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W2137722844 abstract "HomeCirculationVol. 122, No. 18_suppl_3Part 8: Adult Advanced Cardiovascular Life Support Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessResearch ArticlePDF/EPUBPart 8: Adult Advanced Cardiovascular Life Support2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Robert W. Neumar, Charles W. Otto, Mark S. Link, Steven L. Kronick, Michael Shuster, Clifton W. Callaway, Peter J. Kudenchuk, Joseph P. Ornato, Bryan McNally, Scott M. Silvers, Rod S. Passman, Roger D. White, Erik P. Hess, Wanchun Tang, Daniel Davis, Elizabeth Sinz and Laurie J. Morrison Robert W. NeumarRobert W. Neumar Search for more papers by this author , Charles W. OttoCharles W. Otto Search for more papers by this author , Mark S. LinkMark S. Link Search for more papers by this author , Steven L. KronickSteven L. Kronick Search for more papers by this author , Michael ShusterMichael Shuster Search for more papers by this author , Clifton W. CallawayClifton W. Callaway Search for more papers by this author , Peter J. KudenchukPeter J. Kudenchuk Search for more papers by this author , Joseph P. OrnatoJoseph P. Ornato Search for more papers by this author , Bryan McNallyBryan McNally Search for more papers by this author , Scott M. SilversScott M. Silvers Search for more papers by this author , Rod S. PassmanRod S. Passman Search for more papers by this author , Roger D. WhiteRoger D. White Search for more papers by this author , Erik P. HessErik P. Hess Search for more papers by this author , Wanchun TangWanchun Tang Search for more papers by this author , Daniel DavisDaniel Davis Search for more papers by this author , Elizabeth SinzElizabeth Sinz Search for more papers by this author and Laurie J. MorrisonLaurie J. Morrison Search for more papers by this author Originally published2 Nov 2010https://doi.org/10.1161/CIRCULATIONAHA.110.970988Circulation. 2010;122:S729–S767is corrected byCorrectionCorrectionAdvanced cardiovascular life support (ACLS) impacts multiple key links in the chain of survival that include interventions to prevent cardiac arrest, treat cardiac arrest, and improve outcomes of patients who achieve return of spontaneous circulation (ROSC) after cardiac arrest. ACLS interventions aimed at preventing cardiac arrest include airway management, ventilation support, and treatment of bradyarrhythmias and tachyarrhythmias. For the treatment of cardiac arrest, ACLS interventions build on the basic life support (BLS) foundation of immediate recognition and activation of the emergency response system, early CPR, and rapid defibrillation to further increase the likelihood of ROSC with drug therapy, advanced airway management, and physiologic monitoring. Following ROSC, survival and neurologic outcome can be improved with integrated post–cardiac arrest care.Part 8 presents the 2010 Adult ACLS Guidelines: 8.1: “Adjuncts for Airway Control and Ventilation”; 8.2: “Management of Cardiac Arrest”; and 8.3: “Management of Symptomatic Bradycardia and Tachycardia.” Post–cardiac arrest interventions are addressed in Part 9: “Post–Cardiac Arrest Care.”Key changes from the 2005 ACLS Guidelines include Continuous quantitative waveform capnography is recommended for confirmation and monitoring of endotracheal tube placement.Cardiac arrest algorithms are simplified and redesigned to emphasize the importance of high-quality CPR (including chest compressions of adequate rate and depth, allowing complete chest recoil after each compression, minimizing interruptions in chest compressions and avoiding excessive ventilation).Atropine is no longer recommended for routine use in the management of pulseless electrical activity (PEA)/asystole.There is an increased emphasis on physiologic monitoring to optimize CPR quality and detect ROSC.Chronotropic drug infusions are recommended as an alternative to pacing in symptomatic and unstable bradycardia.Adenosine is recommended as a safe and potentially effective therapy in the initial management of stable undifferentiated regular monomorphic wide-complex tachycardia.Part 8.1: Adjuncts for Airway Control and VentilationOverview of Airway ManagementThis section highlights recommendations for the support of ventilation and oxygenation during CPR and the peri-arrest period. The purpose of ventilation during CPR is to maintain adequate oxygenation and sufficient elimination of carbon dioxide. However, research has not identified the optimal tidal volume, respiratory rate, and inspired oxygen concentration required during resuscitation from cardiac arrest.Both ventilation and chest compressions are thought to be important for victims of prolonged ventricular fibrillation (VF) cardiac arrest and for all victims with other presenting rhythms. Because both systemic and pulmonary perfusion are substantially reduced during CPR, normal ventilation-perfusion relationships can be maintained with a minute ventilation