; Steven M. Schexnayder; Eunice “Nici” M. Singletary; Andrew H. Travers; Myra H. Wyckoff; Mary Fran Hazinski
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© Copyright 2015, 2017 American Heart Association, Inc.