2015 Guidelines Update: Part 8 Recommendations

Year Last Reviewed	Topic	Recommendation	Comments
2015	Cardiovascular Care	Coronary angiography should be performed emergently (rather than later in the hospital stay or not at all) for OHCA patients with suspected cardiac etiology of arrest and ST elevation on ECG (Class I, LOE B-NR).	updated for 2015
2015	Cardiovascular Care	Emergent coronary angiography is reasonable for select (e.g. electrically or hemodynamically unstable) adult patients who are comatose after OHCA of suspected cardiac origin but without ST elevation on ECG (Class IIa, LOE B-NR).	updated for 2015
2015	Cardiovascular Care	Coronary angiography is reasonable in post–cardiac arrest patients for whom coronary angiography is indicated regardless of whether the patient is comatose or awake (Class IIa, LOE C-LD).	updated for 2015
2015	Hemodynamic Goals	Avoiding and immediately correcting hypotension (systolic blood pressure less than 90 mm Hg, MAP less than 65 mm Hg) during postresuscitation care may be reasonable (Class IIb, LOE C-LD).	new for 2015
2015	Targeted Temperature Management	We recommend that comatose (ie, lack of meaningful response to verbal commands) adult patients with ROSC after cardiac arrest have TTM (Class I, LOE B-R for VF/pVT OHCA; Class I, LOE C-EO for non-VF/pVT (ie, “nonshockable”) and in-hospital cardiac arrest).	updated for 2015
2015	Targeted Temperature Management	We recommend selecting and maintaining a constant temperature between 32°C and 36°C during TTM (Class I, LOE B-R).	updated for 2015
2015	Targeted Temperature Management	It is reasonable that TTM be maintained for at least 24 hours after achieving target temperature (Class IIa, LOE C-EO).	updated for 2015
2015	Targeted Temperature Management	We recommend against the routine prehospital cooling of patients after ROSC with rapid infusion of cold intravenous fluids (Class III: No Benefit, LOE A).	new for 2015
2015	Targeted Temperature Management	It may be reasonable to actively prevent fever in comatose patients after TTM (Class IIb, LOE C-LD).	new for 2015
2015	Other Neurologic Care	An EEG for the diagnosis of seizure should be promptly performed and interpreted, and then should be monitored frequently or continuously in comatose patients after ROSC (Class I, LOE C-LD).	updated for 2015
2015	Other Neurologic Care	The same anticonvulsant regimens for the treatment of status epilepticus caused by other etiologies may be considered after cardiac arrest (Class IIb, LOE C-LD).	updated for 2015
2015	Respiratory Care	Maintaining the Paco2 within a normal physiological range, taking into account any temperature correction, may be reasonable (Class IIb, LOE B-NR).	updated for 2015
2015	Respiratory Care	To avoid hypoxia in adults with ROSC after cardiac arrest, it is reasonable to use the highest available oxygen concentration until the arterial oxyhemoglobin saturation or the partial pressure of arterial oxygen can be measured (Class IIa, LOE C-EO).	new for 2015
2015	Respiratory Care	When resources are available to titrate the Fio2 and to monitor oxyhemoglobin saturation, it is reasonable to decrease the Fio2 when oxyhemoglobin saturation is 100%, provided the oxyhemoglobin saturation can be maintained at 94% or greater (Class IIa, LOE C-LD).	updated for 2015
2015	Other Critical Care Interventions	The benefit of any specific target range of glucose management is uncertain in adults with ROSC after cardiac arrest (Class IIb, LOE B-R).	updated for 2015
2015	Prognostication of Outcome	The earliest time for prognostication using clinical examination in patients treated with TTM, where sedation or paralysis could be a confounder, may be 72 hours after normothermia (Class IIb, LOE C-EO).	updated for 2015
2015	Other Critical Care Interventions	We recommend the earliest time to prognosticate a poor neurologic outcome using clinical examination in patients not treated with TTM is 72 hours after cardiac arrest (Class I, LOE B-NR).	new for 2015
2015	Other Critical Care Interventions	This time until prognostication can be even longer than 72 hours after cardiac arrest if the residual effect of sedation or paralysis confounds the clinical examination (Class IIa, LOE C-LD).	new for 2015
2015	Other Critical Care Interventions	In comatose patients who are not treated with TTM, the absence of pupillary reflex to light at 72 hours or more after cardiac arrest is a reasonable exam finding with which to predict poor neurologic outcome (FPR, 0%; 95% CI, 0%–8%; Class IIa, LOE B-NR).	new for 2015
2015	Other Critical Care Interventions	In comatose patients who are treated with TTM, the absence of pupillary reflex to light at 72 hours or more after cardiac arrest is useful to predict poor neurologic outcome (FPR, 1%; 95% CI, 0%–3%; Class I, LOE B-NR).	new for 2015
2015	Other Critical Care Interventions	We recommend that, given their unacceptable FPRs, the findings of either absent motor movements or extensor posturing should not be used alone for predicting a poor neurologic outcome (FPR, 10%; 95% CI, 7%–15% to FPR, 15%; 95% CI, 5%–31%; Class III: Harm, LOE B-NR).	new for 2015
2015	Other Critical Care Interventions	The motor examination may be a reasonable means to identify the population who need further prognostic testing to predict poor outcome (Class IIb, LOE B-NR).	new for 2015
