ACLS Training Manual (Fiji 2022) PDF

ACLS Pre Course Reading Table of Contents: 1. Outline of the Course 2. Introduction to ACLS 3. Protocols for ACLS 4. Techniques in ACLS 5. Defibrillation in ACLS 6. Medications. 7. Dysrhythmias 8. Post ROSC Care in ACLS 9. ACS Guidelines. Fiji ACLS...

ACLS Pre Course Reading Table of Contents: 1. Outline of the Course 2. Introduction to ACLS 3. Protocols for ACLS 4. Techniques in ACLS 5. Defibrillation in ACLS 6. Medications. 7. Dysrhythmias 8. Post ROSC Care in ACLS 9. ACS Guidelines. Fiji ACLS ACLS DAY 1 TIME ACTIVITIES 8.00 - 8.30am Registration & Welcome. The mastery concept. 8.30 – 8.45am Pre-test 8.45 – 9.15am BLS & ACLS algorithm – Video and Recap 9.15 – 9.45am Rhythm Interpretation 9.45 – 10.45am Workshops: CPR Practice Defibrillation Drugs 10.45 – 11.15am BREAK 11.15 - 11.45am Communication, Documentation and Time keeping 11.45 - 12.30pm Prevention of cardiac arrest. Who arrests? What can be done? Act now act fast to prevent cardiac arrest. Stopping resuscitation and appropriate levels of care. 12.30 – 1pm Return of Spontaneous Circulation (ROSC) Care 1 – 2pm LUNCH 2 – 2.15pm Mega code Demonstration 2.15 – 3.15pm Mega code Practice 3.15 – 3.30pm BREAK 3.30 – 4.30pm Mega code Assessment (must demonstrate mastery to pass) & Post Test (85% pass mark) 5pm Close Fiji ACLS Fiji ACLS ACLS DAY 2 TIME ACTIVITIES 8.00 - 8.30am Registration & Welcome 8.30 – 8.45am Pre-test 8.45 – 9.15am Recap of Day 1 What is important: Bringing it back to the patient + 4 Simple Qs (too fast/slow, broad/narrow, regular/irregular, and p waves?) Acute presentation (well vs. unwell spectrum) Risk factors for badness (age & prior cardiac function) Cardio version vs. Defibrillation: Sedation, Synchronization & Joules 9.15 – 9.45am Tachyarrhythmia’s: Too fast: broad/ narrow, regular / irregular 9.45 – 10.15am Tachyarrhythmia Workshop ECGs & Causes Safe approach to broad complex tachycardia & sedation for cardio version 10.15 – 10.45am BREAK 10.45 – 11.15am Bradyarrythmias & Heart blocks: Too slow: broad/narrow, regular / irregular, p waves. 11.15 – 11.45am Bradycardia Workshop ECGs & Causes Discussion of pacing (if appropriate) 11.45 – 12.45pm Tachycardia & Bradycardia Mega code practice 1 – 2pm LUNCH 2 – 3pm Mega code Practice 3 – 3.15pm Post Test 3.15 – 4.15pm Mega code Assessment (must demonstrate mastery to pass) 4.30 – 5pm Feedback Certificates & Close Fiji ACLS ANZCOR Guideline 11.1 – Introduction to Advanced Life Support Summary Who does this guideline apply to? This guideline applies to adults who require advanced life support. Who is the audience for this guideline? This guideline is for health professionals and those who provide healthcare in environments where equipment and drugs are available. Recommendations The Australian and New Zealand Committee on Resuscitation (ANZCOR) make the following recommendations: 1. As soon as possible, Advanced Life Support treatments are used to supplement any adult receiving Basic Life Support. 2. Hospitals consider using early warning, rapid response team, or medical emergency team systems to reduce the incidence of in-hospital cardiac arrests and in-hospital mortality. 3. Hospitals use a system validated for their specific patient population to identify individuals at increased risk of serious clinical deterioration, cardiac arrest, or death, both on admission to hospital and during their stay. ANZCOR Guideline 11.1 January 2016 Page 1 of 5  Guideline 1 Definitions Cardiopulmonary resuscitation (CPR) is the technique of chest compressions combined with rescue breathing. The purpose of cardiopulmonary resuscitation is to temporarily maintain a circulation sufficient to preserve brain function until specialised treatment is available. CPR has 3 fundamental components: A Airway assessment and management. B Breathing assessment and management. C Circulation assessment and management. Basic Life Support (BLS) is the preservation or restoration of life by the establishment of and/or the maintenance of airway, breathing and circulation, and related emergency care. Adjunctive equipment is NOT essential for basic life support, however the use of Automated External Defibrillators (AEDs) by persons trained in their use but not trained in ALS techniques is encouraged by ANZCOR. Advanced Life Support (ALS) is basic life support with the addition of invasive techniques e.g. manual defibrillation, advanced airway management, intravenous access and drug therapy. Patients requiring BLS and ALS commonly have underlying problems including: ischaemic heart disease chronic respiratory disease drug overdose / toxicity drowning trauma electrolyte abnormalities peri-arrest arrhythmias. 2 Background BLS is only a temporary measure to maintain ventilation and circulation. Effective external cardiac compression provides a cardiac output of only 20-30% of the pre-arrest value1, and expired air resuscitation provides ventilation with an inspired oxygen concentration of only 15-18%2. Electrical defibrillation is the mainstay of treatment for ventricular fibrillation and pulseless VT. The chance of successful defibrillation decreases with time. Therefore performance of good CPR and decreasing the time to defibrillation are the first priorities in resuscitation from sudden cardiac arrest. The purpose of BLS is to help maintain myocardial and cerebral oxygenation until ALS personnel and equipment are available. Effective BLS may increase the likelihood of successful defibrillation3. Effective BLS buys time until reversible causes can be diagnosed and/or treated. Monitoring what we do is becoming even more important, including: ANZCOR Guideline 11.1 January 2016 Page 2 of 5  the effectiveness of compressions (depth, rate and hands off periods); the adequacy of ventilation (avoiding over-ventilation and consequent deleterious effects); the timing of defibrillation with regard to likelihood of success (eg compressions before and after). Emphasis is now also being focused on the pre-arrest period (early detection and prevention of cardiac arrest) and the post-resuscitation management. An extensive review of many aspects of advanced life support was performed as part of the 2010 and 2015 Consensus on Science process 5-12. The information from this process has been incorporated into the following guidelines wherever appropriate. 3 Prevention of Cardiac Arrest Children and young adults presenting with characteristic symptoms of arrhythmic syncope should have a specialist cardiology assessment, which should include an ECG and in most cases an echocardiogram and exercise test 11 [Class A, Expert consensus opinion]. Characteristics of arrhythmic syncope include: syncope in the supine position, occurring during or after exercise, with no or only brief prodromal symptoms, repetitive episodes, or in individuals with a family history of sudden cardiac death (SCD). In addition, non-pleuritic chest pain, palpitations associated with syncope, seizures (when resistant to treatment, or occurring at night) should raise suspicion of increased risk of arrhythmic syncope. Systematic evaluation in a clinic specializing in the care of those at risk for SCD is recommended in family members of young victims of SCD or those with a known cardiac disorder resulting in an increased risk of SCD 11 [Class B; Expert consensus opinion]. 4 In-Hospital Pre-Arrest Detection and Management In adult patients admitted to hospital, there is variable evidence regarding the use of early warning systems/rapid response team (RRT) systems or medical emergency team (MET) systems (compared with no such systems) to reduce cardiac and respiratory arrests and hospital mortality 11. ANZCOR suggests that hospitals consider the introduction of an EWS/response team/MET system to reduce the incidence of IHCA and in-hospital mortality (CoSTR 2015 weak recommendation, low-quality evidence) 12. It is reasonable, and increasingly made mandatory by health authorities, that hospitals provide a system of care that includes 11,13: staff education about the signs of patient deterioration,; appropriate and regular vital signs monitoring of patients; clear guidance (e.g. via calling criteria or early warning scores) to assist staff in the early detection of patient deterioration; a clear, uniform system of calling for assistance, and; a clinical response to calls for assistance. [Class A; Expert consensus opinion] ANZCOR Guideline 11.1 January 2016 Page 3 of 5 There is insufficient evidence to identify the best methods for the delivery of these components and, based on current evidence, this should be based on local circumstances.11, 13 [Class A; Expert consensus opinion] Hospitals should use a system validated for their specific patient population to identify individuals at increased risk of serious clinical deterioration, cardiac arrest, or death, both on admission and during hospital stay 11 [Class A; Expert consensus opinion]. There is insufficient evidence to identify specific educational strategies that improve outcomes (e.g. early recognition and rescue of deteriorating patient at risk of cardiac/respiratory arrest). Educational efforts have a positive impact on knowledge, skills, attitudes/confidence, and increase the frequency of activation of a response and should therefore be considered 11 [Class A; Expert consensus opinion]. References 1. Kern K. Open-Chest Cardiac Massage. In: Paradis N, Halperin H, Nowak R, eds. Cardiac Arrest. The Science and Practice of Resuscitation Medicine. Baltimore: Williams & Wilkins, 1996:439-51. 2. Idris A, Florete O, Melker R, Chandra N. Physiology of Ventilation, Oxygenation, and Carbon Dioxide Elimination During Cardiac Arrest. In: Paradis N, Halperin H, Nowak R, eds. Cardiac Arrest. The Science and Practice of Resuscitation Medicine. Baltimore: Williams & Wilkins, 1996:382-419. 3. Eftestol T, Wik L, Sunde K, Steen PA. Effects of Cardiopulmonary Resuscitation on Predictors of Ventricular Fibrillation Defibrillation Success During Out-of-Hospital Cardiac Arrest. Circulation 2004;110:10-15. 4. Becker L. The Epidemiology of Sudden Death. In: Paradis N, Halperin H, Nowak R, eds. Cardiac Arrest. The Science and Practice of Resuscitation Medicine. Baltimore: Williams & Wilkins, 1996:28-47. 5. Nolan JP, Hazinski MF, Billi JE, Boettiger BW, Bossaert L, de Caen AR, et al. Part 1: Executive summary: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Resuscitation. [doi: DOI: 10.1016/j.resuscitation.2010.08.002]. 2010;81(1, Supplement 1):e1-e25. 6. Koster RW, Sayre MR, Botha M, Cave DM, Cudnik MT, Handley AJ, et al. Part 5: Adult basic life support: 2010 International consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Resuscitation. [doi: DOI: 10.1016/j.resuscitation.2010.08.005]. 2010;81(1, Supplement 1):e48-e70. 7. Sunde K, Jacobs I, Deakin CD, Hazinski MF, Kerber RE, Koster RW, et al. Part 6: Defibrillation: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation. [doi: DOI: 10.1016/j.resuscitation.2010.08.025]. 2010;81(1, Supplement 1):e71-e85. ANZCOR Guideline 11.1 January 2016 Page 4 of 5 8. Lim SH, Shuster M, Deakin CD, Kleinman ME, Koster RW, Morrison LJ, et al. Part 7: CPR techniques and devices: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation. [doi: DOI: 10.1016/j.resuscitation.2010.08.026]. 2010;81(1, Supplement 1):e86-e92. 9. Deakin CD, Morrison LJ, Morley PT, Callaway CW, Kerber RE, Kronick SL, et al. Part 8: Advanced life support: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation. [doi: DOI: 10.1016/j.resuscitation.2010.08.027]. 2010;81(1, Supplement 1):e93-e174. 