Even if obtaining a stable return of spontaneous circulation (ROSC) is the major endpoint of cardiopulmonary resuscitation (CPR), the following outcome is poor in many cardiac arrest patients with a return of cardiac activity. During their subsequent in-hospital course, many of these victims will die as illustrated by a very high mortality rate in ICU, reaching up to 60–70% in both in-hospital cardiac arrest (IHCA) and out-of-hospital cardiac arrest (OHCA).
Initial, successful, resuscitation after cardiopulmonary resuscitation in patients with sudden cardiac arrest is increasing, as well as their survival through admission to Intensive Care Units (ICU). However, what happens then? Between 50 and 89% of these survivors will die in-hospital and this number is not improving in parallel with initial success. More than 40% of deaths following cardiac arrest patients admitted to ICU can be attributed to withdrawal of life supporting therapy, typically due to expectations of poor outcome.
In patients with a sustainable ROSC, a complex pathophysiological process commonly occurs, called Post-cardiac Arrest Syndrome, which involves in various degrees both hemodynamic disturbances and anoxo-ischemic brain injuries (Reperfusion Injury).
Are we resuscitating our goals? Ourselves?
Sam Dabaja, RN AHA-BLS/ACLS Faculty
The 2018 American Heart Association Focused Updates on Adult Advanced Cardiovascular Life Support
The question prioritized for review this year addressed the use of antiarrhythmic drugs for the treatment of shock-refractory ventricular fibrillation (VF) or pulseless ventricular tachycardia (pVT) during or immediately after cardiac arrest.
1. Amiodarone or lidocaine may be considered for Ventricular Fibrillation/pulseless Ventricular Tachycardia (VF/pVT) that is unresponsive to defibrillation. These drugs may be particularly useful for patients with witnessed arrest, for whom time to drug administration may be shorter.
2. Lidocaine has been added to the ACLS Cardiac Arrest Algorithm and the ACLS Cardiac Arrest Circular Algorithm for treatment of shock-refractory VF/pVT
3. The routine use of Magnesium for cardiac arrest is not recommended in adult patients. Magnesium may be considered for torsades de pointes (i.e., polymorphic VT associated with long QT interval).
4. There is insufficient evidence to support or refute the routine use of a β-blocker early (within the first hour) after return of spontaneous circulation (ROSC).
5. There is insufficient evidence to support or refute the routine use of lidocaine early (within the first hour) after ROSC. In the absence of contraindications, the prophylactic use of lidocaine may be considered in specific circumstances (such as during emergency medical services transport) when treatment of recurrent VF/pVT might prove to be challenging.
The key change contained in the 2018 ACLS Guidelines Focused Update is a revised recommendation enabling consideration of lidocaine as an alternative to amiodarone for shock-refractory VF/pVT. This revision resulted in a change to the Adult Cardiac Arrest Algorithm and to the Adult Cardiac Arrest Circular Algorithm.
The 2018 ILCOR systematic review identified no new studies about the effect of magnesium in adults with shock-refractory VF/pVT. As a result, the ACLS writing group reaffirmed previous recommendations against the routine use of magnesium for VF/pVT cardiac arrest, but it may be considered for torsades de pointes (i.e., polymorphic VT associated with a long QT interval).
There were no new studies about antiarrhythmic use in adults during the first hour after return of spontaneous circulation (ROSC). The ACLS writing group noted there was insufficient evidence to make a recommendation about the routine use of ẞ-blockers or lidocaine early after ROSC. However, they did note that in the absence of contraindications, the prophylactic use of lidocaine may be considered in specific circumstances when treatment of recurrent VF/pVT might prove to be logistically challenging (such as during emergency medical services transport after ROSC).
Source: CPR & ECC Guidelines