Part 4: Advanced life support: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations

doi:10.1016/j.resuscitation.2015.07.042

Resuscitation

Volume 95, October 2015, Pages e71-e120

https://doi.org/10.1016/j.resuscitation.2015.07.042 Get rights and content

Introduction

The International Liaison Committee on Resuscitation (ILCOR) Advanced Life Support (ALS) Task Force performed detailed systematic reviews based on the recommendations of the Institute of Medicine of the National Academies¹ and using the methodological approach proposed by the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) Working Group.² Questions to be addressed (using the PICO [population, intervention, comparator, outcome] format)³ were prioritized by ALS Task Force members (by voting). Prioritization criteria included awareness of significant new data and new controversies or questions about practice. Questions about topics no longer relevant to contemporary practice or where little new research has occurred were given lower priority. The ALS Task Force prioritized 42 PICO questions for review. With the assistance of information specialists, a detailed search for relevant articles was performed in each of 3 online databases (PubMed, Embase, and the Cochrane Library).

By using detailed inclusion and exclusion criteria, articles were screened for further evaluation. The reviewers for each question created a reconciled risk of bias assessment for each of the included studies, using state-of-the-art tools: Cochrane for randomized controlled trials (RCTs),⁴ Quality Assessment of Diagnostic Accuracy Studies (QUADAS)-2 for studies of diagnostic accuracy,⁵ and GRADE for observational studies that inform both therapy and prognosis questions.⁶

GRADE evidence profile tables⁷ were then created to facilitate an evaluation of the evidence in support of each of the critical and important outcomes. The quality of the evidence (or confidence in the estimate of the effect) was categorized as high, moderate, low, or very low,⁸ based on the study methodologies and the 5 core GRADE domains of risk of bias, inconsistency, indirectness, imprecision, and other considerations (including publication bias).⁹

These evidence profile tables were then used to create a written summary of evidence for each outcome (the consensus on science statements). Whenever possible, consensus-based treatment recommendations were then created. These recommendations (designated as strong or weak) were accompanied by an overall assessment of the evidence and a statement from the task force about the values, preferences, and task force insights that underlie the recommendations. Further details of the methodology that underpinned the evidence evaluation process are found in “Part 2: Evidence Evaluation and Management of Conflicts of Interest.”

The task force preselected and ranked outcome measures that were used as consistently as possible for all PICO questions. Longer-term, patient-centered outcomes were considered more important than process variables and shorter-term outcomes. For most questions, we used the following hierarchy starting with the most important: long-term survival with neurologically favorable survival, long-term survival, short-term survival, and process variable. In general, long-term was defined as from hospital discharge to 180 days or longer, and short-term was defined as shorter than to hospital discharge. For certain questions (e.g., related to defibrillation or confirmation of tracheal tube position), process variables such as termination of fibrillation and correct tube placement were important. A few questions (e.g., organ donation) required unique outcomes.

The International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations (CoSTR) statements in this Part are organized in the approximate sequence of interventions for a patient: defibrillation, airway, oxygenation and ventilation, circulatory support, monitoring during cardiopulmonary resuscitation (CPR), drugs during CPR, and special circumstances. We also include statements for postresuscitation care, prognostication of neurologic outcome, and organ donation.

Defibrillation Strategies for Ventricular Fibrillation (VF) or Pulseless Ventricular Tachycardia (pVT)

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Biphasic waveform (ALS 470)
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Pulsed biphasic waveform (ALS 470)
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First-shock energy (ALS 470)
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Single shock versus stacked shocks (ALS 470)
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Fixed versus escalating defibrillation energy levels (ALS 470)
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Recurrent VF (ALS 470)

Airway, Oxygenation, and Ventilation

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Oxygen dose during CPR (ALS 889)
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Basic versus advanced airway (ALS 783)
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Supraglottic airways (SGAs) versus tracheal intubation (ALS 714)
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Confirmation of correct tracheal tube placement (ALS 469)
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Ventilation rate during continuous chest compressions (ALS 808)

Circulatory Support During CPR

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Impedance threshold device (ITD) (ALS 579)
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Mechanical CPR devices (ALS 782)
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Extracorporeal CPR (ECPR) versus manual or mechanical CPR (ALS 723)