10. Bossaert L, O'Connor RE, Arntz H-R, Brooks SC, Diercks D, Feitosa-Filho G, et al. Part 9: Acute coronary syndromes: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation. [doi: DOI: 10.1016/j.resuscitation.2010.09.001]. 2010;81(1, Supplement 1):e175-e212. 11. Soar J, Mancini ME, Bhanji F, Billi JE, Dennett J, Finn J, et al. Part 12: Education, implementation, and teams: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation. [doi: DOI: 10.1016/j.resuscitation.2010.08.030]. 2010;81(1, Supplement 1):e288-e330. 12. Soar J, Callaway C, Aibiki M, Böttiger BW, Brooks SC, Deakin CD, Donnino MW, Drajer S, Kloeck W, Morley PT, Morrison LJ, Neumar RW, Nicholson TC, Nolan JP, Okada K, O’Neil BJ, Paiva EF, Parr MJ, Wang TL, Witt J, on behalf of the Advanced Life Support Chapter Collaborators. Part 4: Advanced life support. 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation 2015;95:e71–e120. 13. Australian Commission on Safety and Quality in Healthcare. National Consensus Statement: Essential Elements for Recognising and Responding to Clinical Deterioration. http://www.safetyandquality.gov.au/wp- content/uploads/2012/01/national_consensus_statement.pdf (accessed Nov 16, 2015). ANZCOR Guideline 11.1 January 2016 Page 5 of 5 ANZCOR Guideline 11.2 – Protocols for Adult Advanced Life Support Summary Who does this guideline apply to? This guideline applies to adults who require advanced life support (ALS). Who is the audience for this guideline? This guideline is for health professionals and those who provide healthcare in environments where equipment and drugs are available. Recommendations The Australian and New Zealand Committee on Resuscitation (ANZCOR) make the following recommendations: 1. That the Adult ALS algorithm be used as a tool to manage all adults who require advanced life support. 2. Good quality CPR and reducing time to defibrillation are the highest priorities in resuscitation from sudden cardiac arrest. 3. Rescuers should aim to minimise interruptions to CPR during any ALS intervention. ANZCOR Guideline 11.2 January 2016 Page 1 of 7  Guideline 1 Advanced Life Support Algorithm The flow diagram illustrates the sequence of actions to be undertaken once equipment and drugs are available. Several tasks in the diagram may be undertaken at the same time. The algorithm is based on the following considerations: 1. The importance of good CPR and early defibrillation in achieving successful outcomes. Ventricular Fibrillation (VF) is in many situations the primary rhythm in sudden cardiac arrest. The vast majority of survivors come from this group. The chance of successful defibrillation decreases with time. Therefore the performance of good CPR and decreasing the time to defibrillation are the highest priorities in resuscitation from sudden cardiac arrest. The amplitude and waveform of VF deteriorate as high energy phosphate stores in the myocardium decrease. This rate of decrease can be slowed, or even reversed by effective BLS.1 2. Automated External Defibrillators (AEDs) can accurately diagnose cardiac rhythms and separate them into two groups: a. “Shockable” = those responsive to defibrillation b. “Non-shockable” = those unresponsive to defibrillation 3. There are interventions that are indicated in all causes of cardiac arrest. 4. There is a group of potentially reversible conditions that, if unrecognised or left untreated during cardiac arrest, may prevent successful resuscitation. 2 Notes on the Algorithm 2.1 Good quality CPR The provision of good quality CPR is the cornerstone of advanced life support. As outlined in Guideline 11.1.1 this includes delivery of chest compressions over the lower half of the sternum at a depth of at least 5 cm, and at a rate of approximately 100-120 per minute, while minimising interruptions to compressions at all times. 2.2 Assess rhythm As soon as the defibrillator is available, the pads should be placed on the patient’s chest, it should be charged and, the rhythm analyzed. If a rhythm compatible with spontaneous circulation is observed, the defibrillator should be disarmed and the pulse checked [Class A; Expert Consensus Opinion]. ANZCOR Guideline 11.2 January 2016 Page 2 of 7 2.3 Shockable Rhythm Ventricular fibrillation is asynchronous chaotic ventricular activity that produces no cardiac output. Pulseless ventricular tachycardia is a wide complex regular tachycardia associated with no clinically detectable cardiac output. A defibrillator shock should be administered according to the algorithm. Administer a single shock and immediately resume CPR for 2 minutes after delivery of shock. Do not delay recommencing CPR to assess the rhythm. [Class A; LOE II to IV]2 2.4 Energy levels Monophasic: the energy level for adults should be set at maximum (usually 360 Joules) for all shocks. [Class A; LOE II]2 Biphasic waveforms: the default initial energy level for adults should be set at 200J. Other energy levels may be used providing there is relevant clinical data for a specific defibrillator that suggests that an alternative energy level provides adequate shock success (eg. usually greater than 90%) [Class A; LOE II]2. ANZCOR suggests that if the first shock is not successful and the defibrillator is capable of delivering shocks of higher energy, it is reasonable to increase the energy to the maximum available for subsequent shocks (CoSTR 2015 weak recommendation, very low quality evidence).3 2.5 Immediate CPR Interruptions to CPR decrease the chance of survival from cardiac arrest. While defibrillation is of paramount importance for VF/VT, a period of well performed CPR immediately after each shock can help maintain myocardial and cerebral viability, and improves the likelihood of subsequent shock success.1 During CPR advanced life support interventions are applied and potential causes of arrest sought. After each defibrillation continue a further 2 minutes of CPR, unless responsiveness or normal breathing become apparent. If using a defibrillator in manual mode, the defibrillator should be charged during CPR as the end of the 2 minute loop of CPR approaches, to minimise interruptions to CPR and increase the likelihood of shock success.4 Rhythm is then reassessed and treatment is directed as necessary. If rhythm assessment results in a significant interruption to CPR then a further 2-minute period of CPR is recommended before further shocks are delivered. This is done to obtain the benefits of CPR on VF waveform and increase the likelihood of shock success. Consideration should be given to administration of a vasopressor in the period of CPR after the second failed defibrillation attempt. Consideration should be given to administration of an antiarrhythmic after the third failed defibrillation attempt. The sequence of escalating advanced life support would then be: 1. attempt defibrillation ensure good CPR 2. attempt defibrillation add vasopressor (adrenaline 1 mg) 3. attempt defibrillation, add anti-arrhythmic (amiodarone 300 mg). [Class A; LOE II to IV]2 ANZCOR Guideline 11.2 January 2016 Page 3 of 7 2.6 Non-shockable rhythm (Non VF/VT) Asystole is characterised by the absence of any cardiac electrical activity. Pulseless Electrical Activity (PEA) (sometimes referred to Electromechanical Dissociation [EMD]) is the presence of a coordinated electrical rhythm without a detectable cardiac output. The prognosis in this group of cardiac rhythms or asystole is much less favourable than with VF/VT. During CPR advanced life support interventions are applied and potential causes of arrest sought. Defibrillation is not indicated and the emphasis is on CPR and other ALS interventions (e.g.. intravenous access, consideration of advanced airway, drugs and pacing). [Class A; Expert consensus opinion]. 2.7 During CPR The following interventions apply to all rhythms and are carried out continuously or during each loop of the algorithm. Each loop comprises 5 sets of 30 compressions (at approximately 100-120 per minute) : 2 breaths, which equates to approximately 2 minutes. Other management priorities during CPR: Minimise interruptions to CPR during ALS interventions [Class A; LOE III-2]. Administer 100% oxygen when available (CoSTR 2015 weak recommendation, very low quality evidence).3 Obtain intravenous or intra-osseous access [Class A; LOE II]. Consider airway adjuncts, but attempts to secure the airway should not interrupt CPR for more than 5 seconds [Class A; Expert consensus opinion]. Waveform capnography should be used to confirm airway placement and monitor the adequacy of CPR (CoSTR 2015 strong recommendation, low quality evidence).3 Adrenaline should be administered every second loop (approximately every 4 minutes) [Class A; Expert consensus opinion]. Other drugs/electrolytes should be considered depending on the individual circumstances [Class A; Expert consensus opinion]. 2.8 Medications during CPR Vasopressors There are no placebo-controlled studies that show that the routine use of any vasopressor at any stage during human cardiac arrest increases survival to hospital discharge, though they have been demonstrated to increase Return of Spontaneous Circulation. Current evidence is insufficient to support or refute the routine use of any particular drug or sequence of drugs. Despite the lack of human data it is reasonable to continue to use vasopressors on a routine basis.5 Adrenaline (1 mg), when indicated, should be administered after rhythm analysis (± shock), at the time of recommencement of CPR [Class A; Expert consensus opinion]. Antiarrhythmics There is no evidence that giving any antiarrhythmic drug routinely during human cardiac arrest increases rate of survival to hospital discharge. In comparison with placebo and lignocaine the use of amiodarone in shock-refractory VF improves the short-term outcome of survival to hospital admission. Despite the lack of human long-term outcome data it is reasonable to continue to use antiarrhythmic drugs on a routine basis.5 ANZCOR Guideline 11.2 January 2016 Page 4 of 7 Amiodarone (300 mg) should be administered after the third failed attempt at defibrillation, at the time of recommencement of CPR [Class A; LOE II]. Other drugs There is no evidence that routinely giving other drugs (e.g. buffers, aminophylline, atropine, calcium, magnesium) during human cardiac arrest increases survival to hospital discharge.5 2.9 Correct Reversible Causes Very few data address the aetiology of cardiac arrest directly. One prospective study and one retrospective study suggested that rescuers can identify some non-cardiac causes of some arrests.6,7 The physical circumstances, history, precipitating events, clinical examination, or the use of adjunct techniques (such as ultrasound) may enable the rescuer to determine a cardiac or non-cardiac cause of the cardiorespiratory arrest. The rescuer should undertake interventions based on the presumed aetiology (cardiac or non-cardiac). 4 Hs and 4 Ts are a simple reminder of conditions that may precipitate cardiac arrest or decrease the chances of successful resuscitation. These conditions should be sought and, if present, corrected in every case [Class A; Expert consensus opinion]. Hypoxaemia Hypovolaemia Hyper/hypokalaemia & metabolic disorders Hypo/hyperthermia Tension pneumothorax Tamponade Toxins / poisons / drugs Thrombosis-pulmonary / coronary Fluid administration There is insufficient evidence to recommend for or against the routine infusion of intravenous fluids during cardiac arrest resuscitation.5 Fluids should be infused if hypovolemia is suspected (hypovolaemic shock would normally require the administration of at least 20 mL/kg) [Class A; Expert consensus opinion]. Thrombolytics Routine administration of fibrinolytics for the treatment of in-hospital and out-of hospital cardiac arrest is not recommended.5 Fibrinolysis should be considered in adult patients with cardiac arrest with proven or suspected pulmonary embolism [Class A; Expert consensus opinion]. 