Series
Out-of-hospital cardiac arrest 2
Lancet 2018; 391: 980–88
This is the second in a Series of
three papers about
out-of-hospital cardiac arrest
Department of Emergency
Medicine, Singapore General
Hospital, Singapore
(M E H Ong MPH); Health
Services and Systems Research,
Duke-NUS Medical School,
Singapore (M E H Ong);
Warwick Clinical Trials Unit,
Warwick Medical School,
University of Warwick,
Coventry, UK (G D Perkins MD);
Heart of England NHS
Foundation Trust,
Birmingham, UK (G D Perkins);
Medical Intensive Care Unit,
AP-HP, Cochin Hospital, Paris,
France (Prof A Cariou MD); and
Paris Descartes University,
Paris, France (Prof A Cariou)
Correspondence to:
Dr Marcus Eng Hock Ong,
Department of Emergency
Medicine, Singapore General
Hospital, Singapore 169856
marcus.ong.e.h@singhealth.
com.sg
980 www.thelancet.com Vol 391 March 10, 2018
Out-of-hospital cardiac arrest: prehospital management
Marcus Eng Hock Ong, Gavin D Perkins, Alain Cariou
Sudden out-of-hospital cardiac arrest is the most time-critical medical emergency. In the second paper of this Series
on out-of-hospital cardiac arrest, we considered important issues in the prehospital management of cardiac arrest.
Successful resuscitation relies on a strong chain of survival with the community, dispatch centre, ambulance, and
hospital working together. Early cardiopulmonary resuscitation and defibrillation has the greatest impact on survival.
If the community response does not restart the heart, resuscitation is continued by emergency medical services’ staff.
However, the best approaches for airway management and the effectiveness of currently used drug treatments are
uncertain. Prognostic factors and rules for termination of resuscitation could guide the duration of a resuscitation
attempt and decision to transport to hospital. If return of spontaneous circulation is achieved, the focus of treatment
shifts to stabilisation, restoration of normal physiological parameters, and transportation to hospital for ongoing care.
Introduction Role of the community working with dispatch
Out-of-hospital cardiac arrest (OHCA) is a global health CPR in the community
problem, with survival varying greatly between The earlier CPR is started in OHCA, the more likely it is
communities.1,2 The chain of survival provides a useful that the patient will survive.6 In a study from Ontario,
concept to understand differences in prehospital systems Canada, the OPALS investigators4 concluded that by­
of emergency care that result in such variations in stander CPR was the most important modifiable factor
survival.3 Survival of patients with OHCA requires a for survival after OHCA (odds ratio [OR] 2·98, 95% CI
coordinated set of actions, including immediate 2·07–4·29).
recognition of cardiac arrest and activation of the Conventional strategies to improve the frequency of
emergency response system, early cardiopulmonary bystander CPR require a concerted public health effort to
resuscitation (CPR), rapid defibrillation, effective ad­ educate and train the population to perform CPR. These
vanced life support, and integrated care after cardiac strategies might include mandatory requirements for
arrest. The chain of survival encompasses the commun­ CPR training in schools or to obtain a driver’s licence (eg,
ity, emergency medical dispatch, and ambulance and Seattle, WA, USA). In general, they are labour intensive
hospital-based services. The medical literature has and require a long-term approach to achieve positive
focused more on hospital and advanced life support outcomes.7 It is also a relatively costly strategy,
treatments than it has on community treatment and considering the large number of people that need to be
issues related to basic life support (figure 1). However, trained to achieve any improvement in delivery of
there has been increasing recognition of the importance bystander CPR.8 Despite large-scale training efforts in
of basic life support, the role of the community, and communities, reported rates of bystander CPR have been
the key function of emergency medical dispatch in low, for reasons including difficulty in identifying cardiac
coordination of bystander CPR and early defibrillation.4,5 arrest, fear of causing harm, emotional distress, and
reluctance to perform mouth-to-mouth resuscitation.9
The dispatch centre (also known as the control room
Search strategy and selection criteria or call centre) has a central role in the coordination of the
In this Series paper, we consider the prehospital management response to OHCA (figure 2). In many ways, it is the
of out-of-hospital cardiac arrest, with a focus on the first links brain of the emergency medical services (EMS) and
in the chain of survival. We searched the Cochrane Library, determines the subsequent dispatch of resources and
MEDLINE, and Embase from Jan 1, 2001, to Dec 31, 2017, with response to an OHCA.
the terms “cardiac arrest” or “resuscitation” in combination Dispatcher-assisted CPR is an attractive intervention to
with “dispatch”, “ambulance”, “pre-hospital”, “emergency increase CPR rates and survival.10 When a bystander calls
medical services”, “defibrillation”, or “cardio-pulmonary the emergency medical response number to request for
resuscitation”. Our search was restricted to English-language help, they create an opportunity for early identification of
publications only. We largely selected publications from the OHCA and provision of bystander CPR.11 The medical
past 10 years, but did not exclude commonly referenced older dispatcher is thus the true first responder at the scene,
publications. We also searched the reference lists of articles and can be key to prompt recognition of cardiac arrest and
identified by this search strategy and selected those we judged initiation of bystander CPR. This strategy requires proper
relevant. Our reference list was modified on the basis of training of dispatchers to ask the right questions, manage
comments from peer reviewers. the emotional state of the caller, and give clear instructions.
Giving just-in-time education over the telephone can

