1. Airway, ventilation, and oxygenation are particularly important in the setting of pregnancy because of increased maternal metabolism and decreased functional reserve capacity due to the gravid uterus, making pregnant patients more prone to hypoxia. Recovery and survivorship after cardiac arrest. 2. These guidelines are not meant to be comprehensive. 1. Since the last time these recommendations were formally reviewed, The administration of hypertonic (8.4%, 1 mEq/ mL) sodium bicarbonate solution for treatment of sodium channel blockade due to TCAs and other toxicants is supported by human observational studies. What is the optimal duration for targeted temperature management before rewarming? Is the IO route of drug administration safe and efficacious in cardiac arrest, and does efficacy vary by IO site? 2. However, an oral airway is preferred because of the risk of trauma with a nasopharyngeal airway. 1. 2. Follow the telecommunicators* instructions. Nine observational studies evaluated rhythmic/ periodic discharges. 2. and 2. 6. 3. Possible contributors to this goal include optimization of cerebral perfusion pressure, management of oxygen and carbon dioxide levels, control of core body temperature, and detection and treatment of seizures (Figure 9). During targeted temperature management of the pregnant patient, it is recommended that the fetus be continuously monitored for bradycardia as a potential complication, and obstetric and neonatal consultation should be sought. 4. Systematic Review Most studies used young, healthy patients but no current method to identify ideal patients. Because of their negative inotropic effect, nondihydropyridine calcium channel antagonists (eg, diltiazem, verapamil) may further decompensate patients with left ventricular systolic dysfunction and symptomatic heart failure. In addition to assessing level of consciousness and performing basic neurological examination, clinical examination elements may include the pupillary light reflex, pupillometry, corneal reflex, myoclonus, and status myoclonus when assessed within 1 week after cardiac arrest. Precharging the defibrillator during ongoing chest compressions shortens the hands-off chest time surrounding defibrillation, without evidence of harm. Although there is no high-quality evidence favoring one technique over another for establishment and maintenance of a patients airway, rescuers should be aware of the advantages and disadvantages and maintain proficiency in the skills required for each technique. 3. The trachea, which is sometimes called the windpipe, conducts air down into the lungs through the bronchi, which are smaller tubular branches. No randomized RCTs have been performed comparing open-chest with external CPR. Hemodynamically unstable patients with atrial fibrillation or atrial flutter with rapid ventricular response should receive electric cardioversion. Anticoagulation alone is inadequate for patients with fulminant PE. In the absence of knowing the manufacturers recommendation for appropriate energy settings, the previous 2010 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care (and reaffirmed in 2015) recommendations for synchronized cardioversion are still applicable [Narrow regular: 50-100 J; Narrow irregular: 120-200 J biphasic or 200 J monophasic; Wide regular: 100 J; Wide irregular: defibrillation dose (not synchronized)]. 6. 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. decrease pauses in chest compressions and improve outcomes? Anterolateral, anteroposterior, anterior-left infrascapular, and anterior-right infrascapular electrode placements are comparably effective for treating supraventricular and ventricular arrhythmias. We recommend that the findings of a best motor response in the upper extremities being either absent or extensor movements not be used alone for predicting a poor neurological outcome in patients who remain comatose after cardiac arrest. experience, training, tools, and skills of the provider when choosing an approach to airway management. Some EEG-correlated patterns of status myoclonus may have poor prognosis, but there may also be more benign subtypes of status myoclonus with EEG correlates. What do survivor-derived outcome measures of the impact of cardiac arrest survival look like, and how The potential mechanisms of action of IV lipid emulsion include active shuttling of the local anesthetic drug away from the heart and brain, increased cardiac contractility, vasoconstriction, and cardioprotective effects.1, The reported incidence of LAST ranges from 0 to 2 per 1000 nerve blocks2 but appears to be decreasing as a result of increasing awareness of toxicity and improved techniques.1, This topic last received formal evidence review in 2015.6, Overdose of sodium channelblocking medications, such as TCAs and other drugs (eg, cocaine, flecainide, citalopram), can cause hypotension, dysrhythmia, and death by blockade of cardiac sodium channels, among other mechanisms. In addition, specific recommendations about the training of resuscitation providers are provided in Part 6: Resuscitation Education Science, and recommendations about systems of care are provided in Part 7: Systems of Care.. IV infusion of epinephrine is a reasonable alternative to IV boluses for treatment of anaphylaxis in patients not in cardiac arrest. If you have been trained in CPR, go on to opening the airway and rescue breathing. 