2019 Focused update on Advanced cardiac life support

American Heart Association published focused update on Advanced Cardiac Life Support in conjunction with 2019 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendation from International liaison committee on resuscitation(ILCOR).

This focus update  provide new recommendations for use of advanced airways, vasopressors and extracorporeal CPR( ECPR).  Rest of the guidelines remain same. Here is a brief summary

CHOICE OF AN ADVANCED AIRWAY

Advanced airway provides definite ventilatory support  during  resuscitation  but placing it  during the ongoing chest compressions  is tricky and can sometimes  cause adverse events.  Based on new trials/ systemic review,  following  are 2019 recommendations

  1.  Either BMV  or an advanced airway may be considered during the CPR.
  2.  If in advanced airway is used,  supraglottic airway can be used in adults with out of hospital cardiac arrest( minimal training personnel)
  3.  For optimally trained professionals,  either supraglottic or endotracheal tube can be used in patients with out of hospital cardiac arrest.  Same for in-hospital cardiac arrest  where trained  individuals are available.
  4.  Frequent experience and frequent retaining is recommended for personal who perform endotracheal intubation,  with emphasis on ongoing quality improvement.

USE OF VASOPRESSORS IN CARDIAC ARREST

Based on new trials of which were included in systemic review,  following recommendations are made.

  1.  Epinephrine should be administered 1 mg every 3-5 minutes.  High-dose epinephrine is not recommended.
  2.  Vasopressin  alone or in combination with epinephrine may be considered in cardiac arrest but offers no advantage.
  3.  Epinephrine should be administered as soon as possible in non shockable rhythm.  In patients with a shockable rhythm,  it is reasonable to administer epinephrine after initial defibrillation attempts have failed.

EXTRACORPOREAL CPR

ECPR refers to the initiation of cardiopulmonary bypass during the resuscitation of a patient in cardiac arrest. This involves the cannulation of a large vein and artery and initiation of venoarterial extracorporeal circulation and oxygenation. There are no RCTs on the use of ECPR for OHCA.  Based on meta-analysis of observational studies, following recommendations are made.

  1. ECPR may be considered for selected patients as rescue therapy when conventional CPR efforts are failing in settings in which it can be expeditiously implemented and supported by skilled providers. There is insufficient evidence to support its routine use.