2015 Korean Guidelines for Cardiopulmonary Resuscitation

Clin Exp Emerg Med 2016;3(S):S1-S9 http://dx.doi.org/10.15441/ceem.16.133 Supplementary

Part 1. The update process and eISSN: 2383-4625 highlights: 2015 Korean Guidelines for Cardiopulmonary Resuscitation Sung Oh Hwang1, Sung Phil Chung2, Keun Jeong Song3, Hyun Kim1, Tae Ho Rho4, Kyu Nam Park5, Young-Min Kim5, June Dong Park6, Ai-Rhan Ellen Kim7, Hyuk Jun Yang8 Received: 16 February 2016 Revised: 19 March 2016 1 Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea Accepted: 19 March 2016 2Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Korea 3Department of Emergency Medicine, Sungkyunkwan University College of Medicine, Seoul, Korea Correspondence to: Sung Oh Hwang 4Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea Department of Emergency Medicine, 5Department of Emergency Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea 6Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea Yonsei University Wonju College of 7Department of Pediatrics, University of Ulsan College of Medicine, Seoul, Korea Medicine, 20 Ilsan-ro, Wonju 26426, 8Department of Emergency Medicine, Gachon University College of Medicine, Incheon, Korea Korea E-mail: [email protected]

THE BACKGROUND AND UPDATE PROCESS OF THE GUIDELINES FOR CARDIOPULMONARY RESUSCITATION

1. The background of the guidelines for cardiopulmonary resuscitation Cardiac arrest can occur inside medical institutions (in-hospital) and outside of medical institutions (out-of-hospital), such as home or public place. The incidence of cardiac arrest varies according to ethnicity, country, and region, ranging from 24 to 186 per 100,000 population.1 In South Korea, annual surveys have been performed since which revealed that the incidence increased from 37.5 per 100,000 population in 2006 to 46.8 in 2010.2 The average survival rate for out-of-hospital cardiac arrest was 3.0% between 2006 and 2010 in South Korea, and only 0.9% of cardiac arrest cases experienced good neurologic recovery.3 The survival rate for out-of-hospital cardiac arrest has subsequently increased to approximately 5% in South Korea, although this rate is still lower than those in the US, Europe, and Japan.4-6 The prevention of cardiac arrest is the most important factor for increasing this survival rate. Furthermore, bystanders should be able to recognize the onset of cardiac arrest, initiate cardiopulmonary resuscitation (CPR), and use an automated external defibrillator. Moreover, the emergency medical system should provide How to cite this article: a rapid response, advanced care, and efficiently facilitate in-hospital treatment for cases of cardi- Hwang SO, Chung SP, Song KJ, Kim H, ac arrest. Rho TH, Park KN, Kim YM, Park JD, Kim AR, Yang HJ. Part 1. The update process Because CPR guidelines apply to the overall general public and healthcare providers, they and highlights: 2015 Korean Guidelines for should comply with each country’s ethnicity, culture, laws, and medical environment. Thus, each Cardiopulmonary Resuscitation. Clin Exp Emerg Med 2016;3(S):S1-S9. country develops CPR guidelines based on the latest scientific knowledge, and provides these guidelines to healthcare providers and the general public to improve survival rates among patients with cardiac arrest. In 1966, the American Heart Association and the American Academy of This is an Open Access article distributed Science developed the first CPR guidelines, which have periodically been updated based on the under the terms of the Creative Commons Attribution Non-Commercial License (http:// available data in the related areas.7-10 In 1993, the American Heart Association and European Re- creativecommons.org/licenses/by-nc/3.0/).

Copyright © 2016 The Korean Society of Emergency Medicine S1 guide.medlive.cn Part 1. The update process and highlights suscitation Council played a pivotal role in organizing the Interna- tion, the Korean Society of Emergency Medical Technicians, and tional Liaison Committee on Resuscitation (ILCOR) to create inter- Korean Red Cross. The development scope for the new Guidelines nationally standardized CPR guidelines. The ILCOR applies newly for Cardiopulmonary Resuscitation was defined using six areas scientific evidence to the existing CPR guidelines at 5-year inter- (BLS, ALS, PLS, NR, post-cardiac arrest care, and education), and vals, and the results are published as the International Consensus expert committees were established for each area. These com- on Cardiopulmonary Resuscitation and Emergency Cardiovascular mittees consisted of 1 chairperson or 2 co-chairs and 6 to 10 ex- Care Science with Treatment Recommendations.11-13 This consen- pert members that were recommend by each academic society. A sus document contains guidelines that are related to CPR, basic steering committee, which consisted of a principal researcher and life support (BLS), advance life support (ALS), pediatric BLS, pedi- the expert committee chairs, was also established to adjust and atric ALS, neonatal resuscitation (NR), education and implementa- coordinate the entire development process. Moreover, to manage tion, acute coronary syndrome, and first aid.14 Therefore, when in- any perceived conflict of interest and perform a detailed review dividual countries update or establish their guidelines for CPR, of the evidence, an evidence review committee was formed from they use the ILCOR guidelines as a scientific basis, while also con- 119 experts (10 to 25 experts per speciality) who were selected sidering the country’s specific medical, legal, and cultural charac- by the committee chairpersons. teristics. Each expert committee selected items that required updating The Korean Guidelines for Cardiopulmonary Resuscitation and from the 2011 Korean Guidelines for Cardiopulmonary Resuscita- Emergency Cardiovascular Care were established in 2006 by the tion, and also identified updated items that were released by the Korean Association of Cardiopulmonary Resuscitation, which is ILCOR. These update items were classified into two types accord- operated by participating academic societies and social organiza- ing to the review method: adaptation or hybrid updating. Items tions that have an interest in CPR. The Korean Guidelines for Car- that were developed and reviewed by the ILCOR were reviewed as diopulmonary Resuscitation and Emergency Cardiovascular Care adaptation items. The hybrid updating items addressed topics that were updated based on emerging scientific evidence in 2011, and were described in the Korean literature or other relevant articles. have been used since that time. The ILCOR announced new Both sets of items were evaluated by the evidence review com- Guidelines for Cardiopulmonary Resuscitation and Emergency mittee, who invited input from evidence review methodology ex- Cardiovascular Care Science in October 2015, which led to the perts during an educational seminar. These evidence review meth- updating of the 2011 Korean Guidelines for Cardiopulmonary Re- odology experts provided instructions to the evidence review ex- suscitation and Emergency Cardiovascular Care.14 perts regarding the guideline update methodologies, which include the Grading of Recommendations Assessment, Development, and 2. The development scope and process for updating the Evaluation (GRADE) method; adaptation methodology; and clini- Korean Guidelines for Cardiopulmonary Resuscitation cal practice guideline development methodologies. The expert The process for updating the 2011 Korean Guidelines for Cardio- committees then held expert workshops to discuss the primary re- pulmonary Resuscitation focused on issues that are directly relat- view results for each update item. The updates that were reviewed ed to cardiac arrest care. Similar to the 2011 ILCOR guidelines, by the expert committees were further discussed at a consensus the 2015 ILCOR guidelines addressed CPR, BLS, ALS, pediatric life conference that was attended by all participating experts. The up- support (PLS), NR, and education and implementation. However, dated guidelines were developed at the consensus conference af- the guidelines for post-cardiac arrest care, which have contribut- ter being presented and discussed in an open forum that anyone ed to an increased survival rate based on recent scientific evi- could attend. Each expert committee created a writing committee dence, were developed separately from the guidelines for ALS. to write the guidelines based on these discussions (Fig. 1). The Guidelines for Cardiopulmonary Resuscitation cover various disciplines, and required experts from all CPR-related aca- 3. Guidelines-related literature review methods demic societies to help develop the guidelines. Thus, the Korean The literature reviewers were recommended by the related aca- Association of Cardiopulmonary Resuscitation requested the par- demic societies or expert committee chairperson, and all of these ticipation of expert members from the Korean Society of Emer- reviewers completed declarations regarding any potential conflict gency Medicine, the Korean Society of Cardiology, the Korean Pe- of interest that might be related to the review, such as employ- diatric Society, the Korean Society of Neonatology, the Korean ment, consultation, ownership of shares, research grants, and re- Society of Anesthesiologists, the Korean Neurological Association, wards. Based on feedback from the expert committee chairper- the Korean Society of Perinatology, the Korean Nurses Associa- sons, the guideline development committee extracted 126 items

S2 www.ceemjournal.org guide.medlive.cn Sung Oh Hwang, et al.

Formation of a steering committee

Formation of expert committee for BLS, ALS, PCC, PLS, NR, and EI (experts from academic societies)

Recruitment of reviewers

ILCOR PICO review and selection of items for update

ILCOR CoSTR Education of reviewers on the evidence review methodology review

New or hybrid topics Search for new Evidence reviews process additional papers and Additional evidence Topics for adaption relevant domestic papers review

AGREE II for ILCOR guidelines

Expert committee conferences Report of review results

Consensus conference

Public audit

Guideline writing

Guideline publication

Fig. 1. The developmental process of the Korean guidelines 2015 for cardiopulmonary resuscitation and emergency cardiac care. BLS, basic life support; ALS, advanced life support; PCC, post-cardiac arrest care; PLS, pediatric life support; NR, neonatal resuscitation; EI, education, implementation; ILCOR, International Liaison Committee on Resuscitation; PICO, population, intervention, comparator, outcome; AGREE, Appraisal of Guidelines for Research and Evaluation; CoSTR, Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations.

(BLS, 24 items; ALS, 24 items; post-cardiac arrest care, 16 items; the Korean CPR clinical practice guidelines) to their specific ex- PLS, 21 items; NR, 25 items; education, 16 items) that have a pert committee, and these drafts contained the ILCOR’s evidence high clinical importance and are relevant to the Korean CPR guide summary and recommendations, the reviewers’ comments, any lines; these items are among the population, intervention, com- update recommendations and justifications, domestic recom- parator, and outcome (PICO) items that were reviewed until Jan- mendations, and the related references. The submitted contents uary 2015 by ILCOR.15-19 One primary reviewer or question owner were reviewed by each expert committee, and then a guideline and 1 to 2 other reviewers were assigned to each of the extracted development committee workshop was organized to revise the PICO items, and these reviewers applied the GRADE method that contents based on the discussions and consensus from all com- was used to develop the 2015 ILCOR Guidelines for Cardiopulmo- mittee members and reviewers who were in attendance. Three nary Resuscitation.20 Only clinical research papers were consid- experts assessed the acceptability of the 2015 ILCOR guidelines ered in the literature review, and non-clinical research papers as source guidelines, using version II of the Appraisal of Guide- (e.g., animal studies or simulation studies) were not included. The lines for Research & Evaluation tool.21 individual expert committees evaluated the identified papers for relevance and applicability to the Korean population. New inter- 4. Suggestions for the recommendations grading national and domestic papers that were published after January The updated recommendations for the Korean CPR clinical practice 2015 (after the ILCOR review was terminated) were also consid- guidelines were classified into four categories, based on direction ered in the evidence review process. The reviewers submitted a (for or against an action) and strength (strong and weak recom- draft of the Korean evidence summary and recommendations (or mendations), as recommended by the GRADE method.20 To deter-

Clin Exp Emerg Med 2016;3(S):S1-S9 S3 guide.medlive.cn Part 1. The update process and highlights mine the recommendation grading, the following factors were used to enhance public awareness regarding the association be- considered. First, strong recommendations were based on items tween cardiovascular disease and cardiac arrest, and to encour- with a high level of evidence, as determined according to the age individuals to reduce their risk of cardiovascular disease. In GRADE method for each item; the overall evidence level for each addition, bystander response to cardiac arrest can be improved item was defined as the lowest evidence level among the key out- using public education regarding the premonitory symptoms of come variables. Second, strong recommendations were based on cardiac arrest, how to recognize cardiac arrest, and what to do items with a large difference between the desirable and undesir- when he or she witnesses cardiac arrest. able effects of each item. Third, weak recommendations were The occurrence of in-hospital cardiac arrests can be reduced based on low levels of reliability in an individual patient’s values by identifying patients who have a high risk of cardiac arrest, and and preferences. Fourth, weak recommendations were based on a by rapidly responding to cases of cardiac arrest.22 Therefore, med- greater requirement for medical resources. During the process of ical institutions with trained medical personnel can reduce the writing the updates, strong recommendations were indicated using occurrence of in-hospital cardiac arrests by maintaining rapid re- the phrases “recommend” or “should do”, and weak recommenda- sponse or medical emergency teams. Furthermore, cardiac arrest tions were indicated using the phrases “suggest” or “can do”. in children is often caused by an accident or injury, and the prevention of accidents or injuries can reduce the number of cardiac HIGHLIGHTS OF THE 2015 KOREAN arrest-related deaths among children. GUIDELINES FOR CARDIOPULMONARY RESUSCITATION 2. The important role of emergency medical dispatchers In the 2015 guidelines, emphasis was placed on the role of emer- The major updates of the 2015 Korean Guidelines for Cardiopul- gency medical dispatchers in helping lay rescuers identify cardiac monary Resuscitation included: 1) a new concept regarding the arrest and begin CPR. This is because most cases of cardiac arrest Chain of Survival (introducing the importance of prevention and are witnessed by lay individuals, who are typically not trained to early detection of cardiac arrest), 2) the importance of identifying manage cardiac arrest and may require time and instruction to cardiac arrest during the treatment of out-of-hospital cardiac ar- identify cardiac arrest and perform CPR. In this context, emergen- rest and the role of emergency medical dispatchers in the CPR cy medical dispatchers can provide telephone guidance to help lay process, 3) chest compression-only CPR for lay rescuers, 4) an ad- rescuers identify cardiac arrest and perform CPR. This technique is justment of the chest compression methods, 5) the usefulness of associated with a higher probability of the lay rescuer initiating end-tidal carbon dioxide measurement during ALS, 6) targeted CPR and shortens the time to CPR initiation.23,24 Therefore, emer- temperature management and coronary angiography during the gency medical dispatchers should be trained to guide bystanders process of post-cardiac arrest care, and 7) recommendations re- in the identification of cardiac arrest and performance of CPR. garding mechanical and extracorporeal CPR. 3. Chest compression-only CPR recommended for lay 1. The importance of prevention and early detection of rescuers cardiac arrest Chest compression-only CPR refers to chest compressions with- In the 2015 Korean Guidelines for Cardiopulmonary Resuscita- out rescue breathing. At the beginning of cardiac arrest, there is tion, the Chain of Survival includes five links: prevention and ear- no difference in the survival rates for chest compression-only ly detection of cardiac arrest, early access, early CPR, early defi- CPR or conventional CPR (rescue breathing and chest compres- brillation, effective ALS and post-cardiac arrest care. The first link sions), and performing only chest compressions improves the sur- is prevention and early detection of cardiac arrest, which is newly vival rate compared to that for when CPR is not performed.25-27 introduced in the 2015 guidelines. This is because the survival Even if they have received CPR training, many lay persons do not rate is low after cardiac arrest, even if CPR is performed, and pre- perform adequate mouth-to-mouth rescue breathing, and they venting the occurrence of cardiac arrest is the most effective may not attempt CPR due to their reluctance to perform rescue method to reduce the number of cardiac arrest-related deaths breathing. Therefore, the 2015 guidelines recommend chest com- among adults and children. Efforts to reduce the risk of cardio- pression-only CPR for lay rescuers, although conventional CPR is vascular disease at the individual and national levels are needed recommended for rescuers who are able to perform rescue to reduce the occurrence of out-of-hospital cardiac arrests. There- breathing and intend to do so. Furthermore, chest compression- fore, public relations activities and public education should be only CPR is recommended when emergency medical dispatchers

S4 www.ceemjournal.org guide.medlive.cn Sung Oh Hwang, et al. guide lay rescuers in the performance of CPR. guidelines also recommend considering temperature management during post-cardiac care for pediatric patients who are unrespon- 4. Adjustment of chest compression depth and rate sive after ROSC due to cardiac arrest, and especially to prevent The 2015 guidelines recommend high-quality CPR that provides fever among children. adequate chest compression depth and rate, sufficient relaxation, Coronary angiography is performed to identify coronary artery and minimal interruptions. The recommendations regarding chest disease as the main cause of cardiac arrest, and appropriate coro- compression depth and rate were updated in the new guidelines nary interventions are important treatments that can increase based on the scientific evidence and expert opinion.28,29 The 2011 the post-cardiac arrest survival rate.36,37 The 2015 guidelines rec- guidelines recommend compression depths of 4 cm for infants, 5 ommend performing emergency coronary angiography if ST ele- cm for children, and ≥ 5 cm for adults (up to 6 cm). In contrast, vation is observed on an electrocardiogram, regardless of the pa- the 2015 guidelines recommend compression depths of 4 cm for tient’s state of consciousness after ROSC, and suggest considering infants, 4 to 5 cm for children, and approximately 5 cm for adults. emergency coronary angiography in cases that may be caused by Furthermore, the 2011 guidelines recommend a chest compres- acute coronary syndrome, even if ST elevation is not observed. In sion rate of ≥ 100 times per minute (up to 120 times per minute) addition, the 2015 guidelines recommend that patients who achieve for adults and children, whereas the 2015 guidelines recommend ROSC after cardiac arrest should be treated at hospitals where a rate of 100 to 120 times per minute for adults and children. targeted temperature management and coronary interventions However, the recommendations regarding the location of chest are available 24 hr/day (i.e., a post-cardiac arrest care center). compression, chest compression to ventilation ratio, sufficient relaxation after chest compression, and minimizing interruptions 7. Recommendations regarding automatic mechanical remain the same as those in the 2011 guidelines. CPR devices and extracorporeal CPR Automatic mechanical CPR devices eliminate the need for manu- 5. Emphasizing the usefulness of end-tidal carbon al chest compressions, although the survival rates were not sig- dioxide measurement during ALS nificantly different when studies compared automatic mechani- There are few methods for evaluating a patient’s hemodynamic cal CPR devices and manual CPR.38-40 Based on these results, the status during CPR or the effectiveness of the CPR. However, the 2015 guidelines do not recommend the use of automatic me- partial pressure of end-tidal carbon dioxide (the partial pressure chanical CPR devices as a routine alternative to the current CPR of carbon dioxide in exhaled air) changes in response to the pro- protocol. However, automatic mechanical CPR devices may be portion of lung perfusion during CPR. Therefore, this pressure can useful while transferring patients in an ambulance or helicopter, be used to assess the adequacy of chest compressions and the or while performing angiography or extracorporeal CPR. possibility of the return of spontaneous circulation (ROSC).30,31 In Extracorporeal CPR maintains artificial circulation using an ex- addition, the partial pressure of end-tidal carbon dioxide can be tracorporeal device in patients with cardiac arrest who do not re- used to check whether an intubated tube is correctly placed after spond to conventional CPR, and this method can improve the endotracheal intubation.32 Therefore, the 2015 guidelines recom- survival rate when it is selectively used by trained personnel in mend using the partial pressure of end-tidal carbon oxide to as- properly equipped hospitals.41,42 The 2015 guidelines recommend sess the effectiveness of CPR, estimate the possibility of ROSC, that, in hospitals with trained personnel who are capable of using and locate the endotracheal tube. extracorporeal devices, extracorporeal CPR should be considered for patients with cardiac arrest who do not achieve ROSC despite 6. Recommendations regarding targeted temperature receiving conventional ALS. management and coronary angiography during post-cardiac arrest care CONFLICT OF INTEREST Updates were made to the items for hypothermia and coronary angiography, which are the main treatments during post-cardiac All authors of the 2015 Korean Guidelines for Cardiopulmonary arrest care. The 2011 guidelines recommended targeted tempera- Resuscitation have documented and signed their declaration of ture management at 32°C to 34°C, whereas the 2015 guidelines conflicts of interest. Reported conflicts of interest are listed on were updated to recommend a target of 32°C to 36°C for ≥ 24 Appendix 1. hours among adults who are unresponsive after ROSC, based on recent evidence regarding core temperature control.33-35 The 2015

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ACKNOWLEDGMENTS the International Liaison Committee on Resuscitation. Circu- lation 2000;102(8 Suppl):I22-59. This work was supported by a grant of Korea Centers for Disease 12. International Liaison Committee on Resuscitation. 2005 Inter- Control and Prevention, Republic of Korea. We thank Eun-Ju Park national Consensus on Cardiopulmonary Resuscitation and and Mi-Ae Shin from the Office of Korean Association of Cardiopul- Emergency Cardiovascular Care Science with Treatment Rec- monary Resuscitation for their administrative support to this work. ommendations. Part 1: introduction. Resuscitation 2005;67: 181-6. REFERENCES 13. Hazinski MF, Nolan JP, Billi JE, et al. Part 1. Executive summary: 2010 International Consensus on Cardiopulmonary Resus- 1. Berdowski J, Berg RA, Tijssen JG, Koster RW. Global incidences citation and Emergency Cardiovascular Care Science With of out-of-hospital cardiac arrest and survival rates: systematic Treatment Recommendations. Circulation 2010;122(16 Suppl review of 67 prospective studies. Resuscitation 2010;81:1479- 2):S250-75. 87. 14. Hazinski MF, Nolan JP, Aickin R, et al. Part 1. Executive Sum- 2. Ro YS, Shin SD, Song KJ, et al. A trend in epidemiology and mary: 2015 International Consensus on Cardiopulmonary Re- outcomes of out-of-hospital cardiac arrest by urbanization suscitation and Emergency Cardiovascular Care Science With level: a nationwide observational study from 2006 to 2010 in Treatment Recommendations. Circulation 2015;132(16 Suppl South Korea. Resuscitation 2013;84:547-57. 1):S2-39. 3. Ro YS, Hwang SS, Shin SD, et al. Presumed regional incidence 15. Finn JC, Bhanji F, Lockey A, et al. Part 8. Education, implemen- rate of out-of-hospital cardiac arrest in Korea. J Korean Med tation, and teams: 2015 International Consensus on Cardio- Sci 2015;30:1396-404. pulmonary Resuscitation and Emergency Cardiovascular Care 4. Chan PS, McNally B, Tang F, Kellermann A; CARES Surveillance Science with Treatment Recommendations. Resuscitation Group. Recent trends in survival from out-of-hospital cardiac 2015;95:e203-24. arrest in the United States. Circulation 2014;130:1876-82. 16. Soar J, Callaway CW, Aibiki M, et al. Part 4. Advanced life sup- 5. Stromsoe A, Svensson L, Axelsson AB, et al. Improved out- port: 2015 International Consensus on Cardiopulmonary Re- come in Sweden after out-of-hospital cardiac arrest and pos- suscitation and Emergency Cardiovascular Care Science with sible association with improvements in every link in the chain Treatment Recommendations. Resuscitation 2015;95:e71-120. of survival. Eur Heart J 2015;36:863-71. 17. Perkins GD, Travers AH, Berg RA, et al. Part 3. Adult basic life 6. Kitamura T, Iwami T, Kawamura T, et al. Nationwide improve- support and automated external defibrillation: 2015 Interna- ments in survival from out-of-hospital cardiac arrest in Japan. tional Consensus on Cardiopulmonary Resuscitation and Circulation 2012;126:2834-43. Emergency Cardiovascular Care Science with Treatment Rec- 7. Cardiopulmonary resuscitation. JAMA 1966;198:372-9. ommendations. Resuscitation 2015;95:e43-69. 8. Proceedings of the 1985 National Conference on Standards 18. Wyllie J, Perlman JM, Kattwinkel J, et al. Part 7. Neonatal re- and Guidelines for Cardiopulmonary Resuscitation and Emer- suscitation: 2015 International Consensus on Cardiopulmonary gency Cardiac Care. July 11-13, Dallas, Texas. Circulation 1986; Resuscitation and Emergency Cardiovascular Care Science with 74(6 Pt 2):IV1-153. Treatment Recommendations. Resuscitation 2015;95:e169- 9. National Conference on Cardiopulmonary Resuscitation (CPR) 201. and Emergency Cardiac Care (ECC). Standards and guidelines 19. Maconochie IK, de Caen AR, Aickin R, et al. Part 6. Pediatric for cardiopulmonary resuscitation (CPR) and emergency car- basic life support and pediatric advanced life support: 2015 diac care (ECC). Part VIII: medicolegal considerations and rec- International Consensus on Cardiopulmonary Resuscitation ommendations. JAMA 1986;255:2979-84. and Emergency Cardiovascular Care Science with Treatment 10. Guidelines for cardiopulmonary resuscitation and emergency Recommendations. Resuscitation 2015;95:e147-68. cardiac care. Emergency Cardiac Care Committee and Sub- 20. Schunemann H, Brozek J, Guyatt G, Oxman A. GRADE hand- committees, American Heart Association. Part I: introduction. book (SA version) [Internet]. [place unknown]: McMaster Uni- JAMA 1992;268:2171-83. versity and Evidence Prime; 2013 [cited 2015 Dec 4]. Avail- 11. Guidelines 2000 for Cardiopulmonary Resuscitation and able from: http://gdt.guidelinedevelopment.org/central_prod/ Emergency Cardiovascular Care. Part 3: adult basic life sup- _design/client/handbook/handbook.html. port. The American Heart Association in collaboration with 21. Brouwers MC, Kho ME, Browman GP, et al. AGREE II: advanc-

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ing guideline development, reporting and evaluation in health 33. Hypothermia After Cardiac Arrest Study Group. Mild thera- care. CMAJ 2010;182:E839-42. peutic hypothermia to improve the neurologic outcome after 22. Maharaj R, Raffaele I, Wendon J. Rapid response systems: a cardiac arrest. N Engl J Med 2002;346:549-56. systematic review and meta-analysis. Crit Care 2015;19:254. 34. Bernard SA, Gray TW, Buist MD, et al. Treatment of comatose 23. Lewis M, Stubbs BA, Eisenberg MS. Dispatcher-assisted car- survivors of out-of-hospital cardiac arrest with induced hy- diopulmonary resuscitation: time to identify cardiac arrest and pothermia. N Engl J Med 2002;346:557-63. deliver chest compression instructions. Circulation 2013;128: 35. Nielsen N, Wetterslev J, Cronberg T, et al. Targeted tempera- 1522-30. ture management at 33°C versus 36°C after cardiac arrest. N 24. Bohm K, Stalhandske B, Rosenqvist M, Ulfvarson J, Hollenberg Engl J Med 2013;369:2197-206. J, Svensson L. Tuition of emergency medical dispatchers in the 36. Hollenbeck RD, McPherson JA, Mooney MR, et al. Early cardi- recognition of agonal respiration increases the use of tele- ac catheterization is associated with improved survival in co- phone assisted CPR. Resuscitation 2009;80:1025-8. matose survivors of cardiac arrest without STEMI. Resuscita- 25. Rea TD, Fahrenbruch C, Culley L, et al. CPR with chest compres- tion 2014;85:88-95. sion alone or with rescue breathing. N Engl J Med 2010;363: 37. Strote JA, Maynard C, Olsufka M, et al. Comparison of role of 423-33. early (less than six hours) to later (more than six hours) or no 26. Svensson L, Bohm K, Castren M, et al. Compression-only CPR cardiac catheterization after resuscitation from out-of-hospi- or standard CPR in out-of-hospital cardiac arrest. N Engl J tal cardiac arrest. Am J Cardiol 2012;109:451-4. Med 2010;363:434-42. 38. Wik L, Olsen JA, Persse D, et al. Manual vs. integrated auto- 27. Iwami T, Kitamura T, Kiyohara K, Kawamura T. Dissemination of matic load-distributing band CPR with equal survival after chest compression-only cardiopulmonary resuscitation and out of hospital cardiac arrest: the randomized CIRC trial. Re- survival after out-of-hospital cardiac arrest. Circulation 2015; suscitation 2014;85:741-8. 132:415-22. 39. Rubertsson S, Lindgren E, Smekal D, et al. Mechanical chest 28. Stiell IG, Brown SP, Nichol G, et al. What is the optimal chest compressions and simultaneous defibrillation vs conventional compression depth during out-of-hospital cardiac arrest re- cardiopulmonary resuscitation in out-of-hospital cardiac ar- suscitation of adult patients? Circulation 2014;130:1962-70. rest: the LINC randomized trial. JAMA 2014;311:53-61. 29. Idris AH, Guffey D, Pepe PE, et al. Chest compression rates 40. Perkins GD, Lall R, Quinn T, et al. Mechanical versus manual and survival following out-of-hospital cardiac arrest. Crit chest compression for out-of-hospital cardiac arrest (PARA- Care Med 2015;43:840-8. MEDIC): a pragmatic, cluster randomised controlled trial. 30. Pearce AK, Davis DP, Minokadeh A, Sell RE. Initial end-tidal Lancet 2015;385:947-55. carbon dioxide as a prognostic indicator for inpatient PEA ar- 41. Sakamoto T, Morimura N, Nagao K, et al. Extracorporeal car- rest. Resuscitation 2015;92:77-81. diopulmonary resuscitation versus conventional cardiopulmo- 31. Levine RL, Wayne MA, Miller CC. End-tidal carbon dioxide nary resuscitation in adults with out-of-hospital cardiac arrest: and outcome of out-of-hospital cardiac arrest. N Engl J Med a prospective observational study. Resuscitation 2014;85:762- 1997;337:301-6. 8. 32. Silvestri S, Ralls GA, Krauss B, et al. The effectiveness of out- 42. Chen YS, Lin JW, Yu HY, et al. Cardiopulmonary resuscitation of-hospital use of continuous end-tidal carbon dioxide moni- with assisted extracorporeal life-support versus conventional toring on the rate of unrecognized misplaced intubation with- cardiopulmonary resuscitation in adults with in-hospital car- in a regional emergency medical services system. Ann Emerg diac arrest: an observational study and propensity analysis. Med 2005;45:497-503. Lancet 2008;372:554-61.