2.10 Post Resuscitation Care After the return of spontaneous circulation (ROSC), post-resuscitation care commences (see Guideline 11.7 and 11.8). ANZCOR Guideline 11.2 January 2016 Page 5 of 7 Re-evaluate the patient using the standard ABCDE approach: Airway Breathing Circulation Disability and Exposure. Other considerations include obtaining a 12 lead ECG and a chest radiograph. The adequacy of perfusion should be assessed, and the need for reperfusion therapy should be considered (eg. thrombolytics or percutaneous coronary intervention). The adequacy of oxygenation and ventilation should be confirmed and maintained (and advanced airway may be required). Targeted Temperature Management may be instituted if indicated, and further investigation for reversible causes should be continued, and treatment instituted where necessary. See also guideline 11.7 and 11.8 [Class A; Expert consensus opinion]. References 1. Eftestol T, Wik L, Sunde K, Steen PA. Effects of Cardiopulmonary Resuscitation on Predictors of Ventricular Fibrillation Defibrillation Success During Out-of-Hospital Cardiac Arrest. Circulation. 2004 June 21;110:10-5. 2. Sunde K, Jacobs I, Deakin CD, Hazinski MF, Kerber RE, Koster RW, et al. Part 6: Defibrillation: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation. [doi: DOI: 10.1016/j.resuscitation.2010.08.025]. 2010;81(1, Supplement 1):e71-e85. 3. Soar J, Callaway C, Aibiki M, Böttiger BW, Brooks SC, Deakin CD, Donnino MW, Drajer S, Kloeck W, Morley PT, Morrison LJ, Neumar RW, Nicholson TC, Nolan JP, Okada K, O’Neil BJ, Paiva EF, Parr MJ, Wang TL, Witt J, on behalf of the Advanced Life Support Chapter Collaborators. Part 4: Advanced life support. 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation 2015;95:e71–e120 4. Edelson DP, Robertson-Dick BJ, Yuen TC, Eilevstjonn J, Walsh D, Bareis CJ, et al. Safety and efficacy of defibrillator charging during ongoing chest compressions: a multi- center study. Resuscitation. 2010 Nov;81(11):1521-6.s 5. Deakin CD, Morrison LJ, Morley PT, Callaway CW, Kerber RE, Kronick SL, et al. Part 8: Advanced life support: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation. [doi: DOI: 10.1016/j.resuscitation.2010.08.027]. 2010;81(1, Supplement 1):e93-e174. 6. Pell JP, Sirel JM, Marsden AK, Ford I, Walker NL, Cobbe SM. Presentation, management, and outcome of out of hospital cardiopulmonary arrest: comparison by underlying aetiology. Heart (British Cardiac Society) 2003;89(8):839-42 7. Kuisma M, Alaspaa A. Out-of-hospital cardiac arrests of non-cardiac origin: epidemiology and outcome. Eur Heart J 1997;18(7):1122-1128. ANZCOR Guideline 11.2 January 2016 Page 6 of 7 ANZCOR Guideline 11.2 January 2016 Page 7 of 7 ANZCOR Guideline 11.6 – Equipment and Techniques in Adult Advanced Life Support Summary Who does this guideline apply to? This guideline applies to adults who require advanced life support (ALS). Who is the audience for this guideline? This guideline is for health professionals and those who provide healthcare in environments where equipment and drugs are available. Recommendations The Australian and New Zealand Committee on Resuscitation (ANZCOR) make the following recommendations: 1. The highest possible inspired oxygen concentration is used on all patients during cardiopulmonary resuscitation (CPR). Oxygen should never be withheld because of the fear of adverse effects. 2. Either an advanced airway or a bag-mask device may be used for airway management during CPR for cardiac arrest in any setting. 3. Waveform capnography should be used to confirm and continuously monitor the position of a tracheal tube during CPR in addition to clinical assessment. 4. Either a supraglottic airway or tracheal tube may be used as the initial advanced airway during CPR for cardiac arrest in any setting. 5. When ventilating a victim without an advanced airway, ventilation should be continued at a ratio of 30 compressions to 2 ventilations. 6. CPR prompt / feedback devices may be considered for clinical use to provide data as part of an overall strategy to improve quality of CPR at a systems level. 7. ETCO2 cut-off values alone should not be used as a mortality predictor or for the decision to stop a resuscitation attempt. 8. If cardiac ultrasound is available and can be performed without interfering with standard ACLS, it may be considered to try and identify potentially reversible causes of cardiac arrest. 9. An ITD should not be routinely used in addition to standard CPR. ANZCOR Guideline 11.6 January 2016 Page 1 of 16  10. Automated mechanical chest compression devices should not be routinely used to replace manual chest compressions. However, they may be a reasonable alternative to high-quality manual chest compressions in situations where sustained high-quality manual chest compressions are impractical or compromise provider safety. 11. eCPR is a reasonable rescue therapy for selected patients with cardiac arrest when initial standard CPR is failing in settings where this can be implemented. ANZCOR Guideline 11.6 January 2016 Page 2 of 16  Guideline A wide range of equipment is available for use in ALS. The role of such equipment should be subject to constant evaluation. The use of any item of equipment requires that the operator is appropriately trained and maintains competency in its use. Frequent retraining (theory and practice) is required to maintain both Basic Life Support (BLS) and ALS skills. The optimal interval for retraining has not been established. Airway adjuncts can be used to facilitate ventilation, to better maintain the airway, or to provide access to the airway (e.g. for suctioning) [Class B; Expert consensus opinion]. 1 Oxygen during CPR There are no adult human studies that directly compare maximal inspired oxygen with any other inspired oxygen concentration. In one observational study of patients receiving 100% oxygen and tracheal intubation during CPR, a higher measured PaO2 during CPR was associated with improved return of spontaneous circulation (ROSC) and hospital admission.1 ANZCOR suggests that the highest possible inspired oxygen concentration is used on all patients during CPR (CoSTR 2015 weak recommendation, very low quality evidence)2. Oxygen should never be withheld because of the fear of adverse effects. There is insufficient evidence to support or refute the use of passive oxygen delivery during compression only CPR to improve outcomes (ROSC, hospital discharge rate and improve neurological survival) when compared with oxygen delivery by positive pressure ventilation. 2 Airway 2.1 Airway manoeuvres The BLS techniques of chin lift and head tilt are covered in Guideline 4. Jaw thrust In this technique, the rescuer is commonly positioned at the top of the victim’s head, although a jaw thrust may be applied from the side or in front. The jaw is clasped with both hands and the mouth is held open by the thumbs. Pressure is applied with the index (or middle) fingers behind the angles of the jaw. The jaw is gently thrust upwards and away from the chest, moving the tongue away from the back of the throat. Gentle head tilt may also be necessary to maintain airway patency with this technique. A jaw thrust may be required in the recovery position if the victim’s airway is not patent [Class A; Expert consensus opinion]. ANZCOR Guideline 11.6 January 2016 Page 3 of 16 2.2 Basic airway adjuncts Oro- and nasopharyngeal airways have long been used in cardiac arrest, despite never being studied in this clinical context. It is reasonable to continue to use oral and naso-pharyngeal airways when performing bag-mask ventilation in cardiac arrest, but in the presence of a known or suspected basal skull fracture an oral airway is preferred. It is still necessary to use head tilt and jaw support, or jaw thrust [Class B; Expert consensus opinion]. Oropharyngeal airway Oral airways should be appropriately sized and not be forcibly inserted. They should be reserved for unconscious, obtunded victims. Laryngospasm or vomiting with aspiration may result in those patients who still have a gag reflex [Class B; Expert consensus opinion]. Nasopharyngeal airway Despite frequent successful use of nasopharyngeal airways by anaesthetists, there are no published data on the use of these airway adjuncts during CPR. One study in anesthetised patients showed that nurses inserting nasopharyngeal airways were no more likely than anaesthetists to cause nasopharyngeal trauma. One study showed that the traditional methods of sizing a nasopharyngeal airway (measurement against the patient’s little finger or anterior nares) do not correlate with the airway anatomy and are unreliable. In one report insertion of a nasopharyngeal airway caused some airway bleeding in 30% of cases. Two case reports involve inadvertent intracranial placement of a nasopharyngeal airway in patients with basal skull fractures. In the presence of a known or suspected basal skull fracture, an oral airway is preferred, but if this is not possible and the airway is obstructed, gentle insertion of a nasopharyngeal airway may be lifesaving (ie. the benefits may far outweigh the risks) 3 [Class B; Expert consensus opinion]. 2.3 Advanced airway devices The endotracheal tube has generally been considered the optimal method of managing the airway during cardiac arrest. There is evidence that without adequate training and experience, the incidence of complications, such as unrecognized oesophageal intubation, is unacceptably high. Alternatives to the tracheal tube that have been studied during CPR include the bag-valve mask device and advanced airway devices such as the laryngeal mask airway (LMA), i-gel, laryngeal tube, and oesophageal-tracheal combitube (Combitube). There is insufficient data to support the routine use of any specific approach to airway management during cardiac arrest. ANZCOR suggests using either an advanced airway or a bag-mask device for airway management during CPR for cardiac arrest in any setting (CoSTR 2015, weak recommendation, very-low-quality evidence).2 The choice of airway used should depend on the skills and training of the healthcare provider. Tracheal intubation may result in increased hands-off time in comparison with insertion of a supraglottic airway (e.g. LMA, laryngeal tube) or a bag-mask device. Both a bag-mask device and an advanced airway are frequently used in the same patient as part of a stepwise approach to airway management, but this has not been formally assessed.2 ANZCOR Guideline 11.6 January 2016 Page 4 of 16 There is inadequate evidence to define the optimal timing of advanced airway placement during cardiac arrest. The airway devices/adjuncts used during a cardiac arrest must be chosen according to local training and availability [Class A; Expert consensus opinion]. To avoid substantial interruptions in chest compressions providers may defer attempts to insert devices/adjuncts until return of spontaneous circulation (ROSC) [Class B; Expert consensus opinion]. 