Abstract

HomeCirculationVol. 132, No. 16_suppl_1Part 1: Executive Summary Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessResearch ArticlePDF/EPUBPart 1: Executive Summary2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Mary Fran Hazinski, Jerry P. Nolan, Richard Aickin, Farhan Bhanji, John E. Billi, Clifton W. Callaway, Maaret Castren, Allan R. de Caen, Jose Maria E. Ferrer, Judith C. Finn, Lana M. Gent, Russell E. Griffin, Sandra Iverson, Eddy Lang, Swee Han Lim, Ian K. Maconochie, William H. Montgomery, Peter T. Morley, Vinay M. Nadkarni, Robert W. Neumar, Nikolaos I. Nikolaou, Gavin D. Perkins, Jeffrey M. Perlman, Eunice M. Singletary, Jasmeet Soar, Andrew H. Travers, Michelle Welsford, Jonathan Wyllie and David A. Zideman Mary Fran HazinskiMary Fran Hazinski , Jerry P. NolanJerry P. Nolan , Richard AickinRichard Aickin , Farhan BhanjiFarhan Bhanji , John E. BilliJohn E. Billi , Clifton W. CallawayClifton W. Callaway , Maaret CastrenMaaret Castren , Allan R. de CaenAllan R. de Caen , Jose Maria E. FerrerJose Maria E. Ferrer , Judith C. FinnJudith C. Finn , Lana M. GentLana M. Gent , Russell E. GriffinRussell E. Griffin , Sandra IversonSandra Iverson , Eddy LangEddy Lang , Swee Han LimSwee Han Lim , Ian K. MaconochieIan K. Maconochie , William H. MontgomeryWilliam H. Montgomery , Peter T. MorleyPeter T. Morley , Vinay M. NadkarniVinay M. Nadkarni , Robert W. NeumarRobert W. Neumar , Nikolaos I. NikolaouNikolaos I. Nikolaou , Gavin D. PerkinsGavin D. Perkins , Jeffrey M. PerlmanJeffrey M. Perlman , Eunice M. SingletaryEunice M. Singletary , Jasmeet SoarJasmeet Soar , Andrew H. TraversAndrew H. Travers , Michelle WelsfordMichelle Welsford , Jonathan WyllieJonathan Wyllie and David A. ZidemanDavid A. Zideman Originally published20 Oct 2015https://doi.org/10.1161/CIR.0000000000000270Circulation. 2015;132:S2–S39Toward International Consensus on ScienceThe International Liaison Committee on Resuscitation (ILCOR) was formed in 1993 and currently includes representatives from the American Heart Association (AHA), the European Resuscitation Council, the Heart and Stroke Foundation of Canada, the Australian and New Zealand Committee on Resuscitation, the Resuscitation Council of Southern Africa, the InterAmerican Heart Foundation, and the Resuscitation Council of Asia. The ILCOR mission is to identify and review international science and information relevant to cardiopulmonary resuscitation (CPR) and emergency cardiovascular care (ECC) and to offer consensus on treatment recommendations. ECC includes all responses necessary to treat sudden life-threatening events affecting the cardiovascular and respiratory systems, with a particular focus on sudden cardiac arrest. For this 2015 consensus publication, ILCOR also included first aid topics in its international review and consensus recommendations.In 1999, the AHA hosted the first ILCOR conference to evaluate resuscitation science and develop common resuscitation guidelines. The conference recommendations were published in the Guidelines 2000 for CPR and ECC.1 Since 2000, researchers from the ILCOR member councils have evaluated and reported their International Consensus on CPR and ECC Science With Treatment Recommendations (CoSTR) in 5-year cycles. The conclusions and recommendations of the 2010 CoSTR were published at the end of 2010.2,3 Since that time, ILCOR meetings and webinars have continued to identify and evaluate resuscitation science. The most recent ILCOR 2015 International Consensus Conference on CPR and ECC Science With Treatment Recommendations was held in Dallas in February 2015, and this publication contains the consensus science statements and treatment recommendations developed with input from the ILCOR task forces, the invited participants, and public comment.The Parts of this CoSTR publication include a summary of the ILCOR processes of evidence evaluation and management of potential or perceived conflicts of interest, and then reports of the consensus of the task forces on adult basic life support (BLS; including CPR quality and use of an automated external defibrillator [AED]); advanced life support (ALS; including post–cardiac arrest care); acute coronary syndromes (ACS); pediatric BLS and ALS; neonatal resuscitation; education, implementation, and teams (EIT); and first aid.The 2015 CoSTR publication is not a comprehensive review of every aspect of resuscitation medicine; not all topics reviewed in 2010 were rereviewed in 2015. This Executive Summary highlights the evidence evaluation and treatment recommendations of this 2015 evidence evaluation process. Not all relevant references are cited here, because the detailed systematic reviews are included in the individual Parts of the 2015 CoSTR publication.A list of all topics reviewed can be found in the Appendix.Evidence Evaluation ProcessThe 2015 evidence evaluation process started in 2012 when ILCOR representatives