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Background: Insufficient left ventricular (LV) unloading during venoarterial extracorporeal life support (VA-ECLS) can result in poor LV recovery and inability to wean from support. Published data suggest a survival benefit with LV mechanical venting (MV), but there is limited data comparing modalities. Methods: We queried the ELSO registry from 2010-2019 for adults undergoing VA-ECLS with MV and stratified them by intra-aortic balloon pump (IABP) or percutaneous ventricular assist device (pVAD). We excluded patients with pulmonary embolism, heart transplant, congenital and valvular heart disease, aortic disease, and central cannulation. We performed a subgroup analysis excluding extracorporeal cardiopulmonary resuscitation (ECPR). The primary outcome was in-hospital mortality. Secondary outcomes were on-support mortality, medical and cannula site bleeding, hemolysis, ischemic stroke, limb ischemia, and renal injury. We used multivariable logistic regression modeling to adjust for clinical covariates. Results: Among 3353 adults with MV on VA-ECLS, 2782 (83%) were vented with IABP and 571 (17%) with pVAD. IABP patients were less likely to be supported for ventricular arrhythmia (9.6% vs 14.3%) and had lower rates of pre-ECLS arrest (49% vs 66%) and concomitant renal (13.5% vs 34.5%), liver (3.4% vs 9.3%), and respiratory (17.6% vs 37.0%) failure, p Conclusion: In adults with MV on VA-ECLS, IABP compared to pVAD is associated with a significantly lower risk of bleeding and a strong signal of improved survival. We cannot exclude residual unmeasured confounding, so prospective studies are needed to compare MV devices.

Introduction: Venoarterial extracorporeal life support (VA-ECLS) imposes increased afterload on the left ventricle (LV), potentially provoking LV distension and impaired ventricular recovery. Prior studies have suggested a survival benefit with LV mechanical venting (MV), but multi-center data are lacking. Methods: We queried the ELSO registry for adults undergoing VA-ECLS and stratified them by the use of MV, including intra-aortic balloon pump and percutaneous ventricular assist device. We excluded patients with pulmonary embolism, heart transplant, congenital and valvular heart disease, aortic disease, and central cannulation. The primary outcome was in-hospital mortality. Secondary outcomes were on-support mortality and major adverse events, including bleeding, hemolysis, ischemic stroke, limb ischemia, and renal injury. We used multivariable logistic regression modeling to adjust for relevant clinical covariates. Results: Among 12734 patients undergoing VA-ECLS, 3353 (26.3%) received MV devices. Patients with MV were older (mean age 56.3 vs 52.7 years), more often male (76.3% vs 68.5%), and more often supported for acute myocardial infarction (43.0% vs 21.7%), p2 vasopressors (41.8% vs 27.2%) and had a higher incidence of acute renal (17.1% vs 10.5%), liver (4.4% vs 3.1%), and respiratory failure (20.9% vs 15.9%), p Conclusions: Among adults supported with peripheral VA-ECLS, LV MV was associated with lower mortality despite a higher rate of important adverse events.

Fulminant myocarditis (FM) is an uncommon syndrome characterized by sudden and severe diffuse cardiac inflammation often leading to death resulting from cardiogenic shock, ventricular arrhythmias, or multiorgan system failure. Historically, FM was almost exclusively diagnosed at autopsy. By definition, all patients with FM will need some form of inotropic or mechanical circulatory support to maintain end-organ perfusion until transplantation or recovery. Specific subtypes of FM may respond to immunomodulatory therapy in addition to guideline-directed medical care. Despite the increasing availability of circulatory support, orthotopic heart transplantation, and disease-specific treatments, patients with FM experience significant morbidity and mortality as a result of a delay in diagnosis and initiation of circulatory support and lack of appropriately trained specialists to manage the condition. This scientific statement outlines the resources necessary to manage the spectrum of FM, including extracorporeal life support, percutaneous and durable ventricular assist devices, transplantation capabilities, and specialists in advanced heart failure, cardiothoracic surgery, cardiac pathology, immunology, and infectious disease. Education of frontline providers who are most likely to encounter FM first is essential to increase timely access to appropriately resourced facilities, to prevent multiorgan system failure, and to tailor disease-specific therapy as early as possible in the disease process.

