2015 ACLS Summary of Key Issues and Major Changes
Vasopressin 2015 (Updated): Vasopressin in combination with epinephrine offers no advantage as a substitute for standard-dose epinephrine in cardiac arrest. 2010
(Old): One dose of vasopressin 40 units IV/ intraosseously may replace either the first or second dose of epinephrine in the treatment of cardiac arrest. Why: Both epinephrine and vasopressin administration during cardiac arrest have been shown to improve ROSC. Review of the available evidence shows that efficacy of the 2 drugs is similar and that there is no demonstrable benefit from administering both epinephrine and vasopressin as compared with epinephrine alone. In the interest of simplicity, vasopressin has been removed from the Adult Cardiac Arrest Algorithm.
ETCO2 for Prediction of Failed Resuscitation
In intubated patients, failure to achieve an ETCO2 of greater than 10 mm Hg by waveform capnography after 20 minutes of CPR may be considered as one component of a multimodal approach to decide when to end resuscitative efforts but should not be used in isolation. Why: Failure to achieve an ETCO2 of 10 mm Hg by waveform capnography after 20 minutes of resuscitation has been associated with an extremely poor chance of ROSC and survival. However, the studies to date are limited in that they have potential confounders and have included relatively small numbers of patients, so it is inadvisable to rely solely on ETCO2 in determining when to terminate resuscitation.
Extracorporeal CPR 2015 (New):
ECPR may be considered among select cardiac arrest patients who have not responded to initial conventional CPR, in settings where it can be rapidly implemented. Why: Although no high-quality studies have compared ECPR to conventional CPR, a number of lower-quality studies suggest improved survival with good neurologic outcome for select patient populations. Because ECPR is resource intensive and costly, it should be considered only when the patient has a reasonably high likelihood of benefit— in cases where the patient has a potentially reversible illness or to support a patient while waiting for a cardiac transplant.
Post–Cardiac Arrest Drug Therapy: Lidocaine
2015 (New): There is inadequate evidence to support the routine use of lidocaine after cardiac arrest. However, the initiation or continuation of lidocaine may be considered immediately after ROSC from cardiac arrest due to VF/pVT. Why: While earlier studies showed an association between giving lidocaine after myocardial infarction and increased mortality, a recent study of lidocaine in cardiac arrest survivors showed a decrease in the incidence of recurrent VF/pVT but did not show either long-term benefit or harm.
Post–Cardiac Arrest Drug Therapy: ß-Blockers
2015 (New): There is inadequate evidence to support the routine use of a ß-blocker after cardiac arrest. However, the initiation or continuation of an oral or IV ß-blocker may be considered early after hospitalization from cardiac arrest due to VF/pVT. Why: In an observational study of patients who had ROSC after VF/pVT cardiac arrest, ß-blocker administration was associated with higher survival rates. However, this finding is only an associative relationship, and the routine use of ß-blockers after cardiac arrest is potentially hazardous because ß-blockers can cause or worsen hemodynamic instability, exacerbate heart failure, and cause bradyarrhythmias. Therefore, providers should evaluate patients individually for their suitability for ß-blockers.
Summary of Key Issues and Major Changes
Key issues and major changes in the 2015 Guidelines Update recommendations for advanced cardiac life support include the following:
• The combined use of vasopressin and epinephrine offers no advantage to using standard-dose epinephrine in cardiac arrest. Also, vasopressin does not offer an advantage over the use of epinephrine alone. Therefore, to simplify the algorithm, vasopressin has been removed from the Adult Cardiac Arrest Algorithm– 2015 Update. 14 American Heart Association
• Low end-tidal carbon dioxide (ETCO2 ) in intubated patients after 20 minutes of CPR is associated with a very low likelihood of resuscitation. While this parameter should not be used in isolation for decision making, providers may consider low ETCO2 after 20 minutes of CPR in combination with other factors to help determine when to terminate resuscitation.
• Steroids may provide some benefit when bundled with vasopressin and epinephrine in treating IHCA. While routine use is not recommended pending follow-up studies, it would be reasonable for a provider to administer the bundle for IHCA.
• When rapidly implemented, ECPR can prolong viability, as it may provide time to treat potentially reversible conditions or arrange for cardiac transplantation for patients who are not resuscitated by conventional CPR.
• In cardiac arrest patients with nonshockable rhythm and who are otherwise receiving epinephrine, the early provision of epinephrine is suggested.
• Studies about the use of lidocaine after ROSC are conflicting, and routine lidocaine use is not recommended. However, the initiation or continuation of lidocaine may be considered immediately after ROSC from VF/pulseless ventricular tachycardia (pVT) cardiac arrest.
• One observational study suggests that ß-blocker use after cardiac arrest may be associated with better outcomes than when ß-blockers are not used. Although this observational study is not strong-enough evidence to recommend routine use, the initiation or continuation of an oral or intravenous (IV) ß-blocker may be considered early after hospitalization from cardiac arrest due to VF/pVT.