Resuscitation 95 (2015) 148–201 Contents lists available at ScienceDirect Resuscitation jou rnal homepage: www.elsevier.com/locate/resuscitation European Resuscitation Council Guidelines for Resuscitation 2015 Section 4. Cardiac arrest in special circumstances a,b,∗ c d e Anatolij Truhlárˇ , Charles D. Deakin , Jasmeet Soar , Gamal Eldin Abbas Khalifa , f g h i Annette Alfonzo , Joost J.L.M. Bierens , Guttorm Brattebø , Hermann Brugger , j k l m,w Joel Dunning , Silvija Hunyadi-Anticeviˇ c´ , Rudolph W. Koster , David J. Lockey , n o,p q,r s t Carsten Lott , Peter Paal , Gavin D. Perkins , Claudio Sandroni , Karl-Christian Thies , u v,w David A. Zideman , Jerry P. Nolan , on behalf of the Cardiac arrest in special 1 circumstances section Collaborators a Emergency Medical Services of the Hradec Králové Region, Hradec Králové, Czech Republic b Department of Anaesthesiology and Intensive Care Medicine, University Hospital Hradec Králové, Hradec Králové, Czech Republic c Cardiac Anaesthesia and Cardiac Intensive Care, NIHR Southampton Respiratory Biomedical Research Unit, Southampton University Hospital NHS Trust, Southampton, UK d Anaesthesia and Intensive Care Medicine, Southmead Hospital, North Bristol NHS Trust, Bristol, UK e Emergency and Disaster Medicine, Six October University Hospital, Cairo, Egypt f Departments of Renal and Internal Medicine, Victoria Hospital, Kirkcaldy, Fife, UK g Society to Rescue People from Drowning, Amsterdam, The Netherlands h Bergen Emergency Medical Services, Department of Anaesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway i EURAC Institute of Mountain Emergency Medicine, Bozen, Italy j Department of Cardiothoracic Surgery, James Cook University Hospital, Middlesbrough, UK k Center for Emergency Medicine, Clinical Hospital Center Zagreb, Zagreb, Croatia l Department of Cardiology, Academic Medical Center, Amsterdam, The Netherlands m Intensive Care Medicine and Anaesthesia, Southmead Hospital, North Bristol NHS Trust, Bristol, UK n Department of Anesthesiology, University Medical Center, Johannes Gutenberg-Universitaet, Mainz, Germany o Barts Heart Centre, St Bartholomew’s Hospital, Barts Health NHS Trust, Queen Mary University of London, London, UK p Department of Anaesthesiology and Critical Care Medicine, University Hospital Innsbruck, Austria q Warwick Medical School, University of Warwick, Coventry, UK r Critical Care Unit, Heart of England NHS Foundation Trust, Birmingham, UK s Department of Anaesthesiology and Intensive Care, Catholic University School of Medicine, Rome, Italy t Birmingham Children’s Hospital, Birmingham, UK u Department of Anaesthetics, Imperial College Healthcare NHS Trust, London, UK v Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, UK w School of Clinical Sciences, University of Bristol, UK Introduction special causes, special environments and special patients. The first part covers treatment of potentially reversible causes of car- Irrespective of the cause of cardiac arrest, early recognition and diac arrest, for which specific treatment exists, and which must calling for help, including appropriate management of the deteri- be identified or excluded during any resuscitation. For improv- orating patient, early defibrillation, high-quality cardiopulmonary ing recall during ALS, these are divided into two groups of four, resuscitation (CPR) with minimal interruption of chest compres- based upon their initial letter – either H or T – and are called sions and treatment of reversible causes, are the most important the ‘4Hs and 4Ts’: Hypoxia; Hypo-/hyperkalaemia and other elec- interventions. trolyte disorders; Hypo-/hyperthermia; Hypovolaemia; Tension In certain conditions, however, advanced life support (ALS) pneumothorax; Tamponade (cardiac); Thrombosis (coronary and guidelines require modification. The following guidelines for resus- pulmonary); Toxins (poisoning). The second part covers cardiac citation in special circumstances are divided into three parts: arrest in special environments, where universal guidelines have to be modified due to specific locations or location-specific causes ∗ of cardiac arrest. The third part is focused on patients with spe- Corresponding author. cific conditions, and those with certain long-term comorbidities E-mail address: [email protected] (A. Truhlár).ˇ 1 where a modified approach and different treatment decisions may The members of the Cardiac arrest in special circumstances section Collaborators are listed in the Collaborators section. be necessary. http://dx.doi.org/10.1016/j.resuscitation.2015.07.017 0300-9572/© 2015 European Resuscitation Council. Published by Elsevier Ireland Ltd. All rights reserved. A. Truhlárˇ et al. / Resuscitation 95 (2015) 148–201 149 Summary of changes since 2010 Guidelines cardiac arrest. A new section covers the common causes and rel- evant modification to resuscitative procedures in this group of The main changes in the ERC Guidelines 2015 in comparison patients. 