2.4 Endotracheal intubation The only published randomised controlled trial that compared tracheal intubation with BVM ventilation was performed in children who required airway management out-of-hospital. In this study there was no difference in survival-to-discharge rates but it is unclear how applicable this paediatric study is to adult resuscitation.4 The study had some important limitations, including the provision of only 6 hours of additional training for intubation, limited opportunity to perform intubations, and short transport times. Two studies compared outcomes from out-of-hospital cardiac arrest in adults treated by either emergency medical technicians or paramedics. The skills provided by the paramedics, including intubation and intravenous (IV) cannulation and drug administration, made no difference in survival to hospital discharge. The reported incidence of unrecognised oesophageal intubation in cardiac arrest ranges from 0-14% with a mean of 4.3%.2 An additional problem common to any advanced airway is that intubation attempts generally require interruptions in chest compressions. Rescuers must weigh the risks and benefits of intubation versus the need to provide effective chest compressions. The intubation attempt will require interruption of chest compressions, but once an advanced airway is in place ventilation will not require interruption or even pausing of chest compressions. To avoid substantial interruptions in chest compressions providers may defer an intubation attempt until return of spontaneous circulation (ROSC) [Class B; Expert consensus opinion]. To ensure competence, healthcare systems that utilise advanced airways should address factors such as adequacy of training and experience, and quality assurance. Providers must confirm tube placement and ensure that the tube is adequately secured [Class A; Expert consensus opinion]. In addition to providing optimal isolation and patency of the airway, intubation allows ventilation with 100% oxygen and suctioning of the airway and also provides possible access for the delivery of some drugs. However, if endotracheal intubation is attempted, ongoing CPR must be maintained, laryngoscopy should be performed during chest compressions and attempts at intubation should not interrupt cardiac compressions for more than 5 seconds [Class A; Expert consensus opinion]. Once an endotracheal tube has been passed: Inflate cuff with enough air to prevent a leak Confirm placement by assessing chest inflation, auscultation, by direct observation, and waveform capnography. Then, firmly secure the tube. ANZCOR Guideline 11.6 January 2016 Page 5 of 16 Confirmation of placement of endotracheal tube Unrecognised oesophageal intubation is the most serious complication of attempted tracheal intubation. Routine confirmation of correct placement of the tracheal tube should reduce this risk. Two studies of waveform capnography to verify tracheal tube position in victims of cardiac arrest after intubation demonstrated 100% sensitivity and 100% specificity in identifying correct tracheal tube placement. One of these studies included 246 intubations in cardiac arrest with 9 oesophageal intubations and the other included 51 cardiac arrests with an overall oesophageal intubation rate of 23% but it is not specified how many of these occurred in the cardiac arrest group. Three studies with a cumulative total of 194 tracheal and 22 oesophageal tube placements demonstrated an overall 64% sensitivity and 100% specificity in identifying correct tracheal tube placement when using the same model capnometer (no waveform capnography) on prehospital cardiac arrest victims. The sensitivity may have been adversely affected by the prolonged resuscitation times and very prolonged transport times of many of the cardiac arrest victims studied. Intubation was performed after arrival at hospital and time to intubation averaged more than 30 minutes. Studies of colorimetric ETCO2 detectors, the syringe aspiration oesophageal detector device the self-inflating bulb oesophageal detector device and non-waveform End Tidal CO2 capnometers show that the accuracy of these devices is similar to the accuracy of clinical assessment for confirming the tracheal position of a tracheal tube in victims of cardiac arrest. ANZCOR recommends using waveform capnography to confirm and continuously monitor the position of a tracheal tube during CPR in addition to clinical assessment (CoSTR 2015, strong recommendation, low-quality evidence).2 See also Guideline 11.1.1 It is also recommended that if waveform capnography is not available, a non-waveform carbon dioxide detector, esophageal detector device or ultrasound, in addition to clinical assessment, are alternatives (CoSTR 2015, strong recommendation, low quality evidence). 2 Values and Preferences These are strong recommendations despite the low quality evidence, as a high value is placed on avoiding unrecognised oesophageal intubation. In 11 studies assessed, the mean incidence of unrecognised oesophageal intubation in cardiac arrest was 4.3% (range 0–14%).2 Additionally, waveform capnography is recommended as it may have other potential uses during CPR (e.g. monitoring ventilation rate, assessing quality of CPR, and alerting the presence of ROSC). Alternatives to endotracheal intubation Supraglottic airway (SGA) devices (e.g. LMA, Laryngeal tube, i-gel, Combitube) are generally considered easier to insert than tracheal tubes. They can be inserted without interrupting chest compressions, and their use in cardiac arrest has been increasing. Ten studies have compared a variety of SGA devices with the tracheal tube during out of hospital cardiac arrest.2 ANZCOR Guideline 11.6 January 2016 Page 6 of 16 No studies comparing alternative advanced airway devices and tracheal intubation have been of a high quality and adequately powered to study long term survival. Studies comparing supraglottic airway to tracheal intubation have generally compared insertion time and ventilation success rates. There is insufficient data to support the routine use of any specific approach to airway management during cardiac arrest.2 ANZCOR suggests using either a supraglottic airway or tracheal tube as the initial advanced airway during CPR for cardiac arrest in any setting. Supraglottic airways are also a backup or rescue airway in a difficult or failed tracheal intubation (CoSTR 2015, weak recommendation, very-low-quality evidence).2 Values and Preferences In the absence of sufficient data obtained from studies of IHCA, it is necessary to extrapolate from data derived from OHCA. The type of airway used should depend on the skills and training of the healthcare provider. Tracheal intubation requires considerably more training and practice. Attempted tracheal intubation may result in unrecognised oesophageal intubation and increased hands-off time in comparison with insertion of an SGA. Both an SGA and tracheal tube are frequently used in the same patients as part of a stepwise approach to airway management.2 3 Ventilation 3.1 Bag-Valve-Mask Device Where difficulty with bag-mask-valve resuscitation is experienced, two trained operators may be required i.e. the first to manage the airway and the second to operate the bag [Class B; Expert consensus opinion]. 3.2 Oxygen-Powered Resuscitators These devices have a limited place but can provide high oxygen concentrations in experienced hands [Class B; Expert consensus opinion]. Devices that do not comply with current Australasian Standards should not be used. 3.3 Mechanical Ventilators One pseudo-randomised study suggests that use of an automatic transport ventilator with intubated patients may enable the EMS team to perform more tasks while subjectively providing similar ventilation to that of a bag-valve device.5 One study suggests that use of an automatic transport ventilator with intubated patients provides similar oxygenation and ventilation as use of a bag-valve device with no difference in survival.6 ANZCOR considers that there is insufficient evidence to support or refute the use of an automatic transport ventilator over manual ventilation during resuscitation of the cardiac arrest victim with an advanced airway. ANZCOR Guideline 11.6 January 2016 Page 7 of 16 Both manual ventilation and mechanical ventilation have advantages and disadvantages in the initial management of cardiac arrests. These relate largely to the risks of hyperventilation (with manual ventilation), and hypoventilation (with mechanical breaths not being delivered). Irrespective of the mode of delivery of breaths, the adequacy of delivery of those delivered breaths should be regularly assessed [Class B; Expert consensus opinion]. 3.4 Hyperventilation may be harmful Reports containing both a small case series and an animal study showed that hyperventilation is associated with increased intrathoracic pressure, decreased coronary and cerebral perfusion, and, in animals, decreased return of spontaneous circulation (ROSC). In a secondary analysis of the case series that included patients with advanced airways in place after out-of-hospital cardiac arrest, ventilation rates of >10 per minute and inspiration times >1 second were associated with no survival. Extrapolation from an animal model of severe shock suggests that a ventilation rate of 6 ventilations per minute is associated with adequate oxygenation and better haemodynamics than ≥12 ventilations per minute 8 [Class B; LOE IV]. 3.5 Inadvertent gas trapping Eighteen articles involving 31 cases reported unexpected return of circulation (and in some cases prolonged neurologically intact survival) after cessation of resuscitation attempts. One case series suggested that this occurred in patients with obstructive airway disease. Four studies reported unexpected return of circulation in 6 cases in which resuscitation had ceased and ventilation was shown on repeated occasions (or was highly likely) to result in gas trapping and consequent hemodynamic compromise. The authors of all these studies suggested that a period of disconnection from ventilation during resuscitation from PEA may be useful to exclude gas trapping 7 [Class B; LOE IV]. Recommendation for frequency of ventilation When ventilating a victim without an advanced airway, ventilation should be continued at a ratio of 30 compressions to 2 ventilations, irrespective of the number of rescuers, until an advanced airway is in place. After an advanced airway (e.g. tracheal tube, LMA, Combitube,) is placed, ventilate the patient’s lungs with supplementary oxygen to make the chest rise. During CPR for a patient with an advanced airway in place it is reasonable to ventilate the lungs at a rate of 6 to 10 ventilations per minute without pausing during chest compressions to deliver ventilations. (CoSTR 2015, weak recommendation , very low quality evidence). 2 Simultaneous ventilation and compression may adversely effect coronary perfusion9 and has been associated with decreased survival.10 One starting point to provide consistent ventilation and an adequate minute volume while minimising interruptions to CPR, and minimising the likelihood of excessive ventilation, is to provide one breath after each 15 compressions (delivering the breath during the relaxation phase of compression, without a significant pause)11 [Class B; Expert Consensus Opinion]. See also Guideline 11.1.1 The adequacy of ventilation with supraglottic airway devices during uninterrupted chest compressions is however unknown. Theoretically, a compression to ventilation ratio of 30:2 may be continued in patients with an advanced airway (ETT, LMA and other supraglottic airways). ANZCOR Guideline 11.6 January 2016 Page 8 of 16 This has advantages for simplicity of teaching, allows intermittent assessment of adequacy of ventilation, and also overcomes the problems associated with inefficient ventilation if breaths are delivered at the same time as the peak of the compressions [Class B; Expert consensus opinion]. Use the same initial tidal volume and rate in patients regardless of the cause of the cardiac arrest. Carbon dioxide estimation via arterial blood gas analysis and capnography may assist with monitoring ventilation and assessing quality of CPR, though these are more reliable once ROSC has been achieved [Class B; Expert consensus opinion]. 