provide callers with step-by-step instructions on how to
perform CPR.
Dispatcher-assisted CPR programmes can nearly
double the frequency of bystander CPR.12 Change in
protocols to compression-only CPR have enabled dis­
patchers to give simple instructions for rescuing adults in
sudden cardiac arrest.13 Dispatch-assisted, compression-
only CPR results in reduced delay in starting CPR,
increased participation, and improved outcomes in
early cardiac arrest.14 In Singapore, a comprehensive
programme of dispatcher-assisted CPR (which included
dispatcher training focusing on communication and
persuasion, review of audio recordings of all OHCA calls,
giving feedback to dispatchers, and public education on
dispatcher-assisted CPR) doubled bystander CPR rates
and increased survival after OHCA.15
Problems with recognition of cardiac arrest by the public
and the dispatcher
One of the main barriers to timely initiation of EMS
response and initiation of CPR is difficulty the general
public has in recognising OHCA, and similarly challenges
for dispatchers to diagnose OHCA over the telephone.16
In particular, a patient in cardiac arrest might still have
gasping movements, due to agonal breathing that can be
misinterpreted as normal respiration.12 This difficulty has
led to the development of “no, no, go” protocols by EMS
systems such as that of Seattle, USA,17 which have been
increasingly adopted elsewhere in the USA, Europe,
South Korea, Taiwan, and Singapore. These pro­ tocols
emphasise deliberate initiation of dispatcher-assisted
CPR instructions if the response to two initial questions
is no: “is the person conscious?” and “is the person
breathing normally?”. Such protocols have substantially
increased the delivery of bystander CPR.18 However, these
protocols also increase the likelihood that a person who is
not in cardiac arrest might receive chest compressions,
although in practice this possibility has not resulted in
any reported adverse outcomes. In the near future, video-
assisted dispatch technologies might enhance the ability
of dispatchers to recognise OHCA.
Public education, community CPR, and defibrillation
training
There has been increasing understanding that prompt
CPR and defibrillation is important for OHCA survival,
irrespective of who performs it.19 Reduction of ambulance
response times is challenging for most EMS systems,
and might not be a cost-effective policy to improve
survival.20 Simplified training programmes have
shown potential to actively recruit lay people into
community efforts. For example, a large public campaign
focusing on compression-only CPR in Arizona, USA,
was successful in increasing bystander CPR rates as well
as survival.21 The aim should not be to dilute the quality
of CPR training, but to extend the reach into the
community to build a pyramid of responders (figure 3).
www.thelancet.com Vol 391 March 10, 2018 981
Series
Current relative emphasis on elements in the chain of survival
H
AED
H
AED
Survival impacts of elements in the chain of survival
Figure 1: Current relative emphasis versus effect on survival of elements in the chain of survival
AED=automated external defibrillator.
Public-access defibrillation
The key challenge to improve strategies that increase
public access to defibrillation is how to link willing lay
responders to public-access defibrillators. Installation of
public-access automated external defibrillators (AEDs)
without linking them to responders might not improve
survival. However, community-wide programmes that
integrate public training on CPR with increased access to
AEDs, for example in Japan,19 have increased the odds of
neurologically intact survival.
Although cost is still a potential barrier to dissemination
of AEDs, strategic placement of AEDs could be a more
pressing issue. For example, Folke and colleagues16
estimated that, for the city of Copenhagen, 1104 AEDs
would be required to cover 67% of arrests with the cost
per quality-adjusted life-year gained being US$40 900.22
However, this cost could possibly be reduced with use of
smart technologies to link existing AEDs with lay
responders.
One exciting development in recent years has been the
potential of smartphone technology to amplify the effect
of volunteer first responders and public AEDs. A national
registry of AEDs that is available to the public is a crucial
prerequisite for success. Ringh and colleagues23 showed
that mobile-phone positioning to alert volunteers to the
location of AEDs significantly increased rates of bystander-
initiated CPR for OHCAs. Smartphone technology can
help trained bystanders to locate both the patient and the
nearest AED. In a world where smartphones are common,
application of this technology could be a potential game
changer. Another interesting possibility in the near future
is that of AEDs mounted on drones, sent to bystanders
performing CPR.24
Decision to resuscitate
Early descriptions of resuscitation described its application
for “hearts that are too good to die”.25 Resuscitation
started promptly has the greatest chance of success.
 Series