Physiological Monitoring During CPR

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End-tidal carbon dioxide (ETCO₂) to predict outcome of cardiac arrest (ALS 459)
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Monitoring physiological parameters during CPR (ALS 656)
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Ultrasound during CPR (ALS 658)

Drugs During CPR

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Epinephrine versus placebo (ALS 788)
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Epinephrine versus vasopressin (ALS 659)
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Epinephrine versus vasopressin in combination with epinephrine (ALS 789)
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Standard-dose epinephrine (SDE) versus high-dose epinephrine (HDE) (ALS 778)
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Timing of administration of epinephrine (ALS 784)
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Steroids for cardiac arrest (ALS 433)
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Antiarrhythmic drugs for cardiac arrest (ALS 428)

Cardiac Arrest in Special Circumstances

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Cardiac arrest during pregnancy (ALS 436)
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Lipid therapy for cardiac arrest (ALS 834)
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Opioid toxicity (ALS 441)
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Cardiac arrest associated with pulmonary embolism (PE) (ALS 435)
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Cardiac arrest during coronary catheterization (ALS 479)

Postresuscitation Care

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Oxygen dose after return of spontaneous circulation (ROSC) in adults (ALS 448)
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Postresuscitation ventilation strategy (ALS 571)
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Postresuscitation hemodynamic support (ALS 570)
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Postresuscitation antiarrhythmic drugs (ALS 493)
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Targeted temperature management (ALS 790)
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Timing of induced hypothermia (ALS 802)
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Prevention of fever after cardiac arrest (ALS 879)
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Postresuscitation seizure prophylaxis (ALS 431)
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Seizure treatment (ALS 868)
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Glucose control after resuscitation (ALS 580)
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Prognostication in comatose patients treated with hypothermic targeted temperature management (TTM) (ALS 450)
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Prognostication in the absence of TTM (ALS 713)
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Organ donation (ALS 449)

The 2010 CoSTR statements10, 11 that have not been addressed in 2015 are listed under the relevant section.

Section snippets

Summary of ALS treatment recommendations

The systematic reviews showed that the quality of evidence for many ALS interventions is low or very low, and this led to predominantly weak recommendations. For some issues, despite a low quality of evidence, the values and preferences of the task force led to a strong recommendation. This was especially so when there was consensus that not doing so could lead to harm. In addition, treatment recommendations were left unchanged unless there were compelling reasons not to do so. The rationale

Defibrillation strategies for VF or pVT

The task force restricted its review to new studies since the 2010 CoSTR12, 13 and topics not reviewed in 2010. There are no major differences between the recommendations made in 2015 and those made in 2010. The PICO questions have been grouped into (1) waveforms, (2) first-shock energy, (3) single shock versus 3 shocks, (4) fixed versus escalating energy levels, and (5) refibrillation. In reviewing these, shock success is usually defined as termination of VF 5 s after the shock.

Consensus on

Airway, oxygenation, and ventilation

The use of supplementary oxygen (when it is available) during CPR is accepted practice, but in other circumstances (e.g., acute myocardial infarction), there is increasing evidence that administration of high-concentration oxygen may be harmful.

The optimal strategy for managing the airway has yet to be determined, but several observational studies have challenged the premise that tracheal intubation improves outcomes. Options for airway management can be categorized broadly into bag-mask

Circulatory support during CPR

The ALS Task Force reviewed the evidence for 3 technologies for which there have been significant developments since 2010: (1) the ITD, (2) automated mechanical chest compression devices, and (3) ECPR. All are already in use in some settings, have strong proponents for their use, and have cost implications for their implementation such that there was considerable debate in reaching a consensus on science and treatment recommendation. In addition, some studies of these technologies had support

Physiological monitoring during CPR

The ability to monitor real-time physiological variables and obtain ultrasound images during CPR, in addition to clinical signs and electrocardiographic monitoring, has the potential to enable rescuers to tailor ALS interventions. Strategies for physiological monitoring include the use of ETCO₂, arterial pressure, central venous pressure (enabling monitoring of coronary perfusion pressure and aortic diastolic pressure), and cerebral oximetry (regional cerebral oxygenation).

