ACLS: Special circumstances

The 2010 American Heart Association (AHA) Guidelines for CPR and Emergency Cardiovascular Care (ECC) listed 15 topic areas which require treatments outside the standard BLS and ACLS guidelines. In 2015, these guidelines were updated with 5 new or updated topic areas. Some highlights include the following situations:

Pregnancy

• Priorities for the pregnant woman in cardiac arrest are provision of high-quality CPR and relief of aortocaval compression.
• During cardiac arrest, if the pregnant woman with a fundus height at or above the umbilicus has not achieved ROSC with usual resuscitation measures plus manual LUD, it is advisable to prepare to evacuate the uterus while resuscitation continues.
• Perimortem cesarean delivery should be considered at 4 minutes after onset of maternal cardiac arrest or resuscitative efforts (for the unwitnessed arrest) if there is no ROSC.

Pulmonary Embolism

• In patients with confirmed PE as the precipitant of cardiac arrest, thrombolysis, surgical embolectomy, and mechanical embolectomy are reasonable emergency treatment options.
• In patients with cardiac arrest and without known PE, routine fibrinolytic treatment given during CPR shows no benefit

Opioid Overdose

• Respiratory arrest: ACLS providers should support ventilation and administer naloxone to patients with a perfusing cardiac rhythm and opioid-associated respiratory arrest or severe respiratory depression. Bag-mask ventilation should be maintained until spontaneous breathing returns, and standard ACLS measures should continue if return of spontaneous breathing does not occur.
• Cardiac arrest: No recommendation regarding use of naloxone. Standard ACLS practices.

Intravenous Lipid Emulsion Therapy

• It may be reasonable to administer ILE, concomitant with standard resuscitative care, to patients with local anesthetic systemic toxicity and particularly to patients who have premonitory neurotoxicity or cardiac arrest due to bupivacaine toxicity.
• It may be reasonable to administer ILE to patients with other forms of drug toxicity who are failing standard resuscitative measures.