1. What are optimal strategies to enhance lay rescuer performance of CPR? 3. Intracardiac drug administration was discouraged in the 2000 AHA Guidelines for CPR and Emergency Cardiovascular Care given its highly specialized skill set, potential morbidity, and other available options for access.1,2 Endotracheal drug administration results in low blood concentrations and unpredictable pharmacological effect and has also largely fallen into disuse given other access options. After initial stabilization, care of critically ill postarrest patients hinges on hemodynamic support, mechanical ventilation, temperature management, diagnosis and treatment of underlying causes, diagnosis and treatment of seizures, vigilance for and treatment of infection, and management of the critically ill state of the patient. 7272 Greenville Ave. 1. If increased auto-PEEP or sudden decrease in blood pressure is noted in asthmatics receiving assisted ventilation in a periarrest state, a brief disconnection from the bag mask or ventilator with compression of the chest wall to relieve air-trapping can be effective. 2. Since last addressed by the 2010 Guidelines, a 2013 systematic review found little evidence to support the routine use of calcium in undifferentiated cardiac arrest, though the evidence is very weak due calcium as a last resort medication in refractory cardiac arrest. This recommendation is supported by the 2020 CoSTR for BLS.22, Recommendation 1 is supported by the 2020 CoSTR for ALS.51 Recommendation 2 is supported by a 2020 ILCOR evidence update,51 which found no new information to update the 2010 recommendations.66. CPR provides a small but critical amount of blood flow to the heart and brain. Multiple randomized trials have been performed in various domains of TTM and were summarized in a systematic review published in 2015.1 Subsequent to the 2015 recommendations, additional randomized trials have evaluated TTM for nonshockable rhythms as well as TTM duration. and 2. Notably, in a clinical study in adults with outof- hospital VF arrest (of whom 43% survived to hospital discharge), the mean duty cycle observed during resuscitation was 39%. However, the efficacy of IV versus IO drug administration in cardiac arrest remains to be elucidated. No pauses for ventilations - compressions are continuous at 100 to 120/min When providing rescue breaths to an adult victim, you should give 1 breath every 6 seconds What are the correct actions to take for scene safety and assessment? Since this topic was last updated in detail in 2015, at least 2 randomized trials have been completed on the effect of steroids on shock and other outcomes after ROSC, only 1 of which has been published to date. 3. There is no proven benefit from the use of antihistamines, inhaled beta agonists, and IV corticosteroids during anaphylaxis-induced cardiac arrest. 6. Cough CPR is described as repeated deep breaths followed immediately by a cough every few seconds in an attempt to increase aortic and intracardiac pressures, providing transient hemodynamic support before a loss of consciousness. 1. In situations such as nonsurvivable maternal trauma or prolonged pulselessness, in which maternal resuscitative efforts are considered futile, there is no reason to delay performing perimortem cesarean delivery in appropriate patients. Obtaining EEG in status myoclonus is important to rule out underlying ictal activity. For many patients and families, these plans and resources may be paramount to improved quality of life after cardiac arrest. Symptoms typically occur within minutes, and findings may include arrhythmias, apnea, hypotension with bradycardia, seizures, and cardiovascular collapse.1 Lactic acidosis is a sensitive and specific finding.2,3 Immediate antidotes include hydroxocobalamin and nitrites; however, the former has a much better safety profile. 4. Given the potential for the rapid development of oropharyngeal or laryngeal edema, immediate referral to a health professional with expertise in advanced airway placement, including surgical airway management, is recommended. If an advanced airway is used, a supraglottic airway can be used for adults with OHCA in settings with low tracheal intubation success rates or minimal training opportunities for endotracheal tube placement. How does integrated team performance, as opposed to performance on individual resuscitation skills, providers are skilled and can implement it quickly. This topic last received formal evidence review in 2010.5. -Adrenergic receptor antagonists (-adrenergic blockers) and L-type calcium channel antagonists (calcium channel blockers) are common antihypertensive and cardiac rate control medications. 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. If recurrent opioid toxicity develops, repeated small doses or an infusion of naloxone can be beneficial. Urgent direct-current cardioversion of new-onset atrial fibrillation in the setting of acute coronary syndrome is recommended for patients with hemodynamic compromise, ongoing ischemia, or inadequate rate control. Initial management of wide-complex tachycardia requires a rapid assessment of the patients hemodynamic stability. On MRI, cytotoxic injury can be measured as restricted diffusion on diffusion-weighted imaging (DWI) and can be quantified by the ADC. To maintain provider skills from initial training, frequent retraining is important. Its use as a neuroprognostic tool is promising, but the literature is limited by several factors: lack of standardized terminology and definitions, relatively small sample sizes, single center study design, lack of blinding, subjectivity in the interpretation, and lack of accounting for effects of medications. The trained lay rescuer who feels confident in performing both compressions and ventilation should open the airway using a head tiltchin lift maneuver when no cervical spine injury is suspected. What is the ideal timing of PMCD for a pregnant woman in cardiac arrest? 