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Appendix 1. The 2015 Korean Guidelines Writing Group disclosure of COI Author name COI Ai-Rhan Ellen Kim Chair, neonatal resuscitation taskforce, Korean Guidelines for Cardiopulmonary Resuscitation (2011, 2015) Chair, neonatal resuscitation committee, Korean Association of Cardiopulmonary Resuscitation Bongjin Lee No COI reported Byung Kook Lee No COI reported Chang Hee Lee No COI reported Chanwoong Kim No COI reported Do Kyun Kim No COI reported Dong Jin Oh No COI reported Dong Yeon Kim Consultant, Elsevier nursing skills education program (2012) Eun Sun Kim No COI reported Gi Beom Kim No COI reported Gi Woon Kim No COI reported Gu Hyun Kang No COI reported Gyu Chong Cho No COI reported Han Suk Kim 2015 ILCOR evidence reviewer, neonatal resuscitation Hee Jo Yoon No COI reported Hye Won Park No COI reported Hyuk Jun Yang 2015 ILCOR First aid taskforce member, 2015 ILCOR question owner Hyun Kim Co-chair, ALS taskforce, Korean Guidelines for Cardiopulmonary Resuscitation (2015) Chair, ALS committee, Korean Association of Cardiopulmonary Resuscitation Hyun Kyung Park No COI reported Jae-Bum Kim No COI reported Jeongmin Kim No COI reported Ji Hoon Kim No COI reported Ji Sook Lee No COI reported Ji Yun Ahn No COI reported Jin Wi No COI reported Jinhee Kim No COI reported Jin-Tae Kim No COI reported June Dong Park Chair, PLS taskforce, Korean Guidelines for Cardiopulmonary Resuscitation (2011, 2015) Chair, PLS committee, Korean Association of Cardiopulmonary Resuscitation June Huh No COI reported June Soo Kim Chair, publication committee, Korean Association of Cardiopulmonary Resuscitation Keun Jeong Song Chair, BLS taskforce, Korean Guidelines for Cardiopulmonary Resuscitation (2011, 2015) Chair, BLS committee, Korean Association of Cardiopulmonary Resuscitation Kyu Nam Park Co-chair, post-cardiac arrest care taskforce, Korean Guidelines for Cardiopulmonary Resuscitation (2011, 2015) Chair, planning and coordinating committee, Korean Association of Cardiopulmonary Resuscitation Kyungil Park No COI reported Mi Jin Lee No COI reported Moon Sung Park No COI reported Sang Gyun Rho No COI reported Sangmo Je No COI reported Seil Oh No COI reported Seung Pill Choi No COI reported Su Jin Cho No COI reported Sun Young Park No COI reported Sung Oh Hwang Chair, Korean Guidelines for Cardiopulmonary Resuscitation (2006, 2011, 2015) General secretary, Korean Association of Cardiopulmonary Resuscitation Patent holder of an automatic cardiopulmonary resuscitation device No financial COI reported

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S8 www.ceemjournal.org guide.medlive.cn Sung Oh Hwang, et al.

Appendix 1. Continued

Author name COI Sung Phil Chung ILCOR evidence reviewer, BLS (2010, 2015) Chair, evidence review and COI management taskforce, Korean Guidelines for Cardiopulmonary Resuscitation (2015) Tai Ho Rho Co-chair, ALS taskforce, Korean Guidelines for Cardiopulmonary Resuscitation (2015) Won Kyoung Jhang No COI reported Yang Ju Tak No COI reported Yeon Hee Kim No COI reported Yong Hoon Cheon No COI reported Yong Soo Jang No COI reported Yong Sung Choi No COI reported Yoon Hee Kim No COI reported Yoon Sil Chang No COI reported Young Han Kim No COI reported Young Min Kim Co-chair, post-cardiac arrest care taskforce, Korean Guidelines for Cardiopulmonary Resuscitation (2015) Program director of Asia TTM master class sponsored by C. R. Bard, Inc. (2013, 2014) Youngsuk Cho No COI reported

COI, conflict of interest; ILCOR, International Liaison Committee on Resuscitation; ALS, advanced life support; PLS, pediatric life support; BLS, basic life support; TTM, targeted temperature management.

Clin Exp Emerg Med 2016;3(S):S1-S9 S9 guide.medlive.cn Clin Exp Emerg Med 2016;3(S):S10-S16 http://dx.doi.org/10.15441/ceem.16.129 Supplementary

Part 2. Adult basic life support: eISSN: 2383-4625 2015 Korean Guidelines for Cardiopulmonary Resuscitation Keun Jeong Song1, Jae-Bum Kim2, Jinhee Kim3, Chanwoong Kim4, Sun Young Park5, Chang Hee Lee6, Yong Soo Jang7, Gyu Chong Cho8, 8 9 10 Youngsuk Cho , Sung Phil Chung , Sung Oh Hwang Received: 16 February 2016 1Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Revised: 19 March 2016 Medicine, Seoul, Korea Accepted: 19 March 2016 2Department of Thoracic and Cardiovascular Surgery, Keimyung University School of Medicine, Daegu, Korea Correspondence to: Keun Jeong Song 3Department of Anesthesiology, Seoul National University Bundang Hospital, Seongnam, Korea Department of Emergency Medicine, 4 Department of Emergency Medicine, Chung-Ang University College of Medicine, Seoul, Korea Samsung Medical Center, 5 Department of Nursing Science, Baekseok University, Cheonan, Korea Sungkyunkwan University School of 6 Department of Emergency Medical Service, Namseoul University, Cheonan, Korea Medicine, 81 Irwon-ro Gangnam-gu, 7Department of Emergency Medicine, Hallym University Kangnam Sacred Heart Hospital, Seoul, Korea Seoul 06351, Korea 8Department of Emergency Medicine, Hallym University Kangdong Sacred Heart Hospital, Seoul, Korea E-mail: [email protected] 9Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Korea 10Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea

CHAIN OF SURVIVAL

Chain of survival is a series of steps required to increase the survival rate of patients with cardiac arrest. To increase the survival rate of patients with cardiac arrest, chain of survival should be strengthened in a community. Chain of survival in 2015 Korean cardiopulmonary resuscitation (CPR) guidelines is composed of five chains: the prevention and immediate recognition of cardiac arrest, early access (activation of emergency medical system [EMS]), early CPR, early defibrillation, and effective advanced life support and post-cardiac arrest care (Fig. 1).

1. The prevention and immediate recognition of cardiac arrest The new concept of preventing and immediately recognizing cardiac arrest was newly introduced in 2015 Korean CPR guidelines as the first link in the chain of survival. The development of cardiac arrest can be prevented by reducing the risk factors of cardiac and cerebrovascular 1 diseases in adults. How to cite this article: Efforts need to be made to reduce these risk factors and precipitating factors that cause car- Song KJ, Kim JB, Kim J, Kim C, Park SY, diac arrest. Inside of a hospital, the signs and symptoms presenting prior to cardiac arrest need Lee CH, Jang YS, Cho GC, Cho Y, Chung SP, Hwang SO. Part 2. Adult basic life support: to be rapidly recognized and treated. The medical emergency team or rapid response team have 2015 Korean Guidelines for a role in this process.2,3 Lay person should be taught about signs or symptoms of cardiac arrest, Cardiopulmonary Resuscitation. Clin Exp Emerg Med 2016;3(S):S10-S16. which will increase their ability to recognize cardiac arrest.

2. Early access This is an Open Access article distributed The second link in the chain of survival is early access which includes making a phone call to the under the terms of the Creative Commons Attribution Non-Commercial License (http:// 119 EMS center and activating EMS. A bystander recognizing cardiac arrest calls the 119 emer- creativecommons.org/licenses/by-nc/3.0/).

S10 Copyright © 2016 The Korean Society of Emergency Medicine guide.medlive.cn Keun Jeong Song, et al. gency medical services and reports an incidence of cardiac arrest. rest need to be transported to a medical center or facility where The emergency medical dispatcher who receives the call dispatch- integrated post-cardiac arrest care including targeted tempera- es an ambulance and emergency personnel to the scene. The ture management or percutaneous coronary intervention can be emergency medical dispatcher should have an ability to instruct performed.10 CPR via telephone to the bystander. MAJOR UPDATE OF THE 2015 KOREAN 3. Early CPR BASIC LIFE SUPPORT GUIDELINES Immediately after the call to 119 EMS center, a bystander should immediately start and continue CPR until emergency personnel The main contents newly added or revised in the 2015 Korean arrive. CPR performed by a bystander increases the survival rate basic life support (BLS) guideline are as follows: (1) Cardiac arrest of the victims with cardiac arrest.4 To increase the rate of bystand- should be immediately evaluated by the presence of apnea or ab- er CPR, schools, militaries, residential areas, work places, and pub- normal respiration. Abnormal respiration represents all forms of lic institutions need to provide education on CPR. respiration that are not normal, such as apnea or agonal gasps.11 (2) Healthcare providers also need to simultaneously check the 4. Early defibrillation patient’s pulse and respiration within 10 seconds, and they should Defibrillation is the most important intervention to treat ventric- not delay compression to check for the absence or presence of a ular fibrillation. Defibrillation is more effective when it is performed pulse. (3) Regarding the order of CPR, chest compression needs to early after ventricular fibrillation develops.5 An automated exter- be performed prior to breathing. Similar to the guideline in 2011, nal defibrillator (AED) is used for early defibrillation. If an AED is the order of compression-airway-breathing (C-A-B sequence) installed in public places through a public access defibrillation needs to be maintained.11,12 (4) High quality CPR is important. It is program, the survival rate of patients with ventricular fibrillation suggested that in adult patients with cardiac arrest, the depth of remarkably increases with early defibrillation.6 AED can be safely compression should be approximately 5 cm, and the rate should used by lay persons after they receives a brief instruction to use. be 100–120/min. It is recommended that the interruption of compression is minimized to less than 10 seconds, and breathing should 5. Effective advanced life support and post-cardiac not be excessively performed.11-18 (5) Healthcare providers, includ- arrest care ing 119 emergency medical technicians, should always perform Effective advanced life support needs to be performed to restore CPR with both compression and ventilation. the spontaneous circulation of patients with cardiac arrest. Inte- grated post-cardiac arrest care is required for patients whose spon- ADULT BLS FOR LAY RESCUERS taneous circulation has recovered from cardiac arrest. Post-cardiac arrest care is an integrated treatment process that includes 2015 Korean CPR guidelines recommend compression-only CPR general intensive care, targeted temperature management, per- when a non-healthcare professional lay person rescues a victim cutaneous coronary intervention for acute coronary syndrome, with cardiac arrest. The steps of BLS consist of determining unre- and the seizure control.7-9 Patients resuscitated from cardiac ar- sponsiveness, calling the 119 emergency dispatcher center, per-

Fig. 1. Chain of survival in 2015 Korean Guidelines for Cardiopulmonary Resuscitation. Components of chain of survival are the prevention and immediate recognition of cardiac arrest, early access, early cardiopulmonary resuscitation, early defibrillation, and effective advanced life support and post-cardiac arrest care.

Clin Exp Emerg Med 2016;3(S):S10-S16 S11 Part 2. Adult basic life support

status.19 Thus, a lay rescuer needs the help of an emergency med- Unresponsive ical dispatcher to determine the respiration status and to provide guidance on how to perform compression-only CPR.20 Call 119, get an AED, and follow instructions of the emergency dispatcher 4. Compression-only CPR No breathing or abnormal breathing It is recommended that lay rescuers perform compression-only (i.e., only gasping) CPR for adult victims with cardiac arrest. The blood oxygen concentration does not rapidly decrease when cardiac arrest sudden- Compression-only CPR ly occurs without hypoxia such as in cases of cardiac arrest from cardiac origin.; instead, it may maintain for a few minutes at the AED arrives early stage of cardiac arrest.21 Therefore, ventilation may not be Turn on AED and necessary during the early stage of cardiac arrest. According to a follow the prompts series of recent clinical trials, the survival rate increases with com- 22,23 Shock advised No shock advised pression-only CPR compared to no CPR. Also, compression- Analyze the heart rhythm only CPR has a similar survival rate compared to standard CPR Defibrillation that includes ventilation in patients with cardiac arrest of non- respiratory origin.24 Standard CPR is recommended if the rescuer 2 minutes of compression-only CPR knows how to ventilate and is willing to provide ventilation. In adult cardiac arrest, the depth of compression should be ap- Fig. 2. Basic life support algorithm for lay persons. AED, automated external defibrillator; CPR, cardiopulmonary resuscitation. proximately 5 cm, and the rate should be maintained at 100–120/ min.15,25 The recommended position of one’s hand when perform- forming compression-only CPR, and using an AED. The sequence ing compression is at the lower half of the sternum. If the depth of adult BLS for lay persons is summarized in BLS algorithm for of compression is greater than 6 cm, there is a possibility of in- lay rescuers (Fig. 2). creasing incidence of complications.26

1. Check for responsiveness 5. AED use The first step of BLS is to check for responsiveness. The safety of An AED should be used immediately when it arrives. If an AED ar- the scene needs to be assessed first before approaching the col- rives while CPR is being performed, one needs to push the power lapsed person. Responsiveness can be evaluated by shouting, “Are button to turn it on. After taking off the patient’s shirt, two pads you alright?” to the collapsed person, and by tapping his/her shoulder. need to be firmly attached to the patient’s bare chest. Chest compressions need to be stopped while the AED analyzes the cardiac 2. 119 Emergency call rhythm of the patient with cardiac arrest. If defibrillation is re- If the collapsed person is unresponsive, a 119 emergency call should quired, the AED says, “need defibrillation” and charges the defi- be made immediately, and an AED needs to be requested. If one brillator by itself. If a voice or screen instruction says, “push the witnesses a collapsed person, he/she needs to request that some- shock button” after charging, one must ensure that no one touch- one call 119 by loudly asking others nearby for help. One should es the patient for safety purposes, and then the shock button can also call 119 if there is no one else around. When calling 119, the be pushed. One must resume chest compressions immediately af- location of the incidence, situation of the incidence, the patient’s ter defibrillation. status, and emergency treatment that is being conducting needs to be reported.1 DISPATCHER-ASSISTED CPR

3. Assessing respiration (recognition of cardiac arrest) The emergency medical dispatcher can assist a lay rescuer to rec- The patient’s respiration should be evaluated after checking re- ognize cardiac arrest and instruct CPR. An emergency medical sponsiveness and making the 119 call. Patients who are unrespon- dispatcher asks the caller if the collapsed person is responsive sive and have apnea or abnormal respiration (e.g., agonal respira- and if his/her respiration is abnormal.27 An emergency medical tion) should be determined to be in cardiac arrest. It is challeng- dispatcher determines cardiac arrest in cases in which the col- ing for a lay rescuer to precisely evaluate the patient’s respiration lapsed person is unresponsive and has apnea or abnormal respi-

S12 www.ceemjournal.org Keun Jeong Song, et al.

unresponsiveness, calling the 119 emergency dispatcher center, Unresponsive checking for breathing and pulse, performing CPR, and using an AED or defibrillator. The sequence of adult BLS for healthcare pro- Call 119 and get a defibrillator (or AED) viders is summarized in BLS algorithm for healthcare providers (Fig. 3). Check pulse and breathing simultaneously (within 10 seconds) 1. Check unresponsiveness, call the 119 dispatcher center As in BLS for lay persons, the first step of BLS is to check for un- Begin cycles of CPR (30 compressions and 2 breaths) responsiveness. The safety of the scene needs to be assessed first

AED (or defibrillator) arrives before approaching the collapsed person. Unresponsiveness can be evaluated by shouting, “Are you alright?” to the collapsed per- Use the AED (or defibrillator) son, and by tapping his/her shoulder.

Shock advised No shock advised 2. Assessing respiration and pulse Analyze the heart rhythm The patient’s respiration should be evaluated after determining Defibrillation responsiveness and making the 119 call. Determination of the ab-

2 minutes of CPR sence or presence of a pulse and respiration should be performed within 10 seconds. To determine the pulse of an adult patient with cardiac arrest, the carotid artery needs to be assessed.11 Fig. 3. Basic life support algorithm for healthcare providers. AED, automated external defibrillator; CPR, cardiopulmonary resuscitation. 3. Chest compression ration. If an emergency medical dispatcher recognizes cardiac ar- In adult cardiac arrest, the depth of compression should be ap- rest, the dispatcher will provide instructions on how to perform proximately 5 cm, and the rate should be maintained at 100–120/ CPR via telephone. Instruction of compression-only CPR to lay min.15,25 The recommended position of one’s hand when perform- rescuers by emergency dispatchers increases bystander CPR rate ing compression is at the lower half of the sternum. If the depth and improves the survival rate of victims with cardiac arrest.27-29 of compression is greater than 6 cm, there is a possibility of in- If the patient with cardiac arrest is submerged or hypoxic, or the creasing complications.26 The recoil of the chest needs to be max- rescuer is able to perform breathing, both chest compression and imized after each compression.31,32 The suggested compression- breathing need to be performed. ventilation ratio is 30:2.33-35 Considering the high quality of CPR and the fatigue of a rescuer, a role of compressor needs to rotate EXEMPTION OF THE LIABILITY IN THE every 2 minutes.11 The interruption of compression should be mini- KOREAN EMERGENCY MEDICAL SERVICE mized to less than 10 seconds during CPR.16,18,36 LAW In the case that an advanced airway is in place, it is suggested that one rescuer continues compression at a rate of 100–120/min There is an exemption clause in the Korean Emergency Medical without interruption, and the other rescuer provides respiration Service Law about liability of the rescuer who provides emergen- with a bag valve mask every 6 seconds (10 breaths/min). Health- cy treatment. The fifth subsection and second article of this law care providers, including 119 emergency medical technicians, should articulates the following: “When a person renders first aid or emer- always perform CPR with both compression and ventilation.11,21,25 gency care to an emergency patient whose life is at stake and there is no intentional or severe fault on property damage or in- 4. Airway and rescue breathing juries as a result of his/her acts, he/she shall not be liable for any When healthcare providers open the airway of patients with car- civil damages and has no criminal liability including for the vic- diac arrest and no evidence of injuries to the head or neck, the tim’s death”. 30 This law protects good Samaritans. airway should always be maintained by using the head tilt-chin lift maneuver. If a cervical injury is suspected, the jaw thrust tech- BLS FOR HEALTHCARE PROVIDERS nique, which does not include head extension, should be used to open the airway. The steps of BLS for healthcare providers consist of determining Mouth-to-mouth ventilation is recommended to provide res-

Clin Exp Emerg Med 2016;3(S):S10-S16 S13 Part 2. Adult basic life support cue breathing to the patient. We recommend to ventilate the pa- Jin Hyuck Lee, Hallym University, Seoul, Korea; Jin Uk Kim, Kyung- tient with inspiration duration of 1 second and with the tidal vol- dong University, Wonju, Korea; Jin Woo Kim, Daejeon Health Sci- ume as the patient’s rising chest is visually identified. Provide ences College, Daejeon, Korea; Kang Nim Kim, Hallym University ventilation once every 6 seconds (10 breaths/min) if there are two Kangdong Sacred Heart Hospital, Seoul, Korea; Myung Lyeol Lee, or more healthcare providers and an advanced airway is inserted. Daewon University College, Jecheon, Korea; Nam Sik Yoon, Chon- Avoid hyperventilation during rescue breathing. nam National University, Gwangju, Korea; Sang Wook Park, Chon- The tidal volume should be maintained at 500 to 600 mL (6–7 nam National University Hospital, Gwangju, Korea; So Hyeon Song, mL/kg) during adult CPR.37-39 The most common cause of failure Daegu Health College, Daegu, Korea; Su Youn Kim, Gangdong in ventilation is inappropriate opening of the airway. If the pa- University, Icheon, Korea. tient’s chest does not rise during the first attempt of breathing, breathing should be conducted again after properly performing REFERENCES the head tilt-chin lift maneuver. When respiration assistance is needed for a patient with spontaneous circulation (e.g., when a 1. Goyal V, Jassal DS, Dhalla NS. Pathophysiology and prevention strong pulse is palpable), ventilation should be performed every 5 of sudden cardiac death. Can J Physiol Pharmacol 2016;94: to 6 seconds or 10–12/min. 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Gazmuri RJ, Ayoub IM, Radhakrishnan J, Motl J, Upadhyaya struction of cardiopulmonary resuscitation increased the inci- MP. Clinically plausible hyperventilation does not exert ad- dence of bystander CPR and improved the outcomes of out- verse hemodynamic effects during CPR but markedly reduces of-hospital cardiac arrests. Resuscitation 2012;83:1235-41. end-tidal PCO2. Resuscitation 2012;83:259-64. 21. Sayre MR, Berg RA, Cave DM, et al. Hands-only (compression- 34. Kill C, Galbas M, Neuhaus C, et al. Chest compression synchro- only) cardiopulmonary resuscitation: a call to action for by- nized ventilation versus intermitted positive pressure ventila- stander response to adults who experience out-of-hospital tion during cardiopulmonary resuscitation in a pig model. PLoS sudden cardiac arrest: a science advisory for the public from One 2015;10:e0127759. the American Heart Association Emergency Cardiovascular 35. Abella BS, Alvarado JP, Myklebust H, et al. 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PRIMED trial. Resuscitation 2014;85:336-42. tion. Resuscitation 2000;44:37-41. 37. Wenzel V, Keller C, Idris AH, Dorges V, Lindner KH, Brimacombe 39. Dorges V, Ocker H, Hagelberg S, Wenzel V, Schmucker P. Opti- JR. Effects of smaller tidal volumes during basic life support misation of tidal volumes given with self-inflatable bags with- ventilation in patients with respiratory arrest: good ventila- out additional oxygen. Resuscitation 2000;43:195-9. tion, less risk? Resuscitation 1999;43:25-9. 40. Kilgannon JH, Jones AE, Shapiro NI, et al. Association between 38. Dorges V, Ocker H, Hagelberg S, Wenzel V, Idris AH, Schmuck- arterial hyperoxia following resuscitation from cardiac arrest er P. Smaller tidal volumes with room-air are not sufficient to and in-hospital mortality. JAMA 2010;303:2165-71. ensure adequate oxygenation during bag-valve-mask ventila-

S16 www.ceemjournal.org Clin Exp Emerg Med 2016;3(S):S17-S26 http://dx.doi.org/10.15441/ceem.16.134 Supplementary

Part 3. Advanced cardiac life support: eISSN: 2383-4625 2015 Korean Guidelines for Cardiopulmonary Resuscitation Mi Jin Lee1, Tai Ho Rho2, Hyun Kim3, Gu Hyun Kang4, June Soo Kim5, Sang Gyun Rho6, Hyun Kyung Park7, Dong Jin Oh8, Seil Oh9, Jin Wi10, 11 12 3 Sangmo Je , Sung Phil Chung , Sung Oh Hwang Received: 16 February 2016 1Department of Emergency Medicine, Kyungpook National University College of Medicine, Daegu, Korea Revised: 19 March 2016 2Division of Cardiology, Department of Internal Medicine, The Catholic University of Korea College of Accepted: 19 March 2016 Medicine, Seoul, Korea 3 Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea Correspondence to: Tai Ho Rho 4 Department of Emergency Medicine, Hallym University College of Medicine, Seoul, Korea Department of Internal Medicine, St. 5 Department of Internal Medicine, Sungkyunkwan University School of Medicine, Seoul, Korea Paul’s Hospital, The Catholic University 6Department of Emergency Medical Services, Sunmoon University, Asan, Korea of Korea College of Medicine, 180 7Department of Emergency Medicine, Kyung Hee University College of Medicine, Seoul, Korea Wangsan-ro, Dongdaemun-gu, Seoul 8Department of Internal Medicine, Hallym University College of Medicine, Seoul, Korea 9Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea 02559, Korea 10Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea E-mail: [email protected] 11Department of Emergency Medicine, CHA University College of Medicine, Seongnam, Korea 12Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Korea Hyun Kim Department of Emergency Medicine, Yonsei University Wonju College of Medicine, 20 Ilsan-ro, Wonju 26426, BACKGROUND OF 2015 GUIDELINES FOR ADULT ADVANCED LIFE Korea SUPPORT E-mail: [email protected]

The chain of survival suggested in the 2015 Korean cardiopulmonary resuscitation (CPR) guidelines consists of the five links of prevention and early detection of cardiac arrest, early access, early cardiopulmonary resuscitation, early defibrillation, and effective advanced life support (ALS) and post-cardiac arrest care. ALS, which constitutes the last link, should immediately follow the basic life support (BLS) if the required manpower, equipment, and drugs are available. ALS includes the following elements: quick recognition of cardiac arrest and activation of the resuscitation team; immediate CPR, manual defibrillation, and pharmacological therapy; and advanced airway management and monitoring of physiological parameters.1 Comprehensive post-cardiac arrest care, which begins immediately after recovery of spontaneous circulation, is also included in ALS. Improvements in the survival and neurologic outcomes in patients with cardiac arrest can be expected only when BLS and ALS are provided in combination. In case of in-hospital car- How to cite this article: diac arrest, effective BLS begins with the first responder quickly confirming cardiac arrest, im- Lee MJ, Rho TH, Kim H, Kang GH, Kim JS, mediately calling for help, asking for manual defibrillator while calling the resuscitation team in Rho SG, Park HK, Oh DJ, Oh S, Wi J, Je S, Chung SP, Hwang SO. Part 3. Advanced the hospital, and conducting a high-quality CPR. The most important principle in cardiac arrest cardiac life support: 2015 Korean Guidelines treatment through ALS is that it should be based on effective BLS. When ventricular fibrillation for Cardiopulmonary Resuscitation. Clin Exp Emerg Med 2016;3(S):S17-S26. (VF) or pulseless ventricular tachycardia (VT) occurs, the survival rate can be increased with immediate CPR and early defibrillation conducted by the witness. Advanced airway management, mechanical chest compression devices, and extracorporeal circulation devices increase the short- This is an Open Access article distributed term survival rate including the return of spontaneous circulation (ROSC) and survival admis- under the terms of the Creative Commons Attribution Non-Commercial License (http:// sion.2-7 However, the evidence supporting that these improve the survival or neurologic out- creativecommons.org/licenses/by-nc/3.0/).

Copyright © 2016 The Korean Society of Emergency Medicine S17 Part 3. Advanced cardiac life support comes at hospital discharge is still insufficient. Long-term survival over the standard-dose epinephrine. Vasopressin has been re- of patients who recover their spontaneous circulation can be im- moved from the adult out-of-hospital cardiac arrest algorithm. proved when combined post-cardiac arrest treatment, which in- However, as per the 2015 Korean CPR guidelines for ALS, vaso- cludes targeted temperature management and percutaneous cor- pressin may provide some benefit when bundled with epinephrine onary intervention, is provided in association with high-quality and steroids in treating in-hospital cardiac arrest.30,31 BLS and effective ALS.8-15 The incidence rate of in-hospital cardi- Although mechanical chest compression devices have been ac arrest can be decreased by early recognition of patients with developed and are currently being used in cardiac arrest patients, deteriorating condition indicating an impending cardiac arrest the use of such devices as a routine alternative to the conven- and responding immediately.16 tional CPR is not recommended. Manual chest compression re- The major issues of ALS described in the 2015 Korean CPR mains the standard care for cardiac arrest; however, in certain guidelines maintained the basic principles suggested in the 2011 circumstances (e.g., in case of limited manpower or prolonged Korean CPR guidelines. The 2015 guidelines continue to empha- CPR, when in a moving ambulance or helicopter, in the angiogra- size on the importance of immediate and effective CPR (chest phy room, or during preparation of extracorporeal CPR [ECPR]), compression with adequate depth and rate, sufficient relaxation, the use of mechanical chest compression devices can be consid- minimal interruption of chest compression, and prevention of hy- ered as a reasonable alternative to high-quality chest compres- perventilation) in patients who experience cardiac arrest.17-21 sion.5,32,33 ECPR is a complex intervention that requires a highly During CPR, the ALS provider uses available monitoring devices, trained team, specialized equipment, and multidisciplinary sup- such as end-tidal carbon dioxide (ETCO2) monitoring devices and port. Only for selected patients who have a cardiac arrest and for pulse oximeter, supplies oxygen via advanced airway, and con- whom the suspected etiology of cardiac arrest is potentially re- ducts manual defibrillation. Furthermore, during ALS, the provider versible, ECPR may be considered an alternative to conventional finds the reversible causes of cardiac arrest and corrects them if CPR.6,7 possible. As ways of advanced airway management, the use of supraglottic airway devices (e.g., laryngeal mask airway, laryngeal CARDIAC ARREST ALGORITHM IN ADULT tube, i-gel) is recommended in addition to endotracheal intubation.22-24 However, the guideline emphasizes that chest compres- Because the necessity of defibrillation and the drugs adminis- sion should not be delayed due to advanced airway management tered for treatment of cardiac arrest differ depending on electro- conducted during CPR. cardiography (ECG) rhythms, understanding of the entire algorithm and initial ECG rhythms is essential for effective ALS. Car- HIGHLIGHTS OF 2015 GUIDELINES FOR diac rhythms during cardiac arrest include shockable rhythms (VF ADULT ALS and pulseless VT) and non-shockable rhythms (asystole and pulseless electrical activity [PEA]). BLS and early defibrillation, The key issues and the major highlights of the 2015 Korean rather than advanced airway management or drug administra- guidelines for ALS include the following. Monitoring physiologic tion, are the most important and preferentially provided treat- parameters during CPR provides meaningful information about ment in cardiac arrest. Few drugs used in the treatment of cardi- the patient’s condition and response to CPR. These parameters ac arrest are supported by evidence. After starting CPR and at- can be monitored continuously, without interrupting chest com- tempting defibrillation, rescuers can establish intravenous (IV) pression. The use of quantitative waveform capnography for access, considering drug administration, and then insert an ad- monitoring of the partial pressure of ETCO2 is recommended after vanced airway. advanced airway management. Capnography is useful for evalu- As in the 2011 guideline, the 2015 guideline combines the ating the effectiveness of chest compression and the possibility treatment processes of cardiac arrest into a universal algorithm; 25,26 of the ROSC during CPR. Low ETCO2 in intubated patients af- this also corresponds to the “megacode concept” used in ALS ed- ter 20 minutes of CPR is associated with poor chances for ROSC ucation. In other words, because changes in ECG rhythms may and survival.26,27 When quantitative capnography is used after occur during ALS provided for cardiac arrest, a combined algo- endotracheal intubation, the healthcare providers can confirm an rithm, rather than separate algorithms for each ECG rhythm, can intratracheal placement of endotracheal tube.28,29 be more effectively used in clinical field. For instance, the scenar- With regard to vasopressors for cardiac arrest treatment, the io in which “VF occurs while treating asystole, and spontaneous combination of vasopressin and epinephrine offers no advantage circulation is recovered after defibrillation,” could occur in prac-

S18 www.ceemjournal.org Mi Jin Lee, et al. tice; in such cases, if VF is observed while treating asystole, the ducted at 100–120 times/min while ventilation should be con- treatment direction should change to treat VF first. ducted once in 6 seconds (10 times/min).21 Hyperventilation The treatment of cardiac arrest starts with BLS. BLS includes should be avoided. Manual defibrillators, rather than automated the recognition of the patient, confirmation of cardiac arrest, call defibrillators, are used in ALS to confirm ECG rhythms and to de- for help, and immediate beginning CPR. Regardless of the ECG fibrillate. rhythm, push hard and fast and release completely in chest com- Although administration of drugs before conducting advanced pression. Moreover, to minimize the fatigue of the chest com- airway management is recommended, depending on the team pressors, the CPR team leader should switch the roles with the members’ skills as well as the ongoing experience in inserting the compressor approximately every 2 minutes (or after 5 cycles of airway and verifying proper position with minimal interruption of compressions and ventilations at a ratio of 30:2). Healthcare pro- chest compression, drug administration and advanced airway viders should interrupt chest compressions as infrequently as management can be conducted simultaneously. In patients with possible and try to limit interruptions to no longer than 10 sec- an initial shockable rhythm, administration of epinephrine (IV or onds except for specific interventions such as use of a defibrilla- intraosseous [IO] injection) immediately after the first shock is tor or analyzing the ECG rhythms through monitors, confirmation recommended. In cases of asystole or PEA (non-shockable of pulse for confirmation of spontaneous circulation (when per- rhythms), early administration of epinephrine can increase the fusing rhythm appears on ECG), and insertion of an advanced air- ROSC, survival to hospital discharge, and neurologically intact way. As ways to evaluate the effectiveness and quality of CPR, survival.34-36 This section discusses in detail the general manage- there are a number of methods and emerging technologies to ment of patients experiencing cardiac arrest and provides an monitor the patient during CPR and potentially help guide ALS overview of the ALS Cardiac Arrest Algorithm (Fig. 1 and Table 1). interventions (e.g., monitoring of ETCO2 partial pressure, diastolic arterial pressure, and central venous oxygen saturation). When an 1. Shockable rhythms (VF/pulseless VT) advanced airway is not in placement, chest compression and res- Because VF and pulseless VT can be treated with defibrillation, cue ventilation should to be conducted in a 30:2 ratio; when the they are referred to as shockable rhythms. The most important advanced airway is secured, chest compression should be con- treatment for VF or pulseless VT is immediate bystander CPR and

Unresponsive and not breathing normally? Check pulse simultaneously

Call resuscitation team Attach defibrillator/monitor Start CPR 30:2

Shockable Non-shockable (VF/pulseless VT) (asystole/PEA) Assess ECG rhythm

Defibrillation Return of spontaneous circulation CPR 2 minutes CPR 2 minutes IV/IO access IV/IO access Epinephrine 1-mg injection Epinephrine 1-mg injection Consider advanced airway Consider advanced airway Immediate post-cardiac arrest care

Fig. 1. Adult advanced life support algorithm. CPR, cardiopulmonary resuscitation; VF, ventricular fibrillation; VT, ventricular tachycardia; ECG, electrocardiography; PEA, pulseless electrical activity; IV, intravenous; IO, intraosseous.

