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CONTEMPO UPDATES
LINKING EVIDENCE AND EXPERIENCE
New Guidelines for Cardiopulmonary
Resuscitation and Emergency Cardiac Care
Changes in the Management of Cardiac Arrest
Karl B. Kern, MD
Henry R. Halperin, MD
John Field, MD
APPROXIMATELY EVERY 6YEARS
the American Heart Associa-
tion, in conjunction with a va-
riety of other national and interna-
tional organizations, has published a
comprehensive review and recommen-
dations for cardiopulmonary resusci-
tation (CPR) and emergency cardiac
care.1-4 Recently the cycle was com-
pleted again with the publication of
“Guidelines 2000 for Cardiopulmo-
nary Resuscitation and Emergency Car-
diovascular Care—International Con-
sensus on Science” (referred to as the
Guidelines).5The American Heart As-
sociation’s Emergency Cardiovascular
Care Committee and its 3 subcommit-
tees (Basic Life Support, Advanced Car-
diac Life Support [ACLS], and Pediat-
ric Life Support [including Basic Life
Support, ALS, and Neonatal]) share re-
sponsibility for updating these recom-
mendations as new science becomes
available. The latest report5sets a new
benchmark in comprehensive, evi-
dence-based, international resuscita-
tion guidelines.
Development of the Guidelines
Following the 1992 Guidelines,4it was
recognized that a more formal, evidence-
based approach to resuscitation sci-
ence was needed. A specific template was
developed and adopted by all the sub-
committees to standardize the evalua-
tion of specific resuscitation topics. This
“Worksheet for Proposed Evidence-
Based Guidelines” was used by the
American Heart Association national
subcommittees, their counterparts on
the International Liaison Committee on
Resuscitation, and was also made avail-
able on the Internet for any other inter-
ested persons to submit a topic for con-
sideration in formulating the Guidelines.
This worksheet strictly defined the level
of scientific evidence and the quality of
that evidence, which led to an integra-
tion of the evidence into a final class of
recommendations6: I, always useful with
excellent supporting data; IIa, prob-
ably useful with good supporting data;
IIb, possibly useful with fair support-
ing data; III, probably harmful; and in-
determinate, with inconclusive support-
ing data. Two major conferences were
held in September 1999 and February
2000 for science review and discus-
sion. More than 500 experts partici-
pated from around the world, with at
least 40% of the attendees being inter-
national representatives. At least 1 US
scientist and 1 additional international
scientist reviewed every topic. Real ef-
fort was made to make the recommen-
dations culturally neutral and adapt-
able throughout the world. The end
result is the first truly international evi-
dence-based guidelines on CPR and
emergency cardiovascular care. One
consequence of the Guidelines’ founda-
tion on international evidence is that
some recommended drugs (particu-
larly their intravenous formulations) and
devices are not currently available in the
United States.
New ACLS Recommendations
All the new or revised recommen-
dations cannot be reviewed in this
summary article. Several of the most
heavily discussed and debated ACLS
changes will be presented, focusing
on changes in the management of car-
diac arrest.
Ventilation. Tracheal intubation re-
mains the procedure of choice for the
unconscious, apneic patient. But it is
well recognized that this skill can be dif-
ficult to perform in the person experi-
encing cardiac arrest and is not with-
out significant challenges, particularly
when performed infrequently. There-
fore, the new Guidelines suggest that
only ACLS providers with regular ex-
perience (6-12 tracheal intubations per
year) should attempt intubation. If tra-
cheal intubation is performed, confir-
mation that the tube is in the trachea
and not the esophagus by an end-tidal
carbon dioxide detector or an esopha-
geal detector device is recommended
(IIa). Likewise, use of a commercially
available tracheal tube holder is rec-
ommended to prevent dislodgment
(IIb). Since the rate of unrecognized dis-
lodgment is low, the sample size needed
to prospectively validate this recom-
mendation is prohibitive. Due to the
dire consequences of such unrecog-
nized tracheal tube dislodgement, how-
ever, such a recommendation seems
reasonable.
Bag-mask ventilation has been the first
choice for basic life support ventilation
but should give way to alternative air-
way ventilation methods once ACLS
providers are available. When tracheal
intubation is neither feasible nor the
best option, several alternative airway
Author Affiliations: Advanced Cardiac Life Support
Subcommittee, American Heart Association, Dallas,
Tex; University of Arizona College of Medicine, Sarver
Heart Center, Tucson (Dr Kern); Johns Hopkins Uni-
versity School of Medicine, Baltimore, Md (Dr Hal-
perin); and Pennsylvania State University College of
Medicine, Hershey (Dr Field).
Corresponding Author and Reprints: Karl B. Kern, MD,
University of Arizona, Sarver Heart Center, Section of
Cardiology, 1501 N Campbell Ave, Tucson, AZ 85724
(e-mail: kernk@u.arizona.edu).
Contempo Updates Section Editor: Alice T. D. Hughes,
MD, Fishbein Fellow.
