1. Emergent electric cardioversion and defibrillation are highly effective at terminating VF/VT and other tachyarrhythmias. The trachea, which is sometimes called the windpipe, conducts air down into the lungs through the bronchi, which are smaller tubular branches. The force from a precordial thump is intended to transmit electric energy to the heart, similar to a low-energy shock, in hope of terminating the underlying tachyarrhythmia. Electric cardioversion can be useful either as firstline treatment or for drug-refractory wide-complex tachycardia due to reentry rhythms (such as atrial fibrillation, atrial flutter, AV reentry, and VT). They may be used in patients with heart failure with preserved ejection fraction. Quantitative waveform capnography - If Petco 2 <10 mm Hg, attempt to improve CPR quality. 2. -Adrenergic blockers may be used in compensated patients with cardiomyopathy; however, they should be used with caution or avoided altogether in patients with decompensated heart failure. 3. Recommendations 1, 2, 3, and 5 are supported by the 2020 CoSTRs for BLS and ALS.13,14 Recommendations 4 and 6 last received formal evidence review in 2015.15. Data from 1 RCT. CPR should be initiated if defibrillation is not successful within 1 min. The routine use of cricoid pressure in adult cardiac arrest is not recommended. Accurate neurological prognostication in brain-injured cardiac arrest survivors is critically important to ensure that patients with significant potential for recovery are not destined for certain poor outcomes due to care withdrawal. The hypothermic heart may be unresponsive to cardiovascular drugs, pacemaker stimulation, and defibrillation; however, the data to support this are essentially theoretical. 1. However, the efficacy of IV versus IO drug administration in cardiac arrest remains to be elucidated. 3. Critical knowledge gaps are summarized in Table 4. 2. The routine use of prophylactic antibiotics in postarrest patients is of uncertain benefit. In addition, status myoclonus may have an EEG correlate that is not clearly ictal but may have prognostic meaning, and additional research is needed to delineate these patterns. What is the optimal timing for head CT for prognostication? After cardiac arrest is recognized, the Chain of Survival continues with activation of the emergency response system and initiation of CPR. Epinephrine is the cornerstone of treatment for anaphylaxis.35, This topic last received formal evidence review in 2010.14. For . The optimal timing for the performance of PMCD is not well established and must logically vary on the basis of provider skill set and available resources as well as patient and/or cardiac arrest characteristics. The systemic impact of the ischemia-reperfusion injury caused by cardiac arrest and subsequent resuscitation requires postcardiac arrest care to simultaneously support the multiple organ systems that are affected. 1. Limited data are available from defibrillator threshold testing with backup transthoracic defibrillation, using variable waveforms and energy doses. Long-term anticoagulation may be necessary for patients at risk for thromboembolic events based on their CHA2 DS2 - VASc score. Studies on push-dose epinephrine for bradycardia specifically are lacking, although limited data support its use for hypotension. For lay rescuers trained in CPR using chest compressions and ventilation (rescue breaths), it is reasonable to provide ventilation (rescue breaths) in addition to chest compressions for the adult in OHCA. A 2017 systematic review identified 1 observational human study and 10 animal studies comparing different ventilation rates after advanced airway placement. There are differing approaches to charging a manual defibrillator during resuscitation. how is cpr performed differently with advanced airway 1. 1. In hemodynamically stable patients, IV adenosine may be considered for treatment and aiding rhythm diagnosis when the cause of the regular, monomorphic rhythm cannot be determined. 2. This topic last received formal evidence review in 2010.22. 2. Thirty-seven recommendations are supported by Level B-Randomized Evidence (moderate evidence from 1 or more RCTs) and 57 by Level B-Nonrandomized evidence. Intraosseous access may be considered if attempts at intravenous access are unsuccessful or not feasible. Survivorship plans that address treatment, surveillance, and rehabilitation need to be provided at hospital discharge to optimize transitions of care to the outpatient setting. Evacuation of the gravid uterus relieves aortocaval compression and may increase the likelihood of ROSC. Evidence in humans of the effect of vasopressors or other medications during cardiac arrest in the setting of hypothermia consists of case reports only. Biphasic and monophasic shock waveforms are likely equivalent in their clinical outcome efficacy. The 2020 Guidelines are organized into knowledge chunks, grouped into discrete modules of information on specific topics or management issues.5 Each modular knowledge chunk includes a table of recommendations that uses standard AHA nomenclature of COR and LOE. Based on the protocols used in clinical trials, it is reasonable to administer epinephrine 1 mg every 3 to 5 min for cardiac arrest. *Red Dress DHHS, Go Red AHA ; National Wear Red Day is a registered trademark. This