Clin Exp Emerg Med 2016;3(S):S17-S26 S19 Part 3. Advanced cardiac life support

Table 1. Reference table of the adult ALS algorithm Core ALS concepts Details Assess ECG rhythm Rotate a compressor and analyze rhythm every 2 minutes Defibrillation Biphasic: Initial dose 120 to 200 J (manufacturer recommendation) Refractory VF/pulseless VT: escalating doses Monophasic: 360 J Chest compression Push hard (5 cm) and fast (100–120/min) Ensure high quality chest compressions Start compression within 5 seconds after defibrillation

Use waveform capnography (achieve ETCO2 > 10 mmHg after endotracheal intubation or 20 minutes of CPR) Advanced airway management Keep bag-valve-mask ventilation until advanced airway in place and ventilation Perform endotracheal intubation or use a supraglottic airway Give 1 breath every 6 seconds (10 breaths/min) with continuous chest compressions Avoid hyperventilation Drug administration (IV/IO) All cardiac arrest Epinephrine: 1 mg every 3 to 5 minutes (every two CPR cycle as equal to 4 minutes) Vasopressin: 40 IU (replace first or second dose of epinephrine) Hospitals that already use vasopressin may continue to use Bundled regimen of epinephrine, vasopressin and steroid may be considered in in-hospital cardiac arrest Refractory VF/pulseless VT Amiodarone: 300 mg bolus (first dose), 150 mg (second dose) Lidocaine (as an alternative if amiodarone is not available): 1-1.5 mg/kg (first dose), 0.5-0.75 mg/kg (second dose) Treat reversible causes Hypovolemia, hypoxia, hydrogen ion (acidosis), hypothermia, hypo/hyperkalemia, tension pneumothorax, toxins, tamponade-cardiac, thrombosis-coronary or pulmonary Consider additional CPR modalities Ultrasound imaging Mechanical chest compressions Extracorporeal CPR

ALS, advanced life support; ECG, electrocardiography; ETCO2, end-tidal carbon dioxide; CPR, cardiopulmonary resuscitation; IV, intravenous; IO, intraosseous; VF, ventricular fibrillation; VT, ventricular tachycardia. defibrillation as soon as possible. When VF is found on ECG moni- VT persists after 2 to 3 shocks, consider administering an antiar- tor during CPR, providers should deliver one shock (biphasic defi- rhythmic such as amiodarone. Three hundred milligram of amio- brillator, 120–200J; monophasic defibrillator, 360J) and then re- darone is recommended as the first dose; when VF/pulseless VT sume CPR immediately for 2 minutes, beginning with chest com- persists, additional 150 mg can be administered after 4 minutes pressions without pulse check or ECG rhythm confirmation. When from initial administration. If amiodarone is not available, lido- the defibrillation energy dose recommended by the manufacturer caine may be considered as an alternative. Although the previous is not known, defibrillation should be conducted at 200J when a 2011 guidelines suggested consideration of magnesium adminis- biphasic defibrillator is used. During chest compression, an IV or tration for refractory VF, the new guidelines do not recommend IO route for drug administration should be established. ECG routine use of magnesium any more, as it does not result in any rhythms should be checked after two minutes of CPR. If VF per- improvement in survival prognosis.41 sists, the second and subsequent energy doses should be equiva- If the ECG rhythms change to asystole or PEA while treating lent, and higher doses may be considered.37,38 The entire process for VF/pulseless VT, the treatment should proceed according to of manual defibrillation should be achievable in less than a the algorithm for non-shockable rhythms. 5-second interruption to chest compression.39,40 During chest compression, epinephrine should be injected, and 2. Non-shockable rhythms (PEA and asystole) bolus IV fluids need to be pushed through the site of injection Asystole refers to ventricular asystole; PEA is a heterogeneous immediately. Meanwhile, another rescuer should perform ad- group of pulseless rhythms that includes pseudo-electromechan- vanced airway management. After 2 minutes of chest compres- ical dissociation, idioventricular rhythms, ventricular escape sions, analyze the rhythm and deliver another shock immediately rhythms, and bradyasystolic rhythms. As asystole and PEA do not if indicated. Although 1 mg of epinephrine should be adminis- require defibrillation during CPR, they are referred to as “non- tered every 3 to 5 minutes in principle, it can be administered ev- shockable rhythms.” PEA is often caused by reversible conditions ery two CPR cycles (4 minutes when rescuers take turns in con- and can be treated if those conditions are identified and correct- ducting chest compression every 2 minutes). When VF/pulseless ed. Typical examples of such reversible causes are often referred

S20 www.ceemjournal.org Mi Jin Lee, et al. to as the “5Hs and 5Ts”: hypovolemic shock, hypoxia, hyperkale- MONITORING DURING ALS mia or hypokalemia, hydrogen ions (metabolic acidosis), hypothermia (the 5Hs), thromboembolism of the pulmonary artery Monitoring both provider performance and patient physiologic (pulmonary embolism), thrombosis of the coronary artery (myo- parameters during CPR is essential to optimizing CPR quality and 44 cardial infarction), tension pneumothorax, cardiac tamponade, feedback on the effectiveness of chest compression. ETCO2 par- and toxins (the 5Ts). Survival from cardiac arrest with asystole is tial pressure, coronary perfusion pressure, and central venous ox- poor. Of note, the hope for resuscitation is to identify and treat a ygen saturation can be used as physiological monitoring indices reversible cause of non-shockable rhythms. during ALS. It is recommended to use quantitative waveform If the ECG rhythm is non-shockable, chest compression should capnography in intubated patients to monitor CPR quality, opti- be immediately performed for 2 minutes. If the QRS complex can mize chest compressions, detect ROSC during chest compression be confirmed in PEA, the pulse should be quickly checked. If there or when rhythm check reveals an organized rhythm, and confir- is no pulse, CPR should be conducted for 2 minutes while the mation of the location of endotracheal intubation.25,26,29 Although route (IV or IO) for drug administration is established. Epinephrine placement of invasive monitors during CPR is not generally war- should be administered every 3 to 5 minutes or every two CPR ranted, physiologic parameters such as arterial pressures and cycles (4 minutes). After 2 minutes of chest compression, rhythms central venous oxygen saturation, when available, may also be should be analyzed. If asystole or PEA persists, chest compression helpful in optimizing CPR and detecting ROSC. should be continued, and then advanced airway management The main determinant of ETCO2 during CPR is perfusion to the should be conducted. Atropine is no longer used in treatment of lungs. Persistently low ETCO2 values < 10 mmHg during CPR in asystole. intubated patients suggest that ROSC is unlikely. Monitoring the

ETCO2 during ALS can help in maintaining high-quality chest 45,46 3. Immediate post-cardiac arrest treatment compression and detecting compressor fatigue. If the ETCO2 Post-cardiac arrest care is offered to patients whose spontaneous partial pressure is measured to be less than 10 mmHg, the quality circulation has recovered as a result of ALS care. Integrated post- of ALS should be improved by increasing performance or chang- cardiac arrest treatment, which includes hemodynamic stabiliza- ing a compressor. If ETCO2 abruptly increases to a normal value of tion, adequate ventilation and controlling of blood oxygen satu- 35 to 40 mmHg, it is reasonable to consider this an indicator of ration, targeted temperature management, and percutaneous ROSC. Continued insufficient ETCO2 (< 10 mmHg) after intubation coronary intervention for acute coronary syndrome, should be and 20 minutes after the initial resuscitation is associated with provided immediately after the recovery of spontaneous circula- extremely poor chances for ROSC and survival outcomes.26,27,47 In tion. non-intubated patients (those with bag-mask ventilation or su-

praglottic airway), ETCO2 may not consistently reflect the true 4. In-hospital resuscitation value, making the measurement less reliable as a prognostic tool.1

For all in-hospital cardiac arrests, cardiopulmonary arrest should However, the measurement of ETCO2 partial pressure should not be recognized immediately and CPR should be started immedi- be used as the single index to monitor the quality of ALS or to ately; if indicated, defibrillation is attempted as soon as possible predict the recovery of spontaneous circulation. and certainly within 3 minutes. The importance of “prevention and early detection of cardiac arrest,” which is the first link sug- MEDICATIONS FOR CARDIAC ARREST gested in the 2015 CPR guidelines, is emphasized not only in out- of-hospital cardiac arrest, but also in in-hospital cardiac arrest. High-quality CPR and rapid defibrillation are most important in The resuscitation team may take the form of a traditional CPR cardiac arrest, and drug administration is considered next. After team, which is called only when cardiac arrest is detected. Alter- starting CPR and conducting defibrillation, IV or IO access has natively, hospitals may have strategies to engage rapid response been established for drug administration. The establishment of teams or medical emergency teams to recognize patients at risk peripheral access is preferred because it does not require inter- of cardiac arrest before cardiac arrest occurs.16,42,43 Contrary to ruption of chest compression. In cases of shockable rhythms, de- out-of-hospital cardiac arrest, vasopressin may provide some fibrillation should be conducted first, and epinephrine adminis- benefit when bundled with epinephrine and steroid in treating tration follows afterward; in cases of non-shockable rhythms, in-hospital cardiac arrests.30,31 drugs should be administered immediately and early once chest compression begins and once the IV route is achieved.36

Clin Exp Emerg Med 2016;3(S):S17-S26 S21 guide.medlive.cn Part 3. Advanced cardiac life support

1. Epinephrine suggested as a treatment option for in-hospital cardiac arrest.30,31 Epinephrine is the universal vasopressor used in cardiac arrest treatment. Epinephrine stimulates adrenergic receptors, produces 3. Antiarrhythmic drug vasoconstriction, increases blood pressure and heart rate, and Although the survival to hospital admission rate was reported to improves perfusion pressure to the brain and heart. Based on im- increase in a study that investigated the effectiveness of antiar- provements in short-term prognosis resulting from epinephrine rhythmic drugs in refractory VF/pulseless VT, no antiarrhythmic as compared to placebo, administration of standard dose of epi- drug has yet been shown to increase long-term survival or neuro- nephrine to cardiac arrest patients is recommended. However, it logic outcome after cardiac arrest due to VF/pulseless VT.53 Amio- is not recommended to add vasopressin to standard-dose epi- darone, however, has been shown to increase short-term survival nephrine. High-dose epinephrine is not recommended for routine to hospital admission when compared with placebo or lidocaine.54 use in cardiac arrest.48 Standard-dose epinephrine (1 mg every 3 Although the use of magnesium was recommended until the to 5 minutes) is recommended for patients experiencing cardiac 2011 guidelines when hypomagnesemia was suspected in pa- arrest. The standard protocol used during CPR for adults is as fol- tients with cardiac arrest, the new guidelines do not recommend lows: 1 mg of epinephrine is administered quickly in the form of routine use of magnesium for adult VF/pulseless VT patients.41 a 1:1,000 ampule or 1:10,000 prefilled syringe formula every 3 to 5 minutes or every two cycles of chest compression rotation (4 1) Amiodarone minutes).49,50 Either IV or IO routes can be used. If IV/IO access is IV amiodarone affects sodium, potassium, and calcium channels delayed or cannot be established, epinephrine may be given by as well as α- and β-adrenergic blocking actions. Amiodarone is the endotracheal route at a dose of 2 to 2.5 mg.51 used to treat refractory VF/pulseless VT that does not respond to The timing of epinephrine administration during CPR depends defibrillation. The initial dose of 300 mg can be injected intrave- on the cardiac arrest rhythm. In cardiac arrest patients with a nously or intraosseously; if there is no response, a second dose of non-shockable rhythm, early administration of epinephrine is 150 mg amiodarone is administered after two cycles of chest suggested.34 Optimal timing of epinephrine cannot be recom- compression rotation (after 4 minutes).55 mended because of insufficient evidence, particularly in relation to defibrillation in cardiac arrest due to a shockable rhythm. In 2) Lidocaine such cases, early defibrillation, rather than the timing of epineph- The short-or long-term effects of lidocaine in refractory VF/pulse- rine administration, should be considered first, and epinephrine is less VT that does not respond to defibrillation or repeats after de- quickly administered after that.34,36 fibrillation have been investigated in only a limited number of studies.56,57 Lidocaine can be considered in cases where amioda- 2. Vasopressin rone is not available.54 The initial dose is 1 to 1.5 mg/kg IV/IO. Re- Vasopressin is a non-adrenergic peripheral vasoconstrictor that peat if indicated at 0.5 to 0.75 mg/kg over 5- to 10-minute inter- increases arterial blood pressure. Vasopressin offers no advantage vals to a maximum of 3 mg/kg. as a substitute for epinephrine in out-of-hospital cardiac arrest. The use of vasopressin in treatment of out-of-hospital cardiac ar- ADDITIONAL CONSIDERATIONS DURING ALS rest as an alternative to epinephrine is no longer recommended. However, those healthcare professionals working in systems that 1. Oxygen supply during CPR already use vasopressin may continue to do so because there is A study on out-of-hospital cardiac arrest analyzed outcome ac- no evidence of harm from using vasopressin when compared to cording the arterial oxygen partial pressure during CPR and re- epinephrine.47 ported that the survival-to-hospital admission rate increased in Considering that vasopressin is currently being used in cases of the group that received high concentration of oxygen.58 When in-hospital cardiac arrest, the evidence to support changing the supplementary oxygen is available, it may be reasonable to use existing guideline is also lacking. The effect of vasopressin in car- the maximal feasible inspiratory concentration during CPR. After diac arrest does not differ from that of epinephrine; therefore, 40 the recovery of spontaneous circulation, it is recommended to units of vasopressin can be administered once through an IV or administer the maximum oxygen concentration that can main- IO route to replace the first or second epinephrine administra- tain the arterial oxygen saturation above 94%. tion.52 Moreover, the “vasopressor bundle” combination therapy, which combines steroids, epinephrine, and vasopressin, is being

S22 www.ceemjournal.org Mi Jin Lee, et al.

2. Factors that predict the prognosis during CPR ducted due to the prolonged CPR, and when there is a lack of

The ETCO2, which reflects the cardiac output induced by chest medical personnel required for CPR. In particular, in certain cir- compression, is the only predicting factor currently being used cumstances, such as inside a moving ambulance, inside angiogra- during CPR. Survival prognosis was found to be poor in studies phy rooms, during prolonged CPR, and during ECPR, the use of that investigated in-hospital and out-of-hospital cardiac arrest mechanical chest compression devices can be considered as a when ETCO2 was maintained at less than 10 mmHg in cardiac ar- reasonable alternative to high-quality chest compression. rest patients with endotracheal intubation even 20 minutes after 26,27 the start of CPR. Hence, an ETCO2 less than 10 mmHg imme- 5. Extracorporeal CPR diately after intubation and 20 minutes after the initial resuscita- ECPR maintains artificial circulation using extracorporeal devices tion is associated with extremely poor chances for ROSC and sur- in patients with cardiac arrest who do not response to conven- 47 vival. The ETCO2 below 10 mmHg that persists even after 20 tional CPR. It is known to exert positive influences on the survival minutes of appropriate ALS can be used as a criterion, in associa- and neurological prognosis of adult cardiac arrest patients; there- 6,7,61 tion with other various factors, to stop ALS. The ETCO2 should not fore, it can be used in selective circumstances. As cannula be used alone as an indication to terminate resuscitation efforts. and devices should be inserted into large arteries and veins while This index cannot be applied in patients that do not have endo- conducting CPR, special equipment and trained members are re- tracheal intubation. In cases of a simple non-waveform capnog- quired. ECPR is a complex intervention that requires a highly raphy used in pre-hospital care, the measurements can be used trained team, specialized equipment, and multidisciplinary sup- to confirm endotracheal intubation. However, these are not rec- port. Only for selected patients who have a cardiac arrest and for ommended for prognostication of survival or as evidence for whom the suspected etiology of cardiac arrest is potentially re- stopping CPR. Multimodal approach to decision of terminating versible, ECPR may be considered as an alternative to conven- resuscitation may be required during CPR. tional CPR.6,7

3. Application of ultrasonography during CPR ACKNOWLEDGMENTS The evidence supporting the effects of ultrasonography used during adult CPR is not sufficient. However, the use of ultrasonogra- Collaborators have been contributed to the review of the scien- phy may be considered to determine the reversible causes of car- tific evidence and the adjustment of new GRADE methods. The diac arrest only in cases that ultrasonography would not interfere collaborators’ are as follows: Eun Jung Park, Ajou University, Su- with CPR.59 Although no evidence supports that the use of echo- won, Korea; Hyo Eun Park, Seoul National University, Seoul, Ko- cardiography improves the prognosis of cardiac arrest patients, it rea; Jeong Hun Lee, Dongguk University, Seoul, Korea; Je Sung can help in diagnosing the cause of treatable cardiac arrest, in- You, Yonsei University, Seoul, Korea; Jung Ho Shin, Armed Forces cluding cardiac tamponade, pulmonary thromboembolism, myo- Capital Hospital, Seongnam, Korea; Kyung Woon Jeung, Chonnam cardial infarction, and aortic dissection. Moreover, it can also be National University, Gwangju, Korea; Kyu Seok Kim, Seoul Nation- used as an alternative of ETCO2 capnography to confirm the loca- al University, Seoul, Korea; Sang Jin Han, Hallym University, Seoul, tion of endotracheal intubation during CPR.60 Korea; Seong Beom Oh, Dankook University, Cheonan, Korea; Seokran Yeom, Busan National University, Busan, Korea; Seung Min Park, 4. The use of mechanical chest compression devices Hallym University, Pyungchon, Korea; Sung Won Jang, Catholic Automated mechanical chest compression devices use a piston University of Korea, Seoul, Korea; Tae Yong Shin, Bundang Jesaeng that compresses the sternum, a band that tightens the thorax, or General Hospital, Seongnam, Korea; Young Hoon Yoon, Korea Uni- both to conduct CPR. Since the announcement of the 2005 versity, Seoul, Korea. guidelines, important clinical studies that used mechanical chest compression devices were conducted. As the evidence supporting REFERENCES effectiveness of mechanical chest compression devices over manual CPR is insufficient yet, manual chest compression remains the 1. Link MS, Berkow LC, Kudenchuk PJ, et al. Part 7. Adult ad- standard care for cardiac arrest.5,32,33 However, mechanical chest vanced cardiovascular life support: 2015 American Heart As- compression devices can be used as reasonable alternatives in the sociation Guidelines update for cardiopulmonary resuscitation following cases: when the conventional chest compression is not and emergency cardiovascular care. Circulation 2015;132(18 possible, when high-quality chest compression cannot be con- Suppl 2):S444-64.

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Emergency of-hospital use of continuous end-tidal carbon dioxide moni- coronary angiography in comatose cardiac arrest patients: do toring on the rate of unrecognized misplaced intubation real-life experiences support the guidelines? Eur Heart J within a regional emergency medical services system. Ann

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Emerg Med 2005;45:497-503. rate of patients with in-hospital cardiac arrest: five years of 29. Grmec S. Comparison of three different methods to confirm experience in a single center in Korea. J Korean Med Sci 2012; tracheal tube placement in emergency intubation. Intensive 27:146-52. Care Med 2002;28:701-4. 43. Kwak HJ, Yun I, Kim SH, et al. The extended rapid response 30. Mentzelopoulos SD, Zakynthinos SG, Tzoufi M, et al. Vaso- system: 1-year experience in a university hospital. J Korean pressin, epinephrine, and corticosteroids for in-hospital cardi- Med Sci 2014;29:423-30. ac arrest. Arch Intern Med 2009;169:15-24. 44. Crowe C, Bobrow BJ, Vadeboncoeur TF, et al. Measuring and 31. Mentzelopoulos SD, Malachias S, Chamos C, et al. Vasopres- improving cardiopulmonary resuscitation quality inside the sin, steroids, and epinephrine and neurologically favorable emergency department. Resuscitation 2015;93:8-13. survival after in-hospital cardiac arrest: a randomized clinical 45. Hamrick JL, Hamrick JT, Lee JK, Lee BH, Koehler RC, Shaffner trial. JAMA 2013;310:270-9. DH. Efficacy of chest compressions directed by end-tidal CO2 32. Rubertsson S, Lindgren E, Smekal D, et al. Mechanical chest feedback in a pediatric resuscitation model of basic life sup- compressions and simultaneous defibrillation vs conventional port. J Am Heart Assoc 2014;3:e000450. cardiopulmonary resuscitation in out-of-hospital cardiac ar- 46. Genbrugge C, Meex I, Boer W, et al. Increase in cerebral oxy- rest: the LINC randomized trial. JAMA 2014;311:53-61. genation during advanced life support in out-of-hospital pa- 33. Perkins GD, Lall R, Quinn T, et al. Mechanical versus manual tients is associated with return of spontaneous circulation. chest compression for out-of-hospital cardiac arrest (PARA- Crit Care 2015;19:112. MEDIC): a pragmatic, cluster randomised controlled trial. Lan- 47. Soar J, Callaway CW, Aibiki M, et al. Part 4. Advanced life sup- cet 2015;385:947-55. port: 2015 International Consensus on Cardiopulmonary Re- 34. Donnino MW, Salciccioli JD, Howell MD, et al. Time to admin- suscitation and Emergency Cardiovascular Care Science with istration of epinephrine and outcome after in-hospital cardiac Treatment Recommendations. Resuscitation 2015;95:e71-120. arrest with non-shockable rhythms: retrospective analysis of 48. Callaham M, Madsen CD, Barton CW, Saunders CE, Pointer J. large in-hospital data registry. BMJ 2014;348:g3028. A randomized clinical trial of high-dose epinephrine and nor- 35. Goto Y, Maeda T, Goto Y. Effects of prehospital epinephrine epinephrine vs standard-dose epinephrine in prehospital car- during out-of-hospital cardiac arrest with initial non-shockable diac arrest. JAMA 1992;268:2667-72. rhythm: an observational cohort study. Crit Care 2013;17:R188. 49. Helm C, Gillett M. Adrenaline in cardiac arrest: prefilled sy- 36. Koscik C, Pinawin A, McGovern H, et al. Rapid epinephrine ringes are faster. Emerg Med Australas 2015;27:312-6. administration improves early outcomes in out-of-hospital 50. Moreira ME, Hernandez C, Stevens AD, et al. Color-coded cardiac arrest. Resuscitation 2013;84:915-20. prefilled medication syringes decrease time to delivery and 37. Stiell IG, Walker RG, Nesbitt LP, et al. BIPHASIC Trial: a ran- dosing error in simulated emergency department pediatric re- domized comparison of fixed lower versus escalating higher suscitations. Ann Emerg Med 2015;66:97-106.e3. energy levels for defibrillation in out-of-hospital cardiac ar- 51. Neumar RW, Otto CW, Link MS, et al. Part 8. Adult advanced rest. Circulation 2007;115:1511-7. cardiovascular life support: 2010 American Heart Association 38. Koster RW, Walker RG, Chapman FW. Recurrent ventricular Guidelines for Cardiopulmonary Resuscitation and Emergency fibrillation during advanced life support care of patients with Cardiovascular Care. Circulation 2010;122(18 Suppl 3):S729- prehospital cardiac arrest. Resuscitation 2008;78:252-7. 67. 39. Cheskes S, Schmicker RH, Verbeek PR, et al. The impact of 52. Hess EP, Russell JK, Liu PY, White RD. A high peak current peri-shock pause on survival from out-of-hospital shockable 150-J fixed-energy defibrillation protocol treats recurrent cardiac arrest during the Resuscitation Outcomes Consortium ventricular fibrillation (VF) as effectively as initial VF. Resusci- PRIMED trial. Resuscitation 2014;85:336-42. tation 2008;79:28-33. 40. Sell RE, Sarno R, Lawrence B, et al. Minimizing pre- and post- 53. Kudenchuk PJ, Cobb LA, Copass MK, et al. Amiodarone for re- defibrillation pauses increases the likelihood of return of spon- suscitation after out-of-hospital cardiac arrest due to ven- taneous circulation (ROSC). Resuscitation 2010;81:822-5. tricular fibrillation. N Engl J Med 1999;341:871-8. 41. Thel MC, Armstrong AL, McNulty SE, Califf RM, O’Connor CM. 54. Dorian P, Cass D, Schwartz B, Cooper R, Gelaznikas R, Barr A. Randomised trial of magnesium in in-hospital cardiac arrest. Amiodarone as compared with lidocaine for shock-resistant Duke Internal Medicine Housestaff. Lancet 1997;350:1272-6. ventricular fibrillation. N Engl J Med 2002;346:884-90. 42. Shin TG, Jo IJ, Song HG, Sim MS, Song KJ. Improving survival 55. Soar J, Nolan JP, Bottiger BW, et al. European Resuscitation

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Council Guidelines for Resuscitation 2015. Section 3: adult graphic evaluation in life support and peri-resuscitation of advanced life support. Resuscitation 2015;95:100-47. emergency patients: a prospective trial. Resuscitation 2010;81: 56. Herlitz J, Ekstrom L, Wennerblom B, et al. Lidocaine in out-of- 1527-33. hospital ventricular fibrillation: does it improve survival? Re- 60. Chou HC, Chong KM, Sim SS, et al. Real-time tracheal ultraso- suscitation 1997;33:199-205. nography for confirmation of endotracheal tube placement dur- 57. Harrison EE. Lidocaine in prehospital countershock refractory ing cardiopulmonary resuscitation. Resuscitation 2013;84:1708- ventricular fibrillation. Ann Emerg Med 1981;10:420-3. 12. 58. Spindelboeck W, Schindler O, Moser A, et al. Increasing arteri- 61. Maekawa K, Tanno K, Hase M, Mori K, Asai Y. Extracorporeal al oxygen partial pressure during cardiopulmonary resuscita- cardiopulmonary resuscitation for patients with out-of-hos- tion is associated with improved rates of hospital admission. pital cardiac arrest of cardiac origin: a propensity-matched Resuscitation 2013;84:770-5. study and predictor analysis. Crit Care Med 2013;41:1186-96. 59. Breitkreutz R, Price S, Steiger HV, et al. Focused echocardio-

S26 www.ceemjournal.org Clin Exp Emerg Med 2016;3(S):S27-S38 http://dx.doi.org/10.15441/ceem.16.130 Supplementary

Part 4. Post-cardiac arrest care: eISSN: 2383-4625 2015 Korean Guidelines for Cardiopulmonary Resuscitation

Young-Min Kim1, Kyu Nam Park1, Seung Pill Choi1, Byung Kook Lee2, Kyungil Park3, Jeongmin Kim4, Ji Hoon Kim1, Sung Phil Chung5, 6 Sung Oh Hwang Received: 16 February 2016 Revised: 19 March 2016 1Department of Emergency Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea Accepted: 19 March 2016 2Department of Emergency Medicine, Chonnam National University Medical School, Gwangju, Korea 3Department of Internal Medicine, Dong-A University College of Medicine, Busan, Korea 4Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea Correspondence to: Young-Min Kim 5Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Korea Department of Emergency Medicine, 6Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea Seoul St. Mary’s Hospital, The Catholic University of Korea College of Medicine, 222 Banpo-daero, Seocho-gu, Seoul 06591, Korea High quality integrated post-cardiac arrest care can significantly influence the outcome of pa- E-mail: [email protected] tients with cardiac arrest, especially neurological recovery, and numerous studies have been conducted on this topic. In the 2015 Korean cardiopulmonary resuscitation (CPR) guidelines, Kyu Nam Park post-cardiac arrest care was emphasized with effective advanced life support as one of the es- Department of Emergency Medicine, sential chains for survival. Based on an in-depth scientific evidence review using a standardized Seoul St. Mary’s Hospital, The Catholic University of Korea College of Medicine, methodological approach proposed by the GRADE (Grading of Recommendations Assessment, 222 Banpo-daero, Seocho-gu, Seoul Development, and Evaluation) working group, the guidelines either partially updated the recom- 06591, Korea mendations or added new recommendations for each specific topic. E-mail: [email protected]

POST-CARDIAC ARREST CARE STRATEGIES (Fig. 1 and Table 1)

1. Airway and breathing When a patient is unconscious after the return of spontaneous circulation (ROSC), the airway should be secured by tracheal intubation, and this should be confirmed by measuring the end- tidal carbon dioxide (ETCO2) and oxygen saturation (SpO2) levels using waveform capnography and pulse oximetry; additionally, mechanical ventilation should be performed while continuously monitoring the ETCO2 and SpO2. To avoid hypoxia, it is reasonable to use the highest available oxygen concentration until appropriate monitoring is available to evaluate the arterial oxygen tension (PaCO2) or arterial oxygen saturation (SaO2) levels. When resources are available to ti- How to cite this article: trate the fraction of inspired oxygen (FiO2) and monitor the saturation, it is reasonable to de- Kim YM, Park KN, Choi SP, Lee BK, Park K, Kim J, Kim JH, Chung SP, Hwang SO. Part 4. crease the FiO2, provided that the SaO2 level can be maintained at the target range. Post-cardiac arrest care: 2015 Korean A study based on a registry reported that hyperoxia within 24 hours after ROSC was associat- Guidelines for Cardiopulmonary ed with a poor outcome compared to hypoxemia or normoxemia within 24 hours.1 In another Resuscitation. Clin Exp Emerg Med 2016;3(S):S27-S38. study, hyperoxia was shown to have a dose-dependent relationship with poor outcomes, rather than with a certain threshold level.2 In addition, hyperoxia was associated with poor prognosis in a study of patients with cardiac arrest who had received mild therapeutic hypothermia.3 In con- This is an Open Access article distributed trast, a study of approximately 12,000 patients with cardiac arrest reported that there was no under the terms of the Creative Commons Attribution Non-Commercial License (http:// association between hyperoxia and mortality after the inspired oxygen level and disease severity creativecommons.org/licenses/by-nc/3.0/).