3.6 Monitoring of ventilation There is insufficient evidence to support or refute the use of peak pressure and minute ventilation monitoring to improve outcome from cardiac arrest. There is indirect evidence that monitoring the respiratory rate with real time feedback is effective in avoiding hyperventilation and achieving ventilation rates closer to recommended values, but there is no evidence that ROSC or survival is improved.3 4 Circulation Healthcare providers should perform chest compressions for adults at a rate of approximately 100-120 compressions per minute (CoSTR 2015, strong recommendation, very low-quality evidence)2 and to compress the lower half of the sternum by approximately 5 cm (approximately 1/3 of the antero-posterior diameter of the chest) (CoSTR 2015, strong recommendation, low-quality evidence).2 Rescuers should allow complete recoil of the chest after each compression. When feasible, rescuers should frequently alternate “compressor” duties (i.e. every 2 minutes), regardless of whether they feel fatigued, to ensure that fatigue does not interfere with delivery of adequate chest compressions. It is reasonable to use a duty cycle (i.e. ratio between compression and release) of 50% [Class A; Expert consensus opinion]. CPR with the patient in a prone position is a reasonable alternative for intubated hospitalised patients who cannot be placed in the supine position [Class B; LOE Expert consensus opinion]. Rescuers should minimise interruptions of chest compressions. It is reasonable for instructors, trainees and providers to monitor and improve the process of CPR to ensure adherence to recommended compression and ventilation rates and depths [Class B; LOE III- 2]. See also Guideline 11.1.1. 4.1 CPR prompt or feedback devices 2,12,13 Evidence from 22 manikin studies consistently demonstrated that CPR prompt/feedback devices used during CPR improved the quality of CPR performance on manikins. Three additional manikin studies examined the utility of video/animations on mobile phone devices: two studies showed improved checklist scores and quality of CPR and faster initiation of CPR while the third study showed that participants using multi-media phone CPR instruction took longer to complete tasks than dispatcher-assisted CPR. Two manikin studies that used two-way video communication to enable the dispatcher to review and comment on CPR in real time produced equivocal findings. ANZCOR Guideline 11.6 January 2016 Page 9 of 16 There is no high level evidence that the use of CPR feedback devices during real time CPR improves survival or return of spontaneous circulation (2015 CoSTR, weak recommendation, very low quality evidence).2 One study each in children and adults showed that metronomes improved chest compression rate and increased end-tidal carbon dioxide. Five studies evaluating the introduction of CPR prompt/feedback devices in clinical practice (pre/post comparisons) found improved CPR performance. There may be some limitations to the use of CPR prompt/feedback devices. Two manikin studies report that chest compression devices may overestimate compression depth if CPR is being performed on a compressible surface such as a mattress on a bed.14 One study reported harm to a single participant when a hand got stuck in moving parts of the CPR feedback device. A further manikin study demonstrated that additional mechanical work is required from the CPR provider to compress the spring in one of the pressure sensing feedback devices. One case report documented soft tissue injury to a patient’s chest when an accelerometer device was used for prolonged CPR. Instructors and rescuers should be made aware that a compressible support surface (e.g. mattress) may cause a feedback device to overestimate depth of compression.14 Recommendations CPR prompt / feedback devices may be considered for clinical use to provide data as part of an overall strategy to improve quality of CPR at a systems level (CoSTR 2015, weak recommendation, very low quality evidence).2 ANZCOR places a higher value on resource allocation and cost effectiveness than widespread implementation of a technology with uncertain effectiveness during real time CPR. We acknowledge that data provided by CPR feedback devices may benefit other victims as part of a broader quality improvement system (2015 CoSTR, Values and Preferences Statement). 2 4.2 Pacing Four studies addressed the efficacy of pacing in cardiac arrest. These studies found no benefit from routine pacing in cardiac arrest patients. Use of pacing (transcutaneous, transvenous, needle) in cardiac arrest (in-hospital or out-of-hospital) did not improve ROSC or survival. There was no apparent benefit related to the time at which pacing was initiated (early or delayed in established asystole), location of arrest (in-hospital or out-of-hospital), or primary cardiac rhythm (asystole, PEA). Five case series, a review with two additional case reports, and a moderate sized case series, support percussion pacing in p-wave asystolic cardiac arrest/complete heart block or hemodynamically unstable patients with bradycardia. In these reports, sinus rhythm with a pulse was restored using different pacing techniques. Electrical pacing is not effective as routine treatment in patients with asystolic cardiac arrest.3 The routine use of pacing (electrical or fist) is not recommended. The use of pacing after cardiac surgery is considered in Guideline 11.10, ‘Resuscitation in Special Circumstances’. ANZCOR Guideline 11.6 January 2016 Page 10 of 16 5 Monitoring during CPR 5.1 Waveform capnography (End-tidal carbon dioxide [ETCO2]) Waveform capnography during CPR has potential roles in: Confirming tracheal tube placement Monitoring the ventilation rate to assist in avoiding hyperventilation Assessing the quality of chest compressions during CPR (CO2 values are associated with compression depth and ventilation rate) Identifying ROSC during CPR (by an increased CO2 value) Assessing prognosis during CPR (low CO2 values may indicate a poor prognosis and less chance of ROSC). Failure to achieve a CO2 value >10 mmHg after 20 min of CPR is associated with a poor outcome in observational studies. Recommendations ANZCOR recommends against using ETCO2 cut-off values alone as a mortality predictor, or for the decision to stop a resuscitation attempt (CoSTR 2015, strong recommendation, low- quality evidence).2 ANZCOR suggests that an ETCO2 10 mm Hg or greater measured after tracheal intubation or after 20 min of resuscitation, may be a predictor of ROSC (CoSTR 2015, weak recommendation, low-quality evidence).2 ANZCOR suggests that an ETCO2 of 10 mm Hg or greater measured after tracheal intubation, or an ETCO2 20 mm Hg or greater measured after 20 min of resuscitation may be a predictor of survival to discharge (CoSTR 2015, weak recommendation, moderate-quality evidence).2 Values and Preferences ANZCOR has put a higher value on not relying on a single variable (ETCO2) and cut-off value when their usefulness in actual clinical practice, and variability according to the underlying cause of cardiac arrest, has not been established. The aetiology (e.g. asphyxia, PE) of cardiac arrest could affect ETCO2 values, and there is concern about the accuracy of ETCO2 values during CPR.2 5.2 Arterial Blood Gas There is evidence from 11 studies that arterial blood gas values are an inaccurate indicator of the magnitude of tissue acidosis during cardiac arrest and CPR in both the in-hospital and out-of-hospital settings. The same studies indicate that both arterial and mixed venous blood gases are required to establish the degree of acidosis.7 Arterial blood gas analysis alone can disclose the degree of hypoxemia and highlight the extent of metabolic acidosis. Arterial CO2 is an indicator of adequacy of ventilation during CPR. If ventilation is constant an increase in PaCO2 is a potential marker of improved perfusion during CPR. ANZCOR Guideline 11.6 January 2016 Page 11 of 16 Arterial blood gas monitoring during cardiac arrest enables estimation of the degree of hypoxemia and the adequacy of ventilation during CPR, but should not interfere with overall performance of good CPR 7 [Class B; LOE II and IV]. 5.3 Ultrasound during cardiac arrest The use of cardiac ultrasound during cardiac arrest may allow identification of many cardiac and non-cardiac causes of cardiac arrest, and three studies have examined the prognostic value of the presence or absence of sonographic cardiac motion in cardiac arrest. Absence of cardiac motion on sonography during resuscitation of patients in cardiac arrest was highly predictive of death. 3 One RCT compared the use of cardiac ultrasound during ALS to no use of cardiac ultrasound in adult patients with PEA arrest. This study enrolled 100 patients in a convenience sample and reported return of spontaneous circulation (ROSC) for at least 10 seconds in 34% of patients in the ultrasound group versus 28% in the group with no ultrasound (p=0.52). Recommendation If cardiac ultrasound is available and can be performed without interfering with standard ALS, it may be considered to try and identify potentially reversible causes of cardiac arrest (CoSTR 2015, weak recommendation, very low quality evidence).2 5.4 Other techniques and devices for circulatory support during CPR Several techniques or adjuncts to standard CPR have been investigated and the relevant data was reviewed extensively as part of the 2010 ILCOR Consensus on Science process.15 The success of any technique depends on the education and training of the rescuers and/or the resources available (including personnel). Techniques reviewed include: Open-chest CPR, Interposed Abdominal Compression CPR, Active Compression-Decompression CPR, Open Chest CPR, Load Distributing Band CPR, Mechanical (Piston) CPR, Lund University Cardiac Arrest System CPR, Impedance Threshold Device, and Extracorporeal Techniques.15 Because information about these techniques and devices is often limited, conflicting, or supportive only for short-term outcomes, no recommendations can be made to support or refute their routine use. While no circulatory adjunct is currently recommended instead of manual CPR for routine use, some circulatory adjuncts are being routinely used in both out-of-hospital and in- hospital resuscitation. If a circulatory adjunct is used, rescuers should be well-trained and a program of continuous surveillance should be in place to ensure that use of the adjunct does not adversely affect survival [Class B; LOE IV]. New evidence for specific techniques to assist circulation during CPR was reviewed in the 2015 ILCOR Consensus on Science process.2 Three technologies for which there have been significant developments since 2010 have been considered: ANZCOR Guideline 11.6 January 2016 Page 12 of 16  (1) The impedance threshold device (ITD) (2) Automated mechanical chest compression devices (3) Extracorporeal CPR (eCPR). (1) The impedance threshold device (ITD) For standard CPR, 1 RCT showed no clinically significant benefit in survival from the addition of the ITD. ANZCOR recommends against the routine use of the ITD in addition to standard CPR (CoSTR 2015, strong recommendation, high quality of evidence). 