The fundamentals of cardiac resuscitation include the immediate provision of high-quality cardiopulmonary resuscitation combined with rapid defibrillation (as appropriate). These mainstays of therapy set the groundwork for other possible interventions such as medications, advanced airways, extracorporeal cardiopulmonary resuscitation, and post–cardiac arrest care, including targeted temperature management, cardiorespiratory support, and percutaneous coronary intervention. Since 2015, an increased number of studies have been published evaluating some of these interventions, requiring a reassessment of their use and impact on survival from cardiac arrest. This 2019 focused update to the American Heart Association advanced cardiovascular life support guidelines summarizes the most recent published evidence for and recommendations on the use of advanced airways, vasopressors, and extracorporeal cardiopulmonary resuscitation during cardiac arrest. It includes revised recommendations for all 3 areas, including the choice of advanced airway devices and strategies during cardiac arrest (eg, bag-mask ventilation, supraglottic airway, or endotracheal intubation), the training and retraining required, the administration of standard-dose epinephrine, and the decisions involved in the application of extracorporeal cardiopulmonary resuscitation and its potential impact on cardiac arrest survival.

The International Liaison Committee on Resuscitation has initiated a continuous review of new, peer-reviewed, published cardiopulmonary resuscitation science. This is the third annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. It addresses the most recent published resuscitation evidence reviewed by International Liaison Committee on Resuscitation Task Force science experts. This summary addresses the role of cardiac arrest centers and dispatcher-assisted cardiopulmonary resuscitation, the role of extracorporeal cardiopulmonary resuscitation in adults and children, vasopressors in adults, advanced airway interventions in adults and children, targeted temperature management in children after cardiac arrest, initial oxygen concentration during resuscitation of newborns, and interventions for presyncope by first aid providers. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the certainty of the evidence on the basis of the Grading of Recommendations, Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence to Decision Framework Highlights sections. The task forces also listed priority knowledge gaps for further research.

Utstein-style reporting templates provide a structured framework with which to compare systems of care for cardiac arrest. The 2004 Utstein reporting template encompassed both out-of-hospital and in-hospital cardiac arrest. A 2015 update of the Utstein template focused on out-of-hospital cardiac arrest, which makes this update of the in-hospital template timely. Representatives of the International Liaison Committee on Resuscitation developed an updated in-hospital Utstein reporting template iteratively by meeting face-to-face, by teleconference, and by online surveys between 2013 and 2018. Data elements were grouped by hospital factors, patient variables, pre-event factors, cardiac arrest and postresuscitation processes, and outcomes. Elements were classified as core or supplemental by use of a modified Delphi process. Variables were described as core if they were considered essential. Core variables should enable reasonable comparisons between systems and are considered essential for quality improvement programs. Together with core variables, supplementary variables are considered useful for research.

Antiarrhythmic medications are commonly administered during and immediately after a ventricular fibrillation/pulseless ventricular tachycardia cardiac arrest. However, it is unclear whether these medications improve patient outcomes. This 2018 American Heart Association focused update on advanced cardiovascular life support guidelines summarizes the most recent published evidence for and recommendations on the use of antiarrhythmic drugs during and immediately after shock-refractory ventricular fibrillation/pulseless ventricular tachycardia cardiac arrest. This article includes the revised recommendation that providers may consider either amiodarone or lidocaine to treat shock-refractory ventricular fibrillation/pulseless ventricular tachycardia cardiac arrest.

Background— Targeted temperature management is recommended after out-of-hospital cardiac arrest. Whether advanced internal cooling is superior to basic external cooling remains unknown. The aim of this multicenter, controlled trial was to evaluate the benefit of endovascular versus basic surface cooling. Methods and Results— Inclusion criteria were the following: age of 18 to 79 years, out-of-hospital cardiac arrest related to a presumed cardiac cause, time to return of spontaneous circulation P =0.107). Improvement in favorable outcome at day 90 in favor of the endovascular group did not reach significance (odds ratio, 1.51; 95% confidence interval, 0.96–2.35; P =0.07). Time to target temperature (33°C) was significantly shorter and target hypothermia was more strictly maintained in the endovascular than in the surface group ( P P =0.009). Conclusion— Despite better hypothermia induction and maintenance, endovascular cooling was not significantly superior to basic external cooling in terms of favorable outcome. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT00392639.

