Nontraumatic Cardiac Arrest: Ventricular Tachycardia, Ventricular Fibrillation, PEA, Asystole, Defibrillation, Epinephrine | EB Medicine
TOC Will Appear Here

Optimizing Survival Outcomes for Adult Patients with Nontraumatic Cardiac Arrest (Pharmacology CME)

Below is a free preview. Log in or subscribe for full access. Or, get a free sample article Emergency Department Management of Abnormal Uterine Bleeding in the Nonpregnant Patient:
Please provide a valid email address.
Table of Contents
Table of Contents
  1. Abstract
  2. Case Presentations
  3. Introduction
  4. Critical Appraisal of the Literature
  5. Etiology And Pathophysiology
  6. Differential Diagnosis
  7. Prehospital Care
  8. Emergency Department Evaluation
  9. Diagnostic Studies
  10. Treatment
    1. Basic Life Support
      1. Chest Compression Rate Goal: 100-120 compressions/min
      2. Chest Compression Depth Goal: 2 to 2.4 inches
      3. Chest Compression Fraction Goal: > 60% Of Resuscitation Time
      4. Allow Full Chest Wall Recoil Between Compressions
      5. Avoid Excessive Ventilation
      6. Defibrillation
    2. Airway Management And Ventilation
    3. Vascular Access
    4. Pharmacologic Interventions
      1. Vasopressors
      2. Antiarrhythmics
      3. Other Drugs
    5. Immediate Postarrest Care In The Emergency Department
      1. Pharmacologic Interventions
      2. Hemodynamic Management
      3. Targeted Temperature Management
    6. Prognostic Indicators Of Outcome
      1. End-Tidal Carbon Dioxide
      2. Ultrasound
      3. Termination Of Resuscitation
  11. Special Circumstances
    1. Pregnancy
    2. Pulmonary Embolism
    3. Opioid Overdose
    4. Torsades de Pointe
    5. Patients With Other Toxicologic Causes Of Arrest
    6. Hyperkalemia
    7. Accidental Hypothermia
  12. Controversies And Cutting Edge
    1. Percutaneous Coronary Interventions
    2. Extracorporeal Cardiopulmonary Resuscitation
    3. Steroids
  13. Disposition
  14. Summary
  15. Risk Management Pitfalls For Cardiac Arrest
  16. Time- And Cost-Effective Strategies
  17. Case Conclusions
  18. Clinical Pathway For Management Of Cardiac Arrest In The Emergency Department
  19. Tables and Figures
    1. Table 1. The Hs And Ts In Pulseless Electrical Activity
    2. Table 2. Physical Examination Findings And Possibly Related Causes Of Arrest
    3. Figure 1. Electrocardiogram Of Ventricular Fibrillation
    4. Figure 2. Electrocardiogram Of Ventricular Tachycardia
    5. Figure 3. Electrocardiogram Of Torsades de Pointe
  20. References


Patient survival after cardiac arrest can be improved significantly with prompt and effective resuscitative care. This systematic review analyzes the basic life support factors that improve survival outcome, including chest compression technique and rapid defibrillation of shockable rhythms. For patients who are successfully resuscitated, comprehensive postresuscitation care is essential. Targeted temperature management is recommended for all patients who remain comatose, in addition to careful monitoring of oxygenation, hemodynamics, and cardiac rhythm. Management of cardiac arrest in circumstances such as pregnancy, pulmonary embolism, opioid overdose and other toxicologic causes, hypothermia, and coronary ischemia are also reviewed.

Case Presentations

Shortly after starting your night shift, you get STAT paged to bed 34. You rush to the room and find the nurses giving chest compressions. You wrack your brain to remember sign-out – wasn’t this the man who came in with chest pain, no ECG changes, but a concerning history? He was stable, just waiting on an inpatient bed! Not anymore, you sigh. You hold compressions to take a look at the monitor, and see V-fib. “Charge to 200 joules,” you say. “Clear!” calls the tech. The patient jumps with the force of the electricity. The nurse resumes compressions, but a few moments later, the patient moans, moving his hand to his chest. As you hold on compressions and continue to stabilize the patient, you wonder if he would be a good candidate to go to the cath lab . . .

Shortly afterward, you get a call from paramedics about a young man who collapsed suddenly while dancing at a nightclub. “He’s in full cardiac arrest,” they say, and you rush back to the critical care bay. You arrive in the resuscitation bay just as EMS arrives. “It’s V-fib,” the paramedic tells you. “He got 1 shock on the way over, and we’re due for a rhythm check now. EMS had them doing CPR at the scene, and they were doing a pretty good job. It’s only been about 10 minutes since the 911 call– the club is right around the corner from here.” You pause CPR and glance at the monitor. It’s still V-fib, so you deliver a shock at 200 joules and one of the nurses takes over CPR. “Great compressions,” you tell him, and you mean it - just the right depth and rate, and no pauses for nonsense. “I’ve got access, Doc,” says the technician. “Perfect,” you respond, “let’s give a milligram of epi.” You sound like you’re in control, but your mind is racing Why V-fib in a seemingly healthy young man?