1 with the Guidelines 2010 are summarised below: • Cardiac arrest following major cardiac surgery is relatively com- mon in the immediate post-operative phase. Key to successful Special causes resuscitation is recognition of the need to perform emergency • resternotomy, especially in the context of tamponade or hae- Survival after an asphyxia-induced cardiac arrest is rare and sur- morrhage, where external chest compressions may be ineffective. vivors often have severe neurological impairment. During CPR, Resternotomy should be performed within 5 min if other inter- early effective ventilation of the lungs with supplementary oxy- ventions have failed. gen is essential. • • Cardiac arrest from shockable rhythms (Ventricular Fibrillation A high degree of clinical suspicion and aggressive treatment can (VF) or pulseless Ventricular Tachycardia (pVT)) during car- prevent cardiac arrest from electrolyte abnormalities. The new diac catheterisation should immediately be treated with up to algorithm provides clinical guidance to emergency treatment of three stacked shocks before starting chest compressions. Use life-threatening hyperkalaemia. • of mechanical chest compression devices during angiography is Hypothermic patients without signs of cardiac instability recommended to ensure high-quality chest compressions and (systolic blood pressure ≥90 mmHg, absence of ventricular ◦ reduce the radiation burden to personnel during angiography arrhythmias or core temperature ≥28 C) can be rewarmed exter- with ongoing CPR. nally using minimally invasive techniques (e.g. with warm forced • In dental surgery, do not move the patient from the dental chair air and warm intravenous fluid). Patients with signs of cardiac in order to start CPR. Quickly recline the dental chair into a hor- instability should be transferred directly to a centre capable of izontal position and place a stool under the head of the chair to extracorporeal life support (ECLS). • increase its stability during CPR. Early recognition and immediate treatment with intramuscular • The in-flight use of AEDs aboard commercial airplanes can result adrenaline remains the mainstay of emergency treatment for anaphylaxis. in up to 50% survival to hospital discharge. AEDs and appropriate • CPR equipment should be mandatory on board of all commer- The mortality from traumatic cardiac arrest (TCA) is very high. cial aircraft in Europe, including regional and low-cost carriers. The most common cause of death is haemorrhage. It is recognised Consider an over-the-head technique of CPR if restricted access that most survivors do not have hypovolaemia, but instead have precludes a conventional method, e.g. in the aisle. other reversible causes (hypoxia, tension pneumothorax, cardiac • The incidence of cardiac arrest on board helicopter emergency tamponade) that must be immediately treated. The new treat- medical services (HEMS) and air ambulances is low. Importance ment algorithm for TCA was developed to prioritise the sequence of pre-flight preparation and use of mechanical chest compres- of life-saving measures. Chest compressions should not delay the sion devices are emphasised. treatment of reversible causes. Cardiac arrests of non-traumatic • Sudden and unexpected collapse of an athlete on the field of play origin leading to a secondary traumatic event should be recog- is likely to be cardiac in origin and requires rapid recognition and nised and treated with standard algorithms. • early defibrillation. There is limited evidence for recommending the routine trans- • The duration of submersion is a key determinant of outcome port of patients with continuing CPR after out-of-hospital cardiac from drowning. Submersion exceeding 10 min is associated with arrest (OHCA) of suspected cardiac origin. Transport may be ben- poor outcome. Bystanders play a critical role in early rescue and eficial in selected patients where there is immediate hospital resuscitation. Resuscitation strategies for those in respiratory or access to the catheterisation laboratory and an infrastructure cardiac arrest continue to prioritise oxygenation and ventilation. providing prehospital and in-hospital teams experienced in • The chances of good outcome from cardiac arrest in diffi- mechanical or haemodynamic support and percutaneous coro- cult terrain or mountains may be reduced because of delayed nary intervention (PCI) with ongoing CPR. • access and prolonged transport. There is a recognised role of Recommendations for administration of fibrinolytics when pul- air rescue and availability