Background— Observational studies in adults have shown a worse outcome associated with hyperoxia after resuscitation from cardiac arrest. Extrapolating from adult data, current pediatric resuscitation guidelines recommend avoiding hyperoxia. We investigated the relationship between arterial partial oxygen pressure and survival in patients admitted to the pediatric intensive care unit (PICU) after cardiac arrest. Methods and Results— We conducted a retrospective cohort study using the Pediatric Intensive Care Audit Network (PICANet) database between 2003 and 2010 (n=122 521). Patients aged o 2 ≥300 mm Hg) and 448 (24%) had hypoxia (Pa o 2 o 2 and PICU mortality. After covariate adjustment, risk of death increased sharply with increasing hypoxia (odds ratio, 1.92; 95% confidence interval, 1.80–2.21 at Pa o 2 of 23 mm Hg). There was also an association with increasing hyperoxia, although not as dramatic as that for hypoxia (odds ratio, 1.25; 95% confidence interval, 1.17–1.37 at 600 mm Hg). We observed an increasing mortality risk with advancing age, which was more pronounced in the presence of congenital heart disease. Conclusions— Both severe hypoxia and, to a lesser extent, hyperoxia are associated with an increased risk of death after PICU admission after cardiac arrest.

Introduction: In case of no return of spontaneous circulation (ROSC) after conventional cardio-pulmonary resuscitation (CPR), out-of-hospital cardiac arrest (OHCA) patients could be referred for extracorporeal life support (ECLS). Guidelines have been published concerning this specific situation (1). The aim of our study was to describe the prognosis of OHCA patients and verify if referral to ECLS was compliant with these recommendations mainly studying time intervals (no-flow < 5 min, low-flow < 100 min). Methods: A prospective survey on OHCA referred to ECLS was implemented from 03/01/12 until 06/11/15 in an Emergency Medical Service (EMS) located in Paris area (France). This survey included 43 patients referred to hospital for ECLS. Variables were given as means and percentages. Results: Patients referred to ECLS were more often men (77%), with a mean age of 51 years old. Most of 43 OHCA occurred at home (51%), although 26% occurred on public area and 16% at workplace. In 40% of cases, CPR was performed by a witness and in 33% by a health professional. A first Basic Life Support ambulance arrived on scene within 7 min 50 sec, whereas EMS ambulance arrived on scene within 18 min 27 sec after OHCA. At EMS arrival on scene, patients were on asystole (44%), ventricular fibrillation (37%), and on spontaneous circulation (12%). The no-flow time interval was 4 min 10 sec on average (6 patients had a no-flow over 5 min) with 43% of patients with no no-flow. Low-flow time-interval was 44 min. External electric shock was delivered before EMS arrival on 21% of cases, and EMS itself delivered a shock in 40% of cases. Epinephrine was used for all patients, 10.35 mg on average. No patient survived OHCA after referral to ECLS. Discussion: Although this is a small series of 43 patients, no OHCA patient referred to ECLS survived. These results are mainly due to a non-shockable initial condition or too long no-flow time intervals. In order to improve the outcome and bring benefit to the proper expected patients through a cost-effective pathway, we released a reminder of the right recommendations in our EMS. (1) Riou B., Adnet F., Baud F et al. A. Recommandation sur les indications de l’assistance circulatoire dans le traitement des arrêts cardiaques réfractaires. Ann Fr Anesth Réanim 2009 ; 28 : 182-6.

This Part of the 2015 American Heart Association (AHA) Guidelines Update for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC) addresses cardiac arrest in situations that require special treatments or procedures other than those provided during basic life support (BLS) and advanced cardiovascular life support (ACLS). This Part summarizes recommendations for the management of resuscitation in several critical situations, including cardiac arrest associated with pregnancy (Part 10.1), pulmonary embolism (PE) (10.2), and opioid-associated resuscitative emergencies, with or without cardiac arrest (10.3). Part 10.4 provides recommendations on intravenous lipid emulsion (ILE) therapy, an emerging therapy for cardiac arrest due to drug intoxication. Finally, updated guidance for the management of cardiac arrest during percutaneous coronary intervention (PCI) is presented in Part 10.5. A table of all recommendations made in this 2015 Guidelines Update as well as those made in the 2010 Guidelines is contained in the Appendix. The special situations of resuscitation section (Part 12) of the 2010 AHA Guidelines for CPR and ECC 1 covered 15 distinct topic areas. The following topics were last updated in 2010: Additional information about drowning is presented in Part 5 of this publication, “Adult Basic Life Support and Cardiopulmonary Resuscitation Quality.” The recommendations in this 2015 Guidelines Update are based on an extensive evidence review process that was begun by the International Liaison Committee on Resuscitation (ILCOR) with the publication of the ILCOR 2010 International Consensus on CPR and ECC Science With Treatment …