Cardiac arrest refers to the abrupt cessation of effective mechanical function of the heart. It may be caused by a variety of cardiac and noncardiac diseases.There are more than half a million adult cardiac arrests in the United States each year, with approximately 325,000 outside the hospital and 200,000 in the hospital. There is a slight male predominance, with 57% of cases occurring in men.Cardiac arrest occurs in all age groups, though incidence increases with age.2

Survival to hospital discharge occurs in approximately 10% of out-of-hospital arrest cases overall, though survival rates are more than 30% for bystander-witnessed cases.In-hospital arrest survival is approximately 20%,4,5 though this estimate varies substantially by hospitaland time of arrest.The presenting cardiac rhythm is an important predictor of outcome in cardiac arrest. The first documented rhythm is ventricular fibrillation (VF) in 17% of cases, ventricular tachycardia (VT) in 7%, pulseless electrical activity (PEA) in 37%, and asystole in 39%.8

Survival to hospital discharge is better overall for shockable rhythms, with more than 33% of patients surviving VF/VT arrests compared to approximately 10% for PEA and asystole.8,9

Critical Appraisal Of The Literature

The body of literature on cardiac arrest is vast, with more than 40,000 articles in PubMed. Fortunately, the International Liaison Committee on Resuscitation (ILCOR) regularly reviews the literature and synthesizes it into practice guidelines for its member organizations, including the American Heart Association (AHA). The AHA publishes guideline updates every 5 years, and these are the “gold standard” in cardiac arrest science. The guidelines summarize clinical resuscitation protocols and their evidentiary basis, as well as noting areas where scientific evidence is lacking. The 2015 updates, published on October 15, 2015 in the journal Circulation, served as the starting point for this review, with additional targeted literature searches performed to address specific clinical questions.

The 2015 AHA guidelines emphasize the importance of immediate, continuous, high-quality cardiopulmonary resuscitation (CPR) and early defibrillation, while recognizing the relative paucity of evidence supporting more “advanced” interventions. Key points from the 2015 guidelines include the following:10

  • Prehospital care
    • Expansion of recommendations for emergency medical services (EMS) dispatchers to instruct bystanders in compression-only CPR for all cases of suspected cardiac arrest
  • Basic life support (BLS)
    • Continuation of emphasis on all aspects of CPR quality, especially rate and depth of chest compressions, as these are the most common errors made by CPR providers
    • Addition of an upper limit for chest compression rate (100-120/min)
    • Addition of an upper limit for chest compression depth (2-2.4 in)
    • Emphasis on decreasing preshock pauses in chest compressions
    • Addition of a specific goal for chest compression fraction (> 60% of total resuscitation time)
  • Advanced/hospital-based life support
    • Continued recommendation that healthcare workers provide both compressions and breaths for all arrest victims, regardless of etiology
    • Addition of specific respiratory rate after intubation (1 breath/6 sec)
    • Recommendation to maximize inspired oxygen during resuscitation
    • Recognition of the potential utility of ultra sound, with the caveat that it must not interfere with CPR or defibrillation
    • Removal of vasopressin from arrest algorithms
    • Addition of rhythm-specific guidelines for timing of epinephrine
      • Shockable rhythm: after defibrillation, as this is the first priority
  • Nonshockable rhythm: as soon as possible
  • Postarrest care
    • Recommendation to consider percutaneous coronary interventions (PCI) in all successfully resuscitated arrest patients with suspected coronary syndromes
    • Recommendation for targeted temperature management at 32°C-36°C for at least 24 hours postarrest
    • Recommendation to avoid prognostication of neurologic outcome until 72 hours after return of spontaneous circulation

