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September 25, 2018 Circulation. 2018;138:e272–e391. DOI: 10.1161/CIR.0000000000000549 e298

CLINICAL STATEMENTS AND GUIDELINES I A 3. Patients presenting with VA with hemodynamic instability should undergo direct current cardioversion.S6-1–S6-3

I B-NR 4. In patients with polymorphic VT or VF with ST-elevation MI, angiography with emergency revascularization is recommended.S6-7–S6-10

I C-EO 5. Patients with a wide-QRS tachycardia should be presumed to have VT if the diagnosis is unclear.

IIa A 6. In patients with hemodynamically stable VT, administration of intravenous procainamide can be useful to attempt to terminate VT.S6-11–S6-13

IIa B-R 7. In patients with a witnessed cardiac arrest due to VF or polymorphic VT that is unresponsive to CPR, defibrillation, and vasopressor therapy, intravenous lidocaine can be beneficial.S6-1,S6-4,S6-5,S6-14,S6-15

IIa B-R 8. In patients with polymorphic VT due to myocardial ischemia, intravenous beta blockers can be useful.S6-16,S6-17

IIa B-NR 9. In patients with a recent MI who have VT/VF that repeatedly recurs despite direct current cardioversion and antiarrhythmic medications (VT/VF storm), an intravenous beta blocker can be useful.S6-17,S6-18

IIb A 10. In patients in cardiac arrest, administration of epinephrine (1 mg every 3 to 5 minutes) during CPR may be reasonable.S6-1,S6-19–S6-24

IIb B-R 11. In patients with hemodynamically stable VT, administration of intravenous amiodarone or sotalol may be considered to attempt to terminate VT.S6-5,S6-13,S6-25,S6-26

III: No Benefit A 12. In patients with cardiac arrest, administration of high-dose epinephrine (>1 mg boluses) compared with standard doses is not beneficial.S6-19,S6-21

III: No Benefit A 13. In patients with refractory VF not related to torsades de pointes, administration of intravenous magnesium is not beneficial.S6-

27,S6-28

III: Harm B-R 14. In patients with suspected AMI, prophylactic administration of lidocaine or high-dose amiodarone for the prevention of VT is potentially harmful.S6-16,S6-29

III: Harm C-LD 15. In patients with a wide QRS complex tachycardia of unknown origin, calcium channel blockers (eg, verapamil and diltiazem) are potentially harmful.S6-30,S6-31

Recommendation-Specific Supportive Text

1.	 The most common electrical mechanisms for cardiac arrest are VF and pulseless VT, but substantial numbers of cardiac arrests begin as severe bradyarrhythmias or asystole. Survival is better for patients presenting with VT or VF than for those with bradyarrhythmic or asystolic mechanisms.S6-32 Rapid arrival of paramedical personnel is the major determinant of survival. A number of strategies for responding to unexpected cardiac arrest, including rapid defibrillation and initiation of CPR for a witnessed cardiac arrest, have improved survival probabilities for cardiac arrest victims.S6-2,S6-3 Nonetheless, the absolute number and proportion of survivors remain low, except in unique circumstances where there is an extraordinarily rapid response time to victims in VF or VT such as in monitored intensive care units, where survival is >90%.S6-33–S6-36 Survival decreases rapidly after the initial 2 minutes from the onset of cardiac arrest, so that by 4 to 5 minutes, survival may be ≤25%, and by 10 minutes it is 0%.S6-33,S6-35,S6-36 Advanced life support activities, other than those directly related to cardioversion and defibrillation for control of tachyarrhythmias, have led to the generation of comprehensive protocols to guide responders. These AHA documents cover the broad expanse of clinical circumstances and considerations of mechanisms.S6-1,S6-37

2.	 Paramedic administration of amiodarone after at least 3 failed shocks and administration of epinephrine improved hospital admission rates when compared with placeboS6-6 or 1.5 mg/kg lidocaineS6-1,S6-4 in RCTs in adults with out-of-hospital cardiac arrest due to refractory VF or polymorphic VT, although survival to hospital discharge and survival with favorable neurologic outcome were not improved with amiodarone or lidocaine.S6-5 However, in the subset of patients with witnessed cardiac arrest due to initial shock-refractory VF or pulseless VT, survival to hospital discharge after amiodarone administration was higher than with placebo.S6-5 The administration of procainamide in out-of-hospital cardiac arrest due to VF or pulseless VT has been associated with more shocks, more pharmacologic interventions, longer resuscitation times, and lower survival.S6-38 3.	 VA with hemodynamic instability, including VF and pulseless monomorphic or polymorphic VT, causes loss of consciousness and leads to death if untreated. A short time to direct current cardioversion is the major determinant of survival, and defibrillation should be performed as quickly as possible. CPR is used until a perfusing rhythm is restored. If defibrillation is unsuccessful in returning spontaneous circulation, responders follow advanced cardiovascular life support activities.S6-1–S6-3 4.	 Quickly identifying and treating patients with out-of-hospital cardiac arrest related to acute coronary occlusion is associated with improved survival and better functional recovery.S6-37 Coronary occlusion as a cause of cardiac arrest is not reliably predicted by clinical and electrocardiographic

Recommendations for Management of Cardiac Arrest (Continued)

COR LOE Recommendations

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