that is much lower than normal. During CPR with an advanced airway in place, a lower rate of rescue breathing is needed to avoid hyperventilation.Ventilation and Oxygen Administration During CPRDuring low blood flow states such as CPR, oxygen delivery to the heart and brain is limited by blood flow rather than by arterial oxygen content.1,2 Therefore, rescue breaths are less important than chest compressions during the first few minutes of resuscitation from witnessed VF cardiac arrest and could reduce CPR efficacy due to interruption in chest compressions and the increase in intrathoracic pressure that accompanies positive-pressure ventilation. Thus, during the first few minutes of witnessed cardiac arrest a lone rescuer should not interrupt chest compressions for ventilation. Advanced airway placement in cardiac arrest should not delay initial CPR and defibrillation for VF cardiac arrest (Class I, LOE C).Oxygen During CPROxygen Administration During CPRThe optimal inspired oxygen concentration during adult CPR has not been established in human or animal studies. In addition, it is unknown whether 100% inspired oxygen (Fio2=1.0) is beneficial or whether titrated oxygen is better. Although prolonged exposure to 100% inspired oxygen (Fio2=1.0) has potential toxicity, there is insufficient evidence to indicate that this occurs during brief periods of adult CPR.3–5 Empirical use of 100% inspired oxygen during CPR optimizes arterial oxyhemoglobin content and in turn oxygen delivery; therefore, use of 100% inspired oxygen (Fio2=1.0) as soon as it becomes available is reasonable during resuscitation from cardiac arrest (Class IIa, LOE C). Management of oxygen after ROSC is discussed in Part 9: “Post-Cardiac Arrest Care.”Passive Oxygen Delivery During CPRPositive-pressure ventilation has been a mainstay of CPR but recently has come under scrutiny because of the potential for increased intrathoracic pressure to interfere with circulation due to reduced venous return to the heart. In the out-of-hospital setting, passive oxygen delivery via mask with an opened airway during the first 6 minutes of CPR provided by emergency medical services (EMS) personnel was part of a protocol of bundled care interventions (including continuous chest compressions) that resulted in improved survival.6–8 When passive oxygen delivery using a fenestrated tracheal tube (Boussignac tube) during uninterrupted physician-managed CPR was compared with standard CPR, there was no difference in oxygenation, ROSC, or survival to hospital admission.9,10 Chest compressions cause air to be expelled from the chest and oxygen to be drawn into the chest passively due to the elastic recoil of the chest. In theory, because ventilation requirements are lower than normal during cardiac arrest, oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway.2At this time there is insufficient evidence to support the removal of ventilations from CPR performed by ACLS providers.Bag-Mask VentilationBag-mask ventilation is an acceptable method of providing ventilation and oxygenation during CPR but is a challenging skill that requires practice for continuing competency. All healthcare providers should be familiar with the use of the bag-mask device.11,12 Use of bag-mask ventilation is not recommended for a lone provider. When ventilations are performed by a lone provider, mouth-to-mouth or mouth-to-mask are more efficient. When a second provider is available, bag-mask ventilation may be used by a trained and experienced provider. But bag-mask ventilation is most effective when performed by 2 trained and experienced providers. One provider opens the airway and seals the mask to the face while the other squeezes the bag. Bag-mask ventilation is particularly helpful when placement of an advanced airway is delayed or unsuccessful. The desirable components of a bag-mask device are listed in Part 5: “Adult Basic Life Support.”The provider should use an adult (1 to 2 L) bag and the provider should deliver approximately 600 mL of tidal volume sufficient to produce chest rise over 1 second.13 This volume of ventilation is adequate for oxygenation and minimizes the risk of gastric inflation. The provider should be sure to open the airway adequately with a head tilt–chin lift, lifting the jaw against the mask and holding the mask against the face, creating a tight seal. During CPR give 2 breaths (each 1 second) during a brief (about 3 to 4 seconds) pause after every 30 chest compressions.Bag-mask ventilation can produce gastric inflation with complications, including regurgitation, aspiration, and pneumonia. Gastric inflation can elevate the diaphragm, restrict lung movement, and decrease respiratory system compliance.14–16Airway AdjunctsCricoid PressureCricoid pressure in nonarrest patients may offer some measure of protection to the airway from aspiration and gastric insufflation during bag-mask ventilation.17–20 However, it also may