PCR and Emergency Cardiovascular Care

A Summary of 2015 AHA Guidelines Update
for CPR and Emergency Cardiovascular Care
Based on the 2015 American Heart Association (AHA) Guidelines Update for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC)1
Key Points
• The guidelines are an update to the 2010 AHA Guidelines for CPR and ECC, incorporating evidence from systematic reviews completed as part of the 2015 International Consensus on CPR and ECC Science With Treatment Recommendations
• (Hazinski MF, Circulation. 2015;132 (18 Suppl 2):S2-S39).
• The 315 recommendations included: 78 class I recommendations, 217 class II recommendations, and 20 class III recommendations.

• “Part 4: Systems of Care and Continuous Quality Improvement,” which replaces the “CPR Overview” part of the 2010 guidelines, focuses on the integrated structures and processes needed for in-hospital care and out-of-hospital resuscitation which measurably improve both quality of care and patient outcomes.
• “Part 10: Special Circumstances of Resuscitation” presents new guidelines for the prevention and management of resuscitation emergencies related to opioid toxicity, updated guidelines for management of cardiac arrests occurring in the second half of pregnancy, and intravenous lipid emulsion therapy for treatment of cardiac arrest due to drug overdose.
• “Part 13: Neonatal Resuscitation” presents new guidelines for resuscitation of newborn infants, which are also applicable to neonates who require resuscitation during the first weeks after birth.

• “Part 14: Education” replaces the “Education, Implementation, and Teams” part of the 2010 guidelines, focusing on evidence-based recommendations aimed at implementation of guideline recommendations.
• Systems of care for out-of-hospital cardiac arrest and in-hospital cardiac arrest must function differently:
o Focus on in-hospital cardiac arrest is shifting from reactive resuscitation to prevention.
o New Chains of Survival are suggested for in-hospital and out-of-hospital systems of care, emphasizing the in-hospital focus on prevention of cardiac arrests and continuous quality improvement.

Clinically Relevant Recommendations
• Upper limits for frequency and depth of chest compression and additional care for specific situations (eg, opioid overdose, unconscious patient) are recommended.
• Use of mechanical piston devices as an aid to conventional CPR can be considered when manual compression may not be able to be adequately delivered.
• Use of vasopressin, epinephrine, and methylprednisolone for in-hospital cardiac arrest, and post-arrest hydrocortisone may be considered but should not be part of routine therapy pending further studies.
• The use of an impedance threshold device with conventional CPR may not improve outcomes as compared with a sham device and is therefore not recommended for routine use.
• All comatose patients with ROSC (Restoration of spontaneous circulation) after arrest should have targeted temperature management with any temperature between 32°C and 36°C for at least 24 hours. Fevers may be suppressed.
• A prehospital ECG should be obtained as early as possible and prehospital activation of the cath lab should occur for all patients with recognized STEMI. If the ECG is not transmitted to a physician, it is reasonable for a trained non-physician interpretation to be used for decision-making, including cath lab activation and administration of fibrinolysis.
• Withholding oxygen therapy in normoxic patients with suspected ACS may be considered due to lack of evidence in support of its use despite tradition.
• Coronary angiography should be performed emergently for out-of-hospital cardiac arrest patients with suspected cardiac etiology of arrest and ST elevation on ECG, and is reasonable for select adults without ST elevation on ECG who are comatose.
• An early warning scoring system that identifies adult and pediatric patients at risk of deterioration and establishment of in-hospital teams to care for patients who are deteriorating are worth considering.
Additional Points of Note
• Much of the data supporting pediatric basic life support is extrapolated from studies in adults. Studies addressing in-hospital and out-of-hospital cardiac arrest in children are needed to optimize CPR delivery and outcomes for children.
• Neonatal resuscitation features an increasing focus on umbilical cord management, maintaining a normal temperature after birth, accurate determination of heart rate, optimizing oxygen use during resuscitation, and less emphasis of routine suctioning for meconium in non-vigorous newborns.
• The authors note that “these results highlight the persistent knowledge gap in resuscitation science that needs to be addressed through expanded research initiatives and funding opportunities.”
Methods Used:
The 2015 guidelines document was written by 24 authors from the AHA and academic/medical institutions in the United States and Canada.
As in the past, the evidence review process involved the AHA and the International Liaison Committee on Resuscitation. For 2015, topics for systematic review were prioritized based on the clinical significance and availability of new evidence. In the absence of new published evidence or controversy, topics were not re-reviewed.