Drugs during CPR

In 2010, ILCOR reduced routine drug administration in adult cardiac arrest to vasopressor and antiarrhythmic drugs. The science was insufficient to comment on critical outcomes such as survival to discharge and survival to discharge with good neurologic outcome with either vasopressors or antiarrhythmic drugs. There was also insufficient evidence to comment on the best time to give drugs to optimize outcome. The task force made a decision to include only RCTs in this systematic review and

Cardiac arrest in special circumstances

There are numerous special circumstances where additional interventions and/or modifications to ALS may be required. The ILCOR ALS Task Force prioritized 5 topics for review: (1) cardiac arrest during pregnancy, (2) lipid therapy for cardiac arrest associated with overdose, (3) opioid toxicity, (4) cardiac arrest caused by PE, and (5) cardiac arrest during coronary catheterization.

Postresuscitation care

Since 2010, there has been a considerable quantity of data published with the domain of postresuscitation care. The ILCOR ALS Task Force prioritized 9 topics for review: (1) oxygen dose after ROSC, (2) post-ROSC ventilation strategy, (3) hemodynamic support, (4) antiarrhythmic drugs, (5) TTM, (6) post-cardiac arrest seizures, (7) glucose control, (8) prognostication, and (9) organ donation.

Acknowledgments

We thank the following individuals (the Advanced Life Support Chapter Collaborators) for their collaborations on the worksheets contained in this section.