©2001 American Medical Association. All rights reserved. (Reprinted) JAMA, March 14, 2001—Vol 285, No. 10 1267
ventilation methods, such as the laryn-
geal mask airway or the esophageal-
tracheal combitube, are now strongly
recommended over continued bag-
mask ventilation (IIa). Both are supe-
rior to bag-mask ventilation for selec-
tive ventilation of the lungs and are
associated with less aspiration of
gastric contents. Such devices are famil-
iar in Europe, but less so in the United
States. Many ACLS providers will need
training in their use.
Defibrillation. The previously pub-
lished statement that all health care pro-
viders with a duty to perform CPR should
be trained, equipped, and authorized to
perform defibrillation has been re-
tained from the 1992 Guidelines. An out-
of-hospital goal of early defibrillation
within 5 minutes of a telephone call is
now recommended. Since many cur-
rent emergency medical service sys-
tems may not yet be able to consistently
meet this goal, recommendations for
training and equipping laypersons to pro-
vide public access defibrillation are dis-
cussed. A strong recommendation is
made for providing certain lay basic life
support providers (specifically police of-
ficers, firefighters, security personnel,
sports marshals, ski patrols, ferryboat
crews, and airline flight attendants) with
automated external defibrillators (IIa).
In-hospital goals for defibrillation
are expressed for the first time in the
Guidelines. It was recommended that
early defibrillation capability, defined as
having appropriate equipment and
trained first responders, be made avail-
able throughout hospitals and affiliated
outpatient facilities (IIa). “The goal for
early defibrillation by first responders is
a collapse-to-shock time interval, when
appropriate, of ,3 minutes in all areas
of the hospital and ambulatory care fa-
cilities (I).”5
This is an aggressive challenge for all
inpatient and outpatient facilities that will
require careful review of their current
practice and results. Many will need to
consider new approaches, including the
use of automated external defibrillators
by nonphysicians, to accomplish this rec-
ommended goal. New data published
since the Guidelines support the impor-
tance of this 3-minute time point.7
Circulatory Adjuncts. A number of
alternative techniques to standard CPR
have been developed to improve hemo-
dynamic support during cardiac arrest,
with the ultimate goal of increasing long-
term survival. Several of these innova-
tions have accumulated substantial
experimental and clinical databases. In-
terposed abdominal compression CPR
and active compression-decompres-
sion CPR have been studied the most.8-15
Despite extensive evaluation, neither has
been shown to be consistently better than
standard CPR and both have received IIb
recommendations. It should be noted
that the active compression-decompres-
sion CPR device has not been approved
for sale and distribution in the United
States, but it is in use internationally.
Several other circulatory adjuncts
were reviewed and recommended as
possibly useful (IIb),16,17 but again none
were found to be definitively better than
current standard chest compressions
and ventilations at a 15:2 ratio.
Pharmacology of ACLS. Perhaps the
most controversial recommendations in
the ACLS portion of the new Guide-
lines concern the addition of vasopres-
sin and amiodarone in the algorithm
for ventricular fibrillation/pulseless
ventricular tachycardia cardiac arrest
(FIGURE).
In past CPR guidelines, epinephrine
has been recommended if spontane-
ous circulation is not restored follow-
ing 3 defibrillating shocks. Experi-
mental animal data supporting the use
of epinephrine are convincing. The
primary benefit of epinephrine during
CPR is to increase peripheral vasocon-
striction. This results in increased per-
fusion pressures, increased myocardial
and cerebral blood flow, and improved
outcome. However, the data for clini-
cal cardiac arrest are much less defini-
tive. No adequate trial of epinephrine
vs placebo has ever been completed in
humans. Clinical trials of standard vs
high-dose epinephrine have been
completed, but none used a placebo
control. Recently, interest in vasocon-
strictors other than epinephrine has
led to both experimental and some
preliminary clinical trials with vaso-
pressin. The data are thus far remark-
ably homogeneous. Animal studies
have almost always (21/23 studies at
the time of the Guidelines review)
supported improved hemodynamics,
myocardial blood flow, and short-term
outcome with vasopressin vs either
placebo or epinephrine. A small pilot
study (n= 40) that randomized pa-
Figure. Ventricular Fibrillation (VF)/Pulseless
Ventricular Tachycardia (VT) Algorithm
Primary ABCD Survey
Basic Cardiopulmonary Resuscitation and Defibrillation
Check Responsiveness
Activate Emergency Response System
Call for Defibrillator
A (Airway) Open the Airway
B (Breathing) Provide Positive-Pressure Ventilations
C (Circulation) Give Chest Compressions
D (Defibrillation) Assess for and Shock VF/Pulseless
VT Up to 3 Times (200 J, 200-300 J, 360 J, or
Equivalent Biphasic) if Necessary
Rhythm After First 3 Shocks?