Return of spontaneous circulation

Airway ∙ Tracheal intubation ∙ Waveform capnography

Breathing ∙ Mechanical ventilation Reversible causes

∙ Goals: SpO2 94-98%, PaCO2 35-45 mmHg, or PETCO2 ∙ Hypovolemia 30-40 mmHg ∙ Hypoxia ∙ Hydrogen ion (acidosis) ∙ Hypokalemia/hyperkalemia ∙ Hypothermia Circulation ∙ Tension pneumothorax ∙ 12-lead ECG ∙ Tamponade, cardiac ∙ Arterial blood pressure monitoring ∙ Toxins ∙ IV fluid and/or vasopressor infusion ∙ Thrombosis, pulmonary ∙ Avoiding and immediately correction hypotension ∙ Thrombosis, coronary (SBP < 90 mmHg, MAP < 65 mmHg) ∙ Goal: SBP ≥100 mmHg

Circulation Yes STEMI or high suspicion of ACS? Coronary angiography±PCI No No Response to verbal commends? Targeted temperature management

Yes

Advanced critical care

Evaluation of neurological prognosis Multimodal approach

Fig. 1. Post-cardiac arrest care algorithm. SpO2, oxygen saturation; PaCO2, arterial oxygen tension; PETCO2, partial pressure of end-tidal carbon dioxide; ECG, electrocardiography; IV, intravenous; SBP, systolic blood pressure; MAP, mean arterial pressure; PCI, percutaneous coronary intervention; STEMI, ST- elevation myocardial infarction; ACS, acute coronary syndrome. were adjusted.4 A meta-analysis of 14 observational studies 2. Circulation showed significant heterogeneity across studies.5 Therefore, it is 1) Hemodynamic stabilization suggested to maintain the SaO2 at a level of 94% to 98% to Post-cardiac arrest patients are often hemodynamically unstable avoid hypoxemia and the potential risk of hyperoxia. due to the underlying etiology of arrest, myocardial dysfunction, Hypocapnia causes cerebral vasoconstriction, and it reduces ce- and systemic ischemia/reperfusion response.11 Therefore, immedi- rebral blood flow.6 Observational studies using a registry of patients ately after ROSC, an arterial catheter should be promptly inserted, with cardiac arrest have reported an association between hypo- and the arterial blood pressure should be monitored continuously. capnia and poor neurologic outcome.7,8 Two observational studies If an arterial catheter cannot be inserted, the blood pressure should reported that mild hypercapnia was associated with more favor- be frequently measured noninvasively until the patient becomes able neurologic outcomes in patients with cardiac arrest in inten- hemodynamically stable. Dobutamine can be helpful for post- sive care units.7,9 However, several other studies did not show a con- cardiac arrest myocardial dysfunction.12 In addition, vasodilation sistent association between hypercapnia and outcome.7-10 There- occurs due to the systemic ischemia/reperfusion response; thus, fore, it is suggested to maintain the CO2 level within a normal physi- dopamine or norepinephrine may be needed, and intravenous flu- 11 ological range (PaCO2 35 to 45 mmHg or ETCO2 30 to 40 mmHg). ids can be an effective treatment depending on the situation. If

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Table 1. The strategies in adult immediate post-cardiac arrest care both of which reported that using a bundle of care, including a Strategy Doses/details hemodynamic goal, was not associated with the neurologic out- 17,18 Airway Consider tracheal intubation and waveform come. In contrast, other studies have found that a bundle of capnography care that included a blood pressure goal improved the neurologic Breathing-oxygenation Avoid hypoxemia outcome. Two prospective observational studies have reported Goal: titrate FiO2 to achieve SpO2 94% to 98% that maintaining a MAP > 65 mmHg improved the neurologic Breathing-ventilation Avoid excessive ventilation

Goal: titrate to target PaCO2 35 to 45 mmHg or outcome, and an additional study demonstrated that the neuro- PETCO2 30 to 40 mmHg logic outcome was better in the patient group who maintained a Circulation-hemodynamics Avoiding and immediately correcting hypotension MAP > 100 mmHg at 2 hours after ROSC, suggesting an associa- (systolic blood pressure < 90 mmHg, mean arte- 19-21 rial pressure < 65 mmHg) tion between MAP and the neurological outcome. Yet, anoth- Goal: systolic blood pressure ≥ 100 mmHg er study reported that in patients with a good neurologic out- Circulation-vasoactive drugs Norepinephrine: 0.1 to 0.5 mcg/kg/min come, maintaining the time-weighted MAP over 70 mmHg was Dopamine: 5 to 10 mcg/kg/min 22 Epinephrine: 0.1 to 0.5 mcg/kg/min associated with the neurologic outcome. Two before-and-after Correct the reversible causes Hypovolemia, hypoxia, hydrogen ion (acidosis), observational studies have investigated the effect of using a bun- hypokalemia/hyperkalemia, hypothermia, ten- dle of care on the survival rate. Both of these studies used a bun- sion pneumothorax, cardiac tamponade, toxins, dle with a MAP > 80 mmHg and > 65 mmHg as a goal, but there pulmonary thrombosis, coronary thrombosis was no significant difference in the survival rate.17,20 FiO2, fraction of inspired oxygen; SpO2, oxygen saturation; PaCO2, arterial oxygen tension; PETCO2, Partial pressure of end-tidal carbon dioxide. Thus, the evidence is insufficient to determine a specific hemodynamic goal for post-cardiac arrest care. It is suggested that hemodynamic instability persists even with the infusion of intra- hypotension (SBP < 90 mmHg or MAP < 65 mmHg) should be venous fluids or vasoactive drugs, a mechanical circulatory assis- immediately corrected, and a hemodynamic goal should be de- tance device should be considered.13 termined for individual patients, while maintaining an SBP > 100 Although there are observational studies of patients with car- mmHg. diac arrest that have investigated the relationship between blood pressure and outcome, a controlled study has not been conducted 2) Evaluation and treatment of reversible causes on a target goal of blood pressure. An observational study exam- After ROSC and during CPR, the resuscitation team should make ined whether treatment with a specific hemodynamic goal (e.g., a efforts to evaluate the reversible causes of cardiac arrest (i.e., the mean arterial pressure [MAP] > 65 mmHg) would improve neuro- five H’s and five T’s: hypovolemia, hypoxia, hydrogen ions [acido- logic and functional outcome compared to treatment without a sis], hyper/hypokalemia, hypothermia, thromboembolism, throm- specific hemodynamic goal. The study reported that the mortality bosis, tension pneumothorax, cardiac tamponade, and tablets) rate was higher and the functional recovery was lower in the pa- and then treat the patient. tient group whose systolic blood pressure (SBP) was < 90 mmHg after CPR compared to other patient groups whose SBP was ≥ 90 (1) Intervention of acute coronary syndromes mmHg.14 Two retrospective studies reported that the survival rate Acute coronary syndromes are a common cause of adult out-of- decreased in patients who maintained an SBP < 90 mmHg and hospital cardiac arrest (OHCA) with no obvious extracardiac cause < 100 mmHg.15,16 As several before-and-after studies have imple- of arrest.23,24 Thus, a 12-lead electrocardiography (ECG) and a mented a bundle of care, which included a blood pressure goal, cardiac marker test should be obtained as soon as possible after the effect of blood pressure cannot be evaluated alone. Moreover, ROSC to confirm the presence or absence of acute coronary syn- different studies have shown different results regarding a specific dromes.25,26 Coronary angiography should be performed emer- level of blood pressure, and the level of evidence from existing gently for patients with OHCA with suspected cardiac etiology studies is insufficient to determine a target blood pressure goal. and ST elevation on ECG, regardless of whether the patient is Seven studies have investigated the effect of a bundle of care conscious.27-29 If acute coronary syndromes are highly suspected on neurologic outcome, and they reported different results. Some in patients with OHCA with suspected cardiac etiology but their studies have found no association between a specific target blood ECG does not show ST elevation after ROSC, early coronary angi- pressure and neurologic outcome. In one of the studies, a MAP ography should be considered, regardless of the consciousness > 80 mmHg was a goal, and in another study, an intervention status.30,31 was performed when a goal of MAP was below 75 mmHg, and

Clin Exp Emerg Med 2016;3(S):S27-S38 S29 Part 4. Post-cardiac arrest care

(2) Treatment of pulmonary embolism was poor; therefore, the aggressive implementation of TTM be- When cardiac arrest due to pulmonary embolism is strongly sus- came necessary. Additionally, ultra-mild hypothermia (36°C) has pected, chest computed tomography (CT) should be performed, if been suggested as another target temperature since a large, well- possible. If cardiac arrest due to pulmonary embolism is confirmed, conducted RCT compared the target temperature levels of 33°C thrombolytics can be administered, or surgical or percutaneous and 36°C, as it found that the neurological outcome and survival embolectomy can be performed.32-34 at 6 months after ROSC were not improved when the temperature was controlled at 36°C versus 33°C.48 TREATMENTS FOR OPTIMIZING NEUROLOG- Based on the scientific evidence, regardless of the initial rhythm ICAL RECOVERY for TTM, it is recommended to select and maintain a constant temperature between 32°C and 36°C in adult patients with car- 1. Temperature control diac arrest who do not show a meaningful response to verbal 1) Prevention and treatment of hyperpyrexia commands after ROSC. When making this recommendation, the Observational studies have reported an association between poor writing group considered the characteristics of the cardiac arrest outcome and fever after ROSC in patients without targeted tem- population in Korea and that pulseless electrical activity or asys- perature management (TTM).35,36 Hyperpyrexia occurs in many tole (i.e., a non-shockable cardiac rhythm) is relatively more fre- patients after TTM. However, the optimal approach to subsequent quently observed as the initial arrest rhythm. However, it is un- TTM remains unknown. Several studies have reported conflicting known whether TTM with mild induced hypothermia (32°C to conclusions regarding the association with outcome.36-38 Although 34°C) or ultra-mild hypothermia (36°C) is helpful to specific sub- the effect of hyperpyrexia on the outcome of post-cardiac arrest groups with cardiac arrest, thus additional studies are needed to patients is not proven, a poor outcome was associated with hy- shed light on this issue. perpyrexia in comatose patients in whom cerebral damage was due to other causes such as cerebral hemorrhage or infarct, and (2) Initiation and duration of TTM it is relatively easy to treat or prevent hyperthermia.39,40 Therefore, Neuronal injury following transient global brain ischemia/reper- it is suggested to continuously prevent or treat fever in adult co- fusion progresses for several days in a complex biochemical cas- matose patients after ROSC from cardiac arrest, regardless of whe cade. Mild induced hypothermia influences various stages during ther the patient received TTM. the process.49,50 In particular, oxidative stress, increased excitatory amino acids, and energy depletion occur immediately after ROSC 2) TTM and during cardiac arrest. Theoretically, it would be helpful if mild (1) Indications and target temperature hypothermia is induced in patients with cardiac arrest as quickly One randomized controlled trial (RCT) and a pseudo-randomized as possible.51,52 For this reason, several studies have compared the trial demonstrated that TTM of 32°C to 34°C improved the neu- prehospital induction of hypothermia and hospital induction of rological outcome at hospital discharge and at 6 months in adult hypothermia. In all seven RCTs with a medium level of evidence, patients with OHCA with a shockable cardiac rhythm.41,42 There- there was no significant difference between the groups in terms fore, OHCA with a shockable rhythm is a main indication for TTM. of a poor neurologic outcome or mortality.53-59 A meta-analysis of Regarding patients with OHCA with a non-shockable rhythm, no seven studies also did not show differences in the mortality rate RCT was available. In a cohort study with a very low level of evi- or poor neurologic outcome between the groups at hospital dis- dence, there was an association between mild induced hypother- charge.46 Accordingly, based on current scientific evidence, it can- mia and 6-month survival in patients with OHCA with a non- not be concluded that the prehospital induction of TTM is better shockable rhythm. However, a meta-analysis of two other cohort than induction at the hospital; hence, more conclusive follow-up studies did not determine an association between mild induced studies are needed. hypothermia (32°C to 34°C) and an improvement in neurological A high quality interventional study is not yet available with results.43-46 For patients with in-hospital cardiac arrest, no RCT which to determine an optimal duration of TTM after cardiac ar- has been published. A retrospective cohort study of 1,836 patients rest. Therefore, based on the duration used in two of the largest found no association between mild induced hypothermia and aforementioned RCTs, it is reasonable to maintain TTM for at least survival or a functionally favorable status at hospital discharge.47 24 hours after achieving the target temperature.41,48 However, in this study, the implementation rate of TTM was very low, and the overall outcome of patients treated without TTM

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(3) Methods of inducing and/or maintaining TTM 2. Glucose control Diverse cooling methods are used to induce and maintain a tar- Hyperglycemia is associated with mortality and a poor neurologic get temperature, but there is no one best method. External sur- outcome in patients who have been resuscitated from cardiac ar- face cooling methods used widely in the past (e.g., a cooling blan- rest, and it should be appropriately controlled. There is little evi- ket, ice packs, and a wet towel) are easy and convenient to use. dence about a target blood glucose level to improve the outcome However, they take longer to lower the patient’s core tempera- of patients with cardiac arrest. An RCT found no difference in the ture, and they are difficult to maintain at a constant level, which 30-day mortality rate between the groups with a target blood adds to the medical staff’s high workload. Recently, body temper- glucose level of 72 to 108 mg/dL and 108 to 144 mg/dL.62 In a ature control has become easier, as cooling equipment that use before-and-after study that used a bundle of care with a target endovascular catheters and external cooling equipment that reg- blood glucose level of 90 to 144 mg/dL, the neurological outcome ulates temperature with an auto-feedback system have become improved after implementing the bundle, but the effect could not available, but they are expensive. Hence, medical staff that plan be attributed only to the controlled blood glucose level.18 Apply- to perform TTM should consider a variety of factors (e.g., the place ing the findings of these studies to cardiac arrest patients may to initiate the treatment, staff’s ability and experience, speed in not be appropriate, because they examined the effect of control- induction, stability during maintenance and rewarming, mobility ling blood glucose level in critically ill patients.63,64 Although is of the equipment, adverse events associated with specific equip- still controversy on how to control the blood glucose level in crit- ment or techniques, convenience of using the equipment, cost, ically ill patients, the strict control of blood glucose was associat- etc.), and the most optimal cooling technique should be chosen ed with an increased occurrence of hypoglycemia.62 Therefore, for individual patients.60 the target range of 144 to 180 mmHg is suggested to prevent Cold crystalloid intravenous fluid infusion is relatively easy to hypoglycemia, although evidence so far is insufficient. Hypergly- induce hypothermia, and it has been widely used in prehospital cemia > 180 mmHg should be treated with an insulin infusion settings or during resuscitation for convenience. However, ac- per the hospital’s protocol, and care should be taken to prevent cording to a meta-analysis of four RCTs, when TTM was initiated hypoglycemia (< 80 mg/dL). If hypoglycemia occurs, it should be in the prehospital setting using cold crystalloid intravenous fluid immediately corrected by administering a glucose solution. The infusion, the risk for re-arrest increased.46 In addition, pulmonary blood glucose level, especially, fluctuates during the induction or edema was increased according to one large-scale RCT.58 There- rewarming period; therefore, it is desirable to frequently test the fore, it is not recommended to perform routine prehospital cool- patient’s blood glucose level. ing of a patient after ROSC with the rapid infusion of cold intravenous fluid. 3. Control of seizures When TTM is performed, the patient’s core temperature should No study has directly compared patients treated for seizure with be continuously monitored in the esophagus, bladder, or pulmo- those not treated for seizure. Furthermore, there is no evidence nary artery. The pulmonary artery is the most accurate, but it has thus far that a specific anticonvulsant or combination therapy a limitation because it requires an invasive procedure. The axillary with anticonvulsant drugs is helpful in comatose patients after temperature or oral temperature is not appropriate for measuring cardiac arrest. Therefore, if seizure occurs or is suspected, an elec- changes in the core temperature, and tympanic temperature sen- troencephalogram (EEG) needs to be performed immediately to sors are difficult to use for a long time and they are often inac- determine the presence of epileptiform activity. Non-convulsive curate. The rectal temperature is commonly used, but there can seizures can occur while TTM is performed with a neuromuscular be temperature gaps when hypothermia is induced rapidly; thus, blocking drug; thus, if possible, an EEG should be continuously careful monitoring is needed.61 monitored, and the arterial blood gas level or change in vital signs Moreover, there is not enough evidence for an optimal speed (e.g., unexplained tachycardia) should be carefully observed.65 To of rewarming. Accordingly, it is suggested to rewarm at a speed control seizures, any commonly used anticonvulsant needs to be of 0.25°C to 0.5°C per hour, which has been used often in previ- promptly injected. In a case of generalized seizure, benzodiaze- ous studies,41,42,48 and maintain normothermia (36.5°C to 37.5°C) pine, phenytoin, sodium valproate, propofol, levetiracetam, phe- up to 72 hours after ROSC in comatose patients even after nor- nobarbital, and similar drugs can be used alone or in combination mothermia is achieved. with each other. In cases of myoclonus, clonazepam, sodium valproate, levetiracetam, propofol, etc. can be used alone or in combination with each other.66 Post-anoxic myoclonic status epilepti-

Clin Exp Emerg Med 2016;3(S):S27-S38 S31 Part 4. Post-cardiac arrest care cus may not respond well to anticonvulsants.67,68 Available evi- al recommendation is to use a multimodal approach rather than dence does not support the prophylactic administration of anti- relying on a single test or finding. convulsants. Therefore, the routine use of prophylactic anticonvulsants in post-cardiac arrest patients is not recommended. 1. Clinical examination For a clinical examination to predict a poor neurologic outcome 4. Sedation within 72 hours after ROSC in comatose patients after cardiac In most post-cardiac arrest patients, mechanical ventilation should arrest, the bilateral absence of pupillary light reflex, or the com- be maintained during post-cardiac arrest care, and sedatives or bination of the absence of pupillary light reflex and absence of analgesics may have to be intermittently or continuously admin- corneal reflex is required in both patients with TTM (FPR 0 [0% to istered. If a patient is sedated while TTM is performed, the time 3%]) and without TTM (FPR 0 [0% to 8%]).71-79 required to reach to the target temperature can be reduced be- The lack of motor movement (M1) or extensor posturing (M2) cause shivering is prevented or reduced. Using a sedation proto- to pain has a high FPR level (27% [12% to 48%]) for predicting a col can be helpful in these cases. poor neurologic outcome in comatose patients who did not re- Sedation after ROSC is a commonly used treatment method, ceive TTM after cardiac arrest, and a similar finding was observed but the level of evidence is not sufficient to make a recommen- in patients who received TTM.71,73-82 Therefore, it is suggested to dation about the duration to administer a sedative or neuromus- not use motor movement to pain alone to predict poor neurologic cular blocker in post-cardiac arrest patients. A meta-analysis of outcomes. Although they have a high sensitivity level (74% [68% 44 studies reported on sedative drugs that were used while TTM to 79%]), they can be used to confirm a patient’s poor neurologic was performed among 68 intensive care units in various coun- outcome or predict a poor neurologic outcome in combination tries found that a large variety of drugs were being used.69 From with other predictors. the analysis, it is impossible to know which drugs may be associ- Myoclonus in comatose patients within 72 hours after cardiac ated with outcome, but mainly the combination therapy of an arrest is associated with a high FPR (10% to 15%) for predicting opioid and sedative was used. It is recommended to maintain a poor neurologic outcomes; thus, it is suggested to not use it alone. sedative over a short duration of action as much as possible, but In contrast, status myoclonus, which occurs within 72 hours after no study has analyzed the effect of using sedatives in patients cardiac arrest, predicts poor neurologic outcome with a high ac- after cardiac arrest or has suggested treatment strategies. One curacy in cases with TTM (FPR 0% [0% to 4%]) and without TTM study has suggested that the continuous administration of neu- (FPR 0% [0% to 5%]).65,67,71,72,83,84 Therefore, it is useful when used romuscular blockers may be associated with a low mortality rate.70 in combination with other predictors. If there is residual sedation However, neuromuscular blockers interfere with clinical examina- and paralysis still remains, the clinical examination can be de- tions, and they obscure the occurrence of seizure. Therefore, if a layed to minimize the possibility of false positives. Seventy-two neuromuscular blocker is continuously administered, the EEG should hours after ROSC is suggested as the earliest time to predict a be continuously monitored. poor neurologic outcome.

EVALUATION OF NEUROLOGICAL 2. Electrophysiological studies PROGNOSTICATION To predict poor neurologic outcome in comatose patients after cardiac arrest, regardless of using TTM, the use of the bilateral In the 2015 guidelines, studies of patients who had and had not absence of N20 waveform recorded from somatosensory evoked received TTM were evaluated. These studies evaluated the diag- potentials (SSEPs) (FPR 1% [0% to 3%]) is recommended 24 to nostic accuracy of clinical examination, electrophysiological stud- 72 hours after cardiac arrest or after rewarming.72-75,80-82,85-89 An ies, biomarkers, and imaging tests for predicting poor neurologi- SSEP recording requires appropriate skills and experience, and ef- cal outcome, and they recommended diagnostic tests with a false forts should be considered to avoid muscle artifacts or electrical positive rate (FPR) close to 0% and a narrow 95% confidence in- interference from the environment of the emergency room or interval (0% to 10%) as predictors. tensive care unit. It is recommended to predict the neurologic outcome at least A lack of EEG background reactivity can accurately predict 72 hours after ROSC, particularly because in most cases, a seda- poor neurologic outcome in comatose patients after cardiac ar- tive and a neuromuscular blocker are administered to comatose rest during TTM (FPR 2% [1% to 7%]) and within 72 hours after patients after cardiac arrest while TTM is performed. An addition- ROSC (FPR 0% [0% to 3%]).80,82,90,91 However, using the pattern

S32 www.ceemjournal.org Young-Min Kim, et al. of background reactivity on EEG has limitations, because they are TTM, burst-suppression observed in the continuous amplitude-in- operator dependent, unquantifiable, and lack standardization. tegrated EEG recordings, status epilepticus, and lack of normal Status epilepticus (i.e., a persistent seizure over 72 hours) is com- trace over 36 hours can be used in combination with other pre- monly associated with a poor neurologic outcome (FPR 0% to dictors.95 6%), if it occurs during hypothermia or rewarming in patients who received TTM.65,92 EEG burst-suppression can show a recov- 3. Biomarkers ery of consciousness, if it occurs for 24 to 48 hours after ROSC in A high level or increasing levels of neuron-specific enolase (NSE) patients who did not receive TTM, or during hypothermia in pa- measured at 48-72 hours after ROSC can be used in combination tients who received TTM,82,93 but persistent burst-suppression with other predictors to predict poor neurologic outcomes of co- that occurs 72 hours after ROSC is always associated with a poor matose patients who received TTM after cardiac arrest.96-98 A care- neurologic outcome.72,94 Therefore, it is suggested to use EEG pre- ful approach is necessary when testing NSE to avoid a false posi- dictors (e.g., the lack of EEG response to external stimulation, EEG tive result that can occur due to hemolysis, and it is recommend- burst-suppression after rewarming, and status epilepticus) after ed to sample various points in time as much as possible. Since 72 hours after ROSC in combination with other predictors to pre- different studies have reported different NSE thresholds to predict dict a poor neurologic outcome in comatose patients after cardi- a poor neurologic outcome with 0% FPR, it is recommended to ac arrest, regardless of using TTM. not use the serum levels of NSE and S100B alone. To predict poor neurologic outcomes of patients who received

Recommended timing of prognostic tests CT NSE NSE N/Ex N/Ex N/Ex N/Ex N/Ex N/Ex N/Ex SSEP

DW-MRI EEG or amplitude integrated EEG (aEEG)

Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7

Targeted temperature management

1. Exclude confounders (especially residual sedation or paralysis)

2. Unconscious and motor= 1 or 2 Observe and re-evaluate at ≥ 72 hours after ROSC No

Two or more of the following: 3. No bilateral pupillary reflexes and bilaterally absent N20 SSEP wave ∙ Marked reduction in the GWR on brain CT obtained within 2 hours ∙ No normal trace on aEEG ≤ 36 hours after ROSC ∙ Status myoclonus ≤ 72 hours after ROSC ∙ High NSE level at 48-72 hours after ROSC No Wait ∙ Unreactive, burst suppression, or status epilepticus on EEG ≥ 72 Presence of 1, 2, and 3? at least hours after ROSC 24 hours ∙ Extensive restriction of diffusion on brain DW-MRI at 2 to 6 days Yes after ROSC Yes Poor outcome very likely

Fig. 2. Neurological prognostication algorithm. N/Ex, neurological examination; CT, computed tomography; NSE, neuron specific enolase; SSEP, somatosensory evoked potential; DW-MRI, diffusion-weighted magnetic resonance imaging; EEG, electroencephalography; ROSC, return of spontaneous circulation; GWR, gray matter/white matter ratio; CT, computed tomography; aEEG, amplitude-integrated electroencephalography.

Clin Exp Emerg Med 2016;3(S):S27-S38 S33 Part 4. Post-cardiac arrest care

4. Imaging tests ROSC. A poor neurologic outcome can be predicted if two of six Global cerebral edema and the marked reduction of the gray mat- factors are observed. Otherwise, the outcome can be determined ter/white matter ratio (GWR) on CT obtained within 2 hours after based on various findings in combination or after additional ob- ROSC can predict poor neurologic outcomes with 0% FPR in co- servation. matose patients who received TTM after cardiac arrest. However, different studies have reported different GWR thresholds with 0% ACKNOWLEDGMENTS FPR, depending on the measurement technique and the studied brain area.77,98,99 An extensive restriction of diffusion detected on We appreciate to the following evidence reviewers who contrib- brain magnetic resonance imaging (MRI) obtained 2 to 6 days af- ute to develop the 2015 Korean Consensus on Cardiopulmonary ter ROSC and quantitatively measured with an apparent diffusion Resuscitation and Emergency Cardiovascular Care Science with coefficient can predict poor neurologic outcomes with 0% FPR in Treatment Recommendations for the population, intervention, comatose patients who received TTM after cardiac arrest.100,101 comparator, and outcome questions in post-cardiac arrest care. However, the apparent diffusion coefficient threshold value with The collaborators’ are as follows: Kyung Su Kim, Seoul National 0% FPR is different among studies, depending on the studied brain University Hospital, Seoul, Korea; Won Young Kim, Ulsan University area and the measurement technique. Asan Medical Center, Seoul, Korea; Jin Joo Kim, Gachon University Therefore, it is recommended to use the marked reduction of Gil Medical Center, Incheon, Korea; Min Seob Sim, Sungkyunk- the GWR on CT obtained within 2 hours after ROSC or the exten- wan University Samsung Medical Center, Seoul, Korea; Yeon Ho sive restriction of diffusion on MRI obtained 2 to 6 days after You, Chungnam National University Hospital, Kwangju, Korea; ROSC in combination with other predictors to predict poor neu- Seung Joon Lee, Myongji Hospital, Seoul, Korea; Young Hwan Lee, rologic outcomes of comatose patients who received TTM after Hallym University Sacred Heart Hospital, Seoul, Korea; Joo Young cardiac arrest. Lee, The Catholic University of Korea Seoul St. Mary’s Hospital, Seoul, Korea; Kyung Woon Jeung, Chonnam National University 5. Neurological prognostication algorithm (Fig. 2) Hospital, Kwangju, Korea; Moon Gu Han, Seoul National University In most post-cardiac arrest comatose patients, cerebral function Bundang Hospital, Seongnam, Korea; Chul Han, Ewha University recovery occurs within 72 hours after ROSC.84,102 However, there Hospital, Seoul, Korea. is a possibility of decreased accuracy of clinical examination due to the influence of sedatives and neuromuscular blockers admin- REFERENCES istered during the application of TTM. First, it is important to exclude confounders (e.g., residual se- 1. Kilgannon JH, Jones AE, Shapiro NI, et al. Association be- dation and paralysis) that can impact clinical examination after tween arterial hyperoxia following resuscitation from cardi- 72 hours after ROSC and the completion of TTM. Second, 72 hours ac arrest and in-hospital mortality. 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tients after cardiac arrest. Lancet 1994;343:1642-3. tinuous amplitude-integrated electroencephalogram applied 85. Stelzl T, von Bose MJ, Hogl B, Fuchs HH, Flugel KA. A com- immediately after return of spontaneous circulation in ther- parison of the prognostic value of neuron-specific enolase apeutic hypothermia-treated cardiac arrest patients. Resus- serum levels and somatosensory evoked potentials in 13 re- citation 2013;84:200-5. animated patients. Eur J Emerg Med 1995;2:24-7. 95. Oh SH, Park KN, Shon YM, et al. Continuous amplitude-inte- 86. Tiainen M, Kovala TT, Takkunen OS, Roine RO. Somatosenso- grated electroencephalographic monitoring is a useful prog- ry and brainstem auditory evoked potentials in cardiac ar- nostic tool for hypothermia-treated cardiac arrest patients. rest patients treated with hypothermia. Crit Care Med 2005; Circulation 2015;132:1094-103. 33:1736-40. 96. Oksanen T, Tiainen M, Skrifvars MB, et al. Predictive power 87. Zingler VC, Krumm B, Bertsch T, Fassbender K, Pohlmann- of serum NSE and OHCA score regarding 6-month neuro- Eden B. Early prediction of neurological outcome after car- logic outcome after out-of-hospital ventricular fibrillation diopulmonary resuscitation: a multimodal approach com- and therapeutic hypothermia. Resuscitation 2009;80:165- bining neurobiochemical and electrophysiological investiga- 70. tions may provide high prognostic certainty in patients after 97. Rundgren M, Karlsson T, Nielsen N, Cronberg T, Johnsson P, cardiac arrest. Eur Neurol 2003;49:79-84. Friberg H. Neuron specific enolase and S-100B as predictors 88. Rothstein TL. The role of evoked potentials in anoxic-isch- of outcome after cardiac arrest and induced hypothermia. emic coma and severe brain trauma. J Clin Neurophysiol Resuscitation 2009;80:784-9. 2000;17:486-97. 98. Lee BK, Jeung KW, Lee HY, Jung YH, Lee DH. Combining brain 89. Zanatta P, Messerotti Benvenuti S, Baldanzi F, Bosco E. Pain- computed tomography and serum neuron specific enolase related middle-latency somatosensory evoked potentials in improves the prognostic performance compared to either the prognosis of post anoxic coma: a preliminary report. Mi- alone in comatose cardiac arrest survivors treated with ther- nerva Anestesiol 2012;78:749-56. apeutic hypothermia. Resuscitation 2013;84:1387-92. 90. Crepeau AZ, Rabinstein AA, Fugate JE, et al. Continuous EEG 99. Kim SH, Choi SP, Park KN, Youn CS, Oh SH, Choi SM. Early in therapeutic hypothermia after cardiac arrest: prognostic brain computed tomography findings are associated with and clinical value. Neurology 2013;80:339-44. outcome in patients treated with therapeutic hypothermia 91. Oddo M, Rossetti AO. Early multimodal outcome prediction after out-of-hospital cardiac arrest. Scand J Trauma Resusc after cardiac arrest in patients treated with hypothermia. Emerg Med 2013;21:57. Crit Care Med 2014;42:1340-7. 100. Els T, Kassubek J, Kubalek R, Klisch J. Diffusion-weighted 92. Wennervirta JE, Ermes MJ, Tiainen SM, et al. Hypothermia- MRI during early global cerebral hypoxia: a predictor for treated cardiac arrest patients with good neurological out- clinical outcome? Acta Neurol Scand 2004;110:361-7. come differ early in quantitative variables of EEG suppres- 101. Mlynash M, Campbell DM, Leproust EM, et al. Temporal and sion and epileptiform activity. Crit Care Med 2009;37:2427- spatial profile of brain diffusion-weighted MRI after cardiac 35. arrest. Stroke 2010;41:1665-72. 93. Kawai M, Thapalia U, Verma A. Outcome from therapeutic 102. Jorgensen EO, Holm S. The natural course of neurological hypothermia and EEG. J Clin Neurophysiol 2011;28:483-8. recovery following cardiopulmonary resuscitation. Resusci- 94. Oh SH, Park KN, Kim YM, et al. The prognostic value of con- tation 1998;36:111-22.