2 For Active Compression CPR, 2 RCTs showed no clinically significant benefit in survival from the addition of the ITD to ACD CPR in a total of 421 out-of-hospital cardiac arrests. Additionally, 2 RCTs did not demonstrate a clinically significant benefit in survival or neurological status from the addition of the ITD to ACD CPR compared with standard CPR. (2) Automated mechanical chest compression devices (ACTs) Two RCTs demonstrated no improvement in survival or neurological outcome at 30, 180 days or 1 yr compared with manual CPR. Three RCTs showed variable survival with good neurology at hospital discharge. Of two studies using the load-distributing band one study, showed harm, while the other showed no effect, and one study using the Lund University Cardiac Arrest System (LUCAS) device showed no effect. Five RCTs showed variable results for survival to hospital discharge. One RCT of IHCA showed benefit with use of a piston device compared with manual chest compressions. Two other RCTs of the LUCAS and 1 using a load-distributing band device showed neither benefit nor harm. Seven RCTs looked at the effect of ACDs on establishing ROSC: 2 showed a benefit, 1 showed harm and four showed no effect. ANZCOR suggests against the routine use of automated mechanical chest compression devices to replace manual chest compressions (CoSTR 2015 weak recommendation, moderate quality of evidence).2 ANZCOR suggests that automated mechanical chest compression devices are a reasonable alternative to high-quality manual chest compressions in situations where sustained high- quality manual chest compressions are impractical or compromise provider safety (CoSTR 2015, weak recommendation, low quality evidence).2 Values and Preferences ANZCOR believes the emphasis in resuscitation should be on providing high-quality chest compressions with adequate depth, rate and minimal interruptions, regardless of whether they are delivered by machine or human. We acknowledge that application of a mechanical chest compression device without a focus on minimising interruptions in compressions and delay to defibrillation could cause harm. ANZCOR Guideline 11.6 January 2016 Page 13 of 16 However, we also acknowledge that 1 large RCT showed equivalence between very high- quality manual chest compressions and mechanical chest compressions delivered with a load-distributing band in a setting with rigorous training and CPR quality monitoring, and we recognise that there are situations where sustained high-quality manual chest compressions may not be practical. Examples include CPR in a moving ambulance, the need for prolonged CPR (eg, hypothermic arrest), and CPR during certain procedures (eg. coronary angiography or preparation for extracorporeal CPR). (3) Extracorporeal CPR (eCPR) For IHCA, two observational studies demonstrated improved neurological survival at 180 days, but no difference at 1 year. These studies also showed improved survival at 30 and 180 days, but not at 1 year, and improved outcome (in both survival and neurology) at hospital discharge. For OHCA, 1 observational study showed improved functional survival with eCPR at 30 and 180 days, and another at 90 days. One of these studies also showed improved survival to hospital discharge, though not in propensity matched samples. ANZCOR suggests eCPR is a reasonable rescue therapy for selected patients with cardiac arrest when initial standard CPR is failing in settings where this can be implemented (CoSTR 2015 weak recommendation, very low quality of evidence).2 Values and Preferences ANZCOR acknowledges that the published series used selected patients for eCPR and that guidelines for clinical practice should apply to similar populations. We recognise that eCPR is a complex intervention that is not universally available, but we consider that it may be successful in individuals where usual CPR techniques have failed and may also buy time for another treatment such as coronary angiography or percutaneous coronary intervention (PCI). 5.5 Open Chest CPR There are no published randomised controlled trials and very limited data in humans comparing open-chest CPR to standard CPR in cardiac arrest. Four relevant human studies, 2 after cardiac surgery and 2 after out-of-hospital cardiac arrest, showed that open-chest cardiac massage improved coronary perfusion pressure and increased ROSC. Evidence from animal studies indicates that open-chest CPR produces greater survival rates, perfusion pressures, and organ blood flow than closed-chest CPR. Open-chest CPR should be considered for patients with cardiac arrest in the early postoperative phase after cardiothoracic surgery or when the chest or abdomen is already open. Open chest CPR should also be considered after penetrating chest injures 15 [Class B; LOE III-2]. ANZCOR Guideline 11.6 January 2016 Page 14 of 16 References 1. Spindelboeck W, Schindler O, Moser A, et al. Increasing arterial oxygen partial pressure during cardiopulmonary resuscitation is associated with improved rates of hospital admission. Resuscitation 2013;84:770–5.542. 2. Soar J, Callaway C, Aibiki M, Böttiger BW, Brooks SC, Deakin CD, Donnino MW, Drajer S, Kloeck W, Morley PT, Morrison LJ, Neumar RW, Nicholson TC, Nolan JP, Okada K, O’Neil BJ, Paiva EF, Parr MJ, Wang TL, Witt J, on behalf of the Advanced Life Support Chapter Collaborators. Part 4: Advanced life support. 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation 2015;95:e71–e1203 3. Deakin CD, Morrison LJ, Morley PT, Callaway CW, Kerber RE, Kronick SL, et al. Part 8: Advanced life support: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation. [doi: DOI: 10.1016/j.resuscitation.2010.08.027]. 2010;81(1, Supplement 1):e93-e174. 4. Gausche M, Lewis RJ, Stratton SJ, et al. Effect of out-of-hospital pediatric endo-tracheal intubation on survival and neurological outcome: a controlled clinicaltrial. JAMA 2000;283:783–90. 5. Weiss SJ, Ernst AA, Jones R, et al. Automatic transport ventilator versus bag valve in the EMS setting: a prospective, randomized trial. South Med J 2005;98:970–6. 6. Johannigman JA, Branson RD, Johnson DJ, Davis Jr K, Hurst JM. Out-of hospital ventilation: bag-valve device vs transport ventilator. Acad Emerg Med 1995;2:719–24. 7. Consensus on Science and Treatment Recommendations Part 4: Advanced life support. Resuscitation 2005;67(2-3): 213-47 8. Consensus on Science and Treatment Recommendations Part 2: Adult basic life support. Resuscitation 2005;67(2-3):187-201. 9. Swenson RD, Weaver WD, Niskanen RA, Martin J, Dahlberg S. Hemodynamics in humans during conventional and experimental methods of cardiopulmonary resuscitation. Circulation 1988;78(3):630-639. 10. Krischer JP, Fine E.G. Weisfeldt ML, Guerci AD, Nagel E, Chandra N. Comparison of prehospital conventional and simultaneous compression-ventilation cardiopulmonary resuscitation. Crit Care Med. 1989 1989 Dec;17(12):1263-9. 11. Yannopoulos D, Tang W, Roussos C, Aufderheide TP, Idris AH, Lurie KG. Reducing ventilation frequency during cardiopulmonary resuscitation in a porcine model of cardiac arrest. Respir Care. 2005 May;50(5):628-35. ANZCOR Guideline 11.6 January 2016 Page 15 of 16 12. Koster RW, Sayre MR, Botha M, Cave DM, Cudnik MT, Handley AJ, et al. Part 5: Adult basic life support: 2010 International consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Resuscitation. [doi: DOI: 10.1016/j.resuscitation.2010.08.005]. 2010;81(1, Supplement 1):e48-e70. 13. Soar J, Mancini ME, Bhanji F, Billi JE, Dennett J, Finn J, et al. Part 12: Education, implementation, and teams: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation. [doi: DOI: 10.1016/j.resuscitation.2010.08.030]. 2010;81(1, Supplement 1):e288-e330. 14. Perkins GD, Kocierz L, Smith SC, McCulloch RA, Davies RP. Compression feedback devices over estimate chest compression depth when performed on a bed. Resuscitation. 2009 Jan;80(1):79-82. 15. Lim SH, Shuster M, Deakin CD, Kleinman ME, Koster RW, Morrison LJ, et al. Part 7: CPR techniques and devices: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation. [doi: DOI: 10.1016/j.resuscitation.2010.08.026]. 2010;81(1, Supplement 1):e86-e92. ANZCOR Guideline 11.6 January 2016 Page 16 of 16 ANZCOR Guideline 11.4 – Electrical Therapy for Adult Advanced Life Support Summary Defibrillation as soon as possible provides the best chance of survival in victims with VF or pulseless VT. Who does this guideline apply to? This guideline applies to adults who require advanced life support. Who is the audience for this guideline? This guideline is for health professionals and those who provide healthcare in environments where equipment and drugs are available. Recommendations The Australian and New Zealand Committee on Resuscitation (ANZCOR) make the following recommendations: 1. A defibrillation shock is delivered as soon as a defibrillator is available. 2. Paddles or pads are placed on the exposed chest in an anterior-lateral position or an anterior-posterior position. 3. In patients with an ICD or a permanent pacemaker the defibrillator pad/paddle is placed on the chest wall ideally at least 8 cm from the generator position. 4. Self-adhesive defibrillation pads are used for defibrillation. 5. Biphasic waveforms are used for defibrillation. 6. For Monophasic waveforms: the initial energy level for adults is set at maximum (usually 360 Joules) for all shocks. 7. For Biphasic waveforms: the default energy level for adults is set at 200J for all shocks. Other energy levels may be used providing there is relevant clinical data for a specific defibrillator that suggests that an alternative energy level provides adequate shock success (e.g. Usually greater than 90%). 8. If the first shock is not successful and the defibrillator is capable of delivering shocks of higher energy, it is reasonable to increase the energy to the maximum available for subsequent shocks. 9. A single shock strategy is used in patients in cardiac arrest requiring defibrillation for VF or pulseless VT. ANZCOR Guideline 11.4 January 2016 Page 1 of 12  10. The use of AEDs to facilitate early defibrillation in hospitals is reasonable, but services that introduce AEDs must be aware of the possible adverse impact of interruptions to CPR, especially in non-shockable rhythms. ANZCOR Guideline 11.4 January 2016 Page 2 of 12  Guideline A defibrillation shock when applied through the chest produces simultaneous depolarization of a mass of myocardial cells and may enable resumption of organised electrical activity. 1 Indications A defibrillation shock is indicated for treating Ventricular Fibrillation (VF) and pulseless Ventricular Tachycardia (VT). 2 Timing of Defibrillation The likelihood of defibrillation success decreases with time until definitive treatment (i.e. defibrillation) is initiated.5 Interruptions to external cardiac compression (e.g. for rhythm assessment or pulse checks) should be minimised. However, good CPR may even increase the likelihood of defibrillation success.1 The results of clinical studies assessing the usefulness of a strategy providing a period of CPR before defibrillation rather than a strategy providing immediate defibrillation are not consistent. In two randomized controlled trials, a period of 1.5 to 3 minutes of CPR by EMS personnel before defibrillation did not improve return of spontaneous circulation (ROSC) or survival to hospital discharge in patients with out-of-hospital VF or pulseless VT, regardless of EMS response interval. One before and after study and another case series failed to demonstrate significant improvements in ROSC or survival to hospital discharge when a strategy of CPR before defibrillation (CPR first) was compared to a shock first strategy. In the Hayakawa study, the CPR first group showed a higher rate of favourable neurologic outcome 30 days and one year after cardiac arrest. One randomized controlled trial and one clinical trial with historic controls comparing CPR first versus shock first also found no overall difference in outcomes. However, in both studies, improvements in ROSC, survival to hospital discharge, neurologic outcome and one-year survival were observed in a subgroup of patients who received CPR first where the EMS response interval was greater than 4 to 5 minutes.2 Recommendation ANZCOR suggest delivering a defibrillation shock as soon as a defibrillator is available [Class A; Consensus expert opinion]. 