2023 American Heart Association (AHA) Focused Update on Advanced Cardiovascular Life Support for Adults: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Summary Cardiac arrest is common and fatal, affecting up to 700,000 people in the United States annually. Advanced cardiac life support measures are commonly used to improve outcomes. This “ 2023 American Heart Association Advanced Cardiovascular Life Support Update for Adults ” summarizes the most recently published evidence and recommendations on medication use, temperature management, percutaneous coronary angiography, extracorporeal cardiopulmonary resuscitation and the treatment of seizures in this population. We discuss the lack of data in recent cardiac arrest literature that limits our ability to assess diversity, equity, and inclusion in this population. Finally, we consider how the cardiac arrest population may constitute an important group of organ donors for those awaiting an organ transplant. |
This publication will focus exclusively on the key parts of the guidelines that affect the evaluation and management of patients in the emergency department.
| Important updates |
• Avoid routine use of calcium in patients with cardiac arrest. Calcium is associated with harm, but is still necessary in certain situations (hyperkalemia, overdose of calcium channel blockers) (level 3 recommendation: no benefit). • Magnesium does not improve return of spontaneous circulation (ROSC), survival, or neurological outcomes, regardless of the rate of presentation (Level 3: no benefit). • Extracorporeal Cardiopulmonary Resuscitation ( ECPR) is reasonable for selected patients with refractory cardiac arrest if performed by appropriately trained personnel on equipped systems (Level 2a: moderate). • Emergency coronary angiography instead of a delayed or selective strategy is not recommended in patients with return of spontaneous circulation (ROSC) after cardiac arrest in the absence of ST segment elevation, shock, electrical instability, signs of myocardial damage significant and continuous ischemia (Level 3: no benefit). • All adults who are unresponsive after return of spontaneous circulation (ROSC) should have a deliberate strategy for temperature management with a recommended continuous temperature goal of 32-37.5 o C (Level 1: strong). • Avoid routine seizure prophylaxis in adult survivors of cardiac arrest (Level 3: no benefit), but treat seizures if they occur (Level 1: severe). |
| The recommendations |
All recommendations are designated with a class of recommendation (COR) and level of evidence (LOE). The class of recommendation (COR) is the strength of the recommendation, while the level of evidence (LOE) is the quality of the scientific evidence.
| Vasopressor medications during cardiac arrest |
• We recommend that epinephrine be administered to patients in cardiac arrest. COR 1, LOE BR. • It is reasonable to administer adrenaline 1 mg every 3 to 5 minutes in cardiac arrest. COR 2a, LOE BR. • With respect to timing, in the case of cardiac arrest with a nonshockable rhythm, it is reasonable to administer epinephrine as soon as possible. COR 2a, LOE C-LD. • Vasopressin alone or vasopressin + methylprednisolone in combination with epinephrine may be considered in cardiac arrest, but offers no advantage as a substitute for epinephrine. COR 2b, LOE BR. • With respect to timing, in the case of cardiac arrest with a shockable rhythm, it may be reasonable to administer epinephrine after initial defibrillation attempts have failed. COR 2b, LOE C-LD. • Routine use of high-dose epinephrine in cardiac arrest is not recommended. COR 3, Without benefit, LOE BR. |
| Editorial Comment : Epinephrine is still recommended, but do not use high doses of epinephrine. Consider administering epinephrine after defibrillation in persons with shockable rhythms. |
| Non-vasopressor medications during cardiac arrest |
• Amiodarone or lidocaine may be considered for ventricular fibrillation/pulseless ventricular tachycardia that does not respond to defibrillation. COR 2b, LOE BR. • For patients with refractory out-of-hospital cardiac arrest (OHCA), the benefit of steroid use during CPR is uncertain. COR 2b, LOE C-LD. • Routine administration of calcium is not recommended for the treatment of cardiac arrest. COR 3, Without benefit, LOE BR. • Routine use of sodium bicarbonate is not recommended in patients with cardiac arrest. COR 3, Without benefit, LOE BR. • Routine use of magnesium for cardiac arrest is not recommended. COR 3, Without benefit, LOE BR. |
| Editorial comment : Calcium, sodium bicarbonate, or magnesium are not routinely used. Amiodarone or lidocaine may be considered for pulseless Vfib/Vtach that does not respond to defibrillation. |
| Extracorporeal CPR |