First responder Public-access AED

smart technology defibrillation

Dispatcher-
assisted CPR
EMS response
H
Patient with Post-resuscitation
Active citizens
cardiac arrest care

Figure 2: Systems approach to improving survival after cardiac arrest

CPR=cardiopulmonary resuscitation. AED=automated external defibrillator. EMS=emergency medical services.

Pyramid of first responder normal breathing (and absence of a central pulse

preparedness
Lay or
volunteer CPR
and AED instructors
Move lay
bystanders
Certified CPR and AED training
this way
Anyone who attends and passes a
certified (>3 h) CPR and AED course
Community awareness: Simplified CPR and AED training
everyone becomes aware of what Anyone who has attended a simplified (<1 h)
CPR is, and how to follow course emphasising dispatcher-assisted CPR and AED use
instructions from EMS dispatchers
Figure 3: Building a pyramid of first responder preparedness
All training programmes referred to include hands-on practice and not just exposure to theory.
CPR=cardiopulmonary resuscitation. AED=automated external defibrillator. EMS=emergency medical services.
If resus­ citation efforts are delayed (as often occurs in
unwitnessed cardiac arrest or when no bystander CPR is
provided), the chances of successful resuscitation are
substantially reduced.
International approaches differ in the decision to
commence or continue resuscitation. In many but not
all settings, resuscitation will be withheld if there is
evidence of irreversible death (eg, rigor mortis, dependent
lividity [hypostasis], or unsurvivable injuries).26 In some
countries, adverse prognostic factors (eg, unwitnessed
cardiac arrest, no bystander CPR for more than 15 min,
or asystolic rhythm and the absence of a potentially
reversible cause such as hypothermia) permit resus­
citation to be withheld,27 when in other countries
resuscitation would be provided in such circumstances.28
In some jurisdictions, advanced decisions by patients to
withhold resuscitation might have to be recorded before
cardiac arrest although their use in the community is
much less common than in hospitals.29–31
EMS response and interventions (including
pharmacotherapeutic interventions)
Resuscitation efforts by health-care professionals usually
follow the Universal Treatment Algorithm.31 After con­
firmation of cardiac arrest by identifying the absence of
for those experienced in central pulse palpation), chest
compressions (5–6 cm depth, rate 100–120 per min,
with minimal interruptions) are delivered while
cardiac monitoring is established (figure 4).32 If the
initial rhythm is ventricular fibrillation or ventricular
tachycardia, defibrillation is attempted followed by
immediate resumption of chest compressions. For
non-shockable rhythms (pulseless electrical activity
and asystole) chest compressions are continued. Before
securing the airway, chest compressions are paused
every 30 compressions to allow the delivery of
two ventilations.33,34 Once the airway is secured,
con­tinuous chest compressions with intermittent
ventilations are recommended.34
There is controversy about the optimal approach to
airway management in OHCA. Observational studies
have produced conflicting results when comparing
basic (eg, bag–valve–mask) with advanced airways (eg,
intu­bation or supraglottic airways).35–37 The training and
ex­perience of the operator undertaking airway manage­
ment is probably an important contributing factor.38
The recently completed AIRWAYS-239 and PART40 trials
will provide valuable information about the optimal
approach to airway management in OHCA.
Medication has featured in cardiac arrest algorithms
since their inception. However, two landmark studies
found no evidence that drugs improved outcomes.41,42
The Ontario Pre-hospital Advanced Life Support
(OPALS) study41 examined outcomes before and after
the introduction of advanced resuscitation techniques
(intubation and drugs). The investigators found no
evidence of improved survival (5·0% before intro­
duction of advanced measures vs 5·1% after their intro­
duction, p=0·83) or favourable neurological outcome
(3·9% vs 3·4%, p=0·73). Olasveengen and colleagues42
randomly assigned 916 patients to resuscitation with
intravenous or without intravenous drugs. Patients
allocated to the intravenous drug group were more
likely to have return of spontaneous circulation
(OR 1·99, 95% CI 1·48–2·67) but were no more likely to