Basic life support (BLS), advanced cardiovascular life support (ACLS), and post–cardiac arrest care are labels of convenience that each describe a set of skills and knowledge that are applied sequentially during the treatment of patients who have a cardiac arrest. There is overlap as each stage of care progresses to the next, but generally ACLS comprises the level of care between BLS and post–cardiac arrest care. ACLS training is recommended for advanced providers of both prehospital and in-hospital medical care. In the past, much of the data regarding resuscitation was gathered from out-of-hospital arrests, but in recent years, data have also been collected from in-hospital arrests, allowing for a comparison of cardiac arrest and resuscitation in these 2 settings. While there are many similarities, there are also some differences between in- and out-of-hospital cardiac arrest etiology, which may lead to changes in recommended resuscitation treatment or in sequencing of care. The consideration of steroid administration for in-hospital cardiac arrest (IHCA) versus out-of-hospital cardiac arrest (OHCA) is one such example discussed in this Part. The recommendations in this 2015 American Heart Association (AHA) Guidelines Update for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC) are based on an extensive evidence review process that was begun by the International Liaison Committee on Resuscitation (ILCOR) after the publication of the ILCOR 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations 1 and was completed in February 2015.2 In this in-depth evidence review process, the ILCOR task forces examined topics and then generated prioritized lists of questions for systematic review. Questions were first formulated in PICO (population, intervention, comparator, outcome) format,3 and then a search strategy and inclusion and exclusion criteria were defined and a search for relevant articles was performed. The evidence was evaluated by using …

At least 350 000 people will suffer cardiac arrest each year in the United States, 1 every 90 seconds.1 Many will then undergo cardiopulmonary resuscitation (CPR) by bystanders and emergency medical services in a desperate attempt to restore life. Numerous studies report that the majority of these efforts will not succeed. Prolonged anoxia, the inability to restore spontaneous circulation, neurological devastation, and other complications combine to limit survival. Nonetheless, thousands will surmount these obstacles and resume normal lives. CPR is a triumph of medicine but also is frequently performed in vain. It is a young science; the term “CPR” was first publicized less than 50 years ago. The roots of resuscitation, however, extend back centuries, with a gradual course of evolution that has been periodically impeded by rejection of inadequate techniques, curiously slow adoption of proven interventions, and even a cyclic process of abandonment and subsequent rediscovery. Examining the history of resuscitation is an essential first step to understanding and following the evolution to modern practices. A detailed review of more current observations, inventions, and clinical trials, in the context of the disappointing statistics of conventional CPR, will elucidate the rationale behind the most recently published resuscitation guidelines, as well as provide fuel for future research. Although components of life support apply to the predominantly asphyxia-related arrests seen in pediatrics, the focus of this review is on resuscitation after cardiopulmonary arrest in the adult. ### Airway “But that life may… be restored to the animal, an opening must be attempted in the trunk of the trachea, into which a tube of reed or cane should be put.” — Andreas Vesalius, 1540 2 The Babylonian Talmud, a sixth century collection of Jewish oral tradition, records that a lamb with a neck injury was saved by a hole into the trachea, supported by …

Background: The outcome of patients after OHCA has been poor. The probability of return of spontaneous circulation decreases over time. New therapeutic attempts like E-ECLS at the ED are tried to improve outcome of selected cases. The "Vienna Cardiac Arrest Registry" (VICAR) was introduced August 1, 2013 to collect Utstein-style data. Our aim was to identify those patients which might fulfill ‘load&go’ criteria for E-ECLS at the ED after OHCA. Methods: Therefore VICAR was retrospectively analysed for following criteria: age Results: Overall 701 patients were registered from August 1, 2013 to April 30, 2014. Excluded were because of poor documentation 26(4%) patients, because of missing criteria data 49(7%) and because they were younger than 18 years 7 (1%). The final analysis included 619(88%) patients; of those 68(11%) were transported under ongoing CPR to the ED. Moreover E-ECLS was applied in 15 patients at the ED. Conclusion: We found 30 (5%) patients to fulfill ’load & go’ criteria. Of 68 patients, who were transported with ongoing CPR to the ED only 8 (8%) met the criteria. Further promotion of these criteria within the ambulance crews is needed. Maybe these criteria could then serve as a decision support for emergency physicians/paramedics, which patients to transport under ongoing CPR to the ED for E-ECLS.