Part of the 2020 American Heart Association (AHA) Guidelines for CPR and Emergency Cardiovascular Care includes recommendations for clinical care of adults with cardiac arrest, including those with life-threatening conditions in whom cardiac arrest is imminent, and after successful resuscitation from cardiac arrest. For each recommendation, the writing group discussed and approved specific recommendation wording and the COR and LOE assignments. It may be reasonable to perform chest compressions so that chest compression and recoil/relaxation times are approximately equal. In the ASPIRE trial (1071 patients), use of the load-distributing band device was associated with similar odds of survival to hospital discharge (adjusted odds ratio [aOR], 0.56; CI, 0.311.00; A 2013 Cochrane review of 10 trials comparing ACD-CPR with standard CPR found no differences in mortality and neurological function in adults with OHCA or IHCA. 2. The writing group acknowledges the following contributors: Julie Arafeh, RN, MSN; Justin L. Benoit, MD, MS; Maureen Chase; MD, MPH; Antonio Fernandez; Edison Ferreira de Paiva, MD, PhD; Bryan L. Fischberg, NRP; Gustavo E. Flores, MD, EMT-P; Peter Fromm, MPH, RN; Raul Gazmuri, MD, PhD; Blayke Courtney Gibson, MD; Theresa Hoadley, MD, PhD; Cindy H. Hsu, MD, PhD; Mahmoud Issa, MD; Adam Kessler, DO; Mark S. Link, MD; David J. Magid, MD, MPH; Keith Marrill, MD; Tonia Nicholson, MBBS; Joseph P. Ornato, MD; Garrett Pacheco, MD; Michael Parr, MB; Rahul Pawar, MBBS, MD; James Jaxton, MD; Sarah M. Perman, MD, MSCE; James Pribble, MD; Derek Robinett, MD; Daniel Rolston, MD; Comilla Sasson, MD, PhD; Sree Veena Satyapriya, MD; Travis Sharkey, MD, PhD; Jasmeet Soar, MA, MB, BChir; Deb Torman, MBA, MEd, AT, ATC, EMT-P; Benjamin Von Schweinitz; Anezi Uzendu, MD; and Carolyn M. Zelop, MD. resuscitation? Compression rate Open-chest CPR can be useful if cardiac arrest develops during surgery when the chest or abdomen is already open, or in the early postoperative period after cardiothoracic surgery. There is concern that delivery of chest compressions without assisted ventilation for prolonged periods could be less effective than conventional CPR (compressions plus breaths) because the arterial oxygen content will decrease as CPR duration increases. Survivorship plans help guide the patient, caregivers, and primary care providers and include a summary of the inpatient course, recommended follow-up appointments, and postdischarge recovery expectations (Figure 12). Although data specific to patients with ROSC after cardiac arrest from anaphylaxis was not identified, an observational study of anaphylactic shock suggests that IV infusion of epinephrine (515 g/min), along with other resuscitative measures such as volume resuscitation, can be successful in the treatment of anaphylactic shock. Amiodarone or lidocaine may be considered for VF/pVT that is unresponsive to defibrillation. reliably checking a pulse, is initiation of CPR beneficial? As an example, there is insufficient evidence concerning the cardiac arrest bundle of care with the inclusion of heads-up CPR to provide a recommendation concerning its use.2 Further investigation in this and other alternative CPR techniques is best explored in the context of formal controlled clinical research. 2. The usefulness of S100 calcium-binding protein (S100B), Tau, neurofilament light chain, and glial fibrillary acidic protein in neuroprognostication is uncertain. 3. Closed on Sundays. A small number of studies has shown that higher Pao, Observational studies have found that increases in ETCO. A 2017 ILCOR systematic review found that a ratio of 30 compressions to 2 breaths was associated with better survival than alternate ratios, a recommendation that was reaffirmed by the AHA in 2018. outcomes? 1. 1. For patients with severe hypothermia (less than 30C [86F]) with a perfusing rhythm, core rewarming is often used. Technologies are now in development to diagnose the underlying cardiac rhythm during ongoing CPR and to derive prognostic information from the ventricular waveform that can help guide patient management. NSE and S100B are the 2 most commonly studied markers, but others are included in this review as well. 2. 2020;142(suppl 2):S366S468. Routine measurement of arterial blood gases during CPR has uncertain value. We recommend that the absence of EEG reactivity within 72 h after arrest not be used alone to support a poor neurological prognosis. Deliver air over 1 second, ensuring that the victim's chest rises. In cardiac arrest secondary to anaphylaxis, standard resuscitative measures and immediate administration of epinephrine should take priority. A systematic review of the literature evaluated all case reports of cardiac arrest in pregnancy about the timing of PMCD, but the wide range of case heterogeneity and reporting bias does not allow for conclusions. 3. 