impede ventilation and interfere with placement of a supraglottic airway or intubation.21–27 The role of cricoid pressure during out-of-hospital cardiac arrest and in-hospital cardiac arrest has not been studied. If cricoid pressure is used in special circumstances during cardiac arrest, the pressure should be adjusted, relaxed, or released if it impedes ventilation or advanced airway placement. The routine use of cricoid pressure in cardiac arrest is not recommended (Class III, LOE C).Oropharyngeal AirwaysAlthough studies have not specifically considered the use of oropharyngeal airways in patients with cardiac arrest, airways may aid in the delivery of adequate ventilation with a bag-mask device by preventing the tongue from occluding the airway. Incorrect insertion of an oropharyngeal airway can displace the tongue into the hypopharynx, causing airway obstruction. To facilitate delivery of ventilations with a bag-mask device, oropharyngeal airways can be used in unconscious (unresponsive) patients with no cough or gag reflex and should be inserted only by persons trained in their use (Class IIa, LOE C).Nasopharyngeal AirwaysNasopharyngeal airways are useful in patients with airway obstruction or those at risk for developing airway obstruction, particularly when conditions such as a clenched jaw prevent placement of an oral airway. Nasopharyngeal airways are better tolerated than oral airways in patients who are not deeply unconscious. Airway bleeding can occur in up to 30% of patients following insertion of a nasopharyngeal airway.28 Two case reports of inadvertent intracranial placement of a nasopharyngeal airway in patients with basilar skull fractures29,30 suggest that nasopharyngeal airways should be used with caution in patients with severe craniofacial injury.As with all adjunctive equipment, safe use of the nasopharyngeal airway requires adequate training, practice, and retraining. No studies have specifically examined the use of nasopharyngeal airways in cardiac arrest patients. To facilitate delivery of ventilations with a bag-mask device, the nasopharyngeal airway can be used in patients with an obstructed airway. In the presence of known or suspected basal skull fracture or severe coagulopathy, an oral airway is preferred (Class IIa, LOE C).Advanced AirwaysVentilation with a bag and mask or with a bag through an advanced airway (eg, endotracheal tube or supraglottic airway) is acceptable during CPR. All healthcare providers should be trained in delivering effective oxygenation and ventilation with a bag and mask. Because there are times when ventilation with a bag-mask device is inadequate, ideally ACLS providers also should be trained and experienced in insertion of an advanced airway.Providers must be aware of the risks and benefits of insertion of an advanced airway during a resuscitation attempt. Such risks are affected by the patient's condition and the provider's expertise in airway control. There are no studies directly addressing the timing of advanced airway placement and outcome during resuscitation from cardiac arrest. Although insertion of an endotracheal tube can be accomplished during ongoing chest compressions, intubation frequently is associated with interruption of compressions for many seconds. Placement of a supraglottic airway is a reasonable alternative to endotracheal intubation and can be done successfully without interrupting chest compressions.The provider should weigh the need for minimally interrupted compressions against the need for insertion of an endotracheal tube or supraglottic airway. There is inadequate evidence to define the optimal timing of advanced airway placement in relation to other interventions during resuscitation from cardiac arrest. In a registry study of 25 006 in-hospital cardiac arrests, earlier time to invasive airway (<5 minutes) was not associated with improved ROSC but was associated with improved 24-hour survival.31 In an urban out-of-hospital setting, intubation that was achieved in <12 minutes was associated with better survival than intubation achieved in ≥13 minutes.32In out-of-hospital urban and rural settings, patients intubated during resuscitation had a better survival rate than patients who were not intubated,33 whereas in an in-hospital setting, patients who required intubation during CPR had a worse survival rate.34 A recent study8 found that delayed endotracheal intubation combined with passive oxygen delivery and minimally interrupted chest compressions was associated with improved neurologically intact survival after out-of-hospital cardiac arrest in patients with adult witnessed VF/pulseless VT. If advanced airway placement will interrupt chest compressions, providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC (Class IIb, LOE C).For a patient with perfusing rhythm who requires intubation, pulse oximetry and electrocardiographic (ECG) status should be monitored continuously during