formed 7 task forces: BLS, ALS, ACS, pediatric BLS and ALS, neonatal resuscitation, EIT, and, for the first time, first aid. Each task force performed detailed systematic reviews based on the recommendations of the Institute of Medicine of the National Academies,4 and the criteria of a measurement tool to assess systematic reviews (AMSTAR).5 The task forces used the methodologic approach for evidence evaluation and development of recommendations proposed by the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) Working Group.6 Each task force identified and prioritized the questions to be addressed (using the PICO [population, intervention, comparator, outcome] format)7 and identified and prioritized the outcomes to be reported. Then, with the assistance of information scientists, a detailed search for relevant articles was performed in each of 3 online databases (PubMed, Embase, and the Cochrane Library).By using detailed inclusion and exclusion criteria, articles were screened for further evaluation. The reviewers for each question created a reconciled risk-of-bias assessment for each of the included studies, using state-of-the-art tools: Cochrane for randomized controlled trials (RCTs),8 Quality Assessment of Diagnostic Accuracy Studies (QUADAS)-2 for studies of diagnostic accuracy,9 and GRADE for observational studies that inform both therapy and prognosis questions.10Using the online GRADE Guideline Development Tool, the evidence reviewers created evidence profile tables11 to facilitate evaluation of the evidence in support of each of the critical and important outcomes. The quality of the evidence (or confidence in the estimate of the effect) was categorized as high, moderate, low, or very low,12 based on the study methodologies and the 5 core GRADE domains of risk of bias, inconsistency, indirectness, imprecision, and publication bias (and occasionally other considerations).6These evidence profile tables were then used to create a written summary of evidence for each outcome (the Consensus on Science statements). These statements were drafted by the evidence reviewers and then discussed and debated by the task forces until consensus was reached. Whenever possible, consensus-based treatment recommendations were created. These recommendations (designated as strong or weak and either for or against a therapy or diagnostic test) were accompanied by an overall assessment of the evidence, and a statement from the task force about the values and preferences that underlie the recommendations. Further details of the methodology of the evidence evaluation process are found in "Part 2: Evidence Evaluation and Management of Conflicts of Interest."This summary uses wording consistent with the wording recommended by GRADE and used throughout this publication. Weak recommendations use the word suggest, as in, "We suggest…." Strong recommendations are indicated by the use of the word recommend, as in, "We recommend…."In the years 2012–2015, 250 evidence reviewers from 39 countries completed 169 systematic reviews addressing resuscitation or first aid questions. The ILCOR 2015 Consensus Conference was attended by 232 participants representing 39 countries; 64% of the attendees came from outside the United States. This participation ensured that this final publication represents a truly international consensus process.Many of the systematic reviews included in this 2015 CoSTR publication were presented and discussed at monthly or semimonthly task force webinars as well as at the ILCOR 2015 Consensus Conference. Public comment was sought at 2 stages in the process. Initial feedback was sought about the specific wording of the PICO questions and the initial search strategies, and subsequent feedback was sought after creation of the initial draft consensus on science statements and treatment recommendations.13 A total of 492 comments were received. At each of these points in the process, the public comments were made available to the evidence reviewers and task forces for their consideration.With the support of science and technology specialists at the AHA, a Web-based information system was built to support the creation of scientific statements and recommendations. An online platform known as the Scientific Evaluation and Evidence Review System (SEERS) was developed to guide the task forces and their individual evidence reviewers. The SEERS system was also used to capture public comments and suggestions.To provide the widest possible dissemination of the science reviews performed for the 2015 consensus, as noted above, the list of completed systematic reviews is included in the Appendix. In addition, in each Part of the 2015 CoSTR document, each summary of the consensus on science and the treatment recommendations contains a live link to the relevant systematic review on the SEERS site. This link is identified by 3 or 4 letters followed by 3 numbers. These