Statement paperEuropean Resuscitation Council Guidelines for Resuscitation: 2018 Update – Antiarrhythmic drugs for cardiac arrest
Introduction
This is the second European Resuscitation Council (ERC) guidelines update following the decision by the International Liaison Committee on Resuscitation (ILCOR) to move to a continuous evidence evaluation process.1, 2, 3 This update follows the publication of the ILCOR 2018 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations (CoSTR) Summary.4 The 2018 ILCOR CoSTR focused on the use of antiarrhythmic drugs to treat cardiac arrest with a shockable rhythm in adults, children and infants and provides an update to the ILCOR 2015 Advanced Life Support (ALS) and Paediatric CoSTRs.5, 6 This topic was prioritised by ILCOR following the publication of a large randomised controlled trial (RCT) that compared amiodarone, lidocaine and placebo (ALPS) in out-of-hospital cardiac arrest (OHCA) patients with shock refractory ventricular fibrillation/pulseless ventricular tachycardia (VF/pVT).7 Here the ERC updates the 2015 ALS and Paediatric guidelines on the use of antiarrhythmic drugs during cardiopulmonary resuscitation (CPR) and immediately after return of spontaneous circulation (ROSC).8, 9
Section snippets
Background
The primary treatment for cardiac arrest with a shockable rhythm (VF/pVT) is early defibrillation and, if required, high-quality chest compressions with minimum interruption.3, 10
Approximately 20% of adult cardiac arrests (in and out-of-hospital) have a shockable rhythm when first monitored.11, 12, 13 Current guidelines recommend that those patients not responding to defibrillation attempts for a primary shockable rhythm, or a non-shockable rhythm that turns shockable require an antiarrhythmic
ILCOR CoSTR 2018
The ILCOR CoSTR 2018 addressed the use of antiarrhythmic drugs in adults and children in any setting (in-hospital or out-of-hospital) with cardiac arrest and a shockable rhythm (VF/pVT) at any time during CPR or immediately after ROSC (defined by consensus as within 1 h of ROSC). The systematic review informing the CoSTR identified 14 adult RCTs (16 articles) and 19 non-RCTS (18 adult studies, 1 paediatric study, 22 articles).16 Given the availability of comparative data from large RCTs, the
Amiodarone and lidocaine use in adult cardiac arrest
As part of this guideline update the ERC surveyed its member National Resuscitation Councils (NRCs) regarding the use of antiarrhythmic drugs during CPR. All of the 24 NRCs that responded reported that amiodarone was the antiarrhythmic drug used most commonly for IHCA. For OHCA, amiodarone was reported as the main antiarrhythmic drug used in 22 countries, lidocaine was the main antiarrhythmic drug used in one country, and the main antiarrhythmic drug used was uncertain in one country.
Magnesium use in adult cardiac arrest
Magnesium therapy has a role in correcting hypomagnesaemia, hypokalaemia, and during the treatment of polymorphic VT (torsade de pointes).8, 19
ERC guidelines 2018
The ERC has not made any previous recommendation on the prophylactic use of antiarrhythmic drugs after a cardiac arrest with a shockable rhythm, and this remains the case after the ILCOR 2018 CoSTR.
ILCOR CoSTR in context of ERC guidelines
No new studies of the use of prophylactic antiarrhythmic drugs in patients immediately (within 1 h) after ROSC following a VF/pVT cardiac arrest were identified in the 2018 ILCOR CoSTR. Observational studies of beta-blocker or lidocaine use after ROSC were reviewed in the 2015 ILCOR ALS CoSTR.5 These
Antiarrhythmic drugs for cardiac arrest in infants and children
Amiodarone and lidocaine are also the two most commonly used antiarrhythmic drugs used during CPR in infants and children.
Conclusion
The ERC acknowledges the quality and rigour of the evidence appraisal conducted by ILCOR. The ERC review of the newly gathered evidence on antiarrhythmic drugs does not lead to any immediate changes in the ERC teaching materials, course content or programs. The review should enable laypeople and healthcare professionals to be confident that guidelines are based on the most up to date evidence.
Implementation of the key messages from Guidelines 2015 with a 2017 and 2018 update supports the ERC’s
Conflict of interest statement
All authors and contributors have formal roles within the ERC and their respective National Resuscitation Councils. JPN is Editor-in-Chief of Resuscitation. JS and GDP are Editors of Resuscitation.
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