Risk Management Pitfalls For Cardiac Arrest

  1. “I followed the guidelines – how was I supposed to know why he was in PEA?”
    PEA is often caused by noncardiac conditions, and will resolve only when these underlying conditions are treated. Standard resuscitation interventions do not resolve physiologic derangements causing PEA, and should be viewed as a bridge to more definitive care. Know the Hs and the Ts, and hunt for the root cause of PEA in every patient.
  2. “I was busy intubating – it’s not my fault that chest compressions were too slow.”
    Chest compressions are the single most important intervention in cardiac arrest regardless of etiology, whereas intubation is not necessary in the majority of cases. Physicians must be meticulous about every aspect of compression quality. Compression rate can be monitored using the CPR quality feedback features available on many modern defibrillators, a metronome or timer, or even by singing (“Stayin’ Alive” has just the right tempo).
  3. “I couldn’t compress any deeper – I was too tired!”
    Achieving adequate compression depth is physically challenging for many rescuers, and as fatigue worsens, compressions suffer. Physicians must monitor their team members for signs of fatigue and change compressors as needed to ensure quality CPR.
  4. “I had no idea we stopped compressions for so long – I was having trouble getting a decent image on the ultrasound.”
    Low chest compression fraction contributes to poor survival outcomes, and needless pauses in CPR are not to be tolerated. In cardiac arrest, nothing is more important than CPR, and compressions should be halted only for scheduled breaths and rhythm checks/ defibrillation. The guidelines specifically stipulate that ultrasound should not be allowed to interfere with CPR.
  5. “That monitor tracing was really weird – I didn’t realize it was V-tach.”
    Defibrillation is the only effective treatment for VF/VT arrest, and it is essential for clinicians to recognize these rhythms rapidly and reliably. While manual defibrillation mode is preferred for clinicians, automated mode may be used in the face of uncertainty about the rhythm.
  6. “I knew it was V-fib, but I couldn’t get the blasted defibrillator hooked up! It’s the tech’s job anyway.”
    It is common practice to delegate defibrillation to nursing staff, and physicians may run dozens of resuscitations without ever touching the defibrillator, leading to skill decay. As leaders, physicians must be the most competent members of the resuscitation team, and should thoroughly understand operation of lifesaving equipment like the defibrillator.
  7. “Sure, I didn’t ventilate – but everyone knows that chest compressions are the only thing that matters!”
    Emphasis on the importance of CPR and defibrillation has led to a misconception that respiratory support is irrelevant. While “hands-only” CPR is acceptable for lay rescuers, health professionals must provide ventilation along with chest compression in all resuscitations. Advanced airway placement is not mandatory, but effective ventilation is. Every breath should produce visible chest rise, and compressions should be coordinated with ventilations in a 30:2 ratio prior to advanced airway placement.
  8. “So I gave a few doses of sodium bicarbonate – what’s wrong with that?”
    The only drugs that are included in resuscitation algorithms are epinephrine (all rhythms) and amiodarone (VF/VT – lidocaine is an acceptable alternative). Unless the patient has a specific indication for bicarbonate, such as hyperkalemia or tricyclic antidepressant overdose, this drug is not warranted and may be harmful.
  9. “I got him back – it’s not my fault that he’s febrile.”
    Targeted temperature management in the range of 32ºC to 36ºC is required for a minimum of 24 hours following successful resuscitation from cardiac arrest. Fever is common in the postresuscitation period, and is known to be deleterious to outcomes, so temperature control must be meticulous.
  10. “Her ECG looked OK – how was I supposed to know this was a STEMI?”
    Acute coronary syndromes are common among cardiac arrest patients, and the ECG is not reliable for diagnosing coronary ischemia in the postarrest period. Cardiac catheterization should be initiated for all successfully resuscitated patients with a suspected cardiac etiology of arrest.

Tables And Figures

Table 1. The Hs And Ts In Pulseless Electrical Activity


Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study is included in bold type following the reference, where available. In addition, the most informative references cited in this paper, as determined by the authors, are noted by an asterisk (*) next to the number of the reference.

