The 2015 Updated Resuscitation Guidelines

Fortunately, it is rare that a patient in the electrophysiology laboratory requires cardiopulmonary resuscitation (CPR). These uncommon situations include cardiac tamponade during ablation procedures or device implantation, refractory ventricular fibrillation during defibrillation threshold testing, pulseless electrical activity in a patient with advanced heart failure and ventricular tachycardia undergoing a prolonged ablation procedure, and acute myocardial infarction caused by inadvertent coronary occlusion during an ablation procedure. Although these scenarios are uncommon, it is critical that the EP team is prepared to promptly and effectively manage these patients when these events occur. Part of this preparation involves familiarity with and certification in Basic Life Support (BLS) and Advanced Cardiac Life Support (ACLS), and periodic drills to practice resuscitation for tamponade in the EP lab. 

The Resuscitation Guidelines have recently been updated.¹ A summary of the changes in the 2015 BLS and ACLS guidelines that pertain to electrophysiologists and the EP lab is below:

BLS

• The 2010 Guidelines are most notable for the reorientation of the universal sequence from A-B-C (Airway, Breathing, Compressions) to C-A-B (Compressions, Airway, Breathing) to minimize time to initiation of chest compressions.
• The most common errors of resuscitation are inadequate compression rate and depth. New to this 2015 Guidelines Update are upper limits of recommended compression rate. In addition, an upper limit of compression depth is introduced based on a report associating increased non–life-threatening injuries with excessive compression depth.
• In adult victims of cardiac arrest, it is reasonable for rescuers to perform chest compressions at a rate of 100 to 120/min. 
• During manual CPR, rescuers should perform chest compressions at a depth of at least 2 inches or 5 cm for an average adult, while avoiding excessive chest compression depths (greater than 2.4 inches [6 cm]). 
• In adult cardiac arrest, total preshock and postshock pauses in chest compressions should be as short as possible.

ACLS

• 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.
• 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.
• The term extracorporeal CPR (ECPR) is used to describe the initiation of extracorporeal circulation and oxygenation during the resuscitation of a patient in cardiac arrest. 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.

In addition to making changes to BLS and ACLS, the 2015 Resuscitation Guidelines make a statement about the use of ultrasound during cardiac arrest: “Bedside cardiac and noncardiac ultrasound are frequently used as diagnostic and prognostic tools for critically ill patients. Ultrasound may be applied to patients receiving CPR to help assess myocardial contractility and to help identify potentially treatable causes of cardiac arrest such as hypovolemia, pneumothorax, pulmonary thromboembolism, or pericardial tamponade. However, it is unclear whether important clinical outcomes are affected by the routine use of ultrasound among patients experiencing cardiac arrest.”¹ Although this statement may be appropriate when ultrasound is applied to the average patient experiencing a cardiac arrest, echocardiography does have a clear role in the evaluation of an unstable patient during or after an EP procedure. Given that pericardial tamponade should be assumed present until proven otherwise in any patient with hemodynamic collapse during or soon after an EP procedure, cardiac ultrasound should be immediately available in the EP lab, as well as in hospital units where patients are recovering after EP procedures. 

Historically, the American Heart Association (AHA) has updated the Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Guidelines every five years, leading to long delays between the availability of new information in the literature and updates to the Guidelines. Now the AHA will make these Guidelines available online (ECCguidelines.heart.org) and will be updating them continuously. This is arguably the most important change to these Guidelines, and likely represents the beginning of a welcome new model for all Practice Guidelines. It is important to recognize too that this new model will inevitably lead to additional work for guideline writing committees. These volunteer writers deserve much gratitude from peers, patients, payers, and industry. Medicine is one of few professions where so much of the efforts to improve outcomes are a product of countless hours of uncompensated, volunteered time.

Reference

1. Neumar RW, Shuster M, Callaway CW, et al. Part 1: executive summary: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015;132(Suppl 2):S315-S367.