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Development of a training programme on life support in pregnant women for prehospital staff
2024, Educacion Medica
la parada cardiaca en la gestante es un reto en la atención extrahospitalaria, y en España disponemos en ese entorno de médicos que podrían hacer cesáreas perimorten.
inicialmente se evaluaron las lagunas de conocimiento en el manejo de la parada cardiaca (PCR) en gestantes por parte del personal de urgencias extrahospitalarias, para crear un curso semipresencial de simulación de soporte vital avanzado en gestantes (SVA-G). En una segunda fase realizamos un curso para determinar el grado de aprendizaje de conocimientos y habilidades adquirido en soporte vital en el gestante
previo a la creación del curso, se analizó que el porcentaje de aciertos sobre el manejo de la PCR en las embarazadas era del 54,48%, y el 67,12% de los alumnos manifestó que no estaba lo suficientemente capacitado para hacerlo. En función de esas lagunas creamos el curso de SVA-G. Un total de 88 estudiantes participaron en 5 ediciones del curso. Los conocimientos aumentaron significativamente después del curso, independientemente de la profesión del alumno. Según informaron los alumnos, la satisfacción con el curso, los conocimientos adquiridos y la aplicabilidad de los contenidos a su actividad, fue muy positiva.
el curso SVA-G mejora los conocimientos del manejo de la RCP en una embarazada y es un curso útil para el personal que trabaja en urgencias extrahospitalarias. Por ello, tras la creación del curso SVA-G, se incluyó en el catálogo de cursos del Plan Nacional de RCP.
Cardiac arrest in pregnant women is a challenge in out-of-hospital care and in Spain we have doctors in this setting who could perform perimortem caesarean sections.
Initially, we evaluated the gaps in knowledge in the management of cardiac arrest (CRA) in pregnant women by out-of-hospital emergency personnel in order to create a blended learning course in advanced life support simulation in pregnant women (ALS-G). In a second phase, we conducted a course to determine the degree of learning of knowledge and skills acquired in life support in pregnant women.
Prior to the creation of the course, it was analysed that the percentage of success in the management of CPR in pregnant women was 54.48% and 67.12% of the students stated that they were not sufficiently trained to do so. Based on these gaps, we created the VAS-G course. A total of 88 students participated in five editions of the course. Knowledge increased significantly after the course, regardless of the learner's profession. Satisfaction with the course, the knowledge acquired and the applicability of the contents to their activity was reported by the students to be very positive.
The SVA-G course improves the knowledge of CPR management in a pregnant woman and is a useful course for personnel working in out-of-hospital emergencies. For this reason, after the creation of the SVA-G course, it was included in the catalogue of courses of the National CPR Plan.
Defibrillation trials: POSED a challenge
2024, Resuscitation Plus
Mechanical chest compression and extracorporeal life support for out-of-hospital cardiac arrest. A 30-month observational study in the metropolitan area of Milan, Italy
2023, Resuscitation
Return of spontaneous circulation (ROSC) is achieved in 25% of out-of-hospital cardiac arrest (OHCA) patients. Mechanical chest compression (mechCPR) may maintain better perfusion during transport, allowing hospital treatments like extracorporeal circulation life support (ECLS). We aim to assess the effectiveness of a pre-hospital protocol introduction.
Observational, retrospective study assessing all OHCA patients aged 12–75, with no-flow time <20 min in a metropolitan area (Milan, Italy, 2013–2016). Primary outcomes: ROSC and Cerebral Performance Category score (CPC) ≤2 at hospital discharge. Logistic regressions with multiple comparison adjustments balanced with propensity scores calculated with inverse probability of treatment weighting were performed.
1366 OHCA were analysed; 305 received mechCPR, 1061 manual chest compressions (manCPR), and 108 ECLS. ROSC and CPC ≤2 were associated with low-flow minutes (odds ratio [95% confidence interval] 0.90 [0.88–0.91] and 0.90 [0.87–0.93]), shockable rhythm (2.52 [1.71–3.72] and 10.68 [5.63–20.28]), defibrillations number (1.15 [1.07–1.23] and 1.15 [1.04–1.26]), and mechCPR (1.86 [1.17–2.96] and 2.06 [1.11–3.81]). With resuscitation times >13 min, mechCPR achieved more frequently ROSC compared to manCPR. Among ECLS patients, 70% had time exceeding protocol: 8 (7.5%) had CPC ≤2 (half of them with low-flow times between 45 and 90 min), 2 (1.9%) survived with severe neurological disabilities, and 13 brain-dead (12.0%) became organ donors.
MechCPR patients achieved ROSC more frequently than manual CPR patients; mechCPR was a crucial factor in an ECLS protocol for refractory OHCA. ECLS offered a chance of survival to patients who would otherwise die.
Protocol for a cluster randomised controlled feasibility study of Prehospital Optimal Shock Energy for Defibrillation (POSED)
2022, Resuscitation Plus
The Prehospital Optimal Shock Energy for Defibrillation (POSED) study will assess the feasibility of conducting a cluster randomised controlled study of clinical effectiveness in UK ambulance services to identify the optimal shock energy for defibrillation.
POSED is a pragmatic, allocation concealed, open label, cluster randomised, controlled feasibility study. Defibrillators within a single UK ambulance service will be randomised in an equal ratio to deliver one of three shock strategies 120–150–200 J, 150–200–200 J, 200–200–200 J. Consecutive adults (≥18 years) presenting with out of hospital cardiac arrest requiring defibrillation will be eligible. The study plans to enrol 90 patients (30 in each group). Patients (or their relatives for non-survivors) will be informed about trial participation after the initial emergency has resolved. Survivors will be invited to consent to participate in follow-up (i.e., at 30 days or discharge).
The primary feasibility outcome is the proportion of eligible patients who receive the randomised study intervention. Secondary feasibility outcomes will include recruitment rate, adherence to allocated treatment and data completeness. Clinical outcomes will include Return of an Organised Rhythm (ROOR) at 2 minutes post-shock, refibrillation rate, Return of Spontaneous Circulation (ROSC) at hospital handover, survival and neurological outcome at 30 days.
The POSED study will assess the feasibility of a large-scale trial and explore opportunities to optimise the trial protocol.
Trial registration: ISRCTN16327029.
Association of multiple rib fractures with the frequency of pneumonia in the post-resuscitation period
2022, Resuscitation Plus
Successful cardiopulmonary resuscitation is associated with a high incidence of chest wall injuries. However, few studies have examined chest wall injury as a risk factor for respiratory complications after cardiopulmonary resuscitation. Therefore, herein, we investigated the association of multiple rib fractures on the incidence of post-resuscitation pneumonia.
This single-centre retrospective cohort study enrolled adult, nontraumatic, out-of-hospital cardiac arrest patients who maintained circulation for more than 48 h between June 2015 and May 2019. Rib fractures were evaluated by computed tomography on the day of hospital admission. The association with newly developed pneumonia within 7 days of hospitalisation was analysed using a Fine-Gray proportional hazards regression model adjusted for the propensity score of multiple rib fractures estimated from age, sex, presence of witnessed status, bystander CPR, initial rhythm, and total CPR time and for previously reported risk factors for pneumonia (therapeutic hypothermia and prophylactic antibiotics).
Overall, 683 patients with out-of-hospital cardiac arrest were treated; 87 eligible cases were enrolled for analysis. Thirty-two (36.8%) patients had multiple rib fractures identified on computed tomography, and 35 (40.2%) patients developed pneumonia. The presence of multiple rib fractures was significantly associated with a higher incidence of pneumonia, consistently both with and without adjustment for background factors (unadjusted hazard ratio 4.63, 95% confidence interval: 2.35–9.13, p < 0.001; adjusted hazard ratio 4.03, 95% confidence interval: 2.08–7.82, p < 0.001).
Multiple rib fractures are independently associated with the development of pneumonia after successful resuscitation.
Targeted Temperature Management After In-Hospital Cardiac Arrest: An Ancillary Analysis of Targeted Temperature Management for Cardiac Arrest With Nonshockable Rhythm Trial Data
2022, Chest
Targeted temperature management (TTM) currently is the only treatment with demonstrated efficacy in attenuating the harmful effects on the brain of ischemia-reperfusion injury after cardiac arrest. However, whether TTM is beneficial in the subset of patients with in-hospital cardiac arrest (IHCA) remains unclear.
Is TTM at 33 °C associated with better neurological outcomes after IHCA in a nonshockable rhythm compared with targeted normothermia (TN; 37 °C)?
We performed a post hoc analysis of data from the published Targeted Temperature Management for Cardiac Arrest with Nonshockable Rhythm randomized controlled trial in 584 patients. We included the 159 patients with IHCA; 73 were randomized to 33 °C treatment and 86 were randomized to 37 °C treatment. The primary outcome was survival with a good neurologic outcome (cerebral performance category [CPC] score of 1 or 2) on day 90. Mixed multivariate adjusted logistic regression analysis was performed to determine whether survival with CPC score of 1 or 2 on day 90 was associated with type of temperature management after adjustment on baseline characteristics not balanced by randomization.
Compared with TN for 48 h, hypothermia at 33 °C for 24 h was associated with a higher percentage of patients who were alive with good neurologic outcomes on day 90 (16.4% vs 5.8%; P = .03). Day 90 mortality was not significantly different between the two groups (68.5% vs 76.7%; P = .24). By mixed multivariate analysis adjusted by Cardiac Arrest Hospital Prognosis score and circulatory shock status, hypothermia was associated significantly with good day 90 neurologic outcomes (OR, 2.40 [95% CI, 1.17-13.03]; P = .03).
Hypothermia at 33 °C was associated with better day 90 neurologic outcomes after IHCA in a nonshockable rhythm compared with TN. However, the limited sample size resulted in wide CIs. Further studies of patients after cardiac arrest resulting from any cause, including IHCA, are needed.