2. Although an advanced airway can be placed without interrupting chest compressions. High-quality CPR, defibrillation when appropriate, vasopressors and/or antiarrhythmics, and airway management remain the cornerstones of cardiac arrest resuscitation, but some emerging data suggest that incorporating patient-specific imaging and physiological data into our approach to resuscitation holds some promise. The ILCOR systematic review included studies regardless of TTM status, and findings were correlated with neurological outcome at time points ranging from hospital discharge to 12 months after arrest.4 Quantitative pupillometry is the automated assessment of pupillary reactivity, measured by the percent reduction in pupillary size and the degree of reactivity reported as the neurological pupil index. Mouth-to-mouth ventilation in the water may be helpful when administered by a trained rescuer if it does not compromise safety. Unfortunately, despite improvements in the design and funding support for resuscitation research, the overall certainty of the evidence base for resuscitation science is low. Based on the training of the rescuers, and only if scene safety can be maintained for the rescuer, sometimes ventilation can be provided in the water (in-water resuscitation), which may lead to improved patient outcomes compared with delaying ventilation until the victim is out of the water. PALS Algorithms 2023 (Pediatric Advanced Life Support) Fist (or percussion) pacing is the delivery of a serial, rhythmic, relatively low-velocity impact to the sternum by a closed fist.1 Fist pacing is administered in an attempt to stimulate an electric impulse sufficient to cause myocardial depolarization. 3. In addition, deterioration of fetal status may be an early warning sign of maternal decompensation. They may repeatedly recur and remit spontaneously, become sustained, or degenerate to VF, for which electric shock may be required. This topic last received formal evidence review in 2010.4. 6. The effectiveness of active compression-decompression CPR is uncertain. Alternatives to IV access for acute drug administration include IO, central venous, intracardiac, and endotracheal routes. Place 2 fingers on the lower half of the breastbone in the middle of the chest and press down by one-third of the depth of the chest (you may need to use one hand to do CPR depending on the size of the infant). Management of hemodynamically unstable patients with SVT must start with prompt restoration of sinus rhythm through the use of cardioversion. 1. The initial phases of resuscitation once cardiac arrest is recognized are similar between lay responders and healthcare providers, with early CPR representing the priority. 4. Standard BLS and ACLS are the cornerstones of treatment, with airway management and ventilation being of particular importance because of the respiratory cause of arrest. A 2020 ILCOR systematic review identified 3 studies involving 57 total patients that investigated the effect of hand positioning on resuscitation process and outcomes. There is also inconsistency in definitions used to describe specific findings and patterns. The bronchi then divide into smaller and smaller tubules called bronchioles. Furthermore, the resource intensity required to begin and maintain an ECPR program should be considered in the context of strengthening other links in the Chain of Survival. Administration of amiodarone or lidocaine to patients with OHCA was last formally reviewed in 2018. The only time you should do continuous compressions is when you have secured an advanced airway such as an ET tube. See Metrics for High-Quality CPR for recommendations on physiological monitoring during CPR. Part 2: Evidence Evaluation and Guidelines Development, Part 3: Adult Basic and Advanced Life Support, Part 4: Pediatric Basic and Advanced Life Support, Part 9: COVID-19 Interim Guidance for Healthcare Providers, Part 10: COVID-19 Interim Guidance for EMS, 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Cardiac arrest survivors, their families, and families of nonsurvivors may be powerful advocates for community response to cardiac arrest and patient-centered outcomes. Resuscitation causes, processes, and outcomes are very different for OHCA and IHCA, which are reflected in their respective Chains of Survival (Figure 1). 4. 1. 1. 2. In the 2020 ILCOR systematic review, no randomized trials were identified addressing the treatment of cardiac arrest caused by confirmed PE. 2. 1. For patients with OHCA, use of steroids during CPR is of uncertain benefit. Benzodiazepine overdose causes CNS and respiratory depression and, particularly when taken with other sedatives (eg, opioids), can cause respiratory arrest and cardiac arrest. Is the IO route of drug administration safe and efficacious in cardiac arrest, and does efficacy vary by IO site? CPR Quality Push hard (at least 2 inches [5 cm]) and fast (100-120/min) and allow complete chest recoil. The use of mechanical CPR devices may be considered in specific settings where the delivery of high-quality manual compressions may be challenging or dangerous for the provider, as long as rescuers strictly limit interruptions in CPR during deployment and removal of the device. 