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. In addition to standard ACLS, several therapies have long been recommended to treat life-threatening hyperkalemia. and 4. Routine use of sodium bicarbonate is not recommended for patients in cardiac arrest. Management of acute PE is determined by disease severity.2 Fulminant PE, characterized by cardiac arrest or severe hemodynamic instability, defines the subset of massive PE that is the focus of these recommendations. Recognition of cardiac arrest by healthcare providers includes a pulse check, but the importance of not prolonging efforts to detect a pulse is emphasized. To accomplish delivery early, ideally within 5 min after the time of arrest, it is reasonable to immediately prepare for perimortem cesarean delivery while initial BLS and ACLS interventions are being performed. Based on the protocols used in clinical trials, it is reasonable to administer epinephrine 1 mg every 3 to 5 min for cardiac arrest. In a trained provider-witnessed arrest of a postcardiac surgery patient, immediate defibrillation for VF/VT should be performed. This topic last received formal evidence review in 2010.12, These recommendations are supported by the 2018 focused update on ACLS guidelines.21, Management of SVTs is the subject of a recent joint treatment guideline from the AHA, the American College of Cardiology, and the Heart Rhythm Society.1, Narrow-complex tachycardia represents a range of tachyarrhythmias originating from a circuit or focus involving the atria or the AV node. 1. These techniques can keep blood flowing to the brain and other organs until medical help arrives. Lidocaine is not included as a treatment option for undifferentiated wide-complex tachycardia because it is a relatively narrow-spectrum drug that is ineffective for SVT, probably because its kinetic properties are less effective for VT at hemodynamically tolerated rates than amiodarone, procainamide, or sotalol are. We recommend selecting and maintaining a constant temperature between 32C and 36C during TTM. The Chain of Survival, introduced in Major Concepts, is now expanded to emphasize the important component of survivorship during recovery from cardiac arrest, requires coordinated efforts from medical professionals in a variety of disciplines and, in the case of OHCA, from lay rescuers, emergency dispatchers, and first responders. Dallas, TX 75231, Customer Service Protocols for management of OHCA in pregnancy should be developed to facilitate timely transport to a center with capacity to immediately perform perimortem cesarean delivery while providing ongoing resuscitation. If a regular wide-complex tachycardia is suspected to be paroxysmal SVT, vagal maneuvers can be considered before initiating pharmacological therapies (see Regular Narrow-Complex Tachycardia). Recovery What is the correct order of steps in the Out-of-Hospital Chain of Survival for adults? What is the ideal initial dose of naloxone in a setting where fentanyl and fentanyl analogues are We suggest against the use of point-of-care ultrasound for prognostication during CPR. Victims of accidental hypothermia should not be considered dead before rewarming has been provided unless there are signs of obvious death. The evidence for what constitutes optimal CPR continues to evolve as research emerges. There is a need for further research specifically on the interface between patient factors and the OT indicates occupational therapy; PT, physical therapy; PTSD, posttraumatic stress disorder; and SLP, speech-language pathologist, Severe accidental environmental hypothermia (body temperature less than 30C [86F]) causes marked decrease in both heart rate and respiratory rate and may make it difficult to determine if a patient is truly in cardiac arrest. Importantly, recommendations are provided related to team debriefing and systematic feedback to increase future resuscitation success. In a large trial, survival and survival with favorable neurological outcome were similar in a group of patients with OHCA treated with ventilations at a rate of 10/min without pausing compressions, compared with a 30:2 ratio before intubation. Twelve studies examined the use of naloxone in respiratory arrest, of which 5 compared intramuscular, intravenous, and/or intranasal routes of naloxone administration (2 RCT. Studies on push-dose epinephrine for bradycardia specifically are lacking, although limited data support its use for hypotension. For synchronized cardioversion of atrial fibrillation using biphasic energy, an initial energy of 120 to 200 J is reasonable, depending on the specific biphasic defibrillator being used. It includes a venous cannula, a pump, an oxygenator, and an arterial cannula. In adult cardiac arrest, total preshock and postshock pauses in chest compressions should be as short as possible. 2. arrest with shockable rhythm? The pharmacokinetic properties, acute effects, and clinical efficacy of emergency drugs have primarily been described when given intravenously. Regardless of waveform, successful defibrillation requires that a shock be of sufficient energy to terminate VF/VT. When an advanced airway (ie, endotracheal tube, Combitube, or LMA) is in place during 2-person CPR, ventilate at a rate of 8 to 10 breaths per minute without attempting to synchronize breaths between compressions. This will aid in both resource utilization and optimizing a patients chance for survival. Human experimental data suggest that benzodiazepines (diazepam, lorazepam), alpha blockers (phentolamine), calcium channel blockers (verapamil), morphine, and nitroglycerine are all safe and potentially beneficial in the cocaine-intoxicated patient; no data are available comparing these approaches.15 Contradictory data surround the use of -adrenergic blockers.68 Patients suffering from cocaine toxicity can deteriorate quickly depending on the amount and timing of ingestion. We recommend targeted temperature management for pregnant women who remain comatose after resuscitation from cardiac arrest. A 2017 ILCOR systematic review concluded that although the evidence from observational studies supporting the use of bundles of care including minimally interrupted chest compressions was of very low certainty (primarily unadjusted results), systems already using such an approach may continue to do so. Check for no breathing or only gasping; if none, begin CPR with compressions. response. 