BACKGROUND: Polarized arrest, a new concept of myocardial protection, has been recently demonstrated to improve cardiac function after cardioplegic arrest during cardiac surgery. The present study investigated whether polarizing state after prolonged cardiac arrest would provide cardioprotective and neuroprotective effects after extracorporeal life support (ECLS). METHODS AND RESULTS: Ventricular fibrillation (VF) was induced in male Wistar rats. After 8 min of untreated VF, veno-arterial ECLS was instituted for 60 min inducing mild therapeutic hypothermia (32°C). At the beginning of ECLS animals were randomized to receive a single iv bolus of 4.5 mL/kg of polarizing solution with adenosine (47 μM), lidocaine (92 μM) and MgSO4 (1 mM) or same volume of saline as control. Restoration of spontaneous circulation was higher in rats that received polarizing solution (p = 0.03). After 24 h survival and neurologic deficit scores were improved and histological damage scores and brain TNF-α were attenuated compared to control (all p Polarizing solution administration led to better recovery of left ventricle end-systolic pressure-volume relationship (Ees), preload recruitable stroke work (PRSW), end-diastolic pressure-volume relationship (EDPVR) and Tau (p Polarized state enhanced phosphorilation of myocardial ERK1 and 2 and Akt, resulting in a lower apoptotic index (TUNEL, p CONCLUSIONS: Polarized state induced by adenosine, lidocaine and magnesium increased survival, neurologic outcome and cardiac function after prolonged cardiac arrest treated with ECLS. Moreover it improved cardioprotection through activation of the pro-survival kinases Akt and ERK1/2.

Background— Extracorporeal membrane oxygenation (ECMO) has served for >2 decades as the standard of care for US children requiring mechanical support as a bridge to heart transplantation. Objective data on the safety and efficacy of ECMO for this indication are limited. We describe the outcomes of ECMO as a bridge to heart transplantation to serve as performance benchmarks for emerging miniaturized assist devices intended to replace ECMO. Methods and Results— Data from the Extracorporeal Life Support Organization Registry and the Organ Procurement Transplant Network database were merged to identify children supported with ECMO and listed for heart transplantation from 1994 to 2009. Independent predictors of wait-list and posttransplantation in-hospital mortality were identified. Objective performance goals for ECMO were developed. Of 773 children, the median age was 6 months (interquartile range, 1 to 44 months); 28% had cardiomyopathy; and in 38%, a bridge to transplantation was intended at ECMO initiation. Overall, 45% of subjects reached transplantation, although one third of those transplanted died before discharge; overall survival to hospital discharge was 47%. Wait-list mortality was independently associated with congenital heart disease, cardiopulmonary resuscitation before ECMO, and renal dysfunction. Posttransplantation mortality was associated with congenital heart disease, renal dysfunction, ECMO duration of >14 days, and initial ECMO indication as a bridge to recovery. In the objective performance goal cohort (n=485), patients with cardiomyopathy had the highest survival to hospital discharge (63%), followed by patients with myocarditis (59%), 2-ventricle congenital heart disease (44%) and 1-ventricle congenital heart disease (33%). Conclusion— Although ECMO is effective for short-term circulatory support, it is not reliable for the long-term circulatory support necessary for children awaiting heart transplantation. Fewer than half of patients bridged with ECMO survive to hospital discharge. More effective modalities for chronic circulatory support in children are urgently needed.