systematic reviews will be updated as additional science is published.This publication was ultimately approved by all ILCOR member organizations and by an international editorial board (listed on the title page of this supplement). The AHA Science Advisory and Coordinating Committee and the Editor-in-Chief of Circulation obtained peer reviews of each Part of this supplement before it was accepted for publication. The supplement is being published online simultaneously by Circulation and Resuscitation.Management of Potential Conflicts of InterestA rigorous conflict of interest (COI) management policy was followed at all times and is described in more detail in "Part 2: Evidence Evaluation and Management of Conflicts of Interest" of this 2015 CoSTR. A full description of these policies and their implementation can be found in "Part 4: Conflict of Interest Management Before, During, and After the 2010 International Consensus Conference on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations" in the 2010 CoSTR.14 As in 2010, anyone involved in any part of the 2015 process disclosed all commercial relationships and other potential conflicts; in total, the AHA processed more than 1000 COI declarations. These disclosures were taken into account in assignment of task force co-chairs and members, writing group co-chairs, and other leadership roles. In keeping with the AHA COI policy, a majority of the members of each task force writing group had to be free of relevant conflicts. Relationships were also screened for conflicts in assigning evidence reviewers for each systematic review.As in 2010, dual-screen projection was used for all sessions of the ILCOR 2015 Consensus Conference. One screen displayed the presenter's COI disclosures continuously throughout his or her presentation. Whenever participants or task force members spoke, their relationships were displayed on one screen, so all participants could see potential conflicts in real time, even while slides were projected on the second screen. During all other ILCOR meetings and during all conference calls and webinars, relevant conflicts were declared at the beginning of each meeting and preceded any comments made by participants with relevant conflicts.Applying Science to Improve SurvivalFrom Consensus on Science to GuidelinesThis publication presents international consensus statements that summarize the science of resuscitation and first aid and, wherever possible, treatment recommendations. ILCOR member organizations will subsequently publish resuscitation guidelines that are consistent with the science in this consensus publication, but they will also take into account geographic, economic, and system differences in practice and the availability of medical devices and drugs and the ease or difficulty of training. All ILCOR member organizations are committed to minimizing international differences in resuscitation practice and to optimizing the effectiveness of resuscitation practice, instructional methods, teaching aids, and training networks.The recommendations of the ILCOR 2015 Consensus Conference confirm the safety and effectiveness of various current approaches, acknowledge other approaches as ineffective, and introduce new treatments resulting from evidence-based evaluation. New and revised treatment recommendations do not imply that clinical care that involves the use of previously published guidelines is either unsafe or ineffective. Implications for education and retention were also considered when developing the final treatment recommendations.Ischemic heart disease is the leading cause of death in the world,15 and in the United States cardiovascular disease is responsible for 1 in 3 deaths, approximately 786 641 deaths every year.16 Annually in the United States, there are approximately 326 200 out-of-hospital cardiac arrests (OHCAs) assessed by emergency medical services (EMS) providers, and there are an additional estimated 209 000 treated in-hospital cardiac arrests (IHCAs).16 There are no significant differences between Europe, North America, Asia, and Australia in the incidence of OHCA. The incidence of patients with OHCA considered for resuscitation is lower in Asia (55 per year per 100 000 population) than in Europe (86), North America (103), and Australia (113).17 The incidence of patients in OHCA with presumed cardiac cause in whom resuscitation was attempted is higher in North America (58 per 100 000 population) than in the other 3 continents (35 in Europe, 32 in Asia, and 44 in Australia).17 However, most victims die out of hospital without receiving the interventions described in this publication.The actions linking the adult victim of sudden cardiac arrest with survival are characterized as the adult Chain of Survival. The links in this Chain of Survival are early recognition of the emergency and activation of the EMS system, early CPR, early defibrillation, early