  1. Modi S, Krahn AD. Sudden cardiac arrest without overt heart disease. Circulation. 2011;123(25):2994-3008. (Review)
  2. Engdahl J, Holmberg M, Karlson BW, et al. The epidemiology of out-of-hospital ‘sudden’ cardiac arrest. Resuscitation. 2002;52(3):235-245. (Review)
  3. Mozaffarian D, Benjamin EJ, Go AS, et al. Heart disease and stroke statistics--2015 update: a report from the American Heart Association. Circulation. 2015;131(4):e29-e322. (Review)
  4. Sandroni C, Nolan J, Cavallaro F, et al. In-hospital cardiac arrest: incidence, prognosis and possible measures to improve survival. Intensive Care Med. 2007;33(2):237-245. (Review)
  5. Merchant RM, Yang L, Becker LB, et al. Incidence of treated cardiac arrest in hospitalized patients in the United States. Crit Care Med. 2011;39(11):2401-2406. (Epidemiologic registry study; 433 patients)
  6. Merchant RM, Berg RA, Yang L, et al. Hospital variation in survival after in-hospital cardiac arrest. J Am Heart Assoc. 2014;3(1):e000400. (Retrospective observational; 135,896 cases)
  7. Peberdy MA, Ornato JP, Larkin GL, et al. Survival from in-hospital cardiac arrest during nights and weekends. JAMA. 2008;299(7):785-792. (Retrospective observational; 86,748 patients)
  8. Meaney PA, Nadkarni VM, Kern KB, et al. Rhythms and outcomes of adult in-hospital cardiac arrest. Crit Care Med. 2010;38(1):101-108. (Retrospective observational; 51,919 patients)
  9. Nadkarni VM, Larkin GL, Peberdy MA, et al. First documented rhythm and clinical outcome from in-hospital cardiac arrest among children and adults. JAMA. 2006;295(1):50- 57. (Retrospective observational; 36,902 patients)
  10. * Neumar RW, Shuster M, Callaway CW, et al. Part 1: Executive summary: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2015;132(18 Suppl 2):S315- S367. (Guidelines)
  11. Bergum D, Nordseth T, Mjolstad OC, et al. Causes of in-hospital cardiac arrest - incidences and rate of recognition. Resuscitation. 2015;87:63-68. (Prospective observational; 302 patients)
  12. McNally B, Robb R, Mehta M, et al. Out-of-hospital cardiac arrest surveillance --- cardiac arrest registry to enhance survival (CARES), United States, October 1, 2005--December 31, 2010. MMWR Surveill Summ. 2011;60(8):1-19. (Retrospective observational study; 31,689 patients)
  13. Wallmuller C, Meron G, Kurkciyan I, et al. Causes of in-hospital cardiac arrest and influence on outcome. Resuscitation. 2012;83(10):1206-1211. (Retrospective analysis; 1041 patients)
  14. Eberle B, Dick WF, Schneider T, et al. Checking the carotid pulse check: diagnostic accuracy of first responders in patients with and without a pulse. Resuscitation. 1996;33(2):107- 116. (Randomized; 206 participants)
  15. Bahr J, Klingler H, Panzer W, et al. Skills of lay people in checking the carotid pulse. Resuscitation. 1997;35(1):23-26. (449 participants)
  16. Dick WF, Eberle B, Wisser G, et al. The carotid pulse check revisited: what if there is no pulse? Crit Care Med. 2000;28(11 Suppl):N183-N185. (Prospective observational; 449 participants)
  17. Ochoa FJ, Ramalle-Gomara E, Carpintero JM, et al. Competence of health professionals to check the carotid pulse. Resuscitation. 1998;37(3):173-175. (Prospective observational; 72 participants)
  18. Hauff SR, Rea TD, Culley LL, et al. Factors impeding dispatcher-assisted telephone cardiopulmonary resuscitation. Ann Emerg Med. 2003;42(6):731-737. (Retrospective observational; 404 patients)
  19. Cummins RO, Hazinski MF. Guidelines based on fear of type II (false-negative) errors. Why we dropped the pulse check for lay rescuers. Resuscitation. 2000;46(1-3):439-442. (Editorial)
  20. Lerner EB, Rea TD, Bobrow BJ, et al. Emergency medical service dispatch cardiopulmonary resuscitation prearrival instructions to improve survival from out-of-hospital cardiac arrest: a scientific statement from the American Heart Association. Circulation. 2012;125(4):648-655. (Review)
  21. Hoke RS, Chamberlain D. Skeletal chest injuries secondary to cardiopulmonary resuscitation. Resuscitation. 2004;63(3):327-338. (Systematic review)
  22. * Link MS, Berkow LC, Kudenchuk PJ, et al. Part 7: adult advanced cardiovascular life support: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2015;132(18 Suppl 2):S444-S464. (Guidelines)
  23. Paradis NA, Martin GB, Goetting MG, et al. Aortic pres-sure during human cardiac arrest. Identification of pseudo-electromechanical dissociation. Chest. 1992;101(1):123-128. (Prospective observational; 200 patients)
  24. Bocka JJ, Overton DT, Hauser A. Electromechanical dissocia-tion in human beings: an echocardiographic evaluation. Ann Emerg Med. 1988;17(5):450-452. (Prospective observational; 22 patients)
  25. * Kleinman ME, Brennan EE, Goldberger ZD, et al. Part 5: adult basic life support and cardiopulmonary resuscitation quality: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2015;132(18 Suppl 2):S414-S435. (Guidelines)
  26. Hallstrom AP, Cobb LA, Johnson E, et al. Dispatcher assisted CPR: implementation and potential benefit. A 12-year study. Resuscitation. 2003;57(2):123-129. (Retrospective observational; 6130 patients)