Persistent or Recurrent VF/VT
Secondary ABCD Survey
More Advanced Assessments and Treatments
A (Airway) Place Airway Device as Soon as Possible
B (Breathing) Confirm Airway Device Placement by
Examination and by Confirmation Device
Secure Airway Device; Purpose-Made Tube Holders
Preferred
Confirm Effective Oxygenation and Ventilation
C (Circulation) Establish Intravenous Access
Identify Rhythm and Monitor
Administer Drugs Appropriate for Rhythm and
Condition
D (Differential Diagnosis) Search for and Treat
Identified Reversible Causes
1 mg of Epinephrine Intravenously, Repeat Every 3-5 min
or
40 U of Vasopressin Intravenously, Single Dose,
1 Time Only
Resume Attempts to Defibrillate
1 × 360 J (or Equivalent Biphasic) Within 30-60 seconds
Consider Antiarrhythmics
Amiodarone (IIb for Persistent or Recurrent
VF/Pulseless VT)
Lidocaine (Indeterminate for Persistent or Recurrent
VF/Pulseless VT)
Magnesium (IIb if Known Hypomagnesemic State)
Procainamide (Indeterminate for Persistent
VF/Pulseless VT; IIb for Recurrent VF/Pulseless VT)
Resume Attempts to Defibrillate
Adapted with permission from the American Heart
Association.5
NEW GUIDELINES FOR CARDIOPULMONARY RESUSCITATION
1268 JAMA, March 14, 2001—Vol 285, No. 10 (Reprinted) ©2001 American Medical Association. All rights reserved.
tients in refractory cardiac arrest to
either vasopressin (40 U intrave-
nously) or epinephrine (1 mg intrave-
nously) found improved 24-hour sur-
vival, but no difference at hospital
discharge, with vasopressin.18 No dif-
ference in outcome was found in an
unpublished study reviewed during
the deliberations of a 200-patient,
in-hospital trial of vasopressin vs epi-
nephrine (Ian Stiell, MD, MSc, unpub-
lished data, 2000). No clinical data yet
exist for vasopressin vs placebo in
human cardiac arrest. The conference
conclusion was that vasopressin is an
effective vasoconstrictor and can be
used once as an alternative to epineph-
rine for the treatment of shock-
refractory ventricular fibrillation (IIb).
Repeated efforts to show efficacy for
antiarrhythmics administered during
CPR for shock-refractory ventricular fi-
brillation have failed until recently.
Amiodarone was recently found to im-
prove survival to hospital admission in
the Amiodarone for Resuscitation After
Out-of-Hospital Cardiac Arrest Due to
Ventricular Fibrillation (ARREST) trial,
a prospective, randomized, double-
blind, placebo-controlled clinical trial of
amiodarone during CPR in patients with
out-of-hospital cardiac arrest due to
shock-refractory ventricular fibrillation
or pulseless ventricular tachycardia.19 Im-
portantly, amiodarone was not com-
pared with lidocaine or other antiar-
rhythmic drugs in this trial. A total of 504
patients who experienced out-of-
hospital cardiac arrest were enrolled.
Each patient was in ventricular fibrilla-
tion despite at least 3 defibrillation
shocks, had already been intubated, had
intravenous access, and had received
1 mg of epinephrine. The primary end
point of survival to hospital admission
was significantly better in the amioda-
rone group compared with placebo
group (108/246 [44%] vs 89/258 [35%];
P,.03). Though this surrogate end point
was recognized by the Guidelines par-
ticipants not to be the final answer, the
trial marked the first time any improve-
ment with antiarrhythmic therapy ad-
ministered during cardiac arrest had been
found. Noteworthy was the interval to
treatment. The mean (SD) interval from
telephone call to drug administration in
the amiodarone group was 21 (8) min-
utes. There is hope that even more pow-
erful outcome improvements may be
possible if the drug can be adminis-
tered earlier. Caution is warranted how-
ever until more data are available. For ex-
ample, some vasoconstrictive agent may
be necessary during CPR before admin-
istering amiodarone to counteract its po-
tent vasodilatory properties. Based on the
ARREST trial, amiodarone was recom-
mended for consideration as an alterna-
tive to lidocaine in shock-refractory ven-
tricular fibrillation/pulseless ventricular
tachycardia cardiac arrest (IIb).
Lidocaine remains an alternative
choice but since it has little outcome data
supporting its use it received only an in-
determinate recommendation. Bretylium
tosylate was eliminated from the algo-
rithm because of a lack of demon-
strated efficacy and because it is no
longer being produced.
Asystole. Recognizing the dismal rate
of survival for collapsed individuals
found in asystole, a new emphasis on not
starting and appropriate stopping ap-
pears in the revised asystole algorithm.
Rescuers are advised to consider the qual-
ity of resuscitation effort thus far, if atypi-
cal or special clinical features exist, and
if there is support for withholding or
stopping resuscitation efforts outside the
hospital. If an adequate resuscitation ef-
fort has been made, and unusual circum-
stances (such as hypothermia, drug over-
dose, or drowning) are not present,
persistent asystole indicates a confirma-
tion of death rather than a treatable car-
diac arrest rhythm. Cessation of resus-
citation efforts is recommended if
asystole persists for at least 10 minutes
after CPR has been performed, ventricu-
lar fibrillation eliminated, successful en-
dotracheal intubation accomplished and
confirmed, adequate ventilation pro-
vided, and appropriate medications ad-
ministered.
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NEW GUIDELINES FOR CARDIOPULMONARY RESUSCITATION
©2001 American Medical Association. All rights reserved. (Reprinted) JAMA, March 14, 2001—Vol 285, No. 10 1269