ALS, and skilled post–cardiac arrest/postresuscitation care. The links in the infant and child Chain of Survival are prevention of conditions leading to cardiopulmonary arrest, early CPR, early activation of the EMS system, early ALS, and skilled post–cardiac arrest/postresuscitation care.Newest Developments in Resuscitation: 2010–2015There is good evidence that survival rates after OHCA are improving.18–22 This is particularly true for those cases of witnessed arrest when the first monitored rhythm is shockable (ie, associated with ventricular fibrillation [VF] or pulseless ventricular tachycardia [pVT]), but increases in survival from nonshockable rhythms are also well documented.23 These improvements in survival have been associated with the increased emphasis on CPR quality as well as improved consistency in the quality of post–cardiac arrest/postresuscitation care.Each task force identified important developments in resuscitation science since the publication of the 2010 CoSTR. These developments are noted in brief below. After the brief list of developments, summaries of the evidence reviews are organized by task force.Adult Basic Life SupportThe following is a summary of the most important evidence-based recommendations for performance of adult BLS:The EMS dispatcher plays a critical role in identifying cardiac arrest, providing CPR instructions to the caller, and activating the emergency response.24–28The duration of submersion is a key prognostic factor when predicting outcome from drowning.29–40The fundamental performance metrics of high-quality CPR remain the same, with an emphasis on compressions of adequate rate and depth, allowing full chest recoil after each compression, minimizing pauses in compressions, and avoiding excessive ventilation. Some additional registry data suggest an optimal range for compression rate and depth.41,42Public access defibrillation programs providing early defibrillation have the potential to save many lives if the programs are carefully planned and coordinated.43–55Advanced Life SupportThe most important developments in ALS included the publication of additional studies of the effects of mechanical CPR devices, drug therapy, and insertion of advanced airway devices on survival from cardiac arrest. In addition, the task force evaluated several studies regarding post–cardiac arrest care and the use of targeted temperature management (TTM).The evidence in support of mechanical CPR devices was again reviewed. Three large trials of mechanical chest compression devices56–58 enrolling 7582 patients showed outcomes are similar to those resulting from manual chest compressions. While these devices should not routinely replace manual chest compressions, they may have a role in circumstances where high-quality manual compressions are not feasible.The Executive Summary for the 2010 CoSTR2,3 noted the insufficient evidence that drug administration improved survival from cardiac arrest. The 2015 systematic review identified large observational studies that challenged the routine use of advanced airways59–65 and the use of epinephrine66–68 as part of ALS. Because of the inherent risk of bias in observational studies, these data did not prompt a recommendation to change practice but do provide sufficient equipoise for large RCTs to test whether advanced airways and epinephrine are helpful during CPR.Post–cardiac arrest care is probably the area of resuscitation that has undergone the greatest evolution since 2010, with substantial potential to improve survival from cardiac arrest. Recent improvements include further delineation of the effects, timing, and components of TTM, and awareness of the need to control oxygenation and ventilation and optimize cardiovascular function.The effect and timing of TTM continues to be defined by many studies published after 2010. One high-quality trial could not demonstrate an advantage to a temperature goal of either 33°C or 36°C for TTM,69 and 5 trials could not identify any benefit from prehospital initiation of hypothermia with the use of cold intravenous fluids.70–74 The excellent outcomes for all patients in these trials reinforced the opinion that post–cardiac arrest patients should be treated with a care plan that includes TTM, but there is uncertainty about the optimal target temperature, how it is achieved, and for how long temperature should be controlled.Acute Coronary SyndromesThe following are the most important evidenced-based recommendations for diagnosis and treatment of ACS since the 2010 ILCOR review:Prehospital ST-segment elevation myocardial infarction (STEMI) activation of the catheterization laboratory reduces treatment delays and also improves patient mortality.Adenosine diphosphate receptor antagonists and unfractionated heparin (UFH) can be given either prehospital or in-hospital for suspected STEMI patients with a planned primary percutaneous coronary