3. The topic of neuroprotective agents was last reviewed in detail in 2010. A more comprehensive description of these methods is provided in Part 2: Evidence Evaluation and Guidelines Development.. Conversely, the -adrenergic effects may increase myocardial oxygen demand, reduce subendocardial perfusion, and may be proarrhythmic. When oxygen-rich blood cannot get to the brain, brain damage can occur within minutes. Patients in anaphylactic shock are critically ill, and cardiovascular and respiratory status can change quickly, making close monitoring imperative. Symptomatic bradycardia may be caused by a number of potentially reversible or treatable causes, including structural heart disease, increased vagal tone, hypoxemia, myocardial ischemia, or medications. The use of ECMO for cardiac arrest or refractory shock due to sodium channel blocker/TCA toxicity may be considered. 4. At very elevated levels, hypermagnesemia can lead to altered consciousness, bradycardia or ventricular arrhythmias, and cardiac arrest.9,10 Hypomagnesemia can occur in the setting of gastrointestinal illness or malnutrition, among other causes, and, when significant, can lead to both atrial and ventricular arrhythmias.11, The ongoing opioid epidemic has resulted in an increase in opioid-associated OHCA, leading to approximately 115 deaths per day in the United States and predominantly impacting patients from 25 to 65 years old.13 Initially, isolated opioid toxicity is associated with CNS and respiratory depression that progresses to respiratory arrest followed by cardiac arrest. Hydroxocobalamin and 100% oxygen, with or without sodium thiosulfate, can be beneficial for cyanide poisoning. This topic last received formal evidence review in 2010.4. Additional investigations are necessary to evaluate cost-effectiveness, resource allocation, and ethics surrounding the routine use of ECPR in resuscitation. 1. 1. -Enough to make the victim's chest rise. Discharges on EEG were divided into 2 types: rhythmic/periodic and nonrhythmic/periodic. No shock waveform has distinguished itself as achieving a consistently higher rate of ROSC or survival. How do you ventilate During CPR with an advanced airway in place? Conversely, polymorphic VT not associated with a long QT is most often due to acute myocardial ischemia.4,5 Other potential causes include catecholaminergic polymorphic VT, a genetic abnormality in which polymorphic VT is provoked by exercise or emotion in the absence of QT prolongation6 ; short QT syndrome, a form of polymorphic VT associated with an unusually short QT interval (corrected QT interval less than 330370 milliseconds)7,8 ; and bidirectional VT seen in digitalis toxicity in which the axis of alternate QRS complexes shifts by 180 degrees.9 Supportive data for the acute pharmacological treatment of polymorphic VT, with and without long corrected QT interval, is largely based on case reports and case series, because no RCTs exist. Each recommendation was developed and formally approved by the writing group. It may be reasonable to initially use minimally interrupted chest compressions (ie, delayed ventilation) for witnessed shockable OHCA as part of a bundle of care. 3. 4. Awareness and incorporation of the potential sources of error in the individual diagnostic tests is important. Thus, the confidence in the prognostication of the diagnostic tests studied is also low. Effective ventilation of the patient with a tracheal stoma may require ventilation through the stoma, either by using mouth-to-stoma rescue breaths or by use of a bag-mask technique that creates a tight seal over the stoma with a round, pediatric face mask. When the victim cannot be placed in the supine position, it may be reasonable for rescuers to provide CPR with the victim in the prone position, particularly in hospitalized patients with an advanced airway in place. Activation of emergency response system 3. In cardiac arrest secondary to anaphylaxis, standard resuscitative measures and immediate administration of epinephrine should take priority. Should severely hypothermic patients in cardiac arrest receive epinephrine or other resuscitation Rescue Breathing for Adults and Children: Step-by-Step Guide - Healthline Throughout the recommendation-specific text, the need for specific research is identified to facilitate the next steps in the evolution of these questions. 4. An IV dose of 0.05 to 0.1 mg (5% to 10% of the epinephrine dose used routinely in cardiac arrest) has been used successfully for anaphylactic shock. 1. insulin) for refractory shock due to -adrenergic blocker or calcium channel blocker overdose? 1. 2. The presence of undifferentiated myoclonic movements after cardiac arrest should not be used to support a poor neurological prognosis. Standardization of methods for quantifying GWR and ADC would be useful. There are many alternative CPR techniques being used, and many are unproven.
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