ILCOR Guidelines in the Treatment of Cardiac Arrest

The International Liaison Committee on Resuscitation (ILCOR) guidelines exist to help summarize research into cardiac arrest and best practices for initiating, carrying out, and terminating resuscitation. This section will focus less on the recognition/treatment of cardiac arrest and more on highly tested terminology, critical steps, and when to terminate lifesaving efforts. 

Terminology

Resuscitation:  defined as the efforts to return spontaneous pulse and breathing to the patient in full cardiac arrest.

Return of Spontaneous Circulation (ROSC): defined as the patient being resuscitated to the point of having a pulse without CPR, with or without the return of spontaneous respirations.

Survival: defined as the patient being resuscitated and surviving through to hospital discharge.

 

Critical Steps

According to ILCOR, the critical lifesaving steps of BLS are; Prevention (through the treatment of chronic conditions), Recognition (and activation of the emergency response), Early High-Quality CPR, and Rapid Defibrillation for shockable rhythms. 

ILCOR goes on to define several other elements of these steps that contribute to high-quality care: The two most highly tested and relevant to EMS are appropriate medication administration and communication.

Appropriate Medication Administration (ALS LEVEL): Cardiac arrest is painful. Remembering to use Fentanyl instead of morphine if hypotension or bradycardia is present is an important step. If morphine is administered and the patient's systolic BP drops below 90, an IV bolus of 250 ml of normal saline is indicated.

Ensure that epinephrine is given in 3 to 5-minute intervals, as it is the only medication that has been shown to improve survival. Amiodarone should be used for wide complex ventricular tachycardias only. 

Communication: Always remember to explain to the patient, family, and any significant others what is being done and why in regard to treatment for cardiac arrest or in any other emergency situation. Communication with and transferring data (ECG/EKG, vital signs, etc.) with the receiving hospital and physician is paramount.

 

Withholding/Terminating Resuscitation

When to stop CPR or avoid starting it is less intuitive than beginning CPR and is naturally not the focus of guidelines such as ACLS and BLS. Below are the ILCOR guidelines for terminating and continuing resuscitation.  

Criteria for Terminating of Withholding Resuscitation

The following criteria, if present, generally indicate that prolonged resuscitative measures may not be required, as outcomes are generally poorer in these populations and have a significantly reduced chance of survival to hospital discharge. 

• Patient 18 years of age or older, AND
• an arrest is presumed cardiac in origin and not associated with a condition potentially responsive to hospital treatment (such as hypothermia, drug overdose, toxicologic exposure, etc),
• endotracheal intubation has been successfully accomplished and maintained,
• standard advanced cardiac life support (ACLS) measures have been applied throughout the resuscitative effort,
• on-scene ALS resuscitation efforts have been sustained for 25 minutes or the patient remains in asystole through four rounds of appropriate ALS drugs,
• the patient has a cardiac rhythm of asystole or agonal rhythm at the time the decision to terminate is made and this rhythm persists until the arrest is actually terminated, and
• victims of blunt trauma in arrest whose presenting rhythm is asystole or who develop asystole while on scene.

Criteria for Continuing Resuscitation

The following criteria, if present, generally indicate that aggressive resuscitative measures should be continued for a prolonged length of time, as outcomes are generally better in these populations, even with extended CPR. 

• Patients under the age of 18,
• etiology for which specific in-hospital treatment may be beneficial,
• persistent or recurrent ventricular tachycardia or fibrillation,
• transient return of pulse,
• signs of neurological viability,
• the arrest was witnessed by EMS personnel or
• family or responsible party is opposed to termination.

Irrelevant Criteria

ILCOR also defines several criteria that were previously considered to be important but, upon further study, were found to have minimal to no effect on outcomes. These should not be considered when deciding when to continue or terminate resuscitative efforts. 

• Elderly patient age (geriatric),
• time of collapse prior to EMS arrival,
• presence of a "do-not-resuscitate (DNR) order" that is not official, and
• “quality of life” valuations.

 

Field Termination of Resuscitation According to Different Groups

Included for completeness sake, there are several other groups that have simplified protocols and definitions that define when EMS efforts to resuscitate a cardiac arrest victim should be terminated. 

The American Heart Association

For exclusively BLS systems, EMS personnel should consider field termination when three termination criteria exist:

1. no EMS professional witnessed the onset of arrest;
2. no ROSC after three full rounds of CPR and AED analysis; and
3. no shock delivered by the AED.

For ALS systems, advanced-level providers consider field termination when four criteria exist:

1. No one witnessed the onset of the arrest.
2. no bystanders performed CPR prior to EMS arrival;
3. the patient never achieved ROSC after full ALS implementation, and
4. no shock delivered by an AED.

The National Association of EMS Physicians

EMS personnel should consider field termination when three criteria exist:

1. no EMS professional witnessed the onset of the arrest;
2. there was never a shockable rhythm present and
3. the patient never achieved ROSC on-scene.

 

Protocol Procedures

Procedures during a cardiac arrest, always according to protocol--especially prior to termination of efforts--include

• direct communication with medical oversight (including the medical condition of the patient, known etiologic factors, therapy rendered, family being present and apprised of the situation, and communication of any resistance or uncertainty on the part of the family),
• maintaining continuous documentation to include the ECG/EKG and a
• mandatory review after-event for grief support and per law enforcement.

Grief support review (according to local protocol) is obtained through EMS-assigned personnel or community agency referral.

Law enforcement review (according to local protocol) takes place on-scene and after the fact in certain situations and includes

• on-scene determination of whether or not the event/patient requires assignment to the medical examiner,
• on-scene law enforcement communication with the attending physician for the death certificate,
• determination of whether or not there is any suspicion about the nature of the death, or if the physician refuses or hesitates to sign the death certificate, and
• whether or not there is an attending physician to be identified. (If not, the patient will be assigned to the medical examiner.)