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 Series

survive (1·16, 0·74–1·82) or survive with favourable

neurological outcome (1·24, 0·77–1·98). Confirm cardiac arrest
Epinephrine is often given to patients in shockable
rhythms who are refractory to attempted defibrillation,
High-quality CPR
and to those in non-shockable rhythms. The rationale
for administration is that it increases aortic diastolic
pressure and improves coronary perfusion. Findings Attach monitoring
from experimental studies, however, suggest that it
could impair cerebral blood flow, increase ventricular
Assess rhythm
arrhythmias, and induce myocardial dysfunction after
return of spontaneous circulation.43 Early resuscitation
algorithms recommended admin­ istration of 0·5 mg
epinephrine intracardiac or 10 mg intravenously.44 Sub­ Shockable Consider and treat High-quality CPR: Non-shockable
sequent data from randomised controlled trials showed reversible causes: Chest compressions
Hypoxia of 5–6cm
no benefit to high-dose epinephrine, leading to the dose Hypovolaemia Rate of chest
being reduced to 1 mg every 3–5 min.45 Jacobs and Hyperkalaemia compressions
Hypothermia or 100–120 min–1
colleagues46 compared 1 mg epinephrine every 3–5 min hyperthermia Avoid leaning
with placebo in a randomised controlled trial in Australia. Thromboembolism Minimal
Deliver shock ×1 Toxins interrupti ons
The trial enrolled 601 adults with OHCA of any cause, Tension Ventilations 10 min–1
when resuscitation was started by paramedics. The trial pneumothorax Manage airway
faced recruitment challenges and closed after enrolment Continue CPR 2 min Tamponade Consider drug Continue CPR 2 min
of only 10% of the intended sample size. The study
showed evidence of improved return of spontaneous No ROSC
circulation with epinephrine (OR 3·4, 95% CI 2·0–5·6) Re-assess rhythm and restart loop
but no difference in long-term survival (2·2, 0·7–6·3). Consider prognostic factors
Continue, terminate, or transport
The PARAMEDIC2 trial,47 which compared 1 mg
epinephrine every 3–5 min with placebo, closed to
recruitment in October, 2017, and will provide further ROSC
Start post-resuscitation care
information about the safety and effectiveness of Transport to hospital
adrenaline.47
The potent vasopressor, vasopressin, has been studied
as an alternative or adjunctive treatment to epinephrine Figure 4: Advanced life support treatment algorithm
for cardiac arrest. A meta-analysis48 of trials that in total CPR=cardiopulmonary resuscitation. ROSC=return of spontaneous circulation.
enrolled over 6000 patients found no improvement in
outcomes compared with epinephrine, prompting the Manual versus mechanical CPR
International Liaison Committee on Resuscitation to High-quality CPR is crucial for optimal outcomes after
recommend against its routine use in cardiac arrest.49 cardiac arrest, yet it is physically demanding and difficult
Anti-arrhythmic drugs are recommended when initial to sustain. Mechanical chest compression devices auto­
attempts at defibrillation do not achieve return of mate the process and deliver consistent, high-quality
spontaneous circulation. The randomised controlled chest compressions. Two devices have been evaluated in
ALPS trial50 treated 3026 patients with shock-refractory large, multicentre, prehospital clinical trials that enrolled
OHCA, with amiodarone, lidocaine, or placebo. Although 12 206 patients with OHCA.51 The Autopulse device
there was no difference in the primary outcome of (Zoll Medical, Chelmsford, MA, USA) consists of a
survival to discharge or favourable neurological outcome load-distributing band encircling the patient’s chest and
in the overall trial population, outcomes were better in squeezing it against a rigid back­board. The LUCAS device
those who received drugs if the cardiac arrest was (Physio-Control and Jolife AB, Lund, Sweden) uses a
witnessed by a bystander or EMS than in those who piston and suction cup to deliver compressions with active
received drugs but were not witnessed by a bystander or recoil. None of the trials individually or when combined
EMS. Compared with placebo, survival was 5% (95% CI in meta-analyses found improved rates of return of
0·3–9·7) higher in the amiodarone group and spontaneous circulation (OR 0·96, 95% CI 0·85–1·10),
5·2% (0·5–9·9) higher in the lidocaine group survival at hospital discharge or after 30 days (0·89,
for bystander-witnessed cardiac arrest. There was no 0·77–1·02), or favourable neurological outcome (0·76,
difference between amiodarone and lidocaine.50 The 0·53–1·11).52 These findings led the International Liaison
special formulation of amiodarone used in this trial Committee on Resuscitation to not recommend the
(which causes less hypotension) is not widely available, routine use of mechanical chest compression devices.49
limiting the generalisability of this aspect of the study Despite the absence of benefit from strategies that
findings at present. routinely deploy mechanical chest compression in

