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Effect of Intra-arrest Transport, Extracorporeal Cardiopulmonary Resuscitation, and Immediate Invasive Assessment and Treatment on Functional Neurologic Outcome in Refractory Out-of-Hospital Cardiac Arrest: A Randomized Clinical Trial. JAMA 2022; 327:737. 70. Suverein MM, Delnoij TSR, Lorusso R, et al. Early Extracorporeal CPR for Refractory Out-of- Hospital Cardiac Arrest. N Engl J Med 2023; 388:299. 71. Jacobs IG, Finn JC, Jelinek GA, et al. Effect of adrenaline on survival in out-of-hospital cardiac arrest: A randomised double-blind placebo-controlled trial. Resuscitation 2011; 82:1138. https://www.uptodate.com/contents/advanced-cardiac-life-support-acls-in-adults/print 35/52 7/6/23, 11:24 AM Advanced cardiac life support (ACLS) in adults - UpToDate 72. Atkinson P, Bowra J, Milne J, et al. International Federation for Emergency Medicine Consensus Statement: Sonography in hypotension and cardiac arrest (SHoC): An international consensus on the use of point of care ultrasound for undifferentiated hypotension and during cardiac arrest. CJEM 2017; 19:459. 73. Lalande E, Burwash-Brennan T, Burns K, et al. Is point-of-care ultrasound a reliable predictor of outcome during atraumatic, non-shockable cardiac arrest? A systematic review and meta- analysis from the SHoC investigators. Resuscitation 2019; 139:159. 74. Lown B. Electrical reversion of cardiac arrhythmias. Br Heart J 1967; 29:469. 75. Delaney B, Loy J, Kelly AM. The relative efficacy of adenosine versus verapamil for the treatment of stable paroxysmal supraventricular tachycardia in adults: a meta-analysis. Eur J Emerg Med 2011; 18:148. 76. Gebril A, Hawes S. Towards evidence-based emergency medicine: best BETs from the Manchester Royal Infirmary. 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Circulation 1988; 77:392. 82. Hooper A, Nolan JP, Rees N, et al. Drug routes in out-of-hospital cardiac arrest: A summary of current evidence. Resuscitation 2022; 181:70. 83. Kawano T, Grunau B, Scheuermeyer FX, et al. Intraosseous Vascular Access Is Associated With Lower Survival and Neurologic Recovery Among Patients With Out-of-Hospital Cardiac Arrest. Ann Emerg Med 2018; 71:588. 84. Berg KM, Soar J, Andersen LW, et al. Adult Advanced Life Support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science https://www.uptodate.com/contents/advanced-cardiac-life-support-acls-in-adults/print 36/52 7/6/23, 11:24 AM Advanced cardiac life support (ACLS) in adults - UpToDate With Treatment Recommendations. Circulation 2020; 142:S92. 85. Reynolds JC, Issa MS, C Nicholson T, et al. Prognostication with point-of-care echocardiography during cardiac arrest: A systematic review. Resuscitation 2020; 152:56. 86. Blyth L, Atkinson P, Gadd K, Lang E. Bedside focused echocardiography as predictor of survival in cardiac arrest patients: a systematic review. Acad Emerg Med 2012; 19:1119. 87. Gaspari R, Weekes A, Adhikari S, et al. Emergency department point-of-care ultrasound in out-of-hospital and in-ED cardiac arrest. Resuscitation 2016; 109:33. 88. Bolvardi E, Pouryaghobi SM, Farzane R, et al. The Prognostic Value of Using Ultrasonography in Cardiac Resuscitation of Patients with Cardiac Arrest. Int J Biomed Sci 2016; 12:110. 89. Tsou PY, Kurbedin J, Chen YS, et al. Accuracy of point-of-care focused echocardiography in predicting outcome of resuscitation in cardiac arrest patients: A systematic review and meta-analysis. Resuscitation 2017; 114:92. 90. Callaway CW, Donnino MW, Fink EL, et al. Part 8: Post-Cardiac Arrest Care: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2015; 132:S465. 91. Lauridsen KG, Baldi E, Smyth M, et al. Clinical decision rules for termination of resuscitation during in-hospital cardiac arrest: A systematic review of diagnostic test accuracy studies. Resuscitation 2021; 158:23. 92. Mohr M, Bahr J, Schmid J, et al. The decision to terminate resuscitative efforts: results of a questionnaire. Resuscitation 1997; 34:51. 