| The use of extracorporeal CPR (ECPR) for patients with cardiac arrest refractory to standard ACLS is reasonable in selected patients when provided within an appropriately trained and equipped system of care. COR 2a, LOE BR. |
| Editorial Comment : Extracorporeal CPR (ECPR) may be considered in patients refractory to standard ACS in the appropriate situation. It is essential to have properly trained personnel and an equipped care system. |
| Percutaneous coronary intervention after cardiac arrest |
• Coronary angiography should be performed urgently in all patients with cardiac arrest with a suspected cardiac cause of the arrest and ST segment elevation on the electrocardiogram. COR 1, LOE B-NR. • Emergency coronary angiography is reasonable for selected adult patients without ST-segment elevation on electrocardiogram but at high risk of significant coronary artery disease where revascularization may provide benefit, such as those with shock, electrical instability, signs of significant myocardial damage in course or ongoing ischemia. COR 2a, LOE B-NR. • Regardless of the patient’s neurological status, coronary angiography is reasonable in all post-cardiac arrest patients in whom coronary angiography is indicated. COR 2a, LOE C-LD. • Emergency coronary angiography instead of a delayed or selective strategy is not recommended in patients with return of spontaneous circulation (ROSC) after cardiac arrest in the absence of ST segment elevation, shock, electrical instability, signs of myocardial damage significant and continuous ischemia. COR 3, Without benefit, LOE BR. |
| Editorial Comment : Yes to PCI after an arrest with STEMI on the ECG. Emergency coronary angiography is not recommended instead of a delayed or selective strategy if there is no STEMI, shock, electrical instability, evidence of significant myocardial injury, and ongoing ischemia. |
| Temperature control |
| We recommend that all adults who do not follow commands after return of spontaneous circulation (ROSC), regardless of site of arrest or rate of presentation, receive treatment that includes a deliberate strategy for temperature control. COR 1, LOE BR. |
| Editorial Comment : If the patient is unable to follow orders after obtaining the ROSC, monitor temperature. |
| Temperature control performance. |
• We recommend selecting and maintaining a constant temperature between 32° C and 37.5° C during post-shutdown temperature control. COR 1, LOE B-NR. • We recommend that hospitals develop protocols for post-arrest temperature screening. COR 1, LOE B-NR. • It is reasonable that temperature control be maintained for at least 24 h after reaching the target temperature. COR 2a, LOE B-NR. • There is insufficient evidence to recommend a specific therapeutic temperature for different subgroups of patients with cardiac arrest. COR 2b, LOE B-NR. • It may be reasonable to actively prevent fever in patients who do not respond to verbal commands after initial temperature monitoring. COR 2b, LOE C-LD. • Patients with spontaneous hypothermia after return of spontaneous circulation (ROSC) who do not respond to verbal commands should not be actively or passively rewarmed at more than 0.5°C per hour. COR 2b, LOE General Director. • The benefit of strategies other than rapid infusion of cold intravenous fluids for prehospital cooling is unclear. COR 2b, LOE BR. • We do not recommend the routine use of rapid infusion of cold intravenous fluids for prehospital cooling of patients after ROSC. COR 3, Without benefit, LOE BR. |
| Editorial comment : Target 32° C to 37.5° C for survivors who remain unresponsive. |
| Seizures and other epileptiform activities. |
• We recommend treatment of clinically apparent seizures in adult survivors of cardiac arrest. COR 1, LOE C-LD. • We recommend rapidly performing and interpreting electroencephalography (EEG) for the diagnosis of seizures in patients who do not follow commands after ROSC. COR 1, LOE C-LD. • Repeated or continuous EEG monitoring is reasonable for patients who do not follow orders after ROSC. COR 2a, LOE C-LD. • Treatment of nonconvulsive seizures (diagnosed solely by EEG) is reasonable in adult survivors of cardiac arrest. COR 2a, LOE BR. • It may be reasonable to perform a therapeutic trial of a non-sedating anticonvulsant medication in adult cardiac arrest survivors with EEG patterns on the ictal-interictal continuum. COR 2b, LOE General Director. • The same antiseizure medications used to treat seizures caused by other etiologies may be considered for seizures detected after cardiac arrest. COR 2b, LOE C-LD. • Seizure prophylaxis is not recommended in adult survivors of cardiac arrest. COR 3, without benefit, LOE BR. |
| Editorial Comment : Avoid seizure prophylaxis, but treat clinically apparent seizures in cardiac arrest survivors. Consider EEG monitoring for patients who remain comatose after ROSC. |