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Panel: Rules for termination of resuscitation in basic and
advanced life support
Basic life support (all criteria must be present)
• Event not witnessed by emergency medical services
personnel
• No automated external defibrillator used or manual shock
applied in out-of-hospital setting
• No return of spontaneous circulation in out-of-hospital
setting
Advanced life support (all criteria must be present)
• Event not witnessed by emergency medical services
personnel
• No automated external defibrillator used or manual shock
applied in out-of-hospital setting
• No return of spontaneous circulation in out-of-hospital
setting
• Arrest not witnessed by bystander
• No bystander-administered cardiopulmonary resuscitation
OHCA, there remain situations in which manual chest
compressions are either not possible or hazardous
in which it is reasonable to consider mechanical CPR.
Examples include during land ambulance or helicopter
transfer to hospital, during percutaneous coronary
intervention, and as a bridge to advanced therapies (eg,
extracorporeal CPR). Mechanical CPR has also been used
to maintain organ perfusion when resuscitation has been
unsuccessful before organ donation. If mechanical CPR
is deployed it is important that interruptions to chest
compressions are kept to a minimum (<10–20 s).
Training resuscitation teams in a pit-stop approach, with
a focus on non-technical skills, can substantially reduce
interruptions to CPR during deployment.53
Refractory arrest
Transport or termination of resuscitation
There are no absolute rules on the optimal duration of
resuscitation. Factors associated with improved outcomes
(eg, witnessed arrest, initial shockable rhythm, bystander
CPR) or the presence of potentially reversible causes,
could guide clinicians to continue with resuscitation
efforts for longer. In an analysis of CPR duration, Grunau
and colleagues54 showed that the elapsed duration at
which the probability of survival fell below 1% was 48 min
in patients with shockable rhythms and 15 min in those
with non-shockable rhythms. A secondary analysis55
of 11 368 cases of OHCA from the US ROC-PRIMED
(Resuscitation Outcomes Consortium Prehospital Resus­
citation Using an Impedance Valve and Early Versus
Delayed) study identified that, with conventional
resuscitation, 90% of patients with good outcome
achieved initial return of spontaneous circulation within
20 min and 99% of those with good outcomes achieved it
within 37 min. There were no survivors with favourable
984 www.thelancet.com Vol 391 March 10, 2018
neurological outcome when return of spontaneous
circulation occurred after 47 min. Similar observations
were made in a Japanese registry study involving
282 183 bystander-witnessed cases of OHCA.56
In the past few decades, it became necessary to
provide clinical prediction rules for the termination of
resuscitation to avoid futile transports. Consequently,
several teams have developed and prospectively tested
termination of resuscitation rules, which can be applied
by prehospital health-care providers even in the absence
of a physician (panel).57–60
When to stop initial resuscitation efforts?
The termination of resuscitation guidelines were
originally developed for prehospital providers of basic life
support in selection of individuals in whom continued
resuscitation and transport to hospital would be futile.57
Since then, the guideline for termination of resuscitation
in basic life support has been prospectively and externally
validated in several studies with both basic and advanced
providers of life support, and is commonly referred to as
the universal termination of resuscitation guideline.58–60 It
states that resuscitation can be discon­tinued in the field
by prehospital providers if the following three criteria are
met: the cardiac arrest was not witnessed by EMS
providers; the patient did not show return of spontaneous
circulation despite attempted resuscitation; and no
shocks were delivered (ie, a non-shockable rhythm) at any
time before transport. A prospective validation of the
guideline showed good specificity and positive predictive
value for futility, while reducing the transport frequency
to 46% of attempted resuscitations by EMS.58 In addition
to the universal guideline for termination of resuscitation
in basic life support, a universal guideline for advanced
life support has been developed. This guideline adds
two criteria to the basic life support rule: arrest not
witnessed by bystander; and no bystander-administered
CPR. Findings from a large validation study60 established
that both rules accurately identified patients with OHCA
who were unlikely to benefit from prolonged CPR
and transport to the hospital for further attempts at
resuscitation. Use of these decisions to stop resuscitative
efforts could substantially decrease the number of
futile emergency EMS transports without appreciably
worsening survival.
Extracorporeal CPR
Extracorporeal CPR is being used increasingly when
conventional resuscitation efforts fail to achieve return
of spontaneous circulation, with encouraging results.61
Several ongoing randomised studies are comparing
extracorporeal CPR with conventional CPR to establish
if this is an effective strategy in refractory cardiac
arrest.62 Interestingly, one of these ongoing trials
aims to show that extracorporeal CPR can be provided
on the resuscitation scene, outside the hospital
(NCT 02527031).63