  27. Akahane M, Ogawa T, Tanabe S, et al. Impact of telephone dispatcher assistance on the outcomes of pediatric out-of-hospital cardiac arrest. Crit Care Med. 2012;40(5):1410-1416. (Observational registry study; 1780 patients)
  28. * Meaney PA, Bobrow BJ, Mancini ME, et al. Cardiopulmonary resuscitation quality: [Corrected] improving cardiac resuscitation outcomes both inside and outside the hospital: a consensus statement from the American Heart Association. Circulation. 2013;128(4):417-435. (Review)
  29. Chardoli M, Heidari F, Rabiee H, et al. Echocardiography integrated ACLS protocol versus conventional cardiopulmonary resuscitation in patients with pulseless electrical activity cardiac arrest. Chin J Traumatol. 2012;15(5):284-287. (Randomized; 100 patients)
  30. Hernandez C, Shuler K, Hannan H, et al. C.A.U.S.E.: cardiac arrest ultra-sound exam – a better approach to managing patients in primary non-arrhythmogenic cardiac arrest. Resuscitation. 2008;76(2):198-206. (Review)
  31. Zengin S, Yavuz E, Al B, et al. Benefits of cardiac sonography performed by a non-expert sonographer in patients with non-traumatic cardiopulmonary arrest. Resuscitation, 2016:epub ahead of print. (Prospective observational; 179 patients)
  32. Salen P, Melniker L, Chooljian C, et al. Does the presence or absence of sonographically identified cardiac activity predict resuscitation outcomes of cardiac arrest patients? Am J Emerg Med. 2005;23(4):459-462. (Prospective observational; 70 patients)
  33. Blaivas M, Fox JC. Outcome in cardiac arrest patients found to have cardiac standstill on the bedside emergency department echocardiogram. Acad Emerg Med. 2001;8(6):616-621. (Prospective observational; 169 patients)
  34. Idris AH, Guffey D, Aufderheide TP, et al. Relationship between chest compression rates and outcomes from cardiac arrest. Circulation. 2012;125(24):3004-3012. (Retrospective observational; 3098 patients)
  35. Idris AH, Guffey D, Pepe PE, et al. Chest compression rates and survival following out-of-hospital cardiac arrest. Crit Care Med. 2015;43(4):840-848. (Retrospective observational; 10,371 patients)
  36. Stiell IG, Brown SP, Christenson J, et al. What is the role of chest compression depth during out-of-hospital cardiac arrest resuscitation? Crit Care Med. 2012;40(4):1192-1198. (Retrospective observational; 1029 patients)
  37. Stiell IG, Brown SP, Nichol G, et al. What is the optimal chest compression depth during out-of-hospital cardiac arrest resuscitation of adult patients? Circulation. 2014;130(22):1962- 1970. (Retrospective observational; 9136 patients)
  38. Hellevuo H, Sainio M, Nevalainen R, et al. Deeper chest compression - more complications for cardiac arrest patients? Resuscitation. 2013;84(6):760-765. (Retrospective observational; 170 patients)
  39. Christenson J, Andrusiek D, Everson-Stewart S, et al. Chest compression fraction determines survival in patients with out-of-hospital ventricular fibrillation. Circulation. 2009;120(13):1241-1247. (Prospective observational; 506 patients)
  40. Vaillancourt C, Everson-Stewart S, Christenson J, et al. The impact of increased chest compression fraction on return of spontaneous circulation for out-of-hospital cardiac arrest patients not in ventricular fibrillation. Resuscitation. 2011;82(12):1501-1507. (Prospective observational; 2103 patients)
  41. Cheskes S, Schmicker RH, Christenson J, et al. Perishock pause: an independent predictor of survival from out-of-hospital shockable cardiac arrest. Circulation. 2011;124(1):58-66. (Retrospective observational; 815 patients)
  42. Cheskes S, Schmicker RH, Verbeek PR, et al. The impact of peri-shock pause on survival from out-of-hospital shockable cardiac arrest during the resuscitation outcomes consortium PRIMED trial. Resuscitation. 2014;85(3):336-342. (Retrospective observational; 2006 patients)
  43. Jost D, Degrange H, Verret C, et al. DEFI 2005: a randomized controlled trial of the effect of automated external defibrillator cardiopulmonary resuscitation protocol on outcome from out-of-hospital cardiac arrest. Circulation. 2010;121(14):1614- 1622. (Randomized controlled; 5107 patients)
  44. Beesems SG, Wijmans L, Tijssen JG, et al. Duration of ventilations during cardiopulmonary resuscitation by lay rescuers and first responders: relationship between delivering chest compressions and outcomes. Circulation. 2013;127(15):1585- 1590. (Retrospective; 199 patients)
  45. Aufderheide TP, Sigurdsson G, Pirrallo RG, et al. Hyperventilation-induced hypotension during cardiopulmonary resuscitation. Circulation. 2004;109(16):1960-1965. (Randomized; 9 animals)
  46. Chan PS, Krumholz HM, Nichol G, American Heart Association National Registry of Cardiopulmonary Resuscita-tion Investigators, et al. Delayed time to defibrillation after in-hospital cardiac arrest. N Engl J Med. 2008;358(1):9-17. (Retrospective observational; 6789 patients)
  47. Wik L, Hansen TB, Fylling F, et al. Delaying defibrillation to give basic cardiopulmonary resuscitation to patients with out-of-hospital ventricular fibrillation: a randomized trial. JAMA. 2003;289(11):1389-1395. (Randomized; 200 patients)