airway placement. Intubation attempts should be interrupted to provide oxygenation and ventilation as needed.To use advanced airways effectively, healthcare providers must maintain their knowledge and skills through frequent practice. It may be helpful for providers to master one primary method of airway control. Providers should have a second (backup) strategy for airway management and ventilation if they are unable to establish the first-choice airway adjunct. Bag-mask ventilation may serve as that backup strategy.Once an advanced airway is inserted, providers should immediately perform a thorough assessment to ensure that it is properly positioned. This assessment should not interrupt chest compressions. Assessment by physical examination consists of visualizing chest expansion bilaterally and listening over the epigastrium (breath sounds should not be heard) and the lung fields bilaterally (breath sounds should be equal and adequate). A device also should be used to confirm correct placement (see the section “Endotracheal Intubation” below).Continuous waveform capnography is recommended in addition to clinical assessment as the most reliable method of confirming and monitoring correct placement of an endotracheal tube (Class I, LOE A). Providers should observe a persistent capnographic waveform with ventilation to confirm and monitor endotracheal tube placement in the field, in the transport vehicle, on arrival at the hospital, and after any patient transfer to reduce the risk of unrecognized tube misplacement or displacement.The use of capnography to confirm and monitor correct placement of supraglottic airways has not been studied, and its utility will depend on airway design. However, effective ventilation through a supraglottic airway device should result in a capnograph waveform during CPR and after ROSC.Once an advanced airway is in place, the 2 providers should no longer deliver cycles of CPR (ie, compressions interrupted by pauses for ventilation) unless ventilation is inadequate when compressions are not paused. Instead the compressing provider should give continuous chest compressions at a rate of at least 100 per minute, without pauses for ventilation. The provider delivering ventilation should provide 1 breath every 6 to 8 seconds (8 to 10 breaths per minute). Providers should avoid delivering an excessive ventilation rate because doing so can compromise venous return and cardiac output during CPR. The 2 providers should change compressor and ventilator roles approximately every 2 minutes to prevent compressor fatigue and deterioration in quality and rate of chest compressions. When multiple providers are present, they should rotate the compressor role about every 2 minutes.Supraglottic AirwaysSupraglottic airways are devices designed to maintain an open airway and facilitate ventilation. Unlike endotracheal intubation, intubation with a supraglottic airway does not require visualization of the glottis, so both initial training and maintenance of skills are easier. Also, because direct visualization is not necessary, a supraglottic airway is inserted without interrupting compressions. Supraglottic airways that have been studied in cardiac arrest are the laryngeal mask airway (LMA), the esophageal-tracheal tube (Combitube) and the laryngeal tube (Laryngeal Tube or King LT). When prehospital providers are trained in the use of advanced supraglottic airways such as the esophageal-tracheal tube, laryngeal tube, and the laryngeal mask airway, they appear to be able to use these devices safely and can provide ventilation that is as effective as that provided with a bag and mask or an endotracheal tube.12,35–41Advanced airway interventions are technically complicated. Failure can occur; thus maintenance of skills through frequent experience or practice is essential.42 It is important to remember that there is no evidence that advanced airway measures improve survival rates in the setting of out-of-hospital cardiac arrest. During CPR performed by providers trained in its use, the supraglottic airway is a reasonable alternative to bag-mask ventilation (Class IIa, LOE B) and endotracheal intubation (Class IIa, LOE A).Esophageal-Tracheal TubeThe advantages of the esophageal-tracheal tube (Combitube) are similar to the advantages of the endotracheal tube when either is compared with bag-mask ventilation: isolation of the airway, reduced risk of aspiration, and more reliable ventilation. The advantages of the esophageal-tracheal tube over the endotracheal tube are related chiefly to ease of training.12,43 Ventilation and oxygenation with the esophageal-tracheal tube compare favorably with those achieved with the endotracheal tube.44In several controlled clinical trials involving both in-hospital and out-of-hospital resuscitation of adults, providers with all levels of experience were able to insert the esophageal-tracheal tube and deliver ventilation comparable to that