2015	Other Critical Care Interventions	We recommend that the presence of myoclonus, which is distinct from status myoclonus, should not be used to predict poor neurologic outcomes because of the high FPR (FPR, 5%; 95% CI, 3%–8% to FPR, 11%; 95% CI, 3%–26%; Class III: Harm, LOE B-NR).	updated for 2015
2015	Other Critical Care Interventions	In combination with other diagnostic tests at 72 or more hours after cardiac arrest, the presence of status myoclonus during the first 72 to 120 hours after cardiac arrest is a reasonable finding to help predict poor neurologic outcomes (FPR, 0%; 95% CI, 0%–4%; Class IIa, LOE B-NR).	new for 2015
2015	Other Critical Care Interventions	In comatose post–cardiac arrest patients who are treated with TTM, it may be reasonable to consider persistent absence of EEG reactivity to external stimuli at 72 hours after cardiac arrest, and persistent burst suppression on EEG after rewarming, to predict a poor outcome (FPR, 0%; 95% CI, 0%–3%; Class IIb, LOE B-NR).	updated for 2015
2015	Other Critical Care Interventions	Intractable and persistent (more than 72 hours) status epilepticus in the absence of EEG reactivity to external stimuli may be reasonable to predict poor outcome (Class IIb, LOE B-NR).	updated for 2015
2015	Other Critical Care Interventions	In comatose post–cardiac arrest patients who are not treated with TTM, it may be reasonable to consider the presence of burst suppression on EEG at 72 hours or more after cardiac arrest, in combination with other predictors, to predict a poor neurologic outcome (FPR, 0%; 95% CI, 0%–11%; Class IIb, LOE B-NR).	updated for 2015
2015	Other Critical Care Interventions	In patients who are comatose after resuscitation from cardiac arrest regardless of treatment with TTM, it is reasonable to consider bilateral absence of the N20 SSEP wave 24 to 72 hours after cardiac arrest or after rewarming a predictor of poor outcome (FPR, 1%; 95% CI, 0%–3%; Class IIa, LOE B-NR).	updated for 2015
2015	Other Critical Care Interventions	In patients who are comatose after resuscitation from cardiac arrest and not treated with TTM, it may be reasonable to use the presence of a marked reduction of the GWR on brain CT obtained within 2 hours after cardiac arrest to predict poor outcome (Class IIb, LOE B-NR).	new for 2015
2015	Other Critical Care Interventions	It may be reasonable to consider extensive restriction of diffusion on brain MRI at 2 to 6 days after cardiac arrest in combination with other established predictors to predict a poor neurologic outcome (Class IIb, LOE B-NR).	new for 2015
2015	Other Critical Care Interventions	Given the possibility of high FPRs, blood levels of NSE and S-100B should not be used alone to predict a poor neurologic outcome (Class III: Harm, LOE C-LD).	updated for 2015
2015	Other Critical Care Interventions	When performed with other prognostic tests at 72 hours or more after cardiac arrest, it may be reasonable to consider high serum values of NSE at 48 to 72 hours after cardiac arrest to support the prognosis of a poor neurologic outcome (Class IIb, LOE B-NR), especially if repeated sampling reveals persistently high values (Class IIb, LOE C-LD).	updated for 2015
2015	Other Critical Care Interventions	We recommend that all patients who are resuscitated from cardiac arrest but who subsequently progress to death or brain death be evaluated for organ donation (Class I, LOE B-NR).	updated for 2015
2015	Other Critical Care Interventions	Patients who do not have ROSC after resuscitation efforts and who would otherwise have termination of efforts may be considered candidates for kidney or liver donation in settings where programs exist (Class IIb, LOE B-NR).	new for 2015
The following recommendations were not reviewed in 2015. For more information, see the 2010 AHA Guidelines for CPR and ECC, “Part 9: Post–Cardiac Arrest Care.”
2010	Systems of Care for Improving Post–Cardiac Arrest Outcomes	A comprehensive, structured, multidisciplinary system of care should be implemented in a consistent manner for the treatment of post–cardiac arrest patients (Class I, LOE B).	not reviewed in 2015
2010	Treatment of Pulmonary Embolism After CPR	In post–cardiac arrest patients with arrest due to presumed or known pulmonary embolism, fibrinolytics may be considered (Class IIb, LOE C).	not reviewed in 2015
2010	Sedation After Cardiac Arrest	It is reasonable to consider the titrated use of sedation and analgesia in critically ill patients who require mechanical ventilation or shivering suppression during induced hypothermia after cardiac arrest (Class IIb, LOE C).	not reviewed in 2015
2010	Cardiovascular System	A 12-lead ECG should be obtained as soon as possible after ROSC to determine whether acute ST elevation is present (Class I, LOE B).	not reviewed in 2015
2010	Neuroprotective	The routine use of coenzyme Q10 in patients treated with hypothermia is uncertain (Class IIb, LOE B).	not reviewed in 2015
2010	Evoked Potentials	Bilateral absence of the N20 cortical response to median nerve stimulation after 24 hours predicts poor outcome in comatose cardiac arrest survivors not treated with therapeutic hypothermia (Class IIa, LOE A).	not reviewed in 2015