  48. Baker PW, Conway J, Cotton C, et al. Defibrillation or cardiopulmonary resuscitation first for patients with out-of-hospital cardiac arrests found by paramedics to be in ventricular fibrillation? A randomised control trial. Resuscitation. 2008;79(3):424-431. (Randomized control; 202 patients)
  49. Stiell IG, Nichol G, Leroux BG, et al. Early versus later rhythm analysis in patients with out-of-hospital cardiac arrest. N Engl J Med. 2011;365(9):787-797. (Randomized; 9933 patients)
  50. Kramer-Johansen J, Edelson DP, Abella BS, et al. Pauses in chest compression and inappropriate shocks: a comparison of manual and semi-automatic defibrillation attempts. Resuscitation. 2007;73(2):212-220. (Prospective observational; 1165 shocks)
  51. Tomkins WG, Swain AH, Bailey M, et al. Beyond the pre-shock pause: the effect of prehospital defibrillation mode on CPR interruptions and return of spontaneous circulation. Resuscitation. 2013;84(5):575-579. (Prospective observational; 44 patients)
  52. Field JM, Hazinski MF, Sayre MR, et al. Part 1: executive summary: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2010;122(18 Suppl 3):S640-S656. (Guidelines)
  53. Takeda T, Tanigawa K, Tanaka H, et al. The assessment of three methods to verify tracheal tube placement in the emergency setting. Resuscitation. 2003;56(2):153-157. (Prospective observational; 137 patients)
  54. Grmec S. Comparison of three different methods to confirm tracheal tube placement in emergency intubation. Intensive Care Med. 2002;28(6):701-704. (Prospective observational; 345 patients)
  55. Neumar RW, Otto CW, Link MS, et al. Part 8: adult advanced cardiovascular life support: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2010;122(18 Suppl 3):S729-S7267. (Guidelines)
  56. * Reades R, Studnek JR, Vandeventer S, et al. Intraosseous versus intravenous vascular access during out-of-hospital cardiac arrest: a randomized controlled trial. Ann Emerg Med. 2011;58(6):509-516. (Randomized controlled; 182 patients)
  57. * Reades R, Studnek JR, Garrett JS, et al. Comparison of first-attempt success between tibial and humeral intraosseous insertions during out-of-hospital cardiac arrest. Prehosp Emerg Care. 2011;15(2):278-281. (Prospective observational; 88 patients)
  58. * Olasveengen TM, Sunde K, Brunborg C, et al. Intravenous drug administration during out-of-hospital cardiac arrest: a randomized trial. JAMA. 2009;302(20):2222-2229. (Randomized; 851 patients)
  59. * Jacobs IG, Finn JC, Jelinek GA, et al. Effect of adrenaline on survival in out-of-hospital cardiac arrest: a randomised double-blind placebo-controlled trial. Resuscitation. 2011;82(9):1138-1143. (Randomized double-blind placebo-controlled; 601 patients)
  60. Gueugniaud PY, Mols P, Goldstein P, et al. A comparison of repeated high doses and repeated standard doses of epinephrine for cardiac arrest outside the hospital. European Epinephrine Study Group. N Engl J Med. 1998;339(22):1595- 1601. (Randomized; 3327 patients)
  61. Brown CG, Martin DR, Pepe PE, et al. A comparison of standard-dose and high-dose epinephrine in cardiac arrest outside the hospital. The Multicenter High-Dose Epineph-rine Study Group. N Engl J Med. 1992;327(15):1051-1055. (Randomized; 1280 patients)
  62. Stiell IG, Hebert PC, Weitzman BN, et al. High-dose epinephrine in adult cardiac arrest. N Engl J Med. 1992;327(15):1045- 1050. (Randomized; 650 patients)
  63. Donnino MW, Salciccioli JD, Howell MD, et al. Time to administration of epinephrine and outcome after in-hospital cardiac arrest with non-shockable rhythms: retrospective analysis of large in-hospital data registry. BMJ. 2014;348:g3028. (Retrospective observational; 25,095 patients)
  64. Goto Y, Maeda T, Goto Y. Effects of prehospital epinephrine during out-of-hospital cardiac arrest with initial non-shockable rhythm: an observational cohort study. Crit Care. 2013;17(5):R188. (Retrospective observational; 209,577 patients)
  65. Wenzel V, Krismer AC, Arntz HR, et al. A comparison of vasopressin and epinephrine for out-of-hospital cardiopulmonary resuscitation. N Engl J Med. 2004;350(2):105-113. (Randomized; 1219 patients)
  66. Aung K, Htay T. Vasopressin for cardiac arrest: a systematic review and meta-analysis. Arch Intern Med. 2005;165(1):17-24. (Meta-analysis; 1519 patients)
  67. Gueugniaud PY, David JS, Chanzy E, et al. Vasopressin and epinephrine vs. epinephrine alone in cardiopulmonary resuscitation. N Engl J Med. 2008;359(1):21-30. (Randomized; 2894 patients)
  68. Kudenchuk PJ, Cobb LA, Copass MK, et al. Amiodarone for resuscitation after out-of-hospital cardiac arrest due to ventricular fibrillation. N Engl J Med. 1999;341(12):871-878. (Randomized; 504 patients)
  69. Dorian P, Cass D, Schwartz B, et al. Amiodarone as compared with lidocaine for shock-resistant ventricular fibrillation. N Engl J Med. 2002;346(12):884-890. (Randomized; 347 patients)
  70. Kudenchuk PJ, Brown SP, Daya M, et al. Amiodarone, lidocaine, or placebo in out-of-hospital cardiac arrest. New Engl J Med. 2016;374:1711-1722. (Randomized; 3026 patients)