This section of the 2010 AHA Guidelines for CPR and ECC addresses cardiac arrest in situations that require special treatments or procedures beyond those provided during basic life support (BLS) and advanced cardiovascular life support (ACLS). We have included 15 specific cardiac arrest situations. The first several sections discuss cardiac arrest associated with internal physiological or metabolic conditions, such as asthma (12.1), anaphylaxis (12.2), pregnancy (12.3), morbid obesity (12.4), pulmonary embolism (PE) (12.5), and electrolyte imbalance (12.6). The next several sections relate to resuscitation and treatment of cardiac arrest associated with external or environmentally related circumstances, such as ingestion of toxic substances (12.7), trauma (12.8), accidental hypothermia (12.9), avalanche (12.10), drowning (12.11), and electric shock/lightning strikes (12.12). The last 3 sections review management of cardiac arrest that may occur during special situations affecting the heart, including percutaneous coronary intervention (PCI) (12.13), cardiac tamponade (12.14), and cardiac surgery (12.15). Asthma is responsible for more than 2 million visits to the emergency department (ED) in the United States each year, with 1 in 4 patients requiring admission to a hospital.1 Annually there are 5,000 to 6,000 asthma-related deaths in the United States, many occurring in the prehospital setting.2 Severe asthma accounts for approximately 2% to 20% of admissions to intensive care units, with up to one third of these patients requiring intubation and mechanical ventilation.3 This section focuses on the evaluation and treatment of patients with near-fatal asthma. Several consensus groups have developed excellent guidelines for the management of asthma that are available on the World Wide Web: ### Pathophysiology The pathophysiology of asthma consists of 3 key abnormalities: Complications of severe asthma, such as tension pneumothorax, lobar atelectasis, pneumonia, and pulmonary edema, can contribute to fatalities. Severe asthma exacerbations are commonly associated with …

The goal of therapy for bradycardia or tachycardia is to rapidly identify and treat patients who are hemodynamically unstable or symptomatic due to the arrhythmia. Drugs or, when appropriate, pacing may be used to control unstable or symptomatic bradycardia. Cardioversion or drugs or both may be used to control unstable or symptomatic tachycardia. ACLS providers should closely monitor stable patients pending expert consultation and should be prepared to aggressively treat those with evidence of decompensation.

The 2010 AHA Guidelines for CPR and ECC for the evaluation and management of acute coronary syndromes (ACS) are intended to define the scope of training for healthcare providers who treat patients with suspected or definite ACS within the first hours after onset of symptoms. These guidelines summarize key out-of-hospital, emergency department (ED), and related initial critical-care topics that are relevant to diagnosis and initial stabilization and are not intended to guide treatment beyond the ED. Emergency providers should use these contents to supplement other recommendations from the ACC/AHA Guidelines, which are used throughout the United States and Canada.1–3 As with any guidelines, these general recommendations must be considered within the context of local resources and their application to individual patients by knowledgeable healthcare providers. The healthcare providers managing the individual patients are best suited to determine the most appropriate treatment strategy. The primary goals of therapy for patients with ACS are to ● Reduce the amount of myocardial necrosis that occurs in patients with acute myocardial infarction (AMI), thus preserving left ventricular (LV) function, preventing heart failure, and limiting other cardiovascular complications ● Prevent major adverse cardiac events (MACE): death, nonfatal MI, and need for urgent revascularization ● Treat acute, life-threatening complications of ACS, such as ventricular fibrillation (VF), pulseless ventricular tachycardia (VT), unstable tachycardias, symptomatic bradycardias (See Part 8: “Advanced Cardiovascular Life Support”), pulmonary edema, cardiogenic shock and mechanical complications of AMI ● An overview of recommended care for the ACS patient is illustrated in Figure 1, the Acute Coronary Syndromes Algorithm. Part 10 provides details of the care highlighted in the numbered algorithm boxes; box numbers in the text correspond to the numbered boxes in the algorithm. In this part, the abbreviation “AMI” refers to acute myocardial infarction, whether associated with ST-elevation myocardial infarction (STEMI) or non-ST-elevation myocardial infarction (NSTEMI). The diagnosis and treatment of AMI, however, will often differ for patients with STEMI versus NSTEMI. Please note carefully which AMI type is being discussed.

