2023 AHA Focused Update on Adult ACLS: Key Points

Perman SM, Elmer J, Maciel CB, et al., on behalf of the American Heart Association.
2023 American Heart Association Focused Update on Adult Advanced Cardiovascular Life Support: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2023;Dec 18:[Epub ahead of print].

The following are key points to remember about a 2023 American Heart Association (AHA) focused update on adult advanced cardiovascular life support (ACLS):

  1. Epinephrine should be administered for patients in cardiac arrest (Class 1). Vasopressin alone or with methylprednisolone in combination with epinephrine may be considered in cardiac arrest but is not a substitute for epinephrine (Class 2b). High-dose epinephrine is not recommended for routine use in cardiac arrest.
  2. Amiodarone or lidocaine may be considered for ventricular fibrillation/pulseless ventricular tachycardia that is unresponsive to defibrillation (Class 2b).
  3. Routine administration of calcium, sodium bicarbonate, and magnesium for cardiac arrest is not recommended.
  4. Use of extracorporeal cardiopulmonary resuscitation (ECPR) for patients with cardiac arrest refractory to standard ACLS is reasonable when equipment and trained staff are available (Class 2a).
  5. Coronary angiography should be performed emergently for all cardiac arrest patients with suspected cardiac arrest and ST-segment elevation on electrocardiography (Class 1). It is reasonable in patients without ST-elevation, but with elevated risk of significant coronary artery disease, where revascularization may provide benefit (Class 2a). Neurological status should not be the deciding factor on whether a patient should have revascularization (Class 2a). There is no benefit of emergency coronary angiography over delayed coronary angiography for patients with return of spontaneous circulation (ROSC) but without ST-segment elevation, shock, electrical instability, signs of significant ongoing myocardial damage, or ongoing ischemia.
  6. All adults who do not follow commands after ROSC, irrespective of arrest location or presenting rhythm, should receive treatment that includes a deliberate strategy for temperature control.
  7. Hospitals should develop protocols for post-arrest temperature control. During post-arrest temperature control, a constant temperature between 32°C and 37.5°C should be maintained (Class 1). It is reasonable that temperature control be maintained for at least 24 hours after achieving target temperature (Class 2a). It is reasonable to prevent fever in patients unresponsive to verbal commands after initial temperature control (Class 2b).
  8. Patients with spontaneous hypothermia after ROSC unresponsive to verbal commands should not routinely be actively or passively rewarmed faster than 0.5°C per hour (Class 2b). The routine use of rapid infusion of cold intravenous fluids for prehospital cooling of patients after ROSC is not recommended.
  9. Seizure activity should be treated. Electroencephalography (EEG) may be used in patients who do not follow commands after ROSC (Class 1). The same seizure medications used for treatment of seizures caused by other etiologies may be considered for seizures detected after cardiac arrest (Class 2b). Seizure prophylaxis in adult survivors of cardiac arrest is not recommended.
  10. Organ donation should be considered in all patients resuscitated from cardiac arrest who meet neurological criteria for death or before planned withdrawal of life-sustaining therapies. Decisions about organ donation should follow local legal and regulatory requirements (Class 1). Organ donation is an important outcome that should be considered in the development and evaluation of systems of care.

Clinical Topics: Arrhythmias and Clinical EP, Implantable Devices, SCD/Ventricular Arrhythmias, Acute Coronary Syndromes

Keywords: Advanced Cardiac Life Support, Heart Arrest

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