  71. Kudenchuk PJ, Newell C, White L, et al. Prophylactic lidocaine for post resuscitation care of patients with out-of-hospital ventricular fibrillation cardiac arrest. Resuscitation. 2013;84(11):1512-1518. (Retrospective observational; 1721 patients)
  72. Skrifvars MB, Pettila V, Rosenberg PH, et al. A multiple logistic regression analysis of in-hospital factors related to survival at six months in patients resuscitated from out-of-hospital ventricular fibrillation. Resuscitation. 2003;59(3):319- 328. (Retrospective observational; 98 patients)
  73. de Oliveira FC, Feitosa-Filho GS, Ritt LE. Use of beta-blockers for the treatment of cardiac arrest due to ventricular fibrillation/pulseless ventricular tachycardia: a systematic review. Resuscitation. 2012;83(6):674-683. (Systematic review)
  74. Driver BE, Debaty G, Plummer DW, et al. Use of esmolol after failure of standard cardiopulmonary resuscitation to treat patients with refractory ventricular fibrillation. Resuscitation. 2014;85(10):1337-1341. (Retrospective observational; 25 patients)
  75. Jentzer JC, Chonde MD, Dezfulian C. Myocardial dysfunction and shock after cardiac arrest. Biomed Res Int. 2015:314796. (Review)
  76. Kilgannon JH, Roberts BW, Reihl LR, et al. Early arterial hypotension is common in the post-cardiac arrest syndrome and associated with increased in-hospital mortality. Resuscitation. 2008;79(3):410-416. (Retrospective observational; 102 patients)
  77. Beylin ME, Perman SM, Abella BS, et al. Higher mean arterial pressure with or without vasoactive agents is associated with increased survival and better neurological outcomes in comatose survivors of cardiac arrest. Intensive Care Med. 2013;39(11):1981-1988. (Retrospective observational; 168 patients)
  78. Callaway CW, Donnino MW, Fink EL, et al. Part 8: post-car-diac arrest care: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2015;132(18 Suppl 2):S465- S482. (Guidelines)
  79. Gaieski DF, Band RA, Abella BS, et al. Early goal-directed hemodynamic optimization combined with therapeutic hypothermia in comatose survivors of out-of-hospital cardiac arrest. Resuscitation. 2009;80(4):418-424. (Case-control; 36 patients)
  80. Sunde K, Pytte M, Jacobsen D, et al. Implementation of a standardised treatment protocol for post resuscitation care after out-of-hospital cardiac arrest. Resuscitation. 2007;73(1):29-39. (Case-control; 119 patients)
  81. Walters EL, Morawski K, Dorotta I, et al. Implementation of a post-cardiac arrest care bundle including therapeutic hypothermia and hemodynamic optimization in comatose patients with return of spontaneous circulation after out-of-hospital cardiac arrest: a feasibility study. Shock. 2011;35(4):360-366. (Retrospective observational; 55 patients)
  82. Havel C, Arrich J, Losert H, et al. Vasopressors for hypotensive shock. Cochrane Database Syst Rev. 2011;11(5):CD003709. (Systematic review; 3212 patients)
  83. Bernard SA, Gray TW, Buist MD, et al. Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia. N Engl J Med. 2002;346(8):557-563. (Randomized; 77 patients)
  84. Dumas F, Grimaldi D, Zuber B, et al. Is hypothermia after cardiac arrest effective in both shockable and nonshockable patients? Insights from a large registry. Circulation. 2011;123(8):877-886. (Retrospective observational; 1145 patients)
  85. Testori C, Sterz F, Behringer W, et al. Mild therapeutic hypothermia is associated with favourable outcome in patients after cardiac arrest with non-shockable rhythms. Resuscitation. 2011;82(9):1162-1167. (Retrospective observational; 374 patients)
  86. * Vaahersalo J, Hiltunen P, Tiainen M, et al. Therapeutic hypothermia after out-of-hospital cardiac arrest in Finnish intensive care units: the FINNRESUSCI study. Intensive Care Med. 2013;39(5):826-837. (Prospective observational; 548 patients)
  87. Nichol G, Thomas E, Callaway CW, et al. Regional variation in out-of-hospital cardiac arrest incidence and outcome. JAMA. 2008;300(12):1423-1431. (Prospective observational; 20,520 patients)
  88. Little NE, Feldman EL. Therapeutic hypothermia after cardiac arrest without return of consciousness: skating on thin ice. JAMA Neurol. 2014;71(7):823-824. (Editorial)
  89. * Nielsen N, Wetterslev J, Cronberg T, et al. Targeted temperature management at 33 degrees C versus 36 degrees C after cardiac arrest. N Engl J Med. 2013;369(23):2197-2206. (Randomized; 939 patients)
  90. Levine RL, Wayne MA, Miller CC. End-tidal carbon dioxide and outcome of out-of-hospital cardiac arrest. N Engl J Med. 1997;337(5):301-306. (Prospective observational; 150 patients)
  91. Ahrens T, Schallom L, Bettorf K, et al. End-tidal carbon dioxide measurements as a prognostic indicator of outcome in cardiac arrest. Am J Crit Care. 2001;10(6):391-398. (Prospective observational; 127 patients)
  92. Ballew KA, Philbrick JT, Caven DE, et al. Predictors of survival following in-hospital cardiopulmonary resuscitation. A moving target. Arch Intern Med. 1994;154(21):2426-2432. (Retrospective observational; 313 patients)