3 Positioning of Electrodes There are no studies in patients with VF/pulseless VT comparing directly the effects of various positions of pad/paddle placement on defibrillation success and ROSC. Most studies evaluate cardioversion (e.g. AF) or secondary endpoints (e.g. transthoracic impedance). Eleven studies found all four positions (anterior-apex, anterior-posterior, anterior-left infrascapular, anterior right-infrascapular) to be equally effective in defibrillation (for VF/pulseless VT) or elective AF cardioversion success. ANZCOR Guideline 11.4 January 2016 Page 3 of 12 Four studies support the anterior-posterior position, one study supports the anterior-lateral position and one study supports the anterior-apex position. Five studies found no effect of electrode position on transthoracic impedance. One study showed that pads/paddles should be placed under the breast tissue and two studies showed that hirsute males should be shaved before to application of pads. Of the 36 studies reviewed, only four examined biphasic waveforms that have gained widespread use.2 Recommendation It is reasonable to place paddles or pads on the exposed chest in an anterior-lateral position. One paddle or pad is placed on the midaxilliary line over the 6th left intercostal space and the other on the right parasternal area over the 2nd intercostal space [Class A; LOE III-2]. Acceptable alternative positions are the anterior-posterior (for paddles and pads) and apex- posterior (for pads). In large-breasted individuals it is reasonable to place the left electrode pad (or paddle) lateral to or underneath the left breast, avoiding breast tissue. Consideration should be given to the rapid removal of excessive chest hair prior to the application of pads/paddles but emphasis must be on minimizing delays in shock delivery 2 [Class B; LOE IV]. 3.1 Positioning of electrodes in the presence of a pacemaker/internal defibrillator Two case series reported pacemaker or implantable cardioverter defibrillator (ICD) malfunction after external defibrillation when the pads were placed in close proximity to the device generator. One small study on atrial cardioversion demonstrated that positioning the pads on the chest at least 8 cm from the device generator did not produce significant damage to pacing sensing and capturing. 2 Recommendation In patients with an ICD or a permanent pacemaker, the placement of pad/paddles should not delay defibrillation. When treating an adult with a permanent pacemaker or an implantable cardioverter defibrillator, the defibrillator pad/paddle should be placed on the chest wall ideally at least 8 cm from the generator position [Class A; LOE IV].The anterior-posterior and anterior-lateral pad/paddle placements on the chest are acceptable in patients with a permanent pacemaker or ICD 2 [Class B; Extrapolated evidence]. One case report suggested that pacemaker spikes generated by devices programmed to unipolar pacing may confuse AED software and emergency personnel and may prevent the detection of VF.2 4 Size of Electrodes One study has demonstrated that transthoracic impedance decreased and shock success increased with increasing pad size (from 8 to 12 cm). Ten other studies showed that larger pad/paddle sizes (8 to 12 cm diameter) lowered transthoracic impedance and that maximum pad/paddle size was limited by the chest wall size and anatomy. No data related to survival outcome were included in these studies.2 ANZCOR Guideline 11.4 January 2016 Page 4 of 12 There is insufficient evidence to recommend a specific electrode size for optimal external defibrillation in adults. However, it is reasonable to use a pad size >8 cm2 [Class B; Extrapolated evidence]. 5 Paddles / Self Adhesive Pads Evidence from one small, good quality retrospective control study in 1987 showed that self- adhesive pads were associated with a significantly improved rate of ROSC and hospital admission compared with hand-held paddles. Several studies have shown the practical benefits of pads over paddles for routine monitoring and defibrillation.2 One prospective study comparing pads and paddles found lower transthoracic impedance when paddles applied at an optimal force of 8 kg were compared with pads. In a cohort study in patients with atrial fibrillation (AF) the use of hand-held paddles placed in the anterior- posterior position increased the success rate of monophasic cardioversion compared with similarly placed self-adhesive electrodes for monophasic defibrillation. The overall cardioversion success rate for biphasic defibrillators was high (>95%) in all groups. In the majority of other studies, self-adhesive electrodes are associated with similarly high cardioversion success rates.2 Recommendation ANZCOR recommend using self-adhesive defibrillation pads in preference to paddles for defibrillation [Class A; Expert consensus opinion]. They are safe and effective and offer advantages (e.g. facilitating pacing, charging during compressions, safety [including removing risk of fires]) over defibrillation paddles [Class A;LOE III-3, Extrapolated evidence]. If paddles are used, the application of firm pressure and conductive gel pads are recommended for maximum electrical contact. Care should be taken to ensure that pads or electrodes are applied in accordance with manufacturer’s instructions and are not in electrical contact with each other [Class A; Expert consensus opinion]. The composition of the conductive material of defibrillation electrodes influences transthoracic impedance. In terms of cardiac arrest outcomes, there is insufficient evidence to recommend a specific composition of the defibrillation electrode conductive material.6 6 Defibrillation Waveform In three randomized trials and four other human studies biphasic waveforms had higher shock success rates compared with monophasic defibrillation. Shock success is usually defined as termination of ventricular fibrillation (VF) 5 seconds after the shock.6 Another randomized study comparing transthoracic incremental monophasic with biphasic defibrillation for out-of-hospital pulseless VT/VF cardiac arrest found no differences in any outcome. A single cohort study using the 2000 International Guidelines demonstrated better hospital discharge and neurologic survival with biphasic than with monophasic waveforms. However, there are confounding factors in that the intervals between the first and second shocks (of three stacked shocks) were shorter with the biphasic defibrillators. There is no clinical evidence for superiority for any specific biphasic waveform over another.2 ANZCOR Guideline 11.4 January 2016 Page 5 of 12 Recommendation Biphasic waveforms are recommended to be used for defibrillation [Class A; Expert consensus opinion]. There is insufficient evidence to recommend any specific biphasic waveform. In the absence of biphasic defibrillators, monophasic defibrillators are acceptable [Class B; Expert consensus opinion]. 7 Energy Levels 7.1 Biphasic truncated exponential waveform Evidence from one well-conducted randomized trial and one other human study employing biphasic truncated exponential (BTE) waveforms suggest that higher energy levels are associated with higher shock success rates. In the randomized trial, the first shock success rate was similar with 150 J and 200 J.2 7.2 Biphasic pulsed waveform In one study using pulsed biphasic waveforms at 130J the first shock success rate was 90%. 2 7.3 Rectilinear biphasic waveform When defibrillation success was defined as ROSC (this differs from the definition used in other studies), one study using a rectilinear biphasic waveform showed that an organized rhythm was restored by the first shock (120 J) in 23% of cases. Success rate for the termination of VF at 5 seconds was not published for this waveform.2 7.4 Monophasic waveform (damped sinusoid or truncated exponential) Evidence from three studies of monophasic defibrillation suggest equivalent outcomes with lower and higher starting energies.2 7.5 Myocardial damage associated with higher energy level shocks Several animal studies have suggested the potential for myocardial damage with higher energy shocks using BTE or monophasic waveforms. Human studies involving BTE waveforms have not shown harm as indicated by biomarker levels, ECG findings, and ejection fractions with energy levels up to 360J.2 7.6 Fixed versus escalating energy levels One randomized trial of 150 J fixed versus 200 J-300 J-360 J shocks and one study (with concurrent controls) of 150 J fixed versus 100 J-150 J-200 J shocks supported the use of an escalating energy biphasic defibrillation protocol compared with a fixed dose defibrillation protocol. In one study (escalating 200J-200J-360J shocks) the success rate of defibrillation for recurrent VF declined with the number of recurrences. However, these studies were not designed to demonstrate an improvement in the rate of ROSC or survival to hospital discharge. ANZCOR Guideline 11.4 January 2016 Page 6 of 12 One study of fixed-dose biphasic defibrillation suggested that defibrillation success improved with three shocks. All of these studies were done with the three shock protocol (before the change in Guidelines 2005).2 Recommended Energy Levels Monophasic: the energy level for adults should be set at maximum (usually 360 Joules) for all shocks. [Class A; LOE III-2]1 Biphasic waveforms: the default energy level for adults should be set at 200J for all shocks. Other energy levels may be used providing there is relevant clinical data for a specific defibrillator that suggests that an alternative energy level provides adequate shock success (e.g. Usually greater than 90%) [Class A; LOE II]. 2 ANZCOR suggest if the first shock is not successful and the defibrillator is capable of delivering shocks of higher energy, it is reasonable to increase the energy to the maximum available for subsequent shocks [CoSTR 2015, weak recommendation, very low quality evidence].3 Escalating shock energy may prevent the risk of refibrillation and is in line with current practices [CoSTR 2015, values and preferences statement]. 