Whichever technique is used, the decision to establish
extracorporeal CPR should be made early (within 10 min)
and only in patients in whom there is a reasonable chance
of neurological recovery26 according to simple criteria:
witnessed arrest; CPR provided by witness; ventricular
tachycardia or ventricular fibrillation (ie, shockable
rhythms) as presenting rhythm; presumed reversible
cause (eg, cardiac [particularly coronary causes], toxic,
hypothermia); no evidence for severe underlying
condition; and available mechanical CPR device. Early
activation of the process is essential to reduce the delay to
extracorporeal CPR. In the most impressive case series
reported to date, patients who received an extracorporeal
CPR strategy started the mechanical assistance after a
mean delay of 64 min after the OHCA.64
Optimisation of care after resuscitation
Management priorities
Guidelines from European Resuscitation Council (ERC)
and European Society of Intensive Care Medicine
(ESICM)65 provide information about how to optimise
the management of the post-resuscitation syndrome.
Post-resuscitation care should start at the location where
return of spontaneous circulation is achieved. The most
important management priorities in the prehospital
setting are circulatory, respiratory, and temperature. In
parallel, all efforts should be made to bring the patient to
the most appropriate receiving centre.
Circulation
Shock is very common in the post-resuscitation period,
resulting from the combination of transient myocardial
dysfunction and vasoplegia caused by whole-body
ischaemia reperfusion.66 Fluids and norepinephrine, with
or without dobutamine, are usually the most effective
treatments. Infusion of relatively large volumes of fluid is
tolerated remarkably well by patients with post-cardiac-
arrest syndrome. In the most severely unwell patients
with refractory shock, the implantation of a mechanical
circulatory assistance might be useful.20 Importantly,
finding and treating the cause of the arrest is of major
importance to control post-resuscitation shock.
Temperature control
Targeted temperature management—the maintenance
of a target temperature between 32°C and 36°C for at
least 24 h—is strongly recommended.65 The supporting
evidence is based on experimental animal data, non-
randomised clinical studies, and two small randomised
trials.6,67 Furthermore, this strategy applies mostly to
comatose adult patients after OHCA with an initial
shockable rhythm, whereas the indication is debated in
patients with an initial non-shockable rhythm.
The usefulness of targeted temperature management
during transport has been examined in clinical studies
in which cold intravenous fluids were administered
after return of spontaneous circulation to induce
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hypothermia.11,23,68–70 Although the intervention decreased
mean core temperature on admission and reduced the
time to achieve the targeted temperature, it did not prove
beneficial and was associated with a significant increase
in adverse events.11 On the basis of this evidence,
prehospital cooling with rapid infusion of large volumes
of cold intravenous fluid immediately after return of
spontaneous circulation is not recommended.
Ventilation
The vast majority of patients with return of spontaneous
circulation need endotracheal intubation and mechanical
ventilation. Particular attention should be paid to ventilator
settings. Avoidance of hypoxaemia is the main goal, but
considering the evidence of harm after myocardial
infarction71 and the possibility of increased neurological
injury after cardiac arrest,72,73 it is recom­mended that the
inspired oxygen concentration maintains arterial blood
oxygen saturation in the range of 94–98%. Because CO2
arterial pressure might affect cerebral blood flow, both
hypocapnia and hypercapnia should be avoided by