intervention (PCI) approach.Prehospital enoxaparin may be used as an alternative to prehospital UFH as an adjunct for primary PCI for STEMI. There is insufficient evidence to recommend prehospital bivalirudin as an alternative.The use of troponins at 0 and 2 hours as a stand-alone measure for excluding the diagnosis of ACS is strongly discouraged.We recommend against using troponins alone to exclude the diagnosis of ACS. We suggest that negative high-sensitivity troponin I (hs-cTnI) measured at 0 and 2 hours may be used together with low-risk stratification or negative cardiac troponin I (cTnI) or cardiac troponin T (cTnT) measured at 0 and 3 to 6 hours with very-low risk stratification to identify those patients who have a less than 1% 30-day risk of a major adverse cardiac event (MACE).We suggest withholding oxygen in normoxic patients with ACS.Primary PCI is generally preferred to fibrinolysis for STEMI reperfusion, but that decision should be individualized based on time from symptom onset (early presenters), anticipated time (delay) to PCI, relative contraindications to fibrinolysis, and other patient factors.For adult patients presenting with STEMI in the emergency department (ED) of a non–PCI-capable hospital, either transport expeditiously for primary PCI (without fibrinolysis) or administer fibrinolysis and transport early for routine angiography in the first 3 to 6 hours (or up to 24 hours).For select adult patients with return of spontaneous circulation (ROSC) after OHCA of suspected cardiac origin with ST-elevation on electrocardiogram (ECG), we recommend emergency cardiac catheterization laboratory evaluation (in comparison with delayed or no catheterization). In select comatose adult patients with ROSC after OHCA of suspected cardiac origin but without ST-elevation on ECG, we suggest emergency cardiac catheterization evaluation.Pediatric Basic and Advanced Life SupportThe most important new developments in pediatric resuscitation since 2010 include the publication of the results of a study of TTM in children following ROSC after OHCA. Additional new developments include refinement of long-standing recommendations regarding fluid therapy and antiarrhythmics. These new developments are summarized here:When caring for children remaining unconscious after OHCA, outcomes are improved when fever is prevented, and a period of moderate therapeutic hypothermia or strict maintenance of normothermia is provided.75The use of restricted volumes of isotonic crystalloid may lead to improved outcomes from pediatric septic shock in specific settings. When caring for children with febrile illnesses (especially in the absence of signs of overt septic shock), a cautious approach to fluid therapy should be used, punctuated with frequent patient reassessment.76The use of lidocaine or amiodarone for treatment of shock-resistant pediatric VF/pVT improves short-term outcomes, but there remains a paucity of information about their effects on long-term outcomes.77Neonatal ResuscitationThe Neonatal Task Force identified new information about the association between admission temperature in newly born infants and morbidity and mortality, evaluated new evidence regarding the role of routine intubation of nonvigorous infants born through meconium-stained amniotic fluid, and evaluated new evidence regarding the use of the ECG to assess heart rate. The systematic reviews of these topics will result in new recommendations.The admission temperature of newly born nonasphyxiated infants is a strong predictor of mortality and morbidity at all gestations. For this reason, it should be recorded as a predictor of outcomes as well as a quality indicator.78–82There is insufficient published human evidence to suggest routine tracheal intubation for suctioning of meconium in nonvigorous infants born through meconium-stained amniotic fluid as opposed to no tracheal intubation for suctioning.83It is suggested in babies requiring resuscitation that the ECG can be used to provide a rapid and accurate estimation of heart rate.84–86Education, Implementation, and TeamsThe most noteworthy reviews or changes in recommendations for EIT since the last ILCOR review in 2010 pertain to training and the importance of systems of care focused on continuous quality improvement.TrainingIt is now recognized that training should be more frequent and less time consuming (high frequency, low dose) to prevent skill degradation; however, the evidence for this is weak.High-fidelity manikins may be preferred to standard manikins at training centers/organizations that have the infrastructure, trained personnel, and resources to maintain the program.The importance of performance measurement and feedback in cardiac arrest response systems (in-hospital and out-of-hospital) is well recognized but remains supported by data of low quality. CPR feedback devices (providing directive feedback) are useful to learn