S38 www.ceemjournal.org Clin Exp Emerg Med 2016;3(S):S39-S47 http://dx.doi.org/10.15441/ceem.16.131 Supplementary

Part 5. Pediatric basic life support: eISSN: 2383-4625 2015 Korean Guidelines for Cardiopulmonary Resuscitation

Ji Sook Lee1, Ji Yun Ahn2, Do Kyun Kim3, Yoon Hee Kim4, Bongjin Lee5, Won Kyoung Jhang6, Gi Beom Kim5, Jin-Tae Kim7, June Huh8, 5 9 10 June Dong Park , Sung Phil Chung , Sung Oh Hwang Received: 16 February 2016 Revised: 19 March 2016 1Department of Emergency Medicine, Ajou University College of Medicine, Suwon, Korea Accepted: 19 March 2016 2Department of Emergency Medicine, Hallym University College of Medicine, Seoul, Korea 3Department of Emergency Medicine, Seoul National University College of Medicine, Seoul, Korea 4Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea Correspondence to: June Dong Park 5Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea Department of Pediatrics, Seoul 6Department of Pediatrics, Ulsan University College of Medicine, Seoul, Korea National University College of 7Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Medicine, 101 Daehak-ro, Jongno-gu, Korea Seoul 03080, Korea 8Department of Pediatrics, Sungkyunkwan University School of Medicine, Seoul, Korea E-mail: [email protected] 9Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Korea 10Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea

Pediatric basic life support (PBLS) is a major component of the emergency medical response to the pediatric victims with cardiac arrest, which should be adequately implemented for a series of survival processes. The pediatric chain of survival comprises five components, including prevention and early recognition of cardiac arrest, early access (activation of emergency medical system [EMS]), early high-quality cardiopulmonary resuscitation (CPR), early defibrillation, and effective advanced life support and post-cardiac arrest care (Fig. 1). The first four processes of the survival chain correspond to PBLS. Similar to adults, in children, prompt and effective CPR is essential for the successful recovery of spontaneous circulation and good neurological outcomes. In children, the survival rate varies depending on the cause of the cardiac arrest. For a cardiac arrest due to an asphyxial arrest, the rate of neurologically normal survival is 70%, while the survival rate is 20% to 30% in the case of a cardiac arrest from ventricular fibrillation (VF).1 Ne- onate is defined as being hospital after birth. An infant is defined as being less than 1 year of age after neonatal period. PBLS guideline applies to children under 8 years of age except neo- nate for both of the lay rescuer and the health care provider. As cardiac arrest from asphyxial arrest is a lot more common in children compared to those due to VF, ventilation is extremely How to cite this article: important in pediatric CPR. Lee JS, Ahn JY, Kim DK, Kim YH, Lee B, Jhang WK, Kim GB, Kim JT, Huh J, Park JD, Chung SP, Hwang SO. Part 5. Pediatric basic life PBLS FOR LAY RESCUERS support: 2015 Korean Guidelines for Cardiopulmonary Resuscitation. Clin Exp Emerg Med 2016;3(S):S39-S47. The algorithm for CPR in infants and pediatric patients experiencing cardiac arrest is the same as that used in adults, signifying unification in the education and training as well as continua- tion of the existing the 2011 Korean CPR guidelines, according to which chest compressions are This is an Open Access article distributed carried out followed by rescue breathing.2-4 A flow diagram of PBLS for lay rescuers is shown in under the terms of the Creative Commons Attribution Non-Commercial License (http:// Fig. 2. creativecommons.org/licenses/by-nc/3.0/).

1. Safety of the rescuer and the patient 2. Determination of the unresponsiveness When conducting CPR, the safety of the rescuer and patient must If an unresponsive patient is gasping or not breathing at all, the be confirmed at the current location. CPR may carry the risk of lay rescuer should understand that the patient is undergoing a transmission of infectious diseases, but the actual risk to the res- cardiac arrest and requires CPR. The rescuer should lightly tap the cuer is extremely low. patient and shout out “are you okay?” or call out the name of the patient if known. Then, the rescuer should promptly check whether the child has injuries or requires medical treatments.

3. Activation of the EMS If the patient shows no response to stimulation and if the rescuer is the only person present, the rescuer should shout for help. If someone else arrives for help, the rescuer should request him or her to make a call to 119 as well as find an automated external Fig. 1. Pediatric chain of survival. The pediatric chain of survival comprises five components, including prevention and early recognition of defibrillator (AED). If there is no one else nearby, the rescuer should cardiac arrest, early access (activation of emergency medical system), make a rescue request to 119 promptly. If the rescuer has a per- early high-quality cardiopulmonary resuscitation, early defibrillation, sonal cellular phone, the rescuer should promptly call 119 at the and effective advanced life support and post-cardiac arrest care. site itself, without leaving the child. The rescuer should let the 119 dispatcher know about the status of the unresponsive patient,

Unresponsive victim

Activate the emergency medical service (call 119) and ask for an AED Follow instructions of the 119 dispatcher

Check if no breathing or only gasping

CPR (chest compression: ventilation= 30:2, repeat the cycle)

AED arrived

Use AED as soon as it is available Act according to AED instructions

Shockable AED analyzes rhythm Non-shockable Shockable rhythm?

Give 1 shock

Resume CPR immediately for 2 minutes (until prompted by AED to allow rhythm check) Continue until ALS providers take over or victim starts to move

Fig. 2. Algorithm of pediatric basic life support for lay rescuers. AED, automated external defibrillator; CPR, cardiopulmonary resuscitation; ALS, advanced life support.

S40 www.ceemjournal.org Ji Sook Lee, et al. request for an AED, and perform the next resuscitation steps by maintained for each compression, irrespective of whether one or following instructions given by the dispatcher. both hands are used, and the chest must be allowed to recoil to If the patient shows no response to stimulation and if there its normal position after every compression. are two or more witnesses, the first rescuer should start CPR im- After each compression, the chest must be allowed to recoil mediately and the other should call an EMS and request for an fully, as proper venous return to the heart can be completed only AED. when the chest is fully relaxed. During pediatric CPR, incomplete Most cases of cardiac arrests in children are due to asphyxial chest recoil is common, particularly when rescuers are fatigued. arrest rather than VF. Therefore, if there is only one rescuer with- Incomplete chest relaxation increases pressure inside the chest out a cellular phone, the rescuer should perform CPR for the first cavity and reduces venous return, coronary perfusion, cardiac out- 2 minutes then call an EMS and bring a nearby AED. The rescuer put, and cerebral perfusion.8,9 should return to the patient as soon as possible and use the AED. Fatigue of the rescuer can lead to inadequate speed and depth If no AED can be found, the rescuer should resume CPR starting of chest compression, as well as chest recoil. Even if the rescuer with chest compression. denies fatigue and continues CPR, the quality of chest compression will decrease within a few minutes.10,11 If there are two or 4. Checking patient breathing more rescuers, they should take turns to perform CPR every 2 If a patient is confirmed to be breathing regularly, the child is not minutes in order to prevent fatigue and reduction in the quality in need of CPR. In such cases, after confirming that there is no and speed of chest compression. The switching between the res- evidence of physical injuries, the rescuer should turn the child cuers to perform chest compression should be done as soon as onto one side and into the recovery position to keep their airway possible (ideally within 5 seconds) to minimize the interruption in open and reduce the risk of aspiration. The breathing status of chest compression. Each rescuer should perform 30 chest com- the patient should be checked continuously until the arrival of the pressions and 2 ventilations, until an EMS arrives or the patient EMS. If the child tries to change his or her position into a more starts breathing. For CPR in infants and children, chest compres- relaxed position, the child should be allowed to do so. sion and ventilation must be provided together to yield the best If a patient is not responding to stimulation and is not breath- outcome. CPR accompanied by both ventilation and chest com- ing or only gasping (cardiac arrest breathing), CPR should be start- pressions must be performed by a person trained in performing ed. In some cases, patients who are in need of CPR and gasping infant or pediatric CPR, both inside and outside the hospital. How- can be mistaken as having normal breathing. Patients who are ever, if a rescuer is not trained in artificial ventilation or is unable gasping should be regarded as not breathing, for which CPR should to perform it, he or she should perform chest compression until be started. an EMS arrives.12,13

5. Chest compression 6. Opening the airway and giving ventilation In CPR, adequate chest compression maintains blood flow to vital As infants or children who are not responding may have their air- organs and increases the possibility of recovery of spontaneous way obstructed by their tongues, their airway must be opened by circulation. If a child is neither responding to stimulation nor tilting the head and lifting the chin for both injured and nonin- breathing, the rescuer should immediately perform chest com- jured patients. For infants, mouth-to-mouth-and-nose technique pression 30 times. Chest compression should be performed at a should be performed. Mouth-to-mouth should be used for chil- speed of 100 to 120 per minute and by pressing down at least dren. While blowing the breath in, the rising of the chest should one-third the depth of the anteroposterior diameter of the rib be confirmed and each breath should take about 1 second. If the cage (chest thickness) or 4 cm in infants and 4 to 5 cm in chil- chest does not rise, the head should be tilted and the mouth dren.5-7 It is best to perform chest compression by laying the pa- should be adequately covered to prevent leaking of the air before tient on a flat and hard surface. trying ventilation again. While performing ventilation for infants, For infants, the lay rescuer or a healthcare provider who is per- if it is difficult to cover both the mouth and nose at once, mouth- forming the CPR should use two fingers to compress the center to-mouth or mouth-to-nose breathing may be performed. For of the chest just below the line between the nipples. For children, mouth-to-mouth, the nose should be occluded, and for mouth- the rescuer should compress the lower half of the sternum with to-nose, the mouth should be occluded. one or both hands. Special attention should be paid to avoid pressing of the xiphoid process or the rib cage. Proper depth should be

Clin Exp Emerg Med 2016;3(S):S39-S47 S41 Part 5. Pediatric basic life support

7. Ratio of chest compression to ventilation following 30 chest compressions should be performed, with the After performing 30 compressions, two ventilations should be shortest possible break in order to minimize the duration of inter- performed immediately. If there is only one rescuer, 2 ventilations ruption of chest compression. When there are two rescuers, one should be in charge of chest compression and the other in charge Table 1. Reference chart of pediatric basic life support for lay rescuers of ventilation to sequentially perform 30 chest compressions and Management Details 2 ventilations. Chest compression and ventilation must not be per- Respiration needed CPR No respiration or only gasping (i.e., no normal formed simultaneously. Interruption of chest compression should breathing) be minimized. It would take approximately 2 minutes for one res- Chest compression Location: the lower half of the sternum for children, cuer to perform 5 cycles of chest compression and ventilation at just below the nipple line for infants Depth: at least one third of the AP diameter of the the ratio of 30:2. Two rescuers should perform chest compression chest (4–5 cm for children and 4 cm for infants) and ventilation by rotating after every 5 cycles (Table 1). Rate: 100–120/min Chest compression-to- Chest compression-to-ventilation= 30:2 ventilation ratio without Perform compression-only CPR, if rescuers are PBLS FOR HEALTHCARE PROVIDERS advanced airway unwilling or unable to deliver breaths Use AED Use AED as soon as it is available PBLS for healthcare provider is essentially very similar to PBLS for AED analyzes rhythm Stop chest compression during rhythm analysis the lay rescuer, except a few differences.14,15 As healthcare pro- CPR after defibrillation Resume immediately chest compression after shock delivery viders usually work in teams rather than individually and because a series of activities is performed concurrently (for example, chest CPR, cardiopulmonary resuscitation; AP, anteroposterior; AED, automated external defibrillator. compression and preparation for ventilation), the priority of each

Unresponsive victim

Call 119 and get AED/defibrillator

Check pulse and look for no breathing or only gasping After 2 minutes (simultaneously within 10 seconds)

∙ Provide rescue breathing: 1 breath/3-5 seconds Definite pulse ∙ Add compressions if pulse remains 60/min with No pulse signs of poor perfusion CPR 1 Rescuer, compression : ventilation= 30:2 2 Rescuers, compression : ventilation= 15:2

Apply AED/defibrillator

Shockable Non-shockable AED analyzes rhythm

Give 1 shock

Resume CPR immediately for 2 minutes

Fig. 3. Algorithm of pediatric basic life support for healthcare providers. AED, automated external defibrillator; CPR, cardiopulmonary resuscitation.

S42 www.ceemjournal.org Ji Sook Lee, et al. activity is relatively less emphasized. A flow diagram of PBLS for 4. Chest compression healthcare providers is shown in Fig. 3. Chest compression should be performed if infants or children do not respond, are not breathing, and do not have a pulse (or if it is 1. Checking for patient response and breathing unclear whether they have a pulse). The differences between a If an unresponsive patient is gasping or not breathing at all, the healthcare provider and a lay rescuer are in the method of chest rescuer should understand that the patient is undergoing a cardi- compression in infants. When a healthcare provider is alone, chest ac arrest and requires CPR. The rescuer should lightly tap the pa- compression using two fingers is performed for an infant. The tient and shout out “are you okay?” or call out the name of the two-thumb encircling method for chest compression is performed patient if known. Then, the rescuer should promptly check wheth- when there are two or more rescuers. The sides of the thorax of er the child has injuries or requires medical treatments. an infant are wrapped around with open hands, with the two thumbs side-by-side on the sternum for strong compression. The 2. Activation of the EMS advantage of the two-thumb encircling method is that it increas- If a patient is neither responding nor breathing (or he/she has ab- es perfusion pressure of the coronary artery to a greater extent normal breathing such as gasping), the rescuer should ask nearby compared to the two-finger chest compression, allowing pressure individuals to activate an EMS and request for an AED. depth and strength consistency to generate higher systolic and diastolic blood pressures.16-18 If it is not possible to wrap the side 3. Checking patient pulse of the thorax with both hands, the chest should be compressed If an infant or a child is neither responding nor breathing nor- using two fingers. The location for chest compression should be mally, a healthcare provider should check for their pulse within the lower half of the sternum in children and the sternum just 10 seconds. For infants, the pulse should be checked on the bra- below the nipple line in infants. chial artery, and for children, on the carotid or femoral artery. If a pulse is not detected within 10 seconds or if it is uncertain, chest 5. Opening the airway and giving ventilation compression should be started.2 After 30 chest compressions (15 compressions in the case of two rescuers), the airway is opened using head-tilt chin-lift maneuver 1) Case of palpable pulse and inadequate breathing followed by 2 ventilations. If there are signs of spinal cord injury, If a pulse is detected to be more than 60 per minute but breath- head tilting should not be performed. Instead, the airway should ing is inadequate, ventilation should be provided at the speed of be opened using the jaw-thrust method. As proper ventilation 12 to 20 times per minute (1 breath every 3 to 5 seconds) until with an opened airway is extremely important for pediatric CPR, the return of spontaneous breathing. The pulse should be rechecked head-tilt chin-lift maneuver should be performed if jaw-thrust is every 2 minutes, and each pulse check should not exceed 10 sec- not sufficient to open the airway. onds. 6. Ventilation 2) Case of bradycardia and poor systemic perfusion 1) Method of ventilation If the pulse rate is less than 60 per minute and the perfusion sta- If it is difficult to concurrently cover the mouth and nose while tus is poor (i.e., pale skin, patches of spots, or cyanosis is observed) performing ventilation on infants, mouth-to-mouth or mouth-to- even with oxygen and adequate ventilation, chest compression nose breathing may be performed. When mouth-to-mouth breath- should be performed. As the cardiac output of infants and chil- ing is performed, the nose should be closed. For mouth-to-nose dren depends greatly on the heart rate, bradycardia with poor breathing, the mouth should be closed. In both cases, rising of systemic perfusion signals the necessity for chest compression. the chest should be confirmed during ventilation. Performing CPR immediately after the occurrence of cardiac arrest can lead to an increased survival rate. Although the critical 2) Ventilation method to prevent hyperventilation value of the heart rate at which chest compression should be Before establishing an advanced airway (such as endotracheal in- performed is not yet clearly defined, chest compression is recom- tubation, or supraglottic airway), ventilation is performed twice mended for a heart rate less than 60 per minute and poor perfu- after 30 chest compressions (one rescuer) or 15 chest compression for the convenience of education and ease of memorization. sions (two healthcare provider rescuers), with mouth-to-mouth breathing or the bag-mask method. After establishing an advanc ed airway, the “compression-ventilation ratio” of CPR is not used.

Clin Exp Emerg Med 2016;3(S):S39-S47 S43 Part 5. Pediatric basic life support

Chest compression at the speed of 100 to 120 per minute and 10 ratio of 30:2. When two rescuers perform CPR on infants or chil- ventilations per minute are performed consistently. Two or more dren, one performs chest compression and the other performs healthcare providers take turns in performing compression every ventilation at the ratio of 15:2, with opening of the airway. The 2 minutes to prevent the rescuers from getting fatigued. If the interruption of chest compression for the ventilation should be perfusion rhythm returns but there is no breathing, ventilation is minimized. After intubation, the ratio of chest compression and performed 12 to 20 times per minute (1 ventilation every 3 to 5 ventilation is no longer followed. Instead, the rescuer responsible seconds). Excessive ventilation during CPR reduced venous return, for chest compression does not stop the compression for ventila- leading to decreased cardiac output and cerebral blood flow, and tion and performs it continuously at the speed of 100 to 120 per increases pressure within the thoracic cavity, leading to decreased minute. The rescuer responsible for ventilation provides ventila- coronary artery perfusion.19 Therefore, rescuers should perform tion at the speed of 10 times per minute (1 ventilation every 6 ventilation by following the recommended frequency of ventila- seconds). tion. Because manual bag-mask ventilation can provide high pressure, ventilation is performed to the extent in which the chest 8. Defibrillation rise is just observed. VF may be the cause of sudden cardiac arrest or it may occur during CPR. The sudden collapse of child in the presence of another 3) Two-rescuer bag-mask ventilation person (for example, a child who collapsed while exercising) that In the case with the difficulty in attaching the mask, severe ob- may be caused by VF or pulseless ventricular tachycardia, imme- struction in the airway, or poor lung elasticity, bag-mask ventila- diate CPR and prompt defibrillation are necessary in such cases. tion performed by two rescuers together can be useful and help- As VF or pulseless ventricular tachycardia may respond to defi- ful in providing effective bag-mask ventilation to the patients. brillation, they are categorized as “shockable rhythms”. One rescuer should maintain the airway and tightly seal the mask In infants, it is better to use a manual defibrillator by well-trained onto the face using both the hands while the other compresses healthcare provider to give a shock. For defibrillation, the first en- the ventilation bag. Both rescuers should confirm rise of the chest. ergy dose is at 2 to 4 J/kg and the second is 4 J/kg or higher; the shock should not exceed the maximum dose for adults.20,21 If a 4) Gastric inflation and cricoid pressure manual defibrillator is not available, an AED with a pediatric ener- As gastric inflation may prevent effective ventilation and induce gy attenuator should be used. However, if both a manual defibril- regurgitation, it should be avoided. To minimize gastric inflation, lator and an AED with a pediatric energy attenuator are lacking, each ventilation should be performed for 1 second to prevent ex- an AED for adults without an attenuator can be used for infants. cessive pressure during exhalation. In addition, the application of cricoid pressure can be considered although its application is not Table 2. Reference chart of pediatric basic life support for healthcare recommended in a routine procedure. It should be considered only providers when the patient is unconscious and there is another healthcare Management Details provider to provide help, and it should be performed with caution Breathing requiring CPR Apnea or agonal breathing as excessive cricoid pressure can block the airway. Check pulse and breathing Check pulse and look for no breathing or only gasping simultaneously within 10 seconds 5) Oxygen Chest compression Location: lower half of sternum (for children), center of the chest, just below the nipple line One hundred percent oxygen is provided during CPR, because (for infant) there has been no report of any harmful effects of differing oxy- Depth: one-third AP diameter of chest (4–5 cm gen concentrations in humans, after the neonatal period. When for children and 4 cm for infants) Rate: 100–120/min the patient’s condition has stabilized, oxygen should be provided Chest compression-to- 1 Rescuer: begin cycles of 30 compressions and 2 with monitoring of the saturation. The provision of humidified ventilation ratio without ventilation oxygen can prevent the drying of the mucous membrane and advanced airway 2 Rescuers: use 15:2 ratio thickening of lung secretions. Oxygen is provided using a mask or Pulse more than 60 per min- Provide ventilation: 1 breath every 3–5 seconds ute with adequate perfusion or about 12–20 breaths per minute a nasal cannula. AED analyzes rhythm Stop compression CPR after defibrillation Resume CPR immediately after defibrillation 7. Ratio of chest compression and ventilation CPR, cardiopulmonary resuscitation; AP, anteroposterior; AED, automated exter- One rescuer performs chest compression and ventilation at the nal defibrillator.

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Rescuers should minimize the time between chest compression head-tilt. If jaw-thrust is not sufficient to maintain the airway, and defibrillation, and resume CPR by restarting chest compres- head-tilt chin-lift maneuver can be performed. If there are two sion immediately after the defibrillation. The use of an AED will rescuers, one opens the airway and the other prevents the move- ensure that rescuers reanalyze the rhythm every 2 minutes, and ment of the cervical spine. As infants and children have relatively defibrillation should be performed immediately after chest com- large heads, the best position to prevent bending of the cervical pression (Table 2). spine can be achieved by placing the back of the head on a re- cessed location or fixing the body in a slightly raised position.25 9. Compression-only CPR Children with multi-organ injuries should be transferred to a trau- In infants and children, performing both chest compression and ma center with a pediatric specialist if possible. Thoracotomy may ventilation is the best CPR methods. As the most common cause be considered for children with penetrative injuries.26 of cardiac arrest in infants and children is asphyxia arrest, ventilation is required as a part of effective CPR.22 Therefore, infant 3. Drowning and pediatric CPR accompanies resuscitation comprising ventila- In the case of drowning, the duration of submersion in water is tion and chest compression. However, if artificial ventilation is an important factor for the prediction of prognosis. The age, prom not possible or the rescuer is not known about how to perform ptness of emergency treatment, form of water (e.g., sea water), ventilation, compression-only CPR must be performed on its own.12,13 water temperature, and the presence or absence of witnesses are not reliable prognosis factors.27 As the survival rate is relatively RESUSCITATION UNDER SPECIAL CONDI- high in the case of drowning in ice water even with long submer- TIONS sion durations, the rescue time should be extended in such case.28,29 Drowned children must start receiving CPR immediately after be- 1. Ventilation through tracheostomy ing rescued from the water. Rescuers with special training may Caretakers of children with tracheostomy (parents, school nurses, start ventilation in water. Because chest compression is not effi- or home healthcare providers) should know how to maintain the cient in water, it is not usually performed.30 As there is no evi- airway, clear airway discharges, and perform CPR through the ar- dence that water causes airway obstruction, no time is wasted to tificial airway. Ventilation should be performed through tracheos- pump out water from the lungs of the rescued person.31 CPR tomy while confirming airway maintenance and rising of the chest. should be started by performing chest compression and the air- If ventilation through tracheostomy is not effective even after ef- way is opened, ventilation is performed twice. If the rescuer is fective suctions, maintenance of the airway should be reconfirmed. alone, 5 cycles of chest compression and ventilation are perform In patients who received tracheostomy, mouth-to-tracheostoma ed before calling EMS and preparing an AED. If there are two res- breathing is performed. When the tracheostoma is already sealed, cuers, one continues CPR while the other activates EMS and pre- bag-mask ventilation is performed through the nose or mouth.23 pares an AED.32

2. Trauma REFERENCES Although the criteria for performing CPR in children with injuries are the same as those in children with other diseases, some as- 1. Lopez-Herce J, Garcia C, Rodriguez-Nunez A, et al. Long-term pects should be emphasized. Errors in the opening and maintain- outcome of paediatric cardiorespiratory arrest in Spain. Re- ing the airway, as well as errors due to unawareness of internal suscitation 2005;64:79-85. bleeding, commonly occur during pediatric resuscitation. Follow- 2. Marsch S, Tschan F, Semmer NK, Zobrist R, Hunziker PR, Hun- ing are some precautions that must be taken while performing ziker S. ABC versus CAB for cardiopulmonary resuscitation: a CPR on pediatric patients with injuries.24 prospective, randomized simulator-based trial. Swiss Med Wkly A suction device should be used if there is a possibility of air- 2013;143:w13856. way obstruction due to broken tooth pieces or blood. If there is 3. Lubrano R, Cecchetti C, Bellelli E, et al. Comparison of times external bleeding, external pressure should be applied to stop the of intervention during pediatric CPR maneuvers using ABC bleeding. Considering the mechanism of injury, if there is a possi- and CAB sequences: a randomized trial. Resuscitation 2012; bility of spinal cord injury, the movement of the cervical spine 83:1473-7. should be minimized and the head or neck should not be pulled 4. Van Vleet LM, Hubble MW. Time to first compression using or moved. The airway should be opened using jaw-thrust, not Medical Priority Dispatch System compression-first dispatch-

Clin Exp Emerg Med 2016;3(S):S39-S47 S45 Part 5. Pediatric basic life support

er-assisted cardiopulmonary resuscitation protocols. Prehosp and Emergency Cardiovascular Care Science with Treatment Emerg Care 2012;16:242-50. Recommendations. Resuscitation 2015;95:e147-68. 5. Sutton RM, French B, Niles DE, et al. 2010 American Heart 16. Menegazzi JJ, Auble TE, Nicklas KA, Hosack GM, Rack L, Goode Association recommended compression depths during pediat- JS. Two-thumb versus two-finger chest compression during ric in-hospital resuscitations are associated with survival. Re- CRP in a swine infant model of cardiac arrest. Ann Emerg Med suscitation 2014;85:1179-84. 1993;22:240-3. 6. Maher KO, Berg RA, Lindsey CW, Simsic J, Mahle WT. Depth of 17. Houri PK, Frank LR, Menegazzi JJ, Taylor R. A randomized, con- sternal compression and intra-arterial blood pressure during trolled trial of two-thumb vs two-finger chest compression in CPR in infants following cardiac surgery. Resuscitation 2009; a swine infant model of cardiac arrest. Prehosp Emerg Care 80:662-4. 1997;1:65-7. 7. Sutton RM, French B, Nishisaki A, et al. American Heart Asso- 18. Whitelaw CC, Slywka B, Goldsmith LJ. Comparison of a two- ciation cardiopulmonary resuscitation quality targets are as- finger versus two-thumb method for chest compressions by sociated with improved arterial blood pressure during pediat- healthcare providers in an infant mechanical model. Resusci- ric cardiac arrest. Resuscitation 2013;84:168-72. tation 2000;43:213-6. 8. Yannopoulos D, McKnite S, Aufderheide TP, et al. Effects of 19. Aufderheide TP, Sigurdsson G, Pirrallo RG, et al. Hyperventila- incomplete chest wall decompression during cardiopulmonary tion-induced hypotension during cardiopulmonary resuscita- resuscitation on coronary and cerebral perfusion pressures in tion. Circulation 2004;109:1960-5. a porcine model of cardiac arrest. Resuscitation 2005;64:363- 20. Berg RA, Samson RA, Berg MD, et al. Better outcome after 72. pediatric defibrillation dosage than adult dosage in a swine 9. Zuercher M, Hilwig RW, Ranger-Moore J, et al. Leaning during model of pediatric ventricular fibrillation. J Am Coll Cardiol chest compressions impairs cardiac output and left ventricu- 2005;45:786-9. lar myocardial blood flow in piglet cardiac arrest. Crit Care 21. Rossano JW, Quan L, Kenney MA, Rea TD, Atkins DL. Energy Med 2010;38:1141-6. doses for treatment of out-of-hospital pediatric ventricular 10. Hightower D, Thomas SH, Stone CK, Dunn K, March JA. Decay fibrillation. Resuscitation 2006;70:80-9. in quality of closed-chest compressions over time. Ann Emerg 22. Berg RA, Hilwig RW, Kern KB, Babar I, Ewy GA. Simulated mouth- Med 1995;26:300-3. to-mouth ventilation and chest compressions (bystander car- 11. Ochoa FJ, Ramalle-Gomara E, Lisa V, Saralegui I. The effect of diopulmonary resuscitation) improves outcome in a swine rescuer fatigue on the quality of chest compressions. Resusci- model of prehospital pediatric asphyxial cardiac arrest. Crit tation 1998;37:149-52. Care Med 1999;27:1893-9. 12. Kitamura T, Iwami T, Kawamura T, et al. Conventional and chest- 23. Spaite DW, Conroy C, Tibbitts M, et al. Use of emergency medi- compression-only cardiopulmonary resuscitation by bystand- cal services by children with special health care needs. Pre- ers for children who have out-of-hospital cardiac arrests: a hosp Emerg Care 2000;4:19-23. prospective, nationwide, population-based cohort study. Lan- 24. Crewdson K, Lockey D, Davies G. Outcome from paediatric cet 2010;375:1347-54. cardiac arrest associated with trauma. Resuscitation 2007; 13. Goto Y, Maeda T, Goto Y. Impact of dispatcher-assisted by- 75:29-34. stander cardiopulmonary resuscitation on neurological out- 25. Nypaver M, Treloar D. Neutral cervical spine positioning in comes in children with out-of-hospital cardiac arrests: a pro- children. Ann Emerg Med 1994;23:208-11. spective, nationwide, population-based cohort study. J Am 26. Maconochie IK, Bingham R, Eich C, et al. European Resuscita- Heart Assoc 2014;3:e000499. tion Council Guidelines for Resuscitation 2015. Section 6. Pae- 14. Berg MD, Schexnayder SM, Chameides L, et al. Part 13. Pedi- diatric life support. Resuscitation 2015;95:223-48. atric basic life support: 2010 American Heart Association Gui 27. Travers AH, Perkins GD, Berg RA, et al. Part 3. Adult Basic Life delines for Cardiopulmonary Resuscitation and Emergency Support and Automated External Defibrillation: 2015 Interna- Cardiovascular Care. Circulation 2010;122(18 Suppl 3):S862- tional Consensus on Cardiopulmonary Resuscitation and Emer- 75. gency Cardiovascular Care Science with Treatment Recom- 15. Maconochie IK, de Caen AR, Aickin R, et al. Part 6. Pediatric mendations. Circulation 2015;132(16 Suppl 1):S51-83. basic life support and pediatric advanced life support: 2015 28. Monsieurs KG, Nolan JP, Bossaert LL, et al. European Resusci- International Consensus on Cardiopulmonary Resuscitation tation Council Guidelines for Resuscitation 2015. Section 1.