View all citing articles on Scopus

^☆: The European Resuscitation Council requests that this document be cited as follows: Soar J, CW Callaway M Aibiki, BW Böttiger, SC Brooks, CD Deakin, MW Donnino, S Drajer, W Kloeck, PT Morley, LJ Morrison, RW Neumar, TC Nicholson, JP Nolan, K Okada, BJ O'Neil, EF Paiva, MJ Parr, TL Wang , J Witt; on behalf of the Advanced Life Support Chapter Collaborators. Part 4: advanced life support: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Resuscitation 2015;95:e71–e120.

^☆☆: This article has been copublished in Circulation.

¹: Co-Chairs and equal first co-authors.

²: The members of the Advanced Life Support Chapter Collaborators are listed in the Acknowledgments section.

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Part 4: Advanced life support: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations☆,☆☆

Introduction

Section snippets

Summary of ALS treatment recommendations

Defibrillation strategies for VF or pVT

Airway, oxygenation, and ventilation

Circulatory support during CPR

Physiological monitoring during CPR

Drugs during CPR

Cardiac arrest in special circumstances

Postresuscitation care

Acknowledgments

First page preview

Resuscitation

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J Emerg Med

Chest

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Ann Emerg Med

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Ann Emerg Med

Ann Emerg Med

Ann Emerg Med

Ann Emerg Med

J Emerg Med

Am J Emerg Med

Resuscitation

Resuscitation

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Ann Emerg Med

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Lancet

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Lancet

Resuscitation

Resuscitation

Am J Emerg Med

Lancet

Resuscitation

Resuscitation

Ann Emerg Med

Resuscitation

Ann Emerg Med

J Emerg Med

Institute of Medicine. Standards for systematic reviews

GRADE handbook

Chapter 5. Defining the review questions and developing criteria for including studies

Chapter 8.5. The Cochrane Collaboration's tool for assessing risk of bias