2. The combination of active compression-decompression CPR and impedance threshold device may be reasonable in settings with available equipment and properly trained personnel. Rescuers should recognize that multiple approaches may be required to establish an adequate airway. Few patients who develop cardiac arrest from carbon monoxide poisoning survive to hospital discharge, regardless of the treatment administered after ROSC, though rare good outcomes have been described. CPR test.docx - How is CPR performed differently when an advanced This work has been largely observational. Lay and trained responders should not delay activating emergency response systems while awaiting the patients response to naloxone or other interventions. Explanation: Compression rate and compression depth, for example, have both been associated with better outcomes, yet these variables have been found to be inversely correlated with each other so that improving one may worsen the other.13 CPR quality interventions are often applied in bundles, making the benefit of any one specific measure difficult to ascertain. Recommendations 1, 2, and 6 last received formal evidence review in 2015.21 Recommendations 3, 4, and 5 are supported by the 2020 CoSTR for BLS.22, This recommendation is supported by a 2020 ILCOR scoping review, which found no new information to update the 2010 recommendations.22,31, This recommendation is supported by a 2020 ILCOR scoping review,22 which found no new information to update the 2010 recommendations.31, Recommendations 1 and 2 are supported by the 2020 CoSTR for BLS.22 Recommendation 3 last received formal evidence review in 2010.46, This recommendation is supported by the 2020 CoSTR for ALS.51. The pharmacokinetic properties, acute effects, and clinical efficacy of emergency drugs have primarily been described when given intravenously. Magnesiums role as an antiarrhythmic agent was last addressed by the 2018 focused update on advanced cardiovascular life support (ACLS) guidelines. In intubated patients, failure to achieve an end-tidal CO. 5. How to Perform CPR: Hands-Only and Mouth-to-Mouth - Healthline To open a person's airway, do the following: Place your hand on their . In cases where the initial shock fails to terminate VF/VT, subsequent shocks may be effective when repeated at the same or an escalating energy setting. We recommend that laypersons initiate CPR for presumed cardiac arrest, because the risk of harm to the patient is low if the patient is not in cardiac arrest. 2. A 2006 systematic review involving 7 studies of transcutaneous pacing for symptomatic bradycardia and bradyasystolic cardiac arrest in the prehospital setting did not find a benefit from pacing compared with standard ACLS, although a subgroup analysis from 1 trial suggested a possible benefit in patients with symptomatic bradycardia. For many patients and families, these plans and resources may be paramount to improved quality of life after cardiac arrest. 2. 4. We recommend targeted temperature management for pregnant women who remain comatose after resuscitation from cardiac arrest. AHA Updates Guidelines for CPR and Emergency Cardiovascular Care Once ROSC is achieved, urgent consultation with a medical toxicologist or regional poison center is suggested. A 2015 systematic review reported significant heterogeneity among studies, with some studies, but not all, reporting better rates of survival to hospital discharge associated with higher chest compression fractions. On CT, brain edema can be quantified as the GWR, defined as the ratio between the density (measured as Hounsfield units) of the gray matter and the white matter. 1. The ITD is a pressure-sensitive valve attached to an advanced airway or face mask that limits air entry into the lungs during the decompression phase of CPR, enhancing the negative intrathoracic pressure generated during chest wall recoil and improving venous return and cardiac output during CPR. The approach to cardiac arrest when PE is suspected but not confirmed is less clear, given that a misdiagnosis could place the patient at risk for bleeding without benefit. Before embarking on empirical drug therapy, obtaining a 12-lead ECG and/or seeking expert consultation for diagnosis is encouraged, if available. 2. It remains to be tested whether patients with signs of shock benefit from emergent coronary angiography and PCI. What is the ideal initial dose of naloxone in a setting where fentanyl and fentanyl analogues are Accordingly, the strength of recommendations is weaker than optimal: 78 Class 1 (strong) recommendations, 57 Class 2a (moderate) recommendations, and 89 Class 2b (weak) recommendations are included in these guidelines. One expected challenge faced through this process was the lack of data in many areas of cardiac arrest research. The 2020 CoSTR recommends that seizures be treated when diagnosed in postarrest patients. 1. Team planning for cardiac arrest in pregnancy should be done in collaboration with the obstetric, neonatal, emergency, anesthesiology, intensive care, and cardiac arrest services. Routine stabilization of the cervical spine in the absence of circumstances that suggest a spinal injury is not recommended. There are no studies comparing cough CPR to standard resuscitation care. For medical management of a periarrest patient, epinephrine has gained popularity, including IV infusion and utilization of push-dose administration for acute bradycardia and hypotension. The use of ECMO for cardiac arrest or refractory shock due to sodium channel blocker/TCA toxicity may be considered. Antidigoxin Fab antibodies should be administered to patients with severe cardiac glycoside toxicity. Patients with accidental hypothermia often present with marked CNS and cardiovascular depression and the appearance of death or near death, necessitating the need for prompt full resuscitative measures unless there are signs of obvious death.