adjusting tidal volumes and respiratory rate. Adjustment
of ventilation to achieve normocarbia can be facilitated by
monitoring the end-tidal CO2 during transport.
Triage and orientation
Many resuscitated patients will develop a post-resuscitation
disease, requiring ICU admission. Identification and
treatment of the cause of the arrest is a priority that
might be difficult to achieve in all hospitals. When there is
evidence for a coronary cause, as reflected by ECG patterns
or symptoms reported by the patient before arrest
suggestive of a coronary cause, it is highly recommended
to send these patients to an available cardiac catheterisation
laboratory.74 In such patients nearly all clinical data
converge to indicate a benefit associated with early
coronary reperfusion.75 Since the publication of the
pioneering study by Spaulding and colleagues,76 which was
the first to show a benefit for angioplasty after cardiac
arrest, findings from several studies have shown that
immediate evaluation in the cardiac catheter laboratory,
with early percutaneous coronary intervention when
indicated, is associated with improved outcomes, includ­
ing survival and neurological recovery.77 In patients
with no clinical or electrical evidence for a coronary
cause, the benefit of the early invasive strategy is de­
bated and the answer will probably come from
the several on­ going trials (DISCO [NCT02309151],
EMERGE [NCT02876458], COACT [NTR4973],
TOMAHAWK [NCT02750462], COUPE [NCT02641626],
and PEARL [NCT02387398]) examining this issue. Early
identification of a respiratory or neurological cause would
enable transfer of the patient to a specialised ICU for
optimal care and might help in assessment of prognosis
and appropriate treatment.78 In comatose patients, a
careful prognostication process is recommended, which
should be based on multimodal evaluation.79 Withdrawal
 Series
of life-sustaining therapy because of perceived poor
neurological prognosis is a common cause of hospital
death after OHCA. Although current guidelines recom­
mend against with­drawal of life-sustaining therapy before
72 h, this practice is common and could increase mortality.80
Conclusion
Survival from OHCA remains poor globally. Strength­en­
ing of the early links in the chain of survival (ie, cardiac
arrest recognition, call for help, bystander CPR, and
bystander AED use) have the greatest potential to
improve survival. If return of spontaneous circulation
occurs, the focus shifts from resuscitation to stabilisation
and transfer to a specialist facility.
Contributors
MEHO wrote the introduction and section on the role of the community.
GDP wrote the section on the emergency medical services’ response.
AC wrote the section on the optimisation of care. All authors were
involved in the conception, writing, and editing of the manuscript.
Declaration of interests
MEHO is currently scientific adviser to Global Healthcare SG and
TIIM SG, and holds patents related to using heart rate variability and
artificial intelligence for medical monitoring. He has no direct conflicts
relating to sections written by him. GDP received support as a National
Institute of Health Research Senior (NIHR) Investigator and has led
studies relating to quality of cardiopulmonary resuscitation (CPR),
mechanical CPR, and drugs in cardiac arrest funded by NIHR. He has
volunteer roles with the UK and European Resuscitation Councils and
the International Committee for Resuscitation. AC received fees for
lectures from Bard and AstraZeneca. He has no direct conflicts relating
to sections written by him.
Acknowledgments
We thank Andrew Fu Wah Ho and Pek Pin Pin for their contributions to
the literature review and preparation of this manuscript. We thank
Charles Deakin for the concept depicted in figure 1.
References
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