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Executive summary. Resuscitation 2015;95:1-80. 31. Modell JH, Idris AH, Pineda JA, Silverstein JH. Survival after 29. Mehta SR, Srinivasan KV, Bindra MS, Kumar MR, Lahiri AK. prolonged submersion in freshwater in Florida. Chest 2004; Near drowning in cold water. J Assoc Physicians India 2000; 125:1948-51. 48:674-6. 32. Graf WD, Cummings P, Quan L, Brutocao D. Predicting out- 30. Szpilman D, Soares M. In-water resuscitation: is it worthwhile? come in pediatric submersion victims. Ann Emerg Med 1995; Resuscitation 2004;63:25-31. 26:312-9.

Clin Exp Emerg Med 2016;3(S):S39-S47 S47 Clin Exp Emerg Med 2016;3(S):S48-S61 http://dx.doi.org/10.15441/ceem.16.132 Supplementary

Part 6. Pediatric advanced life support: eISSN: 2383-4625 2015 Korean Guidelines for Cardiopulmonary Resuscitation

Do Kyun Kim1, Won Kyoung Jhang2, Ji Yun Ahn3, Ji Sook Lee4, Yoon Hee Kim5, Bongjin Lee6, Gi Beom Kim6, Jin-Tae Kim7, June Huh8, 6 9 10 June Dong Park , Sung Phil Chung , Sung Oh Hwang Received: 16 February 2016 Revised: 19 March 2016 1Department of Emergency Medicine, Seoul National University College of Medicine, Seoul, Korea Accepted: 19 March 2016 2Department of Pediatrics, Ulsan University College of Medicine, Seoul, Korea 3Department of Emergency Medicine, Hallym University College of Medicine, Seoul, Korea 4Department of Emergency Medicine, Ajou University College of Medicine, Suwon, Korea Correspondence to: June Dong Park 5Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea Department of Pediatrics, Seoul 6Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea National University College of 7Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Medicine, 101 Daehak-ro, Jongno-gu, Korea Seoul 03080, Korea 8Department of Pediatrics, Sungkyunkwan University School of Medicine, Seoul, Korea E-mail: [email protected] 9Department of Emergency Medicine, Yonsei Universtiy College of Medicine, Seoul, Korea 10Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea

Asphyxial cardiac arrest is more common among children than in adults, and pediatric cardiac arrests result from gradual deterioration due to respiratory failure or sepsis rather than arrhythmic or structural disease itself.1 Approximately 5% to 15% of all in-hospital and out-of-hospital pediatric cardiac arrests exhibit ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT) at the time of diagnosis.2 Approximately 25% of in-hospital cardiac arrests exhibit VF or pulseless VT, and the frequency of these patterns increases with age.3 Therefore, it has been suggested that each hospital organize and maintain an acute response system or rapid response team to improve the treatment of in-hospital cardiac arrest.4

BASIC LIFE SUPPORT CONSIDERATIONS FOR PEDIATRIC ADVANCED LIFE SUPPORT

1. Collaborative management using a team approach It is important to build an efficient team of healthcare professionals that provides advanced life support during cardiopulmonary resuscitation (CPR). The following factors are important in order How to cite this article: for these teams to effectively perform CPR: Chest compressions should be performed immediately Kim DK, Jhang WK, Ahn JY, Lee JS, after the need for CPR has been established, and ventilation should be performed if there is a sec- Kim YH, Lee B, Kim GB, Kim JT, Huh J, Park JD, Chung SP, Hwang SO. Part 6. ond rescuer. Breathing is also important for infants or children, and compression-ventilation CPR, Pediatric advanced life support: 2015 Korean rather than compression-only CPR, should be performed inside hospitals. Although the prepara- Guidelines for Cardiopulmonary Resuscitation. Clin Exp Emerg Med 2016;3(S):S48-S61. tion of a ventilation device can delay effective ventilation in some cases, chest compressions should be performed immediately for both infants and children. High-quality CPR is critical to successful pediatric advanced life support (PALS), and is defined as starting CPR within 10 sec- This is an Open Access article distributed onds after identifying the cardiac arrest, an adequate compression rate, an adequate compression under the terms of the Creative Commons Attribution Non-Commercial License (http:// depth, complete recoil of the chest wall, minimal interruptions in the compressions, a sufficient creativecommons.org/licenses/by-nc/3.0/).

S48 Copyright © 2016 The Korean Society of Emergency Medicine Do Kyun Kim, et al. chest expansion during the ventilation, and the avoidance of hy- tively high skin temperature, despite being in shock. perventilation. If two rescuers are performing chest compressions The criteria for hypotension in infants and children during CPR are: and breathing, the third rescuer (if available) should prepare a • Full-term infants (0 to 28 days old): a systolic pressure of <60 monitor and defibrillator, establish the medication route(s), and mmHg calculate the medication dosage(s). When several rescuers perform • Infants (1 to 12 months old): a systolic pressure of <70 mmHg CPR, the rescuers should clearly communicate their roles using • Children (1 to 10 years old): a systolic pressure of less than (70+ precise and respectful expressions. [2×age in years]) mmHg • Children (>10 years old): a systolic pressure of <90 mmHg 2. Patients on monitoring These blood pressure criteria are below the fifth percentiles for the If the patient has an intra-arterial catheter, the adequacy of the age-specific systolic pressures, and rarely occur in normal children. compressions and the return of spontaneous circulation (ROSC) can be evaluated by observing the pressure waveform. Capnogra- ADVANCED AIRWAY phy is also useful for evaluating the adequacy of the compressions and identifying ROSC. 1. Bag-mask ventilation Bag-mask ventilation is relatively effective and safe in cases of 3. Respiratory failure out-of-hospital CPR, compared to endotracheal intubation.5 Select Respiratory failure is a condition that indicates inadequate oxy- an adequate size of mask, open the airway properly, completely genation and/or ventilation, and should be suspected if the fol- attach the mask to the face, and maintain a sufficient respiratory lowing symptoms are observed. rate and pressure to ensure that the chest rises properly. Hyper- • An increasing respiratory rate and signs of respiratory failure (e.g., ventilation can reduce blood flow to the brain and heart, as it in- nasal flaring, seesaw respirations, and moaning sounds) creases intrathoracic pressure, reduces venous return, and reduces • An inadequate respiratory rate and respiratory effort, thoracic cardiac output.6 In addition, hyperventilation can cause air trap- movement, reduced breath sounds, or breathlessness in patients ping in patients with peripheral airway collapse and barotrauma. with a reduced level of consciousness Excessive inspiratory pressure can cause gastric inflation, which • Cyanosis while an external oxygen supply is being provided can lead to reflux of the stomach contents and pulmonary aspiration. In infants and children without an inserted advanced airway, 4. Shock perform two breaths after every 30 compressions (or after every Hypotension does not develop during the early phase of shock, 15 compressions if there are two rescuers). Stop compressions which is also called compensated shock or normal pressure shock. during the breathing, which should be performed for approxi- Compensated shock presents as tachycardia, cool and pale ex- mately 1 second per breath. Breaths should be performed every 6 tremities, a>2 seconds delay in the capillary refill time, a weak seconds (10 per minute) without interruption of the compressions peripheral pulse with a maintained central pulse, and a normal if an advanced airway is inserted. Perform breathing only every 3 blood pressure. If the compensation mechanisms fail, it can result to 5 seconds (12 to 20 per minute) if ROSC is achieved but respi- in hypoperfusion of the major organs, reduced consciousness, re- ration is inadequate. The ventilation rate should be increased duced urine output, metabolic acidosis, tachypnea, weak central when the patient is young. pulses, and a change in skin color. Cardiac output is the product of heart rate and stroke volume. 2. Two-person bag-mask ventilation If the stroke volume is decreased due to any cause, the heart rate Perform two-person bag-mask ventilation when there are two increases to compensate for the decrease in cardiac output. Sus- rescuers. This technique is especially helpful when a patient has tained sinus tachycardia without other causes can be the first sign airway collapse or low pulmonary compliance, or when the rescuer of shock, although bradycardia can develop after shock has pro- cannot completely attach the bag to the patient’s face.7 During gressed. Reductions in cardiac output and poor perfusion can de- two-person bag-mask ventilation, one rescuer holds the mask to crease the peripheral pressure (intensity or quality), prolong the the face while lifting the patient’s chin with both hands, while the capillary refill time, and lower the skin temperature despite a warm other rescuer compresses the bag. Both rescuers should frequently surrounding temperature. However, the blood vessels of the skin confirm that the patient’s chest is expanding properly. and muscles are inadequately dilated during early septic shock, and the patient may exhibit a palpable peripheral pulse and rela-

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3. Endotracheal intubation extra light bulb, extra batteries, capnometry, tape to fix the tube, Significant training is needed to successfully perform endotracheal and gauze to clean the patient’s face. intubation in infants and children, because they have a unique Perform endotracheal intubation after oxygen administration tracheal structure. Compared to adults, children’s tongues are rel- unless the patient is in cardiac arrest. Assisted ventilation can be atively large, their airways are more flexible, the tip of their epi- performed if the patient’s respiratory effort is insufficient. It should glottis is located at a relatively high and anterior portion of the be performed with the preparation of a secondary method for neck, and their airway is smaller. maintaining the airway, in anticipation of intubation failure. Im- mobilize the cervical vertebrae to prevent spinal injury during the 1) Size of the pediatric endotracheal tube intubation in cases that involve severe trauma to the head, neck, Among children who weigh <35 kg, even with a relatively short or other areas. The procedure duration should not exceed 30 sec- stature, determining the endotracheal tube (ETT)’s size based on onds, as hypoxia or ischemic injury can occur due to inadequate or height is more accurate than using their age (e.g., using a Brosel- delayed intubation. Monitor the patient’s heart rate and oxygen ow resuscitation tape).8,9 However, also prepare tubes that are 0.5 saturation (using pulse oximetry) while performing endotracheal mm larger and smaller in internal diameter (ID) than the calculat- intubation. Stop the procedure and wait until the patient’s condi- ed tube size, regardless of the presence or absence of a cuff. If re- tion improves, while providing oxygen using a bag-mask, if the sistance is felt during the intubation, use the 0.5 mm smaller tube. patient develops bradycardia (<60/min), a change in skin color or If there is significant air leakage at the glottis, the 0.5 mm larger blood circulation status, or oxygen saturation below the normal tube or a cuffed tube should be used. For an un-cuffed tube, use a level. In cases of pediatric cardiac arrest, the endotracheal intuba- tube with an ID of 3.5 mm for infants who are <1 year old, and a tion should not be delayed to set up pulse oximetry, which cannot 4.0-mm tube for children who are 1 to 2 years old. For children function properly if the pulse is not palpable. who are >2 years old, use the following formula: ID of the un- Use either straight or curved laryngoscope blades. Once the tip cuffed tube (in mm)=4+(age in years/4). If a cuffed tube must be of a straight blade passes the epiglottis, place it at the entrance of used in an emergency, use a tube with an ID of 3.0 mm for chil- the vocal cords, lift the base of the tongue, and swipe the blade dren who are <1 year old, and a 3.5 mm tube for children who anteriorly to lift the epiglottis. If a curved blade is used, anteriorly are 1 to 2 years old. For children who are >2 years old, use the adjust the location of the tongue’s base after the tip of the blade following formula:10-13 ID of the cuffed tube (in mm)=3.5+(age in is placed in the epiglottic vallecula. At that point, the laryngoscope years/4). blade or handle should not be used as a lever, and direct pressure on the lips or gum should be avoided. 2) Cuffed ETT The glottis entrance should be exposed for ideal endotracheal Both cuffed and un-cuffed tubes can be used for endotracheal in- intubation. To simplify the intubation in infants and children, align tubation in infants and children. If a cuffed tube is used during the pharynx by placing a pillow under the patient’s head with the surgery, the frequency of reintubation can be reduced without an chin in the sniffing position. For infants or children who are <2 increased risk of complications.10 Using a cuffed tube in the inten- years old, it is acceptable to lay them flat without a pillow to per- sive care unit (ICU) can reduce the risk of aspiration.14 If a cuffed form intubation through the mouth. tube is used, the cuff’s pressure should be constantly monitored The depth of the ETT intubation can be calculated using the fol- and the manufacturer’s recommended pressure should be main- lowing formula: intubation depth (in cm)=the tube’s ID (in tained (usually <20 to 25 cmH2O). A cuffed tube can be more ef- mm)×3. For children who are >2 years old, the formula is: intu- fective if it is selected based on the size, location, and pressure of bation depth (in cm)=(the child’s age in years/2)+12. the cuff in cases with low pulmonary compliance, high airway resistance, or significant air leakage at the glottic area.15,16 4) Checking the tube’s location The correct location of the tube cannot be verified using only clin- 3) Endotracheal intubation ical signs such as chest wall movement or vapor inside the tube. Prepare a suction catheter, bag-mask, oxygen, and stylet before The tube’s location should be checked immediately after intuba- the intubation. The tip of the stylet should not pass the tip of the tion, re-fixing the tube, transfer, and patient movement. The signs tube. Applying a water-based lubricant or sterile distilled water to of a correct tube location are: the tip of the stylet may make it easier to remove after the intu- • Movement of the bilateral chest wall and symmetrical breathing bation. Also prepare a functioning laryngoscope handle, blades, an sounds in both lungs, and particularly in the axillary areas

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• The absence of gastric inflation sounds the tube’s location must be checked using a laryngoscope. • Appropriate end-tidal CO2 (end-tidal carbon dioxide, ETCO2) • If the capnometry is contaminated by gastric contents or an • Adequate oxygen saturation while perfusion is maintained. How- acidic drug, the color persists as the acidic color and does not ever, oxygen saturation can be maintained for approximately 3 accurately reflect the ventilation minutes after hyperoxygenation despite poor ventilation • When epinephrine is intravenously infused, pulmonary perfusion • Laryngoscopic evidence that the tube is placed between the vo- is temporarily reduced and the ETCO2 value can decrease below cal cords the critical value18 • Chest radiography findings that confirm the tube is correctly lo- • If there is severe airway occlusion, such as moderate asthma or

cated pulmonary edema, the exhalation of CO2 can decrease below the For immobilization of the tube, the tube should be fixed in a critical value19 neutral position to prevent the tube from sliding deeper if the pa- • In cases with air leakage at the glottis region, the CO2 is diluted tient’s neck flexes, or sliding out if the patient’s neck extends.17 If and may not be detected, due to the insufficient ventilation the patient’s condition suddenly deteriorates while they are intubated, determine whether the tube is displaced or occluded, pneu- DRUGS THAT ARE USED FOR PALS (Table 1) mothorax is present, or a mechanical error has occurred. 1. Adenosine 5) Capnometry or capnography Adenosine temporarily blocks atrioventricular (AV) node conduc- If possible, verify the location of the ETT using capnometry for all tion and interrupts the re-entrant mechanism. The half-life of ad- age groups and in all circumstances, including in the pre-hospital, enosine is very short, which gives it a broad safety range. Large emergency room, ICU, ward, operation room, or transfer set- doses should be administered through a peripheral vein compared tings.16-18 However, this method cannot detect whether a tube is to a central vein, although adenosine can be also administered in- placed in the right main bronchus, despite the appearance of color traosseously. Additional normal saline should be provided immedi- changes or the proper waveform. Because ETCO2 may not be de- ately after an intravenous (IV) infusion of adenosine to help the tected during cardiac arrest, even if the tube is properly located, adenosine rapidly enter the central circulation.

Table 1. Drugs used in pediatric advanced life support Medication Dose Remarks Adenosine 0.1 mg/kg (maximum 6 mg) Monitor ECG Rapid IV/IO bolus with flush Amiodarone 5 mg/kg IV/IO; may repeat twice up to 15 mg/kg Monitor ECG and blood pressure; adjust administration rate to urgency (IV Maximum single dose 300 mg push during cardiac arrest, more slowly over 20 to 60 minutes with perfusing rhythm). Expert consultation strongly recommended prior to use when patient has a perfusing rhythm. Use caution when administering with other drugs that prolong QT (obtain expert consultation) Atropine 0.02 mg/kg IV/IO Higher doses may be used with organophosphate poisoning 0.04 to 0.06 mg/kg ET (flush with 5 mL of normal saline and follow with 5 ventilations.) Maximum single dose: 0.5 mg Calcium chloride (10%) 20 mg/kg IV/IO, Maximum dose 2 g Administer slowly Epinephrine 0.01 mg/kg (0.1 mL/kg 1:10,000) IV/IO May repeat every 3 to 5 minutes 0.1 mg/kg (0.1 mL/kg 1:1000) ET (flush with 5 mL of normal saline and follow with 5 ventilations) Maximum dose 1 mg IV/IO; 2.5 mg ET Glucose 0.5 to 1 g/kg IV/IO Newborn: 5 to 10 mL/kg D10W Infants and children: 2 to 4 mL/kg D25W Adolescents: 1 to 2 mL/kg D50W Lidocaine Bolus: 1 mg/kg IV/IO Infusion: 20 to 50 µg/kg/min Magnesium sulfate 25 to 50 mg/kg IV/IO over 10 to 20 minutes, faster in torsades de pointes Maximum dose 2 g Sodium bicarbonate 1 mEq/kg per dose IV/IO slowly After adequate ventilation ECG, electrocardiography; IV, intravenous; IO, intraosseous; ET, endotracheal; D10W, 10% dextrose; D25W, 25% dextrose; D50W, 50% dextrose.

Clin Exp Emerg Med 2016;3(S):S48-S61 S51 Part 6. Pediatric advanced life support

2. Amiodarone Epinephrine’s most significant pharmacological action during car- Amiodarone delays conduction in the AV node, prolongs the re- diac arrest is vasoconstriction caused by activation of alpha adren- fractory period and QT interval, and slows ventricular conduction. ergic receptors. This increases the aortic diastolic pressure and the However, amiodarone should be infused as slowly as the patient’s perfusion pressure in the coronary artery, which is a significant de- condition allows, and their blood pressure should be monitored. terminant of successful CPR.29,30 During compressions, the in- The appropriate infusion rate is relatively slow if there is a pulse, creased perfusion pressure in the coronary artery increases the ox- and is relatively fast in cases of cardiac arrest or VF. Hypotension ygen supply to the heart. Epinephrine also improves the rate of can develop due to vasodilation during the administration, and its successful defibrillation by increasing the VF amplitude and myo- magnitude is related to the administration rate. This effect is less cardial contraction, which stimulates spontaneous contraction. frequent when amiodarone is administered as a liquid form.20 An The most common rhythms during pediatric cardiac arrest are electrocardiogram (ECG) should be used to monitor for adminis- asystole and bradycardia, and epinephrine can provide a perfusing tration-related complications, such as bradycardia, AV block, and rhythm in these patients. The epinephrine can be administered us- torsades de pointes. Special care should be taken during the coad- ing an IV/IO infusion, or through the ETT in pediatric patients with ministration of other medications that can prolong the QT interval. symptomatic bradycardia who do not respond to effective assisted The half-life of amiodarone can reach 40 days, so any related ad- ventilation or oxygen supply. However, it is important to monitor verse effect(s) may last a prolonged duration. the oxygen supply and circulation, because catecholamine activity can be reduced by acidosis or hypoxia. If the initial dose of epi- 3. Atropine nephrine is not effective, it should be repeatedly administered ev- As a parasympathetolytic agent, atropine increases cardiac rhythm ery 3 to 5 minutes during CPR. and AV conduction. Atropine is administered as an IV or intraosse- Although epinephrine can be absorbed when it is administered ous (IO) infusion, with no minimum dose, in pediatric cases with a using an ETT, the absorbed amount and serum concentration can- risk of severe bradycardia during emergency endotracheal intuba- not be predicted. Therefore, a continuous IV infusion of epinephrine tion. However, routine atropine administration is not recommend- can be helpful once ROSC is achieved. Epinephrine’s hemodynamic ed for infants and children if emergency endotracheal intubation effects are related to its dosage, with low doses (<0.3 μg/kg/min) is necessary.21-23 Large doses of atropine should be administered in prominently resulting in beta adrenergic activity and higher doses cases of nerve gas poisoning or organophosphate poisoning.24 (>0.3 μg/kg/min) predominantly causing vasoconstriction due to both beta and alpha adrenergic activities. It is preferable to admin- 4. Calcium ister epinephrine via the central circulation, as extravasation of The routine administration of calcium during cardiac arrest does epinephrine can lead to local ischemia, tissue damage, and necro- not improve the patient’s prognosis, and routine administration is sis. Similar to other catecholamines, epinephrine is inactivated in not recommended as life support for patients who are in asysto- alkali solutions and should not be mixed with sodium bicarbonate. le.3,25,26 Calcium is used to treat proven hypocalcemia or hyperka- Epinephrine can be administered during CPR for infants and chil- lemia, especially in patients with hemodynamic dysfunction. A de- dren who are in cardiac arrest, although there is insufficient evi- crease in the levels of ionized calcium is relatively common in se- dence regarding the effects of other vasopressors.31-34 verely ill children, and especially in children with sepsis. Calcium should be considered for treating hypermagnesemia or overdose 6. Glucose with a calcium channel blocker. The most common formation of Infants have low stored levels of glucose, and a high demand for calcium for children is 10% calcium chloride, as it has a higher glucose. Furthermore, infants can readily develop hypoglycemia if bioavailability than calcium gluconate, and this solution should be they have a condition that requires an increased energy supply infused through a central vein due to the risk of peripheral vein (e.g., shock). Therefore, glucose levels should be closely monitored injury.27,28 An IV infusion of calcium should be administered over using a rapid bedside test in cases of coma, shock, or respiratory 10 to 20 seconds for patients in cardiac arrest and over 5 to 10 failure. Once hypoglycemia has been confirmed, it should be minutes for patients with a perfusing rhythm. treated using a glucose-containing fluid.35 Two to four milliliters of 25% glucose solution (250 mg/mL) per kilogram provides 0.5 to 5. Epinephrine 1.0 g/kg of glucose, and 5 to 10 mL of a 10% glucose solution (100 Epinephrine is an intrinsic catecholamine that strongly stimulates mg/mL) also provides a similar amount of glucose. It is preferable the alpha and beta adrenergic receptors of the sympathetic nerves. to treat hypoglycemia using a continuous infusion of a glucose

S52 www.ceemjournal.org Do Kyun Kim, et al. solution, as osmotic diuresis can be caused by a sudden increase 10. Vasopressin in the plasma oncotic pressure after a single administration of a Vasopressin is an intrinsic hormone that activates a specific recep- hypertonic glucose solution. The current recommendation is to tor and mediates systemic vasoconstriction or water reabsorption maintain euglycemia during the CPR and to prevent hypoglycemia in renal tubules. There is insufficient data to determine whether after the CPR, as there are no data regarding whether hyperglyce- the routine use of vasopressin can be recommended in cases of mia is advantageous or harmful after cardiac arrest. pediatric cardiac arrest. Vasopressin or terlipressin (a long-acting drug) can be effective in children or adults who have failed stan- 7. Lidocaine dard treatment for cardiac arrest.45-47 Lidocaine reduces myocardial automaticity and prevents ventricular arrhythmia. But it can depress the myocardium, and reduces TREATMENT FOR PULSELESS ARREST circulation, causing drowsiness, disorientation, muscle twitching, and seizure. Amiodarone and lidocaine can be used in infants and If a child is unresponsive and breathless, the responder should im- children with VF and pulseless VT that does not respond to defi- mediately start high-quality CPR, supply oxygen (if possible), and brilaltion.22,36,37 Nevertheless, there is a significant possibility of ask someone to bring a defibrillator. An ECG monitor or automated adverse effect(s) in cases with a low cardiac output, abnormal he- external defibrillator (AED) electrodes should be attached as soon patic function, or abnormal renal function.38,39 as possible. Cardiac rhythm is monitored using an ECG monitor during CPR for children, although an AED will automatically notify 8. Magnesium the rescuer if the patient has a shockable rhythm (VF or pulseless Magnesium is only administered to patients with proven hypo- VT) or a non-shockable rhythm (asystole or pulseless electrical ac- magnesemia and torsade de pointes.40-42 A rapid IV infusion (for a tivity [PEA]). Temporarily interrupting the compressions may be few minutes) of magnesium sulfate is recommended for torsade necessary to check the rhythm. Asystole or wide QRS bradycardia de pointes, regardless of its cause. Magnesium causes vasodila- is the most common rhythms during asphyxial cardiac arrest. Al- tion, and hypotension can develop when it is rapidly infused. though VF or PEA does not frequently occur in infants or children, there is a high probability of VF-induced cardiac arrest in cases of 9. Sodium bicarbonate sudden witnessed cardiac arrest among older children (Fig. 1). In most studies, the routine administration of sodium bicarbonate has not improved the post-arrest prognosis.43,44 Adequate ventila- 1. Non-shockable rhythm (asystole/PEA) tion, oxygen supply, and effective recovery of systemic perfusion The definition of PEA is the presence of organized electrical activi- (to correct tissue ischemia) should be the primary concerns in pe- ty, such as a slow and wide QRS, without a palpable pulse. There diatric cardiac arrest, because respiratory failure is an important can be a normal heart rate without a pulse and with poor tissue cause in these cases. Once effective ventilation has been con- perfusion during the early stage of suddenly impaired cardiac out- firmed, and epinephrine with compressions has been started to put. This condition is more reversible than asystole and used to be maximize circulation, the administration of sodium bicarbonate known as electromechanical dissociation. can be considered in cases of a prolonged cardiac arrest. Sodium Minimize any interruption in the compressions and continue bicarbonate is also recommended for patients with symptomatic CPR. The second rescuer should establish an IV or IO line and ad- hyperkalemia, hypermagnesemia, and overdose with tricyclic anti- minister epinephrine at 0.01 mg/kg (0.1 mL/kg in a 1:10,000 solu- depressants or other sodium channel blockers. tion) during the CPR, and the same dose should be administered If indicated, sodium bicarbonate is administered as an IV or IO every 3 to 5 minutes. High-dose epinephrine does not improve the infusion, and a diluted solution can be used to prevent increased survival rate, and can cause harm, although it may be considered oncotic pressure in neonates, although there is no evidence that a in exceptional cases, such as cases of overdose with beta block- diluted solution is beneficial in infants or children. The appropriate ers.32,48 dose of sodium bicarbonate can be determined using blood gas If an advanced airway has been placed, the first rescuer should analysis. Because catecholamines are inactivated by sodium bicar- perform constant compressions at a rate of ≥100 to 120 per min- bonate, and calcium forms a precipitate when it is mixed with so- ute, and the second rescuer should provide breaths every 6 seconds dium bicarbonate, 5 to 10 mL of normal saline should be used to (approximately 10 per minute). The rescuer(s) who are performing flush the IV line after administering sodium bicarbonate. the compressions should switch approximately every 2 minutes, while minimizing the interruption, to provide optimal compression

Clin Exp Emerg Med 2016;3(S):S48-S61 S53 Part 6. Pediatric advanced life support

Pediatric cardiac arrest

Shout for help/activate emergency response Request monitor/defibrillator Start CPR

Attach monitor/defibrillator

VF/pulseless VT Asystole/PEA Rhythm shockable?