achieved with endotracheal intubation.35,45–48 In a retrospective study no difference in outcome was observed in patients treated with the esophageal-tracheal tube compared with those treated with endotracheal intubation.38 The esophageal-tracheal tube is reported to provide successful ventilation during CPR in 62% to 100% of patients.35,45–49 For healthcare professionals trained in its use, the esophageal-tracheal tube is an acceptable alternative to both bag-mask ventilation (Class IIa, LOE C) or endotracheal intubation (Class IIa, LOE A) for airway management in cardiac arrest.Fatal complications may occur with use of the esophageal-tracheal tube if the position of the distal lumen of the esophageal-tracheal tube in the esophagus or trachea is identified incorrectly. For this reason, confirmation of tube placement is essential. Other possible complications related to the use of the esophageal-tracheal tube are esophageal trauma, including lacerations, bruising, and subcutaneous emphysema.45,50,51Laryngeal TubeThe advantages of the laryngeal tube (Laryngeal Tube or King LT) are similar to those of the esophageal-tracheal tube; however, the laryngeal tube is more compact and less complicated to insert (unlike the esophageal-tracheal tube, the laryngeal tube can only go into the esophagus). At this time there are limited data published on the use of the laryngeal tube in cardiac arrest.40,41,52,53 In one case series assessing 40 out-of-hospital cardiac arrest patients, insertion of the laryngeal tube by trained paramedics was successful and ventilation was effective in 85% of patients.41 For 3 patients, ventilation was ineffective because of cuff rupture; for 3 other patients, ventilation was ineffective because of massive regurgitation and aspiration before laryngeal tube placement.Another out-of-hospital assessment of 157 attempts at laryngeal tube placement revealed a 97% success rate in a mixed population of cardiac arrest and noncardiac arrest patients.40 For healthcare professionals trained in its use, the laryngeal tube may be considered as an alternative to bag-mask ventilation (Class IIb, LOE C) or endotracheal intubation for airway management in cardiac arrest (Class IIb, LOE C).Laryngeal Mask AirwayThe laryngeal mask airway provides a more secure and reliable means of ventilation than the face mask.54,55 Although the laryngeal mask airway does not ensure absolute protection against aspiration, studies have shown that regurgitation is less likely with the laryngeal mask airway than with the bag-mask device and that aspiration is uncommon. When compared with the endotracheal tube, the laryngeal mask airway provides equivalent ventilation49,55; successful ventilation during CPR has been reported in 72% to 97% of patients.36,37,44,56–58Because insertion of the laryngeal mask airway does not require laryngoscopy and visualization of the vocal cords, training in its placement and use is simpler than that for endotracheal intubation. The laryngeal mask airway also may have advantages over the endotracheal tube when access to the patient is limited,59,60 there is a possibility of unstable neck injury,61 or appropriate positioning of the patient for endotracheal intubation is impossible.Results from studies in anesthetized patients comparing the laryngeal mask airway with endotracheal intubation, as well as additional studies comparing it with other airways or ventilation techniques support the use of the laryngeal mask airway for airway control in a variety of settings by nurses, respiratory therapists, and EMS personnel, many of whom had not previously used this device.12,39,44,55,62–65After successful insertion, a small proportion of patients cannot be ventilated with the laryngeal mask airway.12,44,55 With this in mind, it is important for providers to have an alternative strategy for airway management. Providers who insert the laryngeal mask airway should receive adequate initial training and then should practice insertion of the device regularly. Success rates and the occurrence of complications should be monitored closely. For healthcare professionals trained in its use, the laryngeal mask airway is an acceptable alternative to bag-mask ventilation (Class IIa, LOE B) or endotracheal intubation (Class IIa, LOE C) for airway management in cardiac arrest.Endotracheal IntubationThe endotracheal tube was once considered the optimal method of managing the airway during cardiac arrest. However, intubation attempts by unskilled providers can produce complications, such as trauma to the oropharynx, interruption of compressions and ventilations for unacceptably long periods, and hypoxemia from prolonged intubation attempts or failure to recognize tube misplacement or displacement. It is now clear that the incidence of complications is unacceptably high when intubation is performed by inexperienced providers or monitoring of tube placement is inadequate. The optimal method