8 Single Shock Protocol One study showed no survival benefit from a protocol that included a single shock protocol compared to a three-shock protocol. Evidence from three pre-post design studies suggested significant survival benefit with a single shock defibrillation protocol compared with three stacked shock protocols. However, these studies included confounders related to pre-post design and the multiple interventions that were included as part of the defibrillation protocol. Another pre-post study, with fewer confounding factors, showed a significantly lower hands- off-ratio (ie, percentage of total CPR time when no compressions were provided) with the one-shock protocol but no statistical difference in survival.2 One observational study of fixed-dose biphasic defibrillation suggested higher defibrillation success with three shocks. The same paper also suggested that chest compressions immediately following a shock did not result in recurrence of VF. In contrast, another study showed earlier recurrence of VF when chest compressions were resumed immediately after the shock compared with delayed resumption of compressions. There was no difference in total incidence of recurrent VF or outcome. A single study demonstrated early termination of recurrent VF was associated with increased ROSC, but quality of CPR was poor and few patients achieved ROSC. Another study showed decreased survival when defibrillation for recurrent VF was, for a variety of reasons, delayed.2 One randomised controlled clinical trial has been published since 2010 comparing single versus stacked shocks and showed no difference in outcome.7 Priorities in resuscitation should include early assessment of the need for defibrillation, provision of CPR until a defibrillator is available, and minimization of interruptions in chest compressions. Rescuers can optimize the likelihood of defibrillation success by optimizing the performance of CPR, timing of shock delivery with respect to CPR, and the combination of waveform and energy levels. Rescuers can safely continue CPR while charging a manual defibrillator.8 ANZCOR Guideline 11.4 January 2016 Page 7 of 12 Recommended shock protocol It is recommended that a single shock strategy be used in patients in cardiac arrest requiring defibrillation for VF or pulseless VT [Class A; Expert consensus opinion]. When using this strategy, CPR should be resumed immediately following shock delivery and interruptions minimised [Class A; LOE IV]. CPR should be continued during charging of the defibrillator, and CPR should not be interrupted until rhythm reanalysis is undertaken [Class A; Expert consensus opinion]. 9 Precautions Be aware of electrical hazards in the presence of water, metal fixtures, oxygen and flammable substances. Warn of impending discharge by a “stand clear” command. 9.1 Oxygen and fire risk Four case reports involving adults and one case report involving a neonate described fires caused by sparks generated during defibrillation attempts when paddles were used in the vicinity of high flow (>10 L/min) oxygen.2 In two manikin studies the oxygen concentration in the zone of defibrillation was not increased when ventilation devices (bag-valve device, self-inflating bag, Hamilton Viola ventilator) were left attached to a tracheal tube or when the oxygen source was vented at least 1 meter behind the patient’s mouth. One study described higher oxygen concentrations and longer washout periods when oxygen is administered in confined spaces without adequate ventilation. There are no case reports of fires caused by sparking when shocks were delivered using adhesive pads.6 9.2 Recommended technique Rescuers should take precautions to minimize sparking (by paying attention to pad/paddle placement, contact, etc) during attempted defibrillation. Rescuers should try to ensure that defibrillation is not attempted in an oxygen-enriched atmosphere (e.g. when high-flow oxygen is directed across the chest) [Class A; Expert consensus opinion]. Rescuers should minimise interruptions to CPR while defibrillating the patient. Rescuers should be able to safely charge a manual defibrillator during CPR when using pads. The defibrillator should be disarmed if a shock is not required [Class B; Expert consensus opinion]. Manual chest compressions should not continue during the delivery of a shock because safety has not been established. Specifically, rescuers should: AVOID charging the paddles unless they are placed on the victim’s chest AVOID placing the defibrillator paddles/pads over ECG electrodes (risk of burns or sparks), ECG leads (may melt), medication patches, an implanted device (e.g. a pacemaker), or a central line insertion site AVOID having, or allowing any person to have, any direct or indirect contact with the victim during defibrillation (a shock may be received) ANZCOR Guideline 11.4 January 2016 Page 8 of 12  AVOID having the victim in contact with metal fixtures e.g. bed rails (risk of burn) AVOID delivering the shock with a gap between the paddle/pad and chest wall (spark hazard) AVOID defibrillating if victim, operator and/or close bystander are situated in an explosive/flammable (e.g. petrol) environment AVOID allowing oxygen from a resuscitator to flow onto the victim’s chest during delivery of the shock when using paddles (risk of fire) [Class A; LOE IV]. 10 Confirmation of Shock Delivery Check that the victim has a muscle response to the shock and there is ECG (electrocardiogram) evidence of shock delivery. If it does not appear that the shock has been delivered, consider that the “synchronize” mode of the defibrillator may be on or there may be a flat battery, lead fracture, charge dump etc. 11 Failure of Defibrillation If the attempt at defibrillation is unsuccessful: Recommence CPR with oxygen (follow algorithm in Guideline 11.2). Check paddle or electrode position. Check that there is adequate skin contact (clipping or shaving of body hair under the defibrillator paddle/pad may be required). Consider changing the defibrillator pads. 12 Use of Automated External Defibrillators (AEDs) AED use should not be restricted to trained personnel. Allowing use of AEDs by individuals without prior formal training can be beneficial and may be life saving. Since even brief training improves performance (e.g. speed of use, correct pad placement), it is recommended that training in the use of AEDs be provided. Implementation of AED programs in public settings should be based on the characteristics of published reports of successful programs in similar settings.9 Services that implement the use of AEDs must be aware of the possible adverse impact of interruptions to CPR, especially in non-shockable rhythms.4 Home AED use, for high-risk individuals who do not have an ICD, is safe and feasible and may be considered on an individual basis, but has not been shown to change overall survival rates.9 Because population (e.g. rates of witnessed arrest) and program (e.g. response time) characteristics affect survival, when implementing an AED program, community and program leaders should consider factors such as location, development of a team with a responsibility for monitoring and maintaining the devices, training and retraining programs for those who are likely to use the AED, coordination with the local EMS, and identification of a group of paid or volunteer individuals who are committed to using the AED for victims of arrest.9 ANZCOR Guideline 11.4 January 2016 Page 9 of 12 12.1 AEDs in manual mode Modern defibrillators can be operated in both manual and semi-automatic modes. However, few studies compare these two options. One randomized controlled study showed no difference in survival to hospital discharge rate but significant reduction in time to first shock in the AED group versus the manual group (1.1 vs 2.0 minutes). One good concurrent controlled out-of-hospital cardiac arrest study in 36 rural communities showed no improvements in ROSC, survival and neurological outcome but significantly shorter times to first shock and higher VF conversion rates when paramedics used AEDs in semi-automatic mode compared with manual mode. One retrospective study demonstrated no improvement in survival to hospital discharge for in-hospital adult cardiac arrest when comparing AED with manual defibrillators. In patients with initial asystole or pulseless electrical activity (PEA), AEDs were associated with a significantly lower survival (15%) compared with manual defibrillators (23%, p = 0.04). In a study of three different EMS systems and one in-hospital center, the manual mode of defibrillation was associated with a lower total hands-off ratio (ie, percentage of total CPR time when no compressions were provided) than AED mode. However, more shocks were delivered inappropriately by rescuers using manual defibrillators (26% manual vs. 6% AEDs). A randomized manikin study simulating cardiac arrest showed a lower hands-off ratio, mainly due to a shorter pre-shock pause, when trained paramedics used the defibrillator in manual mode compared with semi-automatic mode. More inappropriate shocks (12% vs 0), were delivered in manual mode. All episodes of VF were detected and shocked appropriately. A shorter pre-shock pause and lower total hands-off-ratio increase vital organ perfusion and the probability of ROSC.2 There are no survival differences between defibrillation in semiautomatic and manual modes during in- and out-of-hospital resuscitation; however, the semi-automatic mode is preferred because it is easier to use and may deliver fewer inappropriate shocks. Trained personnel may deliver defibrillation in manual mode. Use of the manual mode enables chest compressions to be continued during charging, thereby minimizing the pre-shock pause. When using the defibrillator in manual mode, frequent team training and ECG recognition skills are essential. The defibrillation mode that results in the best outcome will be influenced by the system, and provider skills, training and ECG recognition.6 In one in-hospital study, the use of AEDs was not associated with improved survival in those patients with shockable rhythms, but was associated with lower survival in those with non- shockable rhythms.4 Recommendation The use of AEDs is reasonable to facilitate early defibrillation in hospitals 2, but services that introduce AEDs must be aware of the possible adverse impact of interruptions to CPR, especially in non-shockable rhythms 4 [Class B; LOE IV]. ANZCOR Guideline 11.4 January 2016 Page 10 of 12 13 Use of the Defibrillator for Quality Assurance 13.1 Data collection Collection of data from defibrillators enables a comparison of actual performance during cardiac arrests and training events. The results of many observational studies suggest that the rate and depth of external cardiac compressions and ventilation rate were at variance with current guidelines. Monitor/defibrillators modified to enable collection of data on compression rate and depth and ventilation rate may be useful for monitoring and improving process and outcomes after cardiac arrest.2 However, rescuers should be aware of the potential overestimation of compression depth when the victim is on a soft surface.10 13.2 Waveform analysis Retrospective analysis of the VF waveform analysis in multiple clinical and animal studies and theoretical models suggest that it is possible to predict the success of defibrillation from the fibrillation waveform with varying reliability. One animal study was neutral. No human studies have specifically evaluated whether treatment altered by predicting success of defibrillation can improve successful defibrillation, ROSC or survival from cardiac arrest. Multiple waveform parameters have been examined without consensus on the most important parameters to predict outcome.2 There is insufficient evidence to support routine use of VF waveform analysis to guide defibrillation management in adult in hospital and out of hospital cardiac arrest.2 There is insufficient evidence to support or refute the use of artefact filtering algorithms for analysis of ECG rhythm during CPR.10 References 1. Eftestol T, Wik L, Sunde K, Steen PA. Effects of cardiopulmonary resuscitation on predictors of ventric