Lidocaine or Shock amiodarone Pulse present (ROSC)

CPR 2 minutes CPR 2 minutes Advanced airway Advanced airway IO/IV access and epinephrine IO/IV access and epinephrine

Post-cardiac arrest care

Fig. 1. Algorithm of pediatric cardiac arrest. CPR, cardiopulmonary resuscitation; VF, ventricular fibrillation; VT, ventricular tachycardia; PEA, pulseless electrical activity; IO, intraosseous; IV, intravenous; ROSC, return of spontaneous circulation. quality and rate, and to avoid compression-induced fatigue. During DEFIBRILLATORS this period, the rhythm should be monitored while minimizing any interruption of the compressions. If the rhythm is non-shockable, As AEDs can detect the pediatric heart rhythm, they should be install CPR should be continued with epinephrine administration until ed in facilities that treat children with a risk of arrhythmia or cardiac there is evidence of ROSC or a decision is made to cease CPR. If arrest. The ideal defibrillator can adjust the energy dose for children. the rhythm changes to a shockable rhythm, immediate compressions and defibrillation should always be performed, and the rhythm 1. Electrode size should be rechecked after 2 minutes of CPR. The period between A manual defibrillator typically has different sizes of electrodes for stopping or restarting the compressions and the defibrillation should adults and children, and some manual defibrillators have self-ad- be minimized. Find reversible cause(s) and correct them. hesive electrodes. In pediatric cases, the largest appropriate electrode should be selected based on the patient’s chest size. The 2. Shockable rhythm (VF/pulseless VT) electrodes should not contact each other, and the space between Defibrillation is the most important treatment for VF, and provides the two electrodes should ≥3 cm. Self-adhesive electrodes should an overall survival rate of approximately 17% to 20%.49 The re- be completely attached to the patient’s chest by firmly pressing sulting survival rate is higher for primary VF, compared to second- them onto the chest. The adult size of electrodes (8 to 10 cm) is ary VF, and the survival rate after adult cardiac arrest decreases by used for children who are ≥1 year old or weigh ≥10 kg, and the 7% to 10% for every 1-minute delay in starting CPR and defibril- pediatric size is used for infants who are <1 year old or weigh lation.50 The survival rate is highest when high-quality CPR is per- <10 kg. formed with minimal interruptions during the early stage of cardiac arrest. The output of defibrillation is better when the rescuer 2. Interface minimizes the time between the compressions and defibrillation. Self-adhesive electrodes have pre-applied electrode gel on the interface that should be placed on the patient’s chest. However, electrode gel must be applied for manual electrodes. Normal saline, ultrasound gel, or alcohol are not appropriate replacements

S54 www.ceemjournal.org Do Kyun Kim, et al. for electrode gel. if there are enough rescuers. Rhythm should be checked after 2 minutes of CPR, and the defibrillator should be charged at 4 J/kg. 3. Electrode placement If a shockable rhythm persists, defibrillation should be applied at 4 The manufacture’s recommendations should be followed when J/kg, and the algorithm for asystole/PEA should be followed if a placing self-adhesive electrodes of an AED or monitor/defibrillator. non-shockable rhythm is observed. Resume the compressions im- Manual electrodes are placed at the apex (at the left lower rib, mediately after the second defibrillation, and continue CPR for ap- lateral to the left nipple) and the right upper quadrant of the proximately 2 minutes. Epinephrine should be administered at 0.01 chest, which locates the heart between the electrodes. The elec- mg/kg (0.1 mL/kg in a 1:10,000 solution) every 3 to 5 minutes dur- trodes must be firmly applied to maintain a strong contact, and ing the CPR. If there is a third rescuer, epinephrine should be pre- there is no benefit to placing the electrodes on the anterior and pared before checking the rhythm and administered as soon as posterior sides of the patient’s trunk. possible. The rescuer who is in charge of the defibrillator should prepare the third defibrillator charge before checking the ECG 4. Energy dose rhythm (>4 J/kg and <10 J/kg or the maximum adult dose). If The lowest energy dose for effective defibrillation and the upper there is a shockable rhythm, an additional defibrillation should be limit for safe defibrillation in infants or children are unknown. The administered (>4 J/kg and <10 J/kg or the maximum adult dose), first recommended energy dose is 2 to 4 J/kg for monophasic or and CPR should be immediately resumed. If the defibrillation is biphasic defibrillators if the infant or child exhibits VF or pulseless unsuccessful, amiodarone or lidocaine should be administered VT. The second recommended dose is 4 J/kg, and any subsequent while continuing the CPR. The algorithm for pulseless cardiac ar- dose should never exceed the maximum adult dose.50,51 If there is rest is always followed if there is a non-shockable rhythm. If an no exact energy dose meter on the defibrillator, use the next high- advanced airway is placed, one rescuer should continue compres- est energy on the energy selector when escalating the dose.52-54 sions at a rate of ≥100 to 120 per minute, and the second rescuer should perform breathing every 6 seconds (10 per minute). If there 5. AEDs are two or more rescuers, they should switch every 2 minutes to VF can be accurately detected by most AEDs in children of all prevent compression-induced fatigue and to maintain adequate ages. If the AED does not have an energy attenuating device, a compression rate and quality. If there is an organized rhythm at 2 manual defibrillator is preferred for children who are <1 year old. minutes after the defibrillation, check the pulse to determine

An AED with an energy attenuating device can be used unless a whether it is a perfusing rhythm. ROSC is predicted if the ETCO2 manual defibrillator is available. If both an AED with an energy at- rapidly increases during the compressions or the monitored arterial tenuating device and a manual defibrillator are unavailable, an waveform increases. If both ROSC and a pulse are achieved, post- AED without an energy attenuating device can be used in children. CPR management can be started. However, if VF re-develops after successful defibrillation, CPR should be re-started and defibrilla- 6. Integrating defibrillation and CPR tions should be attempted with the dose which achieved success- CPR should be performed until the defibrillator is prepared and ful defibrillation. Find and correct any other reversible causes. defibrillation is feasible, and the compressions should be re-started immediately after the defibrillation. It is ideal to only interrupt the MANAGEMENT OF TORSADE DE POINTES compressions for checking cardiac rhythm, performing defibrillation, and breathing before placing an advanced airway. Once the Torsade de pointes is polymorphic VT and is associated with a pro- rhythm has been evaluated, start and continue the compressions longed QT interval. A prolonged QT interval can develop due to until the defibrillator is charged, even in cases with a shockable congenital conditions or drug toxicity, and is associated with class rhythm. The first defibrillation (2 to 4 J/kg) should be started as 1A antiarrhythmic drugs (procainamide, quinidine, and disopyra- soon as possible, and CPR with compressions should be immedi- mide), class III antiarrhythmic drugs (sotalol and amiodarone), tri- ately re-started after the defibrillation. It is very important to min- cyclic antidepressants, digoxin, and drug interactions.55,56 Torsade imize the interval between starting or stopping the compressions de pointes typically progresses to VF or pulseless VT. Therefore, if and the defibrillation. Continue CPR for approximately 2 minutes, pulseless cardiac arrest develops, the rescuer must start CPR and although this sequence may be changed based on an expert’s perform defibrillation. Regardless of the cause, magnesium (at 25 opinion if the environment can facilitate continuous invasive to 50 mg/kg to a maximum dose of 2 g) should be rapidly admin- monitoring (e.g., in a hospital). An IV or IO line can be established istered over a few minutes as an IV infusion.

Clin Exp Emerg Med 2016;3(S):S48-S61 S55 Part 6. Pediatric advanced life support

POST-CPR MANAGEMENT utes after early mechanical ventilation, and it is recommended that normal arterial oxygen partial pressure be maintained unless there Post-CPR management should begin immediately after ROSC in is a specific reason for deviation.57,59,60 Cardiac anomalies in chil- patients who had shock, respiratory failure, and cardiac arrest. The dren should be evaluated via echocardiography immediately after purposes of post-CPR management are to: (1) maintain brain CPR, as the proper oxygen saturation can vary based on the pa- function, (2) avoid secondary organ damage, (3) correct the tient’s hemodynamic status and congenital heart disease(s). Naso- cause(s) of the cardiac arrest, and (4) prepare for the next treat- gastric or orogastric tube insertion is needed, as gastric inflation ment step with an optimal hemodynamic status. Because the pa- can cause discomfort and ventilation impairment. tient’s condition can deteriorate after a short period of temporary stabilization, the patient should be frequently monitored. Thor- 2. Cardiovascular management oughly determine whether the airway is secure, oxygen is supplied, Because circulatory failure can develop after recovery from cardiac and ventilation and perfusion are stabilized. Look for evidence of arrest, continuous or frequent evaluation of the cardiovascular trauma and reevaluate the patient’s neurological condition during system should be performed to rapidly detect any decreased car- the examination. Check for any history of allergy, disease, medica- diac output or the development of shock. Inadequate tissue perfu- tion, or vaccination, and evaluate the patient’s renal and hepatic sion can result in a prolonged capillary refill time, a reduced or ab- functions (dysfunction can indirectly affect the patient’s prognosis). sent peripheral pulse, a change in consciousness, cold extremities, tachycardia, a decreased urine output, and hypotension. An insuf- 1. Management of the respiratory system ficient administration of fluid after CPR can cause a reduction in After children have received CPR, oxygen should be supplied until the cardiac output or shock that develops secondary to the re- adequate oxygenation and proper oxygen carrying capacity is duced peripheral vascular resistance and myocardial stunning.61 achieved, as measured using pulse oximetry or direct arterial blood Heart rate, blood pressure, and oxygen saturation should be gas analysis. High-dose oxygen should be administered if there are constantly monitored after CPR, and blood pressure should be symptoms of significant respiratory distress (e.g., anxiety, breath- monitored using an intra-arterial catheter (if possible) in patients ing impairment, cyanosis, or hypoxemia), and endotracheal intu- with cardiovascular dysfunction. Because hypotension can fre- bation with mechanical ventilation can be performed. If the intu- quently occur during the period of ROSC after CPR, and this con- bated patient experiences a sudden deterioration, consider the dition is associated with a poor prognosis, the systolic pressure possibility of displacement or obstruction of the ETT, pneumotho- should be maintained at or above the fifth age-specific percentile, rax, or mechanical errors. Analgesics or sedatives can be used for and IV fluids or inotropic agents should be administered.62-64 Urine anxious patients if these factors are confirmed to be absent. How- output is a significant indicator of internal organ perfusion, and ever, careful attention is warranted, as seizures can be masked by should be monitored using a urine catheter in patients with he- the use of a neuromuscular blocker. modynamic dysfunction. The IO route should be removed once a

A target arterial CO2 partial pressure can be established and secure IV line is established. maintained based on the patient’s specific condition after ROSC is achieved. There is no evidence that hypercapnia or hypocapnia are 3. Drugs to maintain cardiac output more beneficial than eucapnia for improving the patient’s survival Myocardial impairment and vascular instability frequently occur rate and quality of life.57,58 Oxygen should be supplied to provide after recovery from cardiac arrest. After CPR, systemic and pulmo- proper oxygenation for intubated patients, and the respiratory rate nary vascular resistance usually increase during the early phase, should be maintained at 30 to 40 per minute for infants and 20 to except in cases of septic shock. Cardiovascular function also con- 30 per minute for children. A sufficient tidal volume will cause the stantly changes after CPR, as it exhibits a hyperdynamic status chest to visibly rise. Once mechanical ventilation is started, the during the early phase, which subsides towards a gradual weaken- tidal volume should be maintained at 6 mL/kg, which should cause ing of cardiac function. Therefore, if abnormal cardiovascular the chest to visibly rise and yield respiratory sounds at the periph- function is observed or suspected after CPR, an adequate dose of ery of the lung that can be detected using auscultation. A value of vasoactive drug(s) should be administered to improve cardiac approximately 3 to 6 cmH2O should be used for positive end-expi- function and tissue perfusion. The selection and dose of the ratory pressure, although a higher value can be used if the func- drug(s) should be based on the individual patient’s status, and tional residual capacity is reduced and the lung has collapsed. should be administered using an accurate IV route. Arterial blood gas analysis should be performed at 10 to 15 min-

S56 www.ceemjournal.org Do Kyun Kim, et al.

1) Epinephrine is a relatively selective inotrope that can increase myocardial con- Epinephrine is used to treat shock for any reason, which does not traction and reduce systemic vascular resistance.68 Dobutamine is respond to fluid administration and exhibits extremely low sys- effective for increasing cardiac output and blood pressure in in- temic perfusion. As a strong vasoconstrictor, epinephrine increases fants and children. In particular, dobutamine can be used to treat systemic vascular resistance and heart rate through its chrono- secondary reductions in cardiac output due to decreased myocar- tropic activity. Epinephrine can be administered during bradycar- dial function, such as in the post-cardiac arrest situation. Tachy- dia with hemodynamic changes that do not respond to oxygen cardia and premature ventricular contractions can occur at high and mechanical ventilation. doses of dobutamine. Low-dose epinephrine (<0.3 µg/kg/min) works as a strong inotropic agent and reduces systemic vascular resistance by activat- 4) Norepinephrine ing beta adrenergic receptors. If the dose is increased to >0.3 µg/ Norepinephrine is a neurotransmitter that is secreted from the kg/min, epinephrine exerts both an inotropic effect and increases sympathetic nerve, and is a strong inotrope that it works on the systemic vascular resistance by activating the vascular alpha ad- peripheral alpha and beta sympathetic nerves to induce strong renergic receptors. As epinephrine’s effects vary according to the myocardial and peripheral vascular contractions. The alpha sym- dose in different patients, the dose must be frequently adjusted to pathomimetic effect is predominant at the standard dose. As nor- achieve its intended effect. Epinephrine is more effective than do- epinephrine is a strong vasoconstrictor, it can be used to treat pamine in patients with severe circulatory compromise, and espe- septic shock that does not respond to fluid infusion and exhibits cially in infants.65 low systemic vascular resistance, spinal shock, and anaphylaxis. The infusion rate may be adjusted according to the patient’s blood 2) Dopamine pressure and perfusion status. Dopamine has beta and alpha sympathomimetic effects through a direct dopaminergic effect and an indirect stimulatory effect on 5) Nitroprusside norepinephrine secretion. The dose of dopamine must be fre- Nitroprusside is a vasodilator that induces the local production of quently adjusted when it is used to treat shock with low systemic nitric oxide in all blood vessels. At the therapeutic dose, it has no vascular resistance and no response to fluid administration. Al- direct effects on myocytes, and increases cardiac output by reduc- though it barely affects the systemic hemodynamic status at low ing the resistance of the systemic and pulmonary blood vessels. doses (0.5 to 2 µg/kg/min), dopamine typically increases the blood The combination of nitroprusside and inotropes can be used in pa- flow to the heart and intestine, and increases cardiac output and tients with severe hypertension or reduced cardiac output due to blood pressure in neonates.66 At doses of >5 µg/kg/min, dopa- reduced myocardial function and increased vascular resistance. mine induces cardiac beta adrenergic receptor activity, which in- However, it should not be used if the blood volume is reduced, as duces the secretion of norepinephrine from the cardiac sympa- it can cause severe hypotension. Nitroprusside is rapidly metabo- thetic nerve. However, dopamine’s ability to stimulate myocardial lized and should be constantly infused with a dextrose solution, and vascular contraction can be reduced in some cases, such as and should not be mixed with normal saline. Levels of thiocyanate chronic heart failure patients with depletion of myocardial norepi- should be monitored in cases with prolonged use, and especially nephrine, and infants who are <1 month old with incomplete de- when the infusion rate is >2 µg/kg/min. velopment of the cardiac sympathetic nerve. At doses of >20 µg/ kg/min, dopamine induces excessive vasoconstriction and reno- 6) Inodilators vascular dilatation disappears. Therefore, epinephrine or dobuta- Inodilators, such as amrinone and milrinone, are used for patients mine are recommended in cases where >20 µg/kg/min of dopa- with reduced cardiac function or increased resistance of the sys- mine would be needed to increase myocardial contraction. Dopa- temic and pulmonary blood vessels. Similar to vasodilators, inodi- mine is a catecholamine that can be partially inactivated in alkali lators do not increase the myocardial oxygen demand, increase solutions, and should not be mixed with bicarbonate.67 the cardiac output, and have minimal effect on the heart rate. Hy- potension is not common if the circulating blood volume is ade- 3) Dobutamine quate, but can occur due to vasodilation if there is an inadequate Dobutamine is a synthetic catecholamine that exerts relatively se- circulating blood volume. Therefore, fluid administration may be lective effects on the beta-1 adrenergic receptor, and has minimal necessary to counteract vasodilation after drug administration.69 effects on the beta-2 adrenergic receptor. Therefore, dobutamine

Clin Exp Emerg Med 2016;3(S):S48-S61 S57 Part 6. Pediatric advanced life support

4. Nervous system management specific enolase and S100 calcium-binding protein B levels. Fur- The primary purpose of CPR is to maintain brain function, and care thermore, electroencephalogram results within 7 days after cardiac must be taken to prevent secondary damage to the nervous sys- arrest may help predict neurologic outcomes,76,80 but the outcomes tem after CPR. Hyperventilation has a negative effect on the prog- cannot be predicted using only electroencephalogram results. nosis of the nervous system, as it affects both cardiac function and cerebral perfusion. Short periods of intentional hyperventila- REFERENCES tion are acceptable in cases with signs of brain herniation, such as a sudden increase in intracranial pressure, mydriasis without a 1. Kuisma M, Suominen P, Korpela R. Paediatric out-of-hospital light reflex, bradycardia, or hypertension. Target temperature cardiac arrests: epidemiology and outcome. Resuscitation management can be considered for unconscious infants or chil- 1995;30:141-50. dren with ROSC after cardiac arrest. The body temperature should 2. Donoghue AJ, Nadkarni V, Berg RA, et al. Out-of-hospital pe- not be allowed to drop below 32°C, or to increase above 37.5°C, diatric cardiac arrest: an epidemiologic review and assess- even if target temperature management is not performed.70-75 As ment of current knowledge. Ann Emerg Med 2005;46:512-22. fever has a negative effect on the recovery of brain function, it 3. Meert KL, Donaldson A, Nadkarni V, et al. Multicenter cohort should be actively treated using an antipyretic drug and an exter- study of in-hospital pediatric cardiac arrest. Pediatr Crit Care nal cooling method. Tremors can occur at low temperatures, and Med 2009;10:544-53. can be prevented using a sedative. Neuromuscular blockade can 4. Tibballs J, Kinney S. 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Comparison of 1- versus quate perfusion, and/or ischemic injuries in the kidney(s), can re- 2-person bag-valve-mask techniques for manikin ventilation duce urine output (infants and children: <1 mL/kg/hr, adolescents: of infants and children. Ann Emerg Med 2005;46:37-42. <30 mL/hr). Avoid using drugs with renal toxicity until the pa- 8. Daugherty RJ, Nadkarni V, Brenn BR. Endotracheal tube size tient’s renal function has been confirmed, and adjust the dose of estimation for children with pathological short stature. Pedi- drugs that undergo renal excretion. atr Emerg Care 2006;22:710-7. 9. Hofer CK, Ganter M, Tucci M, Klaghofer R, Zollinger A. How 6. Gastrointestinal system management reliable is length-based determination of body weight and In cases with no bowel sounds, abdominal distention, or required tracheal tube size in the paediatric age group? The Broselow mechanical ventilation, perform nasogastric or orogastric intuba- tape reconsidered. Br J Anaesth 2002;88:283-5. tion to prevent or treat gastric inflation. However, nasogastric in- 10. Weiss M, Dullenkopf A, Fischer JE, Keller C, Gerber AC; Euro- tubation is prohibited in patients with facial injuries or basal skull pean Paediatric Endotracheal Intubation Study Group. Pro- fractures, because the tube can enter the cranium. spective randomized controlled multi-centre trial of cuffed or uncuffed endotracheal tubes in small children. Br J Anaesth 7. Factors predicting prognosis 2009;103:867-73. The survival rate is higher in cases with a pupillary reflex within 24 11. Dullenkopf A, Gerber AC, Weiss M. Fit and seal characteristics hours after CPR, compared to that in cases that do not fulfill this of a new paediatric tracheal tube with high volume-low pres- criterion,3,77-80 and there are reports that a poor prognosis may be sure polyurethane cuff. 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2006;50:557-61. 51. 13. Duracher C, Schmautz E, Martinon C, Faivre J, Carli P, Orliaguet 27. Martin TJ, Kang Y, Robertson KM, Virji MA, Marquez JM. Ion- G. Evaluation of cuffed tracheal tube size predicted using the ization and hemodynamic effects of calcium chloride and Khine formula in children. Paediatr Anaesth 2008;18:113-8. calcium gluconate in the absence of hepatic function. Anes- 14. Browning DH, Graves SA. Incidence of aspiration with endo- thesiology 1990;73:62-5. tracheal tubes in children. J Pediatr 1983;102:582-4. 28. Broner CW, Stidham GL, Westenkirchner DF, Watson DC. A 15. Khine HH, Corddry DH, Kettrick RG, et al. Comparison of prospective, randomized, double-blind comparison of calcium cuffed and uncuffed endotracheal tubes in young children chloride and calcium gluconate therapies for hypocalcemia in during general anesthesia. Anesthesiology 1997;86:627-31. critically ill children. J Pediatr 1990;117:986-9. 16. Newth CJ, Rachman B, Patel N, Hammer J. The use of cuffed 29. Niemann JT, Criley JM, Rosborough JP, Niskanen RA, Alferness versus uncuffed endotracheal tubes in pediatric intensive C. Predictive indices of successful cardiac resuscitation after care. J Pediatr 2004;144:333-7. prolonged arrest and experimental cardiopulmonary resusci- 17. Kim JT, Kim HJ, Ahn W, et al. Head rotation, flexion, and ex- tation. Ann Emerg Med 1985;14:521-8. tension alter endotracheal tube position in adults and chil- 30. Sanders AB, Ewy GA, Taft TV. Prognostic and therapeutic im- dren. Can J Anaesth 2009;56:751-6. portance of the aortic diastolic pressure in resuscitation from 18. Cantineau JP, Merckx P, Lambert Y, Sorkine M, Bertrand C, cardiac arrest. Crit Care Med 1984;12:871-3. Duvaldestin P. Effect of epinephrine on end-tidal carbon di- 31. Enright K, Turner C, Roberts P, Cheng N, Browne G. Primary oxide pressure during prehospital cardiopulmonary resuscita- cardiac arrest following sport or exertion in children present- tion. Am J Emerg Med 1994;12:267-70. ing to an emergency department: chest compressions and 19. Ornato JP, Shipley JB, Racht EM, et al. Multicenter study of a early defibrillation can save lives, but is intravenous epineph- portable, hand-size, colorimetric end-tidal carbon dioxide de- rine always appropriate? Pediatr Emerg Care 2012;28:336-9. tection device. Ann Emerg Med 1992;21:518-23. 32. Dieckmann RA, Vardis R. High-dose epinephrine in pediatric 20. Somberg JC, Bailin SJ, Haffajee CI, et al. Intravenous lidocaine out-of-hospital cardiopulmonary arrest. Pediatrics 1995;95:901- versus intravenous amiodarone (in a new aqueous formulation) 13. for incessant ventricular tachycardia. Am J Cardiol 2002;90:853- 33. Jacobs IG, Finn JC, Jelinek GA, Oxer HF, Thompson PL. Effect 9. of adrenaline on survival in out-of-hospital cardiac arrest: a 21. Jones P, Peters MJ, Pinto da Costa N, et al. Atropine for criti- randomised double-blind placebo-controlled trial. Resuscita- cal care intubation in a cohort of 264 children and reduced tion 2011;82:1138-43. mortality unrelated to effects on bradycardia. PLoS One 2013; 34. Matamoros M, Rodriguez R, Callejas A, et al. In-hospital pediat- 8:e57478. ric cardiac arrest in Honduras. Pediatr Emerg Care 2015;31:31- 22. Jones P, Dauger S, Denjoy I, et al. The effect of atropine on 5. rhythm and conduction disturbances during 322 critical care 35. Beiser DG, Carr GE, Edelson DP, Peberdy MA, Hoek TL. Derange- intubations. Pediatr Crit Care Med 2013;14:e289-97. ments in blood glucose following initial resuscitation from in- 23. Fastle RK, Roback MG. Pediatric rapid sequence intubation: hospital cardiac arrest: a report from the national registry of incidence of reflex bradycardia and effects of pretreatment cardiopulmonary resuscitation. Resuscitation 2009;80:624-30. with atropine. Pediatr Emerg Care 2004;20:651-5. 36. Valdes SO, Donoghue AJ, Hoyme DB, et al. Outcomes associat- 24. Zwiener RJ, Ginsburg CM. Organophosphate and carbamate ed with amiodarone and lidocaine in the treatment of in-hos- poisoning in infants and children. Pediatrics 1988;81:121-6. pital pediatric cardiac arrest with pulseless ventricular tachy- 25. de Mos N, van Litsenburg RR, McCrindle B, Bohn DJ, Parshuram cardia or ventricular fibrillation. Resuscitation 2014;85:381-6. CS. Pediatric in-intensive-care-unit cardiac arrest: incidence, 37. Dorian P, Cass D, Schwartz B, Cooper R, Gelaznikas R, Barr A. survival, and predictive factors. Crit Care Med 2006;34:1209- Amiodarone as compared with lidocaine for shock-resistant 15. ventricular fibrillation. N Engl J Med 2002;346:884-90. 26. Srinivasan V, Morris MC, Helfaer MA, Berg RA, Nadkarni VM; 38. Wilson FC, Harpur J, Watson T, Morrow JI. Adult survivors of American Heart Association National Registry of CPR Investi- severe cerebral hypoxia: case series survey and comparative gators. Calcium use during in-hospital pediatric cardiopulmo- analysis. NeuroRehabilitation 2003;18:291-8. nary resuscitation: a report from the National Registry of 39. Thomson PD, Melmon KL, Richardson JA, et al. Lidocaine Cardiopulmonary Resuscitation. Pediatrics 2008;121:e1144- pharmacokinetics in advanced heart failure, liver disease, and

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renal failure in humans. Ann Intern Med 1973;78:499-508. 54. Meaney PA, Nadkarni VM, Atkins DL, et al. Effect of defibrilla- 40. Allegra J, Lavery R, Cody R, et al. Magnesium sulfate in the tion energy dose during in-hospital pediatric cardiac arrest. treatment of refractory ventricular fibrillation in the prehos- Pediatrics 2011;127:e16-23. pital setting. Resuscitation 2001;49:245-9. 55. van Haarst AD, van ‘t Klooster GA, van Gerven JM, et al. The 41. Hassan TB, Jagger C, Barnett DB. A randomised trial to inves- influence of cisapride and clarithromycin on QT intervals in tigate the efficacy of magnesium sulphate for refractory ven- healthy volunteers. Clin Pharmacol Ther 1998;64:542-6. tricular fibrillation. Emerg Med J 2002;19:57-62. 56. Ray WA, Murray KT, Meredith S, Narasimhulu SS, Hall K, Stein 42. Thel MC, Armstrong AL, McNulty SE, Califf RM, O’Connor CM. CM. Oral erythromycin and the risk of sudden death from Randomised trial of magnesium in in-hospital cardiac arrest. cardiac causes. N Engl J Med 2004;351:1089-96. Duke Internal Medicine Housestaff. Lancet 1997;350:1272-6. 57. Bennett KS, Clark AE, Meert KL, et al. Early oxygenation and 43. Vukmir RB, Katz L; Sodium Bicarbonate Study Group. Sodium ventilation measurements after pediatric cardiac arrest: lack bicarbonate improves outcome in prolonged prehospital car- of association with outcome. Crit Care Med 2013;41:1534- diac arrest. Am J Emerg Med 2006;24:156-61. 42. 44. Lokesh L, Kumar P, Murki S, Narang A. A randomized con- 58. Del Castillo J, Lopez-Herce J, Matamoros M, et al. Hyperoxia, trolled trial of sodium bicarbonate in neonatal resuscitation- hypocapnia and hypercapnia as outcome factors after cardiac effect on immediate outcome. Resuscitation 2004;60:219-23. arrest in children. Resuscitation 2012;83:1456-61. 45. Duncan JM, Meaney P, Simpson P, et al. Vasopressin for in- 59. Ferguson LP, Durward A, Tibby SM. Relationship between ar- hospital pediatric cardiac arrest: results from the American terial partial oxygen pressure after resuscitation from cardiac Heart Association National Registry of Cardiopulmonary Re- arrest and mortality in children. Circulation 2012;126:335- suscitation. Pediatr Crit Care Med 2009;10:191-5. 42. 46. Mann K, Berg RA, Nadkarni V. Beneficial effects of vasopres- 60. Guerra-Wallace MM, Casey FL 3rd, Bell MJ, Fink EL, Hickey sin in prolonged pediatric cardiac arrest: a case series. Resus- RW. Hyperoxia and hypoxia in children resuscitated from car- citation 2002;52:149-56. diac arrest. Pediatr Crit Care Med 2013;14:e143-8. 47. Matok I, Vardi A, Augarten A, et al. Beneficial effects of terli- 61. Topjian AA, French B, Sutton RM, et al. Early postresuscitation pressin in prolonged pediatric cardiopulmonary resuscitation: hypotension is associated with increased mortality following a case series. Crit Care Med 2007;35:1161-4. pediatric cardiac arrest. Crit Care Med 2014;42:1518-23. 48. Perondi MB, Reis AG, Paiva EF, Nadkarni VM, Berg RA. A com- 62. Lin YR, Li CJ, Wu TK, et al. Post-resuscitative clinical features parison of high-dose and standard-dose epinephrine in chil- in the first hour after achieving sustained ROSC predict the dren with cardiac arrest. N Engl J Med 2004;350:1722-30. duration of survival in children with non-traumatic out-of- 49. Berg MD, Samson RA, Meyer RJ, Clark LL, Valenzuela TD, Berg hospital cardiac arrest. Resuscitation 2010;81:410-7. RA. Pediatric defibrillation doses often fail to terminate pro- 63. Lin YR, Wu HP, Chen WL, et al. Predictors of survival and neu- longed out-of-hospital ventricular fibrillation in children. Re- rologic outcomes in children with traumatic out-of-hospital suscitation 2005;67:63-7. cardiac arrest during the early postresuscitative period. J 50. Rossano JW, Quan L, Kenney MA, Rea TD, Atkins DL. Energy Trauma Acute Care Surg 2013;75:439-47. doses for treatment of out-of-hospital pediatric ventricular 64. Young MN, Hollenbeck RD, Pollock JS, et al. Higher achieved fibrillation. Resuscitation 2006;70:80-9. mean arterial pressure during therapeutic hypothermia is not 51. Berg RA, Samson RA, Berg MD, et al. Better outcome after associated with neurologically intact survival following cardi- pediatric defibrillation dosage than adult dosage in a swine ac arrest. Resuscitation 2015;88:158-64. model of pediatric ventricular fibrillation. J Am Coll Cardiol 65. Zaritsky A, Chernow B. Use of catecholamines in pediatrics. J 2005;45:786-9. Pediatr 1984;105:341-50. 52. Rodriguez-Nunez A, Lopez-Herce J, del Castillo J, Bellon JM; 66. Bellomo R, Chapman M, Finfer S, Hickling K, Myburgh J. Low- Iberian-American Paediatric Cardiac Arrest Study Network dose dopamine in patients with early renal dysfunction: a RIBEPCI. Shockable rhythms and defibrillation during in-hos- placebo-controlled randomised trial. Australian and New pital pediatric cardiac arrest. Resuscitation 2014;85:387-91. Zealand Intensive Care Society (ANZICS) Clinical Trials Group. 53. Gutgesell HP, Tacker WA, Geddes LA, Davis S, Lie JT, McNa- Lancet 2000;356:2139-43. mara DG. Energy dose for ventricular defibrillation of children. 67. Ushay HM, Notterman DA. Pharmacology of pediatric resus- Pediatrics 1976;58:898-901. citation. Pediatr Clin North Am 1997;44:207-33.