93. Marco CA, Bessman ES, Schoenfeld CN, Kelen GD. Ethical issues of cardiopulmonary resuscitation: current practice among emergency physicians. Acad Emerg Med 1997; 4:898. 94. de Vos R, Oosterom L, Koster RW, de Haan RJ. Decisions to terminate resuscitation. Resuscitation Committee. Resuscitation 1998; 39:7. 95. Bailey ED, Wydro GC, Cone DC. Termination of resuscitation in the prehospital setting for adult patients suffering nontraumatic cardiac arrest. National Association of EMS Physicians Standards and Clinical Practice Committee. Prehosp Emerg Care 2000; 4:190. 96. Horsted TI, Rasmussen LS, Lippert FK, Nielsen SL. Outcome of out-of-hospital cardiac arrest- why do physicians withhold resuscitation attempts? Resuscitation 2004; 63:287. 97. Levine RL, Wayne MA, Miller CC. End-tidal carbon dioxide and outcome of out-of-hospital cardiac arrest. N Engl J Med 1997; 337:301. 98. Grmec S, Klemen P. Does the end-tidal carbon dioxide (EtCO2) concentration have prognostic value during out-of-hospital cardiac arrest? Eur J Emerg Med 2001; 8:263. https://www.uptodate.com/contents/advanced-cardiac-life-support-acls-in-adults/print 37/52 7/6/23, 11:24 AM Advanced cardiac life support (ACLS) in adults - UpToDate 99. Ahrens T, Schallom L, Bettorf K, et al. End-tidal carbon dioxide measurements as a prognostic indicator of outcome in cardiac arrest. Am J Crit Care 2001; 10:391. 100. Morrison LJ, Visentin LM, Kiss A, et al. Validation of a rule for termination of resuscitation in out-of-hospital cardiac arrest. N Engl J Med 2006; 355:478. 101. Ong ME, Jaffey J, Stiell I, et al. Comparison of termination-of-resuscitation guidelines for basic life support: defibrillator providers in out-of-hospital cardiac arrest. Ann Emerg Med 2006; 47:337. 102. Stiell IG, Nesbitt LP, Pickett W, et al. The OPALS Major Trauma Study: impact of advanced life- support on survival and morbidity. CMAJ 2008; 178:1141. 103. Ruygrok ML, Byyny RL, Haukoos JS, Colorado Cardiac Arrest & Resuscitation Collaborative Study Group and the Denver Metro EMS Medical Directors. Validation of 3 termination of resuscitation criteria for good neurologic survival after out-of-hospital cardiac arrest. Ann Emerg Med 2009; 54:239. 104. Morrison LJ, Verbeek PR, Zhan C, et al. Validation of a universal prehospital termination of resuscitation clinical prediction rule for advanced and basic life support providers. Resuscitation 2009; 80:324. 105. Jabre P, Bougouin W, Dumas F, et al. Early Identification of Patients With Out-of-Hospital Cardiac Arrest With No Chance of Survival and Consideration for Organ Donation. Ann Intern Med 2016; 165:770. Topic 278 Version 88.0 https://www.uptodate.com/contents/advanced-cardiac-life-support-acls-in-adults/print 38/52 7/6/23, 11:24 AM Advanced cardiac life support (ACLS) in adults - UpToDate GRAPHICS ACLS cardiac arrest algorithm for suspected or confirmed COVID-19 patients https://www.uptodate.com/contents/advanced-cardiac-life-support-acls-in-adults/print 39/52 7/6/23, 11:24 AM Advanced cardiac life support (ACLS) in adults - UpToDate https://www.uptodate.com/contents/advanced-cardiac-life-support-acls-in-adults/print 40/52 7/6/23, 11:24 AM Advanced cardiac life support (ACLS) in adults - UpToDate PPE: personal protective equipment; CPR: cardiopulmonary resuscitation; IV: intravenous; IO: intraosseous. Refer to UpToDate topics on post-cardiac arrest management for additional information. Reproduced with permission. 