  93. Shih CL, Lu TC, Jerng JS, et al. A web-based Utstein style registry system of in-hospital cardiopulmonary resuscitation in Taiwan. Resuscitation. 2007;72(3):394-403. (Prospective observational; 330 patients)
  94. Lavonas EJ, Drennan IR, Gabrielli A, et al. Part 10: special circumstances of resuscitation: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2015;132(18 Suppl 2):S501-S518. (Guidelines)
  95. Katz V, Balderston K, DeFreest M. Perimortem cesarean delivery: were our assumptions correct? Am J Obstet Gynecol. 2005;192(6):1916-1920. (Case series; 38 cases)
  96. Bottiger BW, Arntz HR, Chamberlain DA, et al. Thrombolysis during resuscitation for out-of-hospital cardiac arrest. N Engl J Med. 2008;359(25):2651-2662. (Randomized; 1050 patients)
  97. Abu-Laban RB, Christenson JM, Innes GD, et al. Tissue plasminogen activator in cardiac arrest with pulseless electrical activity. N Engl J Med. 2002;346(20):1522-1528. (Randomized; 233 patients)
  98. Han B, Compton WM, Jones CM, Cai R. Nonmedical prescription opioid use and use disorders among adults aged 18 through 64 years in the United States, 2003-2013. JAMA. 2015;314(14):1468-1478. (Survey study; 472,200 respondents)
  99. US Food and Drug Administration. FDA approves new hand-held autoinjector to reverse opioid overdose. Released April 3, 2014. Accessed November 2, 2015. (News bulletin)
  100. * Jamaty C, Bailey B, Larocque A, et al. Lipid emulsions in the treatment of acute poisoning: a systematic review of human and animal studies. Clin Toxicol (Phila). 2010;48(1):1-27. (Systematic review)
  101. Farstad M, Andersen KS, Koller ME, et al. Rewarming from accidental hypothermia by extracorporeal circulation. A retrospective study. Eur J Cardiothorac Surg. 2001;20(1):58-64. (Retrospective observational; 26 patients)
  102. Plaisier BR. Thoracic lavage in accidental hypothermia with cardiac arrest--report of a case and review of the literature. Resuscitation. 2005;66(1):99-104. (Review)
  103. * Dumas F, Cariou A, Manzo-Silberman S, et al. Immediate percutaneous coronary intervention is associated with better survival after out-of-hospital cardiac arrest: insights from the PROCAT (Parisian Region Out of hospital Cardiac ArresT) registry. Circ Cardiovasc Interv. 2010;3(3):200-207. (Retrospective observational 714 patients)
  104. Hollenbeck RD, McPherson JA, Mooney MR, et al. Early cardiac catheterization is associated with improved survival in comatose survivors of cardiac arrest without STEMI. Resuscitation. 2014;85(1):88-95. (Retrospective observational; 269 patients)
  105. Cronier P, Vignon P, Bouferrache K, et al. Impact of routine percutaneous coronary intervention after out-of-hospital cardiac arrest due to ventricular fibrillation. Crit Care. 2011;15(3):R122. (Prospective observational; 111 patients)
  106. Strote JA, Maynard C, Olsufka M, et al. Comparison of role of early (less than six hours) to later (more than six hours) or no cardiac catheterization after resuscitation from out-of-hospital cardiac arrest. Am J Cardiol. 2012;109(4):451-454. (Retrospective observational; 240 patients)
  107. Shin TG, Choi JH, Jo IJ, et al. Extracorporeal cardiopulmonary resuscitation in patients with inhospital cardiac arrest: a comparison with conventional cardiopulmonary resuscitation. Crit Care Med. 2011;39(1):1-7. (Retrospective observational; 406 patients)
  108. Chen YS, Lin JW, Yu HY, et al. Cardiopulmonary resus-citation with assisted extracorporeal life-support versus conventional cardiopulmonary resuscitation in adults with in-hospital cardiac arrest: an observational study and propensity analysis. Lancet. 2008;372(9638):554-561. (Prospective observational; 172 patients)
  109. Maekawa K, Tanno K, Hase M, et al. Extracorporeal cardiopulmonary resuscitation for patients with out-of-hospital cardiac arrest of cardiac origin: a propensity-matched study and predictor analysis. Crit Care Med. 2013;41(5):1186-1196. (Retrospective observational; 162 patients)
  110.  Lin JW, Wang MJ, Yu HY, et al. Comparing the survival between extracorporeal rescue and conventional resuscitation in adult in-hospital cardiac arrests: propensity analysis of three-year data. Resuscitation. 2010;81(7):796-803. (Retrospective observational; 122 patients)
  111. Sakamoto T, Morimura N, Nagao K, et al. Extracorporeal cardiopulmonary resuscitation versus conventional cardiopulmonary resuscitation in adults with out-of-hospital cardiac arrest: a prospective observational study. Resuscitation. 2014;85(6):762-768. (Prospective observational; 454 patients)
  112. Mentzelopoulos SD, Malachias S, Chamos C, et al. Vasopressin, steroids, and epinephrine and neurologically favorable survival after in-hospital cardiac arrest: a randomized clinical trial. JAMA. 2013;310(3):270-279. (Randomized; 268 patients)
  113. Mentzelopoulos SD, Zakynthinos SG, Tzoufi M, et al. Vasopressin, epinephrine, and corticosteroids for in-hospital cardiac arrest. Arch Intern Med. 2009;169(1):15-24. (Randomized; 100 patients)
Get A Sample Issue Of Emergency Medicine Practice
Enter your email to get your copy today! Plus receive updates on EB Medicine every month.
Please provide a valid email address.