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68. Ruffolo RR Jr, Spradlin TA, Pollock GD, Waddell JE, Murphy PJ. 76. Kessler SK, Topjian AA, Gutierrez-Colina AM, et al. Short-term Alpha and beta adrenergic effects of the stereoisomers of do- outcome prediction by electroencephalographic features in butamine. J Pharmacol Exp Ther 1981;219:447-52. children treated with therapeutic hypothermia after cardiac 69. Barton P, Garcia J, Kouatli A, et al. Hemodynamic effects of i.v. arrest. Neurocrit Care 2011;14:37-43. milrinone lactate in pediatric patients with septic shock: a 77. Abend NS, Topjian AA, Kessler SK, et al. Outcome prediction by prospective, double-blinded, randomized, placebo-controlled, motor and pupillary responses in children treated with thera- interventional study. Chest 1996;109:1302-12. peutic hypothermia after cardiac arrest. Pediatr Crit Care Med 70. Doherty DR, Parshuram CS, Gaboury I, et al. Hypothermia ther- 2012;13:32-8. apy after pediatric cardiac arrest. Circulation 2009;119:1492- 78. Fink EL, Berger RP, Clark RS, et al. Serum biomarkers of brain 500. injury to classify outcome after pediatric cardiac arrest. Crit 71. Fink EL, Clark RS, Kochanek PM, Bell MJ, Watson RS. A tertia- Care Med 2014;42:664-74. ry care center’s experience with therapeutic hypothermia af- 79. Moler FW, Donaldson AE, Meert K, et al. Multicenter cohort ter pediatric cardiac arrest. Pediatr Crit Care Med 2010;11:66- study of out-of-hospital pediatric cardiac arrest. Crit Care Med 74. 2011;39:141-9. 72. Laptook A, Tyson J, Shankaran S, et al. Elevated temperature 80. Nishisaki A, Sullivan J 3rd, Steger B, et al. Retrospective analy- after hypoxic-ischemic encephalopathy: risk factor for ad- sis of the prognostic value of electroencephalography patterns verse outcomes. Pediatrics 2008;122:491-9. obtained in pediatric in-hospital cardiac arrest survivors dur- 73. Lin JJ, Hsia SH, Wang HS, Chiang MC, Lin KL. Therapeutic hy- ing three years. Pediatr Crit Care Med 2007;8:10-7. pothermia associated with increased survival after resuscita- 81. Pfeifer R, Borner A, Krack A, Sigusch HH, Surber R, Figulla HR. tion in children. Pediatr Neurol 2013;48:285-90. Outcome after cardiac arrest: predictive values and limitations 74. Moler FW, Silverstein FS, Holubkov R, et al. Therapeutic hypo- of the neuroproteins neuron-specific enolase and protein S-100 thermia after out-of-hospital cardiac arrest in children. N Engl and the Glasgow Coma Scale. Resuscitation 2005;65:49-55. J Med 2015;372:1898-908. 82. Topjian AA, Lin R, Morris MC, et al. Neuron-specific enolase 75. Scholefield BR, Morris KP, Duncan HP, et al. Evolution, safety and S-100B are associated with neurologic outcome after pe- and efficacy of targeted temperature management after pedi- diatric cardiac arrest. Pediatr Crit Care Med 2009;10:479-90. atric cardiac arrest. Resuscitation 2015;92:19-25.

Clin Exp Emerg Med 2016;3(S):S48-S61 S61 Clin Exp Emerg Med 2016;3(S):S62-S65 http://dx.doi.org/10.15441/ceem.16.135 Supplementary

Part 7. Neonatal resuscitation: eISSN: 2383-4625 2015 Korean Guidelines for Cardiopulmonary Resuscitation

Ai-Rhan Ellen Kim1, Han Suk Kim2, Su Jin Cho3, Yong Sung Choi4, Eun Sun Kim5, Hye Won Park6, Yong Hoon Cheon7, Moon Sung Park8, 9 10 11 12 Yoon Sil Chang , Young Han Kim , Dong Yeon Kim , Hee Jo Yoon , Received: 16 February 2016 Yeon Hee Kim13, Sung Phil Chung14, Sung Oh Hwang15 Revised: 19 March 2016 Accepted: 19 March 2016 1Department of Pediatrics, University of Ulsan College of Medicine, Seoul, Korea 2Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea Correspondence to: Ai-Rhan Ellen Kim 3Department of Pediatrics, Ewha Womans University School of Medicine, Seoul, Korea Division of Neonatology, Department of 4Department of Pediatrics, Kyung Hee University College of Medicine, Seoul, Korea 5Department of Pediatrics, Kangwon National University College of Medicine, Chuncheon, Korea Pediatrics, Asan Medical Center 6Department of Pediatrics, Konkuk University School of Medicine, Seoul, Korea Children’s Hospital, 88 Olympic-ro 7Department of Pediatrics, Inha University College of Medicine, Incheon, Korea 43-gil, Songpa-gu, Seoul 05505, Korea 8Department of Pediatrics, Ajou University College of Medicine, Suwon, Korea E-mail: [email protected] 9Department of Pediatrics, Sungkyungkwan University School of Medicine, Seoul, Korea 10Department of Obstetrics and Gynecology, Yonsei University of College of Medicine, Seoul, Korea 11Department of Nursing, The Catholic University of Korea School of Nursing, Seoul, Korea 12Department of Anesthesiology and Pain Medicine, Dankook University College of Medicine, Cheonan, Korea 13Department of Obstetrics and Gynecology, The Catholic University of Korea College of Medicine, Seoul, Korea 14Department of Emergency Medicine, Yonsei Universtiy College of Medicine, Seoul, Korea 15Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea

The following is a summary of the 2015 Korean Neonatal Resuscitation Guidelines. An extensive review of scientific evidence by experts of Neonatal Resuscitation Committee for the 2015 Kore- an Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care including neonatologists, nurse, obstetrician, perinatologist, and anesthesiologist was performed to update the 2011 Korean Neonatal Resuscitation Guidelines.

OVERVIEW

It has been reported that approximately 85% of term babies will start spontaneous breathing within 10 to 30 seconds after birth, an additional 10% will respond to drying and stimulation for How to cite this article: Kim AR, Kim HS, Cho SJ, Choi YS, breathing, about 3% will breathe after positive-pressure ventilation (PPV), 2% will need intuba- Kim ES, Park HW, Cheon YH, Park MS, tion, and 0.1% will require chest compression and/or epinephrine during transition to extra- Chang YS, Kim YH, Kim DY, Yoon HJ, uterine life.1-3 Kim YH, Chung SP, Hwang SO. Part 7. Neonatal resuscitation: 2015 Korean One of the key factors for neonatal resuscitation is anticipation. Determining who will require Guidelines for Cardiopulmonary resuscitation, what equipment needs to be prepared, whom to join, and how each members Resuscitation. Clin Exp Emerg Med 2016;3(S):S62-S65. should participate in the resuscitation are all important factors in anticipating neonatal deterioration. Beginning resuscitation with antenatal counseling and a team briefing are also important.4,5 This is an Open Access article distributed Heart rate and respiration are used to identify the need for neonatal resuscitation and to as- under the terms of the Creative Commons Attribution Non-Commercial License (http:// sess response to resuscitation. Heart rate could be checked by either auscultating along the left creativecommons.org/licenses/by-nc/3.0/).

S62 Copyright © 2016 The Korean Society of Emergency Medicine Ai-Rhan Ellen Kim, et al. side of chest or palpating the umbilical cord base. If the heart is recommended that the temperature of newly born, non-asphy rate cannot be determined by auscultation/palpation and the xiated infants should be maintained between 36.5°C and 37.5°C baby is not vigorous, pulse oximetry (could underestimate heart after birth through resuscitation or stabilization to admission. It rate) or cardiac monitoring can be used for alternatives mea- is important to record of the temperature of non-asphyxiated in- sures.6-9 Oxygen saturation determined by pulse oximetry indi- fants, because as it is a strong predictor of mortality and morbid- cates color, a third vital sign. The most sensitive indicator of a ity for all gestations.9 Hypothermic infants with a temperature successful resuscitation is an increase in heart rate. The critical less than 36°C on hospital admission could be rewarmed using factor to achieve successful neonatal resuscitation is an effective either the rapid (0.5°C/hr or greater) or the slow (less than 0.5°C/ ventilation. hr) rewarming method. After the aforementioned “initial care,” physicians should de- NEONATAL RESUSCITATION ALGORITHM termine the heart rate. If the newborn infant’s heart rate is lower than 100 beats/min or gasping or apnea is observed, physicians Newly born term infants who are breathing or crying and have a should provide an effective ventilation with a face mask or endo- good tone immediately after birth should be dried and taken to tracheal intubation (recommending intubation prior to beginning the mother for routine care, with continuous evaluation (Fig. 1). chest compression). If the newly born infant has a heart rate great- However, preterm or term infants who are not breathing or crying er than or equal to 100 beats/min and shows labored breathing and have poor tone should be dried and stimulated to initiate or persistent cyanosis, continuous positive airway pressure will be breathing, and kept in a position to open the airway effectively. It required.10-12 Only approximately 60 seconds after birth is allotted to initiate ventilation after determination of heart rate. When Birth PPV begins, consider using electrocardiogram monitoring for accurate assessment of the heart rate. After 30 seconds of PPV that

Term? initiates chest movement, the heart rate is reassessed. If the heart Breathing or crying? Routine care rate is lower than 60 beats/min, corrective steps should be taken Good tone? to ensure adequate ventilation.13 Alternative airways such as endotracheal intubation (if face mask was used) or laryngeal mask Provide initial care (dry, warm, and clear airway) (if intubation is unsuccessful or not possible for late preterm in- HR≥ 100/min, labored breathing or fants of more than 34 weeks gestation or in case of term infants) persistently cyanotic Monitor SpO2 14 Assess breathing, HR Oxygen as needed can be used to secure airway. If the infant’s heart rate is not re- HR<100/min, Consider CPAP covered, perform chest compression with 100% oxygen. Com- gasping or apneic pression point (lower 1/3 of the sternum) and compression-to- PPV Monitor SpO2/ECG ventilation ratio (3:1) remains unchanged. Superimposed thumbs may be a better technique for cardiac compression in newborns

Assess HR and can be continued from the head of the bed while accessing

HR<100/min the umbilical line. Reassessment of heart rate is performed after 60 seconds of chest compression, at which time medications Ensure adequate ventilation Continue PPV should be administered. Medication is rarely indicated during Consider advanced airway neonatal resuscitation because bradycardia during newborn resuscitation is usually due to inadequate lung inflation or hypox- Assess HR emia, and initiating ventilation is the most critical and important HR<60/min step to resolution. Epinephrine remains a major medication. The Start chest compressions with recommended fluid for acute hypovolemia is normal saline or compression-ventilation ratio of 3:1 type-0-negative blood via an umbilical venous catheter or via an HR<60/min intraosseous needle, if required, in term and preterm newborns. Medication A newly born infant with meconium-stained amniotic fluid does not need a routine intubation for tracheal suctioning even Fig. 1. Neonatal resuscitation algorithm. HR, heart rate; CPAP, continuous positive airway pressure; PPV, positive-pressure ventilation; ECG, when non-vigorous. Instead, adequate oxygenation and ventila- electrocardiogram. tion should be considered first.15-19

Clin Exp Emerg Med 2016;3(S):S62-S65 S63 Part 7. Neonatal resuscitation

A few changes have been made with regard to resuscitation of 20 minutes of age in newborns with greater than 34 weeks of preterm infants. With regard to cord clamping, delaying umbilical gestation, it may be reasonable to stop resuscitation in settings cord clamping for more than 30 seconds is suggested for preterm with limited resources.9 In all cases, risk and benefits of attempt- infants not requiring resuscitation. For preterm infants requiring ing resuscitation and life-sustaining treatment should be dis- resuscitation, there is insufficient evidence supporting a delayed cussed with parents, and decision should be made in the best in- cord clamping at birth. Routine use of umbilical cord milking for terest of the infant. infants of gestational age 28 weeks or less is not recommended; however, it may be considered on individual basis or in research EDUCATIONAL PROGRAM settings.4,9,20 Maintenance of the room temperature to approximately 23°C Further refinement in the current instructor program is needed to to 25°C in preparation for the birth of preterm infants and using prepare instructors to train providers. It is suggested that neona- radiant warmer, plastic wrap, warm blankets, hat, thermal mat- tal resuscitation training for neonatal resuscitation providers be tress, warm humidified gases are recommended for preterm in- conducted as frequently as 6 months or more,29,30 however, the fants of less than 32 weeks of gestation to reduce hypothermia.21,22 best interval for renewal is to be determined. It is recommended that hyperthermia (38°C) should be avoided. Regarding the use of oxygen, resuscitation of newborns of 35- REFERENCES week gestation or greater should begin with 21% oxygen. Resus- citation of newborns of less than 35 weeks of gestation should 1. Ersdal HL, Mduma E, Svensen E, Perlman JM. Early initiation begin with 21% to 30% oxygen.23-25 Free-flow oxygen adminis- of basic resuscitation interventions including face mask venti- tration may be initiated using an oxygen blender at 30%, and ti- lation may reduce birth asphyxia related mortality in low-in- trate oxygen to achieve preductal oxygen saturation targets for come countries: a prospective descriptive observational study. healthy term infants after vaginal delivery.26 When PPV is required Resuscitation 2012;83:869-73. for resuscitating preterm infants, it is preferable to use positive 2. Perlman JM, Risser R. Cardiopulmonary resuscitation in the end expiratory pressure devices to inflate lungs at 5 cm H2O be- delivery room: associated clinical events. Arch Pediatr Adolesc tween the positive pressures.27 The routine use of initial sustained Med 1995;149:20-5. inflation longer than 5 seconds for preterm infants without spon- 3. Barber CA, Wyckoff MH. Use and efficacy of endotracheal ver- taneous respiration is not recommended.9 sus intravenous epinephrine during neonatal cardiopulmonary resuscitation in the delivery room. Pediatrics 2006;118:1028- POST-CARDIAC ARREST CARE 34. 4. Perlman JM, Wyllie J, Kattwinkel J, et al. Part 11. Neonatal re- Once newborns who required resuscitation are stabilized, they suscitation: 2010 International Consensus on Cardiopulmonary should be hospitalized where close monitoring is possible. Infants Resuscitation and Emergency Cardiovascular Care Science of more than 36 weeks of gestation with evolving moderate-to- with Treatment Recommendations. Circulation 2010;122(16 severe hypoxic ischemic encephalopathy should be considered for Suppl 2):S516-38. therapeutic hypothermia at an institution where multidisciplinary 5. Wyllie J, Perlman JM, Kattwinkel J, et al. Part 11. Neonatal re- care and well-defined protocols can be applied (i.e., cooling with- suscitation: 2010 International Consensus on Cardiopulmonary in 6 hours, temperature control at 33°C to 34°C for 72 hours, and Resuscitation and Emergency Cardiovascular Care Science with rewarming over, at least, 4 hours).5 Treatment Recommendations. Resuscitation 2010;81 Suppl 1:e260-87. DISCONTINUING RESUSCITATION 6. Dawson JA, Saraswat A, Simionato L, et al. Comparison of heart rate and oxygen saturation measurements from Masimo and Evidence for delivery prognostic score for preterm infants of less Nellcor pulse oximeters in newly born term infants. Acta Paedi- than 25 weeks of gestation is insufficient to support its use. It atr 2013;102:955-60. may be reasonable to stop resuscitation for newborns with an 7. Kamlin CO, Dawson JA, O’Donnell CP, et al. Accuracy of pulse Apgar score of 0 after 10 minutes of optimal resuscitation; how- oximetry measurement of heart rate of newborn infants in ever, the decision to stop resuscitation should be individualized.28 the delivery room. J Pediatr 2008;152:756-60. If spontaneous respiration is not seen or Apgar scores of 1 to 3 at 8. van Vonderen JJ, Hooper SB, Kroese JK, et al. Pulse oximetry

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measures a lower heart rate at birth compared with electro- 19. Yoder BA. Meconium-stained amniotic fluid and respiratory cardiography. J Pediatr 2015;166:49-53. complications: impact of selective tracheal suction. Obstet Gy- 9. Perlman JM, Wyllie J, Kattwinkel J, et al. Part 7. Neonatal re- necol 1994;83:77-84. suscitation: 2015 International Consensus on Cardiopulmonary 20. Wyllie J, Perlman JM, Kattwinkel J, et al. Part 7. Neonatal resus- Resuscitation and Emergency Cardiovascular Care Science citation: 2015 International Consensus on Cardiopulmonary with Treatment Recommendations. Circulation 2015;132(16 Resuscitation and Emergency Cardiovascular Care Science with Suppl 1):S204-41. Treatment Recommendations. Resuscitation 2015;95:e169-201. 10. Morley CJ, Davis PG, Doyle LW, et al. Nasal CPAP or intubation 21. Chawla S, Amaram A, Gopal SP, Natarajan G. Safety and effi- at birth for very preterm infants. N Engl J Med 2008;358:700- cacy of Trans-warmer mattress for preterm neonates: results 8. of a randomized controlled trial. J Perinatol 2011;31:780-4. 11. SUPPORT Study Group of the Eunice Kennedy Shriver NICHD 22. te Pas AB, Lopriore E, Dito I, Morley CJ, Walther FJ. Humidified Neonatal Research Network, Finer NN, Carlo WA, et al. Early and heated air during stabilization at birth improves temper- CPAP versus surfactant in extremely preterm infants. N Engl J ature in preterm infants. Pediatrics 2010;125:e1427-32. Med 2010;362:1970-9. 23. Armanian AM, Badiee Z. Resuscitation of preterm newborns 12. Dunn MS, Kaempf J, de Klerk A, et al. Randomized trial com- with low concentration oxygen versus high concentration ox- paring 3 approaches to the initial respiratory management of ygen. J Res Pharm Pract 2012;1:25-9. preterm neonates. Pediatrics 2011;128:e1069-76. 24. Kapadia VS, Chalak LF, Sparks JE, Allen JR, Savani RC, Wyckoff 13. Kattwinkel J, Perlman JM, Aziz K, et al. Part 15. Neonatal re- MH. Resuscitation of preterm neonates with limited versus suscitation: 2010 American Heart Association Guidelines for high oxygen strategy. Pediatrics 2013;132:e1488-96. Cardiopulmonary Resuscitation and Emergency Cardiovascu- 25. Rook D, Schierbeek H, Vento M, et al. Resuscitation of pre- lar Care. Circulation 2010;122(18 Suppl 3):S909-19. term infants with different inspired oxygen fractions. J Pediatr 14. Esmail N, Saleh M, Ali A. Laryngeal mask airway versus endo- 2014;164:1322-6. tracheal intubation for Apgar score improvement in neonatal 26. Mariani G, Dik PB, Ezquer A, et al. Pre-ductal and post-ductal resuscitation. Egypt J Anesth 2002;18:115-21. O2 saturation in healthy term neonates after birth. J Pediatr 15. Chettri S, Adhisivam B, Bhat BV. Endotracheal suction for non- 2007;150:418-21. vigorous neonates born through meconium stained amniotic 27. Szyld E, Aguilar A, Musante GA, et al. Comparison of devices for fluid: a randomized controlled trial. J Pediatr 2015;166:1208- newborn ventilation in the delivery room. J Pediatr 2014;165: 13. 234-9. 16. Davis RO, Philips JB 3rd, Harris BA Jr, Wilson ER, Huddleston 28. Harrington DJ, Redman CW, Moulden M, Greenwood CE. The JF. Fatal meconium aspiration syndrome occurring despite long-term outcome in surviving infants with Apgar zero at 10 airway management considered appropriate. Am J Obstet Gy- minutes: a systematic review of the literature and hospital- necol 1985;151:731-6. based cohort. Am J Obstet Gynecol 2007;196:463. 17. Dooley SL, Pesavento DJ, Depp R, Socol ML, Tamura RK, Wirin- 29. Ernst KD, Cline WL, Dannaway DC, et al. Weekly and consecu- ga KS. Meconium below the vocal cords at delivery: correlation tive day neonatal intubation training: comparable on a pedi- with intrapartum events. Am J Obstet Gynecol 1985;153:767- atrics clerkship. Acad Med 2014;89:505-10. 70. 30. Mosley CM, Shaw BN. A longitudinal cohort study to investi- 18. Rossi EM, Philipson EH, Williams TG, Kalhan SC. Meconium as- gate the retention of knowledge and skills following atten- piration syndrome: intrapartum and neonatal attributes. Am J dance on the Newborn Life support course. Arch Dis Child Obstet Gynecol 1989;161:1106-10. 2013;98:582-6.

Clin Exp Emerg Med 2016;3(S):S62-S65 S65 Clin Exp Emerg Med 2016;3(S):S66-S68 http://dx.doi.org/10.15441/ceem.16.136 Supplementary

Part 8. Cardiopulmonary resuscitation eISSN: 2383-4625 education: 2015 Korean Guidelines for Cardiopulmonary Resuscitation

Hyuk Jun Yang1, Gi Woon Kim2, Gyu Chong Cho3, Yang Ju Tak4, Received: 16 February 2016 5 6 Sung Phil Chung , Sung Oh Hwang Revised: 19 March 2016 1Department of Emergency Medicine, Gachon University College of Medicine, Incheon, Korea Accepted: 19 March 2016 2Department of Emergency Medicine, Ajou University College of Medicine, Suwon, Korea 3Department of Emergency Medicine, Hallym University College of Medicine, Chuncheon, Korea Correspondence to: Hyuk Jun Yang 4Division of Emergency Rescue, Korea National University of Transportation College of Public Health and Department of Emergency Medicine, Life Science, Chungju, Korea Gachon University College of Medicine, 5Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Korea 21 Namdong-daero, 774beon-gil, 6Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea Namdong-gu, Incheon 21565, Korea E-mail: [email protected] Cardiac arrest is a major social and public healthcare issue. According to the 2015 statistics of the Korea Centers for Disease Control and Prevention, 45.1 persons per 100,000 population had a cardiac arrest and the rate of resuscitation for cardiac arrest is 4.8%, which is low in comparison with the economic scale of the country.1 Moreover, the mean prevalence of patients dis- charged with cerebral performance categories 1 or 2, which indicate good neurological prognosis for patients who had cardiac arrest, was only 2.3%.2 This is also lower than the 9.6% of the overall survival rate to hospital discharge reported in a CARES (Cardiac Arrest Registry to En- hance Survival) research that covered the entire United States of America from 2005 to 2010 and the 8.9% reported for Osaka, Japan, from 2007 to 2009.3,4 In addition, resuscitation rates differ by five- to six-fold at the maximum between regions, thus requiring multilateral considerations. In order to successfully apply the newly introduced 2015 cardiopulmonary resuscitation (CPR) guidelines to the society, a well-planned integrated application strategy is required, along with an educational strategy as a core factor.

KEY RECOMMENDATION IN CPR EDUCATION

1. Setting the goal of education The objective of CPR education should be focused on ensuring that students obtain knowledge How to cite this article: and skill in CPR, which can be immediately applied to actual cardiac arrest patients, and to main- Yang HJ, Kim GW, Cho GC, Tak YJ, tain these knowledge and skill for a considerable amount of time. Every educational step should Chung SP, Hwang SO. Part 8. Cardiopulmonary resuscitation education: be geared toward helping students effectively achieve this objective. 2015 Korean Guidelines for Cardiopulmonary Resuscitation. Clin Exp Emerg Med 2016;3(S):S66-S68. 2. Practice while watching method In order to minimize the side effects due to alterations of the obtained education according to the performance and skill level of different CPR instructors, video or computer-based (self) learn- This is an Open Access article distributed ing programs are recommended as media thereby students can obtain knowledge and skill in CPR, under the terms of the Creative Commons Attribution Non-Commercial License (http:// with little or no intervention at all by the instructor.5,6 Especially in terms of learning the basic creativecommons.org/licenses/by-nc/3.0/).

CPR, including directions for automated external defibrillator, prac- of the education can greatly improve the CPR performance of an ticing while watching is essential. individual or team.11

3. Skill-learning centralized education DEVISING AN EFFECTIVE EDUCATIONAL Delivering the knowledge is necessary. However, most of the time, METHOD sessions should be allocated and conducted to help students to enable them to repeatedly practice and eventually acquire CPR 1. Using realistic dummy skills. The objective is to enable the students to learn to effective- As CPR cannot be applied to a real person during skill practice, ly perform CPR within a given time during the education without dummies are used. The currently used dummies are very similar in additional out-of-class practice. Unnecessary lectures should be function to real patients owing to the rapid advancement in sci- minimized. entific technology. A basic dummy is enough for the purpose of delivering and practicing the basic knowledge and skill in CPR. 4. Re-education cycle However, when education is aimed at training for expert-level Both the general public and medical personnel who do not often CPR through diversified scenarios, more-realistic dummies are perform CPR easily forget their knowledge and skill in CPR after 3 recommended.12 As a result, the purpose, target, costs, and bene- to 6 months from completing the basic and expert resuscitation fits of education should be equally considered to determine the courses.5,6 In order to maintain their knowledge and performance type of dummy to use. of the CPR, targets in need of assistance are identified during the education to be introduced with re-educations or re-evaluations 2. Checklists/means to assist memorization via convenient means such as online self-learning program or The use of checklists/means to assist memorization among stu- video sessions, at the longest term of 6-month cycle. Accumulat- dents shows a positive effect on upskilling their CPR performance. ing evidence shows that the existing 2-year cycle for license re- To further utilize this strong point, both the student and the in- newal in basic and expert resuscitation is not adequate. However, structor must be well acquainted with using the checklists/means this re-education cycle is yet to be optimized because of insuffi- to assist memorization. cient basis. 3. Feedback device 5. Use of a measurable skill evaluation tool It is recommended that a device be used for giving direct feed- It is recommended that the degrees of depth, frequency, and full backs on speed, depth, relaxation, hand position during chest com- relaxation in chest compressions during practice and evaluation pression in CPR education.13,14 If such a feedback device is not in CPR education should be numerically measured in order to available, a feedback device based on auditory guidance such as monitor the skill CPR level while providing feedbacks by utilizing music or metronome is recommended in order to improve the a prompt or a measuring device. In case a device for feedback is speed of chest compression.15 not available, auditory guidance (metronome or music) can be used.7,8 4. Debriefing Debriefing refers to a time of structuring the educational experi- 6. Reinforced education for non-technical skills ence through discussions, debates, and feedbacks at the end of Considering actual CPR situations, wherein more than two rescu- the simulation process. Many studies show that debriefing is the ers rather than a single rescuer perform the resuscitation in abso- most important step in simulation-type educations.16 Considering lute majority, non-technical skills greatly affect the result of the this, debriefing must be essentially included in CPR education and CPR, such as teamwork between the members of the CPR team, recommended after the students undergo actual cases of CPR. leadership for tuning up the activities within the team, and patient turnover between team members, must be included in the 5. Roles of social media technology education.9,10 Various social media technologies have been widely used recently. Interest is increasing on a method in which people who are able 7. Debriefing and seminar-type delivery and willing to conduct CPR would be notified of a nearby out-of- Debriefings, inquiries, and discussions at the end of each step or hospital cardiac arrest patient by actively utilizing social media.17,18 the entire CPR education are strongly recommended, as summary It is suggested that for this method, scientific technology and so-

Clin Exp Emerg Med 2016;3(S):S66-S68 S67 Part 8. Cardiopulmonary resuscitation education cial media should be used to notify people who are able and will- course versus 30-min video self-training: a controlled rando ing to conduct CPR when they are near a suspected out-of-hos- mized study. Resuscitation 2007;74:476-86. pital cardiac arrest patient. 7. Rawlins L, Woollard M, Williams J, Hallam P. Effect of listen- ing to Nellie the Elephant during CPR training on performance ACKNOWLEDGMENTS of chest compressions by lay people: randomised crossover trial. BMJ 2009;339:b4707. This guideline is performed and completed by a current subsidy 8. Woollard M, Poposki J, McWhinnie B, Rawlins L, Munro G, O’Me business of the Centers for Disease Control and Prevention, Min- ara P. Achy breaky makey wakey heart? A randomised cross- istry of Health and Welfare, Korea. over trial of musical prompts. Emerg Med J 2012;29:290-4. 9. Bhanji F, Mancini ME, Sinz E, et al. Part 16. Education, imple- Collaborators mentation, and teams: 2010 American Heart Association Guide- We thank to Chang Hee Lee from Namseoul University, Dai Hai lines for Cardiopulmonary Resuscitation and Emergency Car- Choi from Dongguk University, Eun Young Park from Korea Red diovascular Care. Circulation 2010;122(18 Suppl 3):S920-33. Cross, Gu Hyun Kang from Hallym University, Kyung Kuk Hwang 10. Soar J, Mancini ME, Bhanji F, et al. Part 12. Education, imple- from Chungbuk National University, Seung Min Park from Hallym mentation, and teams: 2010 International Consensus on Car- University, Youngsuk Cho from Hallym University, Yun Hee Oh diopulmonary Resuscitation and Emergency Cardiovascular from Asan medical Center as evidence reviewer, and thank to Care Science with Treatment Recommendations. Resuscita- Jong Hwan Shin from Seoul National University, Youngsuk Cho tion 2010;81 Suppl 1:e288-330. from Hallym University, Yun Hee Oh from Asan Medical Center as 11. Edelson DP, Litzinger B, Arora V, et al. Improving in-hospital question owner. cardiac arrest process and outcomes with performance debriefing. Arch Intern Med 2008;168:1063-9. REFERENCES 12. Lo BM, Devine AS, Evans DP, et al. Comparison of traditional versus high-fidelity simulation in the retention of ACLS knowl- 1. Korea Centers for Disease Control and Prevention. Research edge. Resuscitation 2011;82:1440-3. on sudden cardiac arrest: major statistics [Internet]. Cheon- 13. Yeung J, Davies R, Gao F, Perkins GD. A randomised control trial gju: Korea Centers for Disease Control and Prevention [cited of prompt and feedback devices and their impact on quality 2015 Oct 14]. Available from: http://www.cdc.go.kr/CDC/con- of chest compressions: a simulation study. Resuscitation 2014; tents/CdcKrContentView.jsp?cid=66386&menuIds=HOME001- 85:553-9. MNU1130-MNU1110-MNU2383-MNU 2387. 14. Cheng A, Brown LL, Duff JP, et al. Improving cardiopulmonary 2. Ahn KO, Shin SD, Suh GJ, et al. Epidemiology and outcomes resuscitation with a CPR feedback device and refresher simu- from non-traumatic out-of-hospital cardiac arrest in Korea: a lations (CPR CARES Study): a randomized clinical trial. JAMA nationwide observational study. Resuscitation 2010;81:974- Pediatr 2015;169:137-44. 81. 15. Kim SC, Hwang SO, Cha KC, et al. A simple audio-visual prompt 3. McNally B, Robb R, Mehta M, et al. Out-of-hospital cardiac device can improve CPR performance. J Emerg Med 2013;44: arrest surveillance: Cardiac Arrest Registry to Enhance Sur- 128-34. vival (CARES), United States, October 1, 2005-December 31, 16. Cheng A, Hunt EA, Donoghue A, et al. Examining pediatric re- 2010. MMWR Surveill Summ 2011;60:1-19. suscitation education using simulation and scripted debrief- 4. Shin SD, Kitamura T, Hwang SS, et al. Association between ing: a multicenter randomized trial. JAMA Pediatr 2013;167: resuscitation time interval at the scene and neurological out- 528-36. come after out-of-hospital cardiac arrest in two Asian cities. 17. Zijlstra JA, Stieglis R, Riedijk F, Smeekes M, van der Worp WE, Resuscitation 2014;85:203-10. Koster RW. Local lay rescuers with AEDs, alerted by text mes- 5. Lynch B, Einspruch EL, Nichol G, Becker LB, Aufderheide TP, sages, contribute to early defibrillation in a Dutch out-of-hos- Idris A. Effectiveness of a 30-min CPR self-instruction pro- pital cardiac arrest dispatch system. Resuscitation 2014;85: gram for lay responders: a controlled randomized study. Re- 1444-9. suscitation 2005;67:31-43. 18. Ringh M, Rosenqvist M, Hollenberg J, et al. Mobile-phone dis- 6. Einspruch EL, Lynch B, Aufderheide TP, Nichol G, Becker L. Re- patch of laypersons for CPR in out-of-hospital cardiac arrest. tention of CPR skills learned in a traditional AHA Heartsaver N Engl J Med 2015;372:2316-25.

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