psychomotor CPR skills.Retraining cycles of 1 to 2 years are not adequate to maintain competence in resuscitation skills. The optimal retraining intervals are yet to be defined, but more frequent training may be helpful for providers likely to encounter a cardiac arrest.SystemsYou can't improve what you don't measure, so systems that facilitate performance measurement and quality improvement initiatives are to be used where possible.Data-driven, performance-focused debriefing can help improve performance of resuscitation teams.There is increasing evidence (albeit of low quality) that treatment of post–cardiac arrest patients in regionalized cardiac arrest centers is associated with increased survival.87,88 OHCA victims should be considered for transport to a specialist cardiac arrest center as part of a wider regional system of care.Advances in the use of technology and social media for notification of the occurrence of suspected OHCA and sourcing of bystanders willing to provide CPR. The role of technology/social media in the bystander CPR response for OHCA is evolving rapidly.First AidThe First Aid Task Force reviewed evidence on the medical topics of stroke assessment, treatment of hypoglycemia in patients with diabetes, and on the injury topics of first aid treatment of open chest wounds and severe bleeding and on identification of concussion.The single most important new treatment recommendation of the 2015 International Consensus on First Aid Science With Treatment Recommendations is the recommendation in favor of the use of stroke assessment systems by first aid providers to improve early identification of possible stroke and enable subsequent referral for definitive treatment. The FAST (Face, Arm, Speech, Time)89,90 tool and the Cincinnati Prehospital Stroke Scale91 are recommended, with the important caveat that recognition specificity can be improved by including blood glucose measurement.First aid providers are often faced with the signs and symptoms of hypoglycemia. Failure to treat this effectively can lead to serious consequences such as loss of consciousness and seizures. The 2015 CoSTR recommends the administration of glucose tablets for conscious individuals who can swallow. If glucose tablets are not immediately available, then recommendations for various substitute forms of dietary sugars have been made.92–94The recommendation for the management of open chest wounds by not using an occlusive dressing or device, or any dressing or device that may become occlusive, emphasizes the inherent serious life-threatening risk of creating a tension pneumothorax.95Recommendations for the management of severe bleeding include the use of direct pressure, hemostatic dressings,96–99 and tourniquets.100–106 However, formal training in the use of hemostatic dressings and tourniquets will be required to ensure their effective application and use.The 2015 First Aid Task Force recommends the development of a simple validated concussion scoring system for use by first aid providers in the accurate identification and management of concussion (minor traumatic brain injury), a condition commonly encountered by first aid providers in the prehospital environment.Summary of the 2015 ILCOR Consensus on Science With Treatment RecommendationsThe following sections contain summaries of the key systematic reviews of the 2015 CoSTR. These summaries are organized by task force. Note that there are few references cited in the summaries; we refer the reader to the detailed information prepared by each task force in other Parts of the 2015 CoSTR.Adult Basic Life SupportThe ILCOR 2015 Consensus Conference addressed intervention, diagnostic, and prognostic questions related to the performance of BLS. The body of knowledge encompassed in this Part comprises 23 systematic reviews, with 32 treatment recommendations, derived from a GRADE evaluation of 27 randomized clinical trials and 181 observational studies of variable design and quality conducted over a 35-year period. These have been grouped into (1) early access and cardiac arrest prevention, (2) early high-quality CPR, and (3) early defibrillation.Early Access and Cardiac Arrest PreventionEarly access for the victim of OHCA begins when a bystander contacts the EMS dispatcher, who then coordinates the emergency response to that cardiac arrest. The dispatcher's role in identifying possible cardiac arrest, dispatching responders, and providing instructions to facilitate bystander performance of chest compressions has been demonstrated in multiple countries with consistent improvement in cardiac arrest survival. Dispatchers should be educated to identify unconsciousness with abnormal breathing. This education should include recognition of, and significance of, agonal breaths across a range of clinical presentations and descriptions. If the victim is unconscious with abnormal or absent breathing, it is reasonable to a