To the Editor: The “reappraisal” of the literature on mouth-to-mouth ventilation during bystander-initiated CPR, by a working group of the Basic Life Support and Pediatric Life Support subcommittees of the American Heart Association (AHA),1 is misleading and incomplete. There is no convincing evidence that the low incidence of initiation of CPR out of hospital by lay bystanders is the result of fear of becoming infected by mouth-to-mouth ventilation. Such fear should not be promoted. If such fear exists, however, it should be mitigated by explaining that initiating CPR is safe and by carrying a pocket-size barrier for ventilation of strangers. The errors in this article concerning behavioral, educational, epidemiological, and logistics issues will be summarized in a separate letter by Braslow and Brennan. Although the article says “… it is not intended to change any current AHA recommendations,” its publication has created confusion and the erroneous impression for laypersons and the media that in sudden coma, bystanders will save lives by merely pushing on the sternum (step C, circulation support). In cardiac arrest, oxygenated blood must be circulated to restore heartbeat and to keep the brain viable, requiring “head tilt plus blowing plus pumping.” The article suggests that mouth-to-mouth ventilation can be omitted in various forms of sudden loss of consciousness.1 Laypersons cannot differentiate between various forms of sudden coma and between the absence versus presence of a weak pulse. Coma always results in upper airway obstruction if the neck is flexed (references 26 to 31 in the article by Becker et al),2 3 4 5 6 as experienced by anesthesiologists every day. There are 20 million general anesthesias given in the United States each year. The data in Figure 1 are misleading1 because Gordon’s measurements of 1950 (reference 24 in the article by Becker et …

Four rhythms produce pulseless cardiac arrest: ventricular fibrillation (VF), rapid ventricular tachycardia (VT), pulseless electrical activity (PEA), and asystole. Survival from these arrest rhythms requires both basic life support (BLS) and advanced cardiovascular life support (ACLS). The foundation of ACLS care is good BLS care, beginning with prompt high-quality bystander CPR and, for VF/pulseless VT, attempted defibrillation within minutes of collapse. For victims of witnessed VF arrest, prompt bystander CPR and early defibrillation can significantly increase the chance for survival to hospital discharge. In comparison, typical ACLS therapies, such as insertion of advanced airways and pharmacologic support of the circulation, have not been shown to increase rate of survival to hospital discharge. This section details the general care of a patient in cardiac arrest and provides an overview of the ACLS Pulseless Arrest Algorithm. During cardiac arrest, basic CPR and early defibrillation are of primary importance, and drug administration is of secondary importance. Few drugs used in the treatment of cardiac arrest are supported by strong evidence. After beginning CPR and attempting defibrillation, rescuers can establish intravenous (IV) access, consider drug therapy, and insert an advanced airway. ### Central Versus Peripheral Infusions Central line access is not needed in most resuscitation attempts. If IV access has not been established, the provider should insert a large peripheral venous catheter. Although in adults peak drug concentrations are lower and circulation times longer when drugs are administered via peripheral sites rather than central sites, the establishment of peripheral access does not require interruption of CPR.1,2 Drugs typically require 1 to 2 minutes to reach the central circulation when given via a peripheral vein but require less time when given via central venous access. If a resuscitation drug is administered by a peripheral venous route, administer the drug by bolus injection and follow with a 20-mL bolus of …

Acute myocardial infarction (AMI) and unstable angina (UA) are part of a spectrum of clinical disease collectively identified as acute coronary syndromes (ACS). The pathophysiology common to this spectrum of disease is a ruptured or eroded atheromatous plaque.1–5 The electrocardiographic (ECG) presentation of these syndromes encompasses ST-segment elevation myocardial infarction (STEMI), ST-segment depression, and nondiagnostic ST-segment and T-wave abnormalities. A non–ST-elevation myocardial infarction (NSTEMI) is diagnosed if cardiac markers are positive with ST-segment depression or with nonspecific or normal ECGs. Sudden cardiac death may occur with any of these conditions. ACS is the most common proximate cause of sudden cardiac death.6–10 Effective interventions for patients with ACS, particularly STEMI, are extremely time-sensitive. The first healthcare providers to encounter the ACS patient can have a big impact on patient outcome if they provide efficient risk stratification, initial stabilization, and referral for cardiology care. It is critical that basic life support (BLS) and advanced cardiovascular life support (ACLS) healthcare providers who care for ACS patients in the out-of-hospital, emergency department (ED), and hospital environments be aware of the principles and priorities of assessment and stabilization of these patients. These guidelines target BLS and ACLS healthcare providers who treat patients with ACS within the first hours after onset of symptoms, summarizing key out-of-hospital, ED, and some initial critical-care topics that are relevant to stabilization. They also continue to build on recommendations from the ACC/AHA Guidelines,11,12 which are used throughout the United States and Canada.13 As with any medical guidelines, these general recommendations must be considered within the context of local resources and application to individual patients by knowledgeable healthcare providers. The primary goals of therapy for patients with ACS are to