2010 American Heart Association

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Automatic Transport Ventilators In both out-of-hospital and in-hospital settings, automatic transport ventilators (ATVs) can be useful for ventilation of adult patients in noncardiac arrest who have an advanced airway in place (Class IIb, LOE C). There are very few studies evaluating the use of ATVs attached to advanced airways during ongoing resuscitative efforts. During prolonged resuscitative efforts the use of an ATV (pneumatically powered and time- or pressure-cycled) may allow the EMS team to perform other tasks while providing adequate ventilation and oxygenation (Class IIb, LOE C). 126,127 Providers should always have a bag-mask device available for backup. Suction Devices Both portable and installed suction devices should be available for resuscitation emergencies. Portable units should provide adequate vacuum and flow for pharyngeal suction. The suction device should be fitted with largebore, nonkinking suction tubing and semirigid pharyngeal tips. Several sterile suction catheters of various sizes should be available for suctioning the lumen of the advanced airway, along with a nonbreakable collection bottle and sterile water for cleaning tubes and catheters. The installed suction unit should be powerful enough to provide an airflow of �40 L/min at the end of the delivery tube and a vacuum of �300 mm Hg when the tube is clamped. The amount of suction should be adjustable for use in children and intubated patients. Summary All basic and advanced healthcare providers should be able to provide ventilation with a bag-mask device during CPR or when the patient demonstrates cardiorespiratory compromise. Airway control with an advanced airway, which may include an endotracheal tube or a supraglottic airway device, is a fundamental ACLS skill. Prolonged interruptions in chest compressions should be avoided during advanced airway placement. All providers should be able to confirm and monitor correct placement of advanced airways; this key skill is required to ensure the safe and effective use of these devices. Training, frequency of use, and monitoring of success and complications are more important than the choice of a specific advanced airway device for use during CPR. Part 8.2: Management of Cardiac Arrest Overview This section details the general care of a patient in cardiac arrest and provides an overview of the 2010 ACLS Adult Cardiac Arrest Algorithms (Figures 1 and 2). Cardiac arrest can be caused by 4 rhythms: ventricular fibrillation (VF), pulseless ventricular tachycardia (VT), pulseless electric activity (PEA), and asystole. VF represents disorganized electric activity, whereas pulseless VT represents organized electric activity of the ventricular myocardium. Neither of these rhythms generates significant forward blood flow. PEA encompasses a heterogeneous group of organized electric rhythms that are associated with either Neumar et al Part 8: Adult Advanced Cardiovascular Life Support S735 absence of mechanical ventricular activity or mechanical ventricular activity that is insufficient to generate a clinically detectable pulse. Asystole (perhaps better described as ventricular asystole) represents absence of detectable ventricular electric activity with or without atrial electric activity. Survival from these cardiac arrest rhythms requires both basic life support (BLS) and a system of advanced cardiovascular life support (ACLS) with integrated post–cardiac arrest care. The foundation of successful ACLS is highquality CPR, and, for VF/pulseless VT, attempted defibrillation within minutes of collapse. For victims of witnessed VF arrest, early CPR and rapid defibrillation can significantly increase the chance for survival to hospital discharge. 128–133 In comparison, other ACLS therapies such as some medications and advanced airways, although associated with an increased rate of ROSC, have not been shown to increase the rate of survival to hospital discharge. 31,33,134–138 The majority of clinical trials testing these ACLS interventions, however, preceded the recently renewed emphasis on high-quality CPR and advances in post–cardiac arrest care (see Part 9: “Post–Cardiac Arrest Care”). Therefore, it remains to be determined if improved rates of ROSC achieved with ACLS interventions might better translate into improved long-term outcomes when combined with higherquality CPR and post–cardiac arrest interventions such as therapeutic hypothermia and early percutaneous coronary intervention (PCI). The 2010 ACLS Adult Cardiac Arrest Algorithms (Figures 1 and 2) are presented in the traditional box-and-line format and a new circular format. The 2 formats are provided to facilitate learning and memorization of the treatment recommendations discussed below. Overall these algorithms have been simplified and redesigned to emphasize the importance of high-quality CPR that is fundamental to the management of all cardiac arrest rhythms. Periodic pauses in CPR should be as brief as possible and only as necessary to assess rhythm, shock VF/VT, perform a pulse check when an organized rhythm is detected, or place an advanced airway. Monitoring and optimizing quality of CPR on the basis of either mechanical parameters (chest compression rate and depth, adequacy of relaxation, and minimization of pauses) or, when feasible, physiologic parameters (partial pressure of end-tidal CO 2 [PETCO 2], arterial pressure during the relaxation phase of chest compressions, or central venous oxygen saturation [ScvO 2]) are encouraged (see “Monitoring During CPR” below). In the absence of an advanced airway, a synchronized compression–ventilation ratio of 30:2 is recommended at a compression rate of at least 100 per minute. After placement of a supraglottic airway or an endotracheal tube, the provider performing chest compressions should deliver at least 100 compressions per minute continuously without pauses for ventilation. The provider delivering ventilations should give 1 breath every 6 to 8 seconds (8 to 10 breaths per minute) and should be particularly careful to avoid delivering an excessive number of ventilations (see Part 8.1: “Adjuncts for Airway Control and Ventilation”). Downloaded from circ.ahajournals.org at NATIONAL TAIWAN UNIV on October 18, 2010
S736 Circulation November 2, 2010 In addition to high-quality CPR, the only rhythm-specific therapy proven to increase survival to hospital discharge is defibrillation of VF/pulseless VT. Therefore, this intervention is included as an integral part of the CPR cycle when the rhythm check reveals VF/pulseless VT. Other ACLS inter- Figure 1. ACLS Cardiac Arrest Algorithm. ventions during cardiac arrest may be associated with an increased rate of ROSC but have not yet been proven to increase survival to hospital discharge. Therefore, they are recommended as considerations and should be performed without compromising quality of CPR or timely defibril- Downloaded from circ.ahajournals.org at NATIONAL TAIWAN UNIV on October 18, 2010
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ous disclosure and management of po
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decrease the number of futile trans
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essential bridge between BLS and lo
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we continue to support a combinatio
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● Since 2005 considerable new dat
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Guidelines Part 1: Executive Summar
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implementation in UK intensive care
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DNAR Orders in OHCA Out-of-hospital
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lood flow to vital organs and to ac
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2010 American Heart Association

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