10.1161/CIRCULATIONAHA.120.047463. Copyright 2020 American Heart Association, Inc. Graphic 127851 Version 9.0 https://www.uptodate.com/contents/advanced-cardiac-life-support-acls-in-adults/print 41/52 7/6/23, 11:24 AM Advanced cardiac life support (ACLS) in adults - UpToDate BLS health care provider adult cardiac arrest algorithm 2020 update BLS: basic life support; AED: automated external defibrillator; CPR: cardiopulmonary resuscitation; ALS: advanced life support. Reprinted with permission. Circulation 2020; 142:S366-S468. Copyright 2020 American Heart Association, Inc. Graphic 105569 Version 8.0 https://www.uptodate.com/contents/advanced-cardiac-life-support-acls-in-adults/print 42/52 7/6/23, 11:24 AM Advanced cardiac life support (ACLS) in adults - UpToDate Adult cardiac arrest algorithm https://www.uptodate.com/contents/advanced-cardiac-life-support-acls-in-adults/print 43/52 7/6/23, 11:24 AM Advanced cardiac life support (ACLS) in adults - UpToDate https://www.uptodate.com/contents/advanced-cardiac-life-support-acls-in-adults/print 44/52 7/6/23, 11:24 AM Advanced cardiac life support (ACLS) in adults - UpToDate Reprinted with permission. Highlights of the 2020 American Heart Association Guidelines for CPR and ECC. Copyright 2020 American Association, Inc. Graphic 129983 Version 9.0 https://www.uptodate.com/contents/advanced-cardiac-life-support-acls-in-adults/print 45/52 7/6/23, 11:24 AM Advanced cardiac life support (ACLS) in adults - UpToDate Key principles in the performance of ACLS Excellent CPR is crucial. Anything short of excellent CPR does not achieve adequate cerebral and coronary perfusion. Excellent chest compressions must be performed throughout the resuscitation without interruption, using proper timing (100 to 120 compressions per minute) and force (5 to 6 cm [2 to 2.5 inches] depth), and allowing for complete chest recoil. Excellent chest compressions take priority over ventilation. If a second rescuer is present, ventilations must be performed using proper timing (6 to 8 breaths per minute in the intubated patient; ratio of 30 compressions to 2 ventilations if not intubated) and force (deliver each breath over one second, and only until chest begins to rise). Avoid hyperventilation. Do not stop compressions until the defibrillator is fully charged. Defibrillate VF and pulseless VT as rapidly as possible. Rapidly identify and treat causes of non-shockable arrest (PEA, asystole). Important causes include the 5 H's and 5 T's: Hypoxia, Hypovolemia, Hydrogen ions (acidosis), Hyper/Hypo-kalemia, Hypothermia; Tension pneumothorax, Tamponade-cardiac, Toxins, Thrombosis-coronary (MI), Thrombosis-pulmonary (PE). If immediately reversible causes (eg, tension pneumothorax, cardiac tamponade) are not corrected rapidly, the patient has little chance of survival. ACLS: advanced cardiac life support; CPR: cardiopulmonary resuscitation; VF: ventricular fibrillation; VT: ventricular tachycardia; PEA: pulseless electrical activity; MI: myocardial infarction; PE: pulmonary embolism. Graphic 83671 Version 5.0 https://www.uptodate.com/contents/advanced-cardiac-life-support-acls-in-adults/print 46/52 7/6/23, 11:24 AM Advanced cardiac life support (ACLS) in adults - UpToDate Manual defibrillation performance bundle 1. Attach and charge the defibrillator while continuing excellent chest compressions. 2. Stop compressions and assess rhythm (should take no more than 5 seconds). 3. If VF or VT is present, deliver shock; if non-shockable rhythm is present, resume excellent CPR (and clear the charged defibrillator*). 4. Resume excellent chest compressions and CPR immediately after the shock is delivered. Critical point: Interruptions in chest compressions must be kept to a minimum: Do NOT stop compressions while defibrillator is being charged. The defibrillator is charged during CPR in anticipation of treating a shockable arrhythmia and to minimize interruptions in CPR. If a non-shockable arrhythmia is present, the charged defibrillator should be discharged into the machine, rather than the defibrillation pads, according to the manufacturer's instructions. VF: ventricular fibrillation; VT: pulseless ventricular tachycardia. Graphic 83670 Version 7.0 https://www.uptodate.com/contents/advanced-cardiac-life-support-acls-in-adults/print 47/52 7/6/23, 11:24 AM Advanced cardiac life support (ACLS) in adults - UpToDate Treatable conditions associated with cardiac arrest Condition Common associated clinical settings Acidosis Diabetes, diarrhea, drug