of managing the airway during cardiac arrest will vary based on provider experience, characteristics of the EMS or healthcare system, and the patient's condition. Frequent experience or frequent retraining is recommended for providers who perform endotracheal intubation (Class I, LOE B).31,66 EMS systems that perform prehospital intubation should provide a program of ongoing quality improvement to minimize complications (Class IIa, LOE B).No prospective randomized clinical trials have performed a direct comparison of bag-mask ventilation versus endotracheal intubation in adult victims of cardiac arrest. One prospective, randomized controlled trial in an EMS system with short out-of-hospital transport intervals67 showed no survival advantage for endotracheal intubation over bag-mask ventilation in children; providers in this study had limited training and experience in intubation.The endotracheal tube keeps the airway patent, permits suctioning of airway secretions, enables delivery of a high concentration of oxygen, provides an alternative route for the administration of some drugs, facilitates delivery of a selected tidal volume, and, with use of a cuff, may protect the airway from aspiration.Indications for emergency endotracheal intubation are (1) the inability of the provider to ventilate the unconscious patient adequately with a bag and mask and (2) the absence of airway protective reflexes (coma or cardiac arrest). The provider must have appropriate training and experience in endotracheal intubation.During CPR providers should minimize the number and duration of interruptions in chest compressions, with a goal to limit interruptions to no more than 10 seconds. Interruptions for supraglottic airway placement should not be necessary at all, whereas interruptions for endotracheal intubation can be minimized if the intubating provider is prepared to begin the intubation attempt—ie, insert the laryngoscope blade with the tube ready at hand—as soon as the compressing provider pauses compressions. Compressions should be interrupted only for the time required by the intubating provider to visualize the vocal cords and insert the tube; this is ideally less than 10 seconds. The compressing provider should be prepared to resume chest compressions immediately after the tube is passed through the vocal cords. If the initial intubation attempt is unsuccessful, a second attempt may be reasonable, but early consideration should be given to using a supraglottic airway.In retrospective studies, endotracheal intubation has been associated with a 6% to 25% incidence of unrecognized tube misplacement or displacement.68–72 This may reflect inadequate initial training or lack of experience on the part of the provider who performed intubation, or it may have resulted from displacement of a correctly positioned tube when the patient was moved. The risk of tube misplacement, displacement, or obstruction is high,67,70 especially when the patient is moved.73 Thus, even when the endotracheal tube is seen to pass through the vocal cords and tube position is verified by chest expansion and auscultation during positive-pressure ventilation, providers should obtain additional confirmation of placement using waveform capnography or an exhaled CO2 or esophageal detector device (EDD).74The provider should use both clinical assessment and confirmation devices to verify tube placement immediately after insertion and again when the patient is moved. However, no single confirmation technique is completely reliable.75,76 Continuous waveform capnography is recommended in addition to clinical assessment as the most reliable method of confirming and monitoring correct placement of an endotracheal tube (Class I, LOE A).If waveform capnography is not available, an EDD or nonwaveform exhaled CO2 monitor in addition to clinical assessment is reasonable (Class IIa, LOE B). Techniques to confirm endotracheal tube placement are further discussed below.Clinical Assessment to Confirm Tube PlacementProviders should perform a thorough assessment of endotracheal tube position immediately after placement. This assessment should not require interruption of chest compressions. Assessment by physical examination consists of visualizing chest expansion bilaterally and listening over the epigastrium (breath sounds should not be heard) and the lung fields bilaterally (breath sounds should be equal and adequate). A device should also be used to confirm correct placement in the trachea (see below). If there is doubt about correct tube placement, use the laryngoscope to visualize the tube passing through the vocal cords. If still in doubt, remove the tube and provide bag-mask ventilation until the tube can be replaced.Use of Devices" @default.
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W2137722844 title "Part 8: Adult Advanced Cardiovascular Life Support" @default.
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