overdose, renal dysfunction, sepsis, shock Anemia Gastrointestinal bleeding, nutritional deficiencies, recent trauma Cardiac Post-cardiac surgery, malignancy, post-myocardial infarction, pericarditis, trauma tamponade Hyperkalemia Drug overdose, renal dysfunction, hemolysis, excessive potassium intake, rhabdomyolysis, major soft tissue injury, tumor lysis syndrome Hypokalemia* Alcohol abuse, diabetes mellitus, diuretics, drug overdose, profound gastrointestinal losses Hypothermia Alcohol intoxication, significant burns, drowning, drug overdose, elder patient, endocrine disease, environmental exposure, spinal cord disease, trauma Hypovolemia Significant burns, diabetes, gastrointestinal losses, hemorrhage, malignancy, sepsis, trauma Hypoxia Upper airway obstruction, hypoventilation (CNS dysfunction, neuromuscular disease), pulmonary disease Myocardial infarction Cardiac arrest Poisoning History of alcohol or drug abuse, altered mental status, classic toxidrome (eg, sympathomimetic), occupational exposure, psychiatric disease Pulmonary embolism Immobilized patient, recent surgical procedure (eg, orthopedic), peripartum, risk factors for thromboembolic disease, recent trauma, presentation consistent with acute pulmonary embolism Tension Central venous catheter, mechanical ventilation, pulmonary disease (eg, asthma, pneumothorax chronic obstructive pulmonary disease), thoracentesis, thoracic trauma CNS: central nervous system. Hypomagnesemia should be assumed in the setting of hypokalemia, and both should be treated. Adapted from: Eisenberg MS, Mengert TJ. Cardiac resuscitation. N Engl J Med 2001; 344:1304. Graphic 52416 Version 8.0 https://www.uptodate.com/contents/advanced-cardiac-life-support-acls-in-adults/print 48/52 7/6/23, 11:24 AM Advanced cardiac life support (ACLS) in adults - UpToDate Options for hands-free pacemaker/defibrillator pad positioning Positioning options for hands-free pacemaker/defibrillator pads showing anterior/lateral positioning (left) and anterior/posterior positioning (right). Graphic 103268 Version 2.0 https://www.uptodate.com/contents/advanced-cardiac-life-support-acls-in-adults/print 49/52 7/6/23, 11:24 AM Advanced cardiac life support (ACLS) in adults - UpToDate Adult bradycardia algorithm 2020 update Reprinted with permission. ACLS Provider Manual. Copyright 2020 American Heart Association, Inc. Graphic 130748 Version 10.0 https://www.uptodate.com/contents/advanced-cardiac-life-support-acls-in-adults/print 50/52 7/6/23, 11:24 AM Advanced cardiac life support (ACLS) in adults - UpToDate Adult tachycardia with a pulse algorithm 2020 update Reprinted with permission. ACLS Provider Manual. Copyright 2020 American Heart Association, Inc. Graphic 130747 Version 10.0 https://www.uptodate.com/contents/advanced-cardiac-life-support-acls-in-adults/print 51/52 7/6/23, 11:24 AM Advanced cardiac life support (ACLS) in adults - UpToDate Contributor Disclosures Jonathan Elmer, MD, MS, FNCS Grant/Research/Clinical Trial Support: National Institutes of Health [Post- cardiac arrest care]. All of the relevant financial relationships listed have been mitigated. Ron M Walls, MD, FRCPC, FAAEM Other Financial Interest: Airway Management Education Center [Health care provider education and resources]; First Airway [Health care provider education and resources]. All of the relevant financial relationships listed have been mitigated. Richard L Page, MD No relevant financial relationship(s) with ineligible companies to disclose. Jonathan Grayzel, MD, FAAEM No relevant financial relationship(s) with ineligible companies to disclose. Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a multi-level review process, and through requirements for references to be provided to support the content. Appropriately referenced content is required of all authors and must conform to UpToDate standards of evidence. Conflict of interest policy https://www.uptodate.com/contents/advanced-cardiac-life-support-acls-in-adults/print 52/52