To maintain provider skills from initial training, frequent retraining is important. 1. 2. 4. OHCA is a resource-intensive condition most often associated with low rates of survival. 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). In a recent meta-analysis of 7 published studies (33 795 patients), only 0.13% (95% CI, 0.03% 0.58%) of patients who fulfilled the BLS termination criteria survived to hospital discharge. 3. Tension pneumothorax is a rare life-threatening complication of asthma and a potentially reversible cause of arrest. After immediately initiating the emergency response system, what is your next action according to the Adult In-Hospital Cardiac Chain of Survival? 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. 1100 Introduction. 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. CPR should be initiated if defibrillation is not successful within 1 min. The most common cause of ventilation difficulty is an improperly opened airway. Because of limited evidence, the cornerstone of management of cardiac arrest secondary to anaphylaxis is standard BLS and ACLS, including airway management and early epinephrine. You perform a rapid assessment and determine that your patient is experiencing cardiac arrest. Emergency Response Services (ERS) are provided through an electronic monitoring system used by functionally impaired adults who live alone or who are functionally isolated in the community. 2. For shockable rhythms, trial protocols have directed that epinephrine be given after the third shock. CPR is the single-most important intervention for a patient in cardiac arrest, and chest compressions should be provided promptly. Initial management of wide-complex tachycardia requires a rapid assessment of the patients hemodynamic stability. Shout for nearby help/activate the resuscitation team; the provider can activate the resuscitation team at this time or after checking for breathing and pulse. It may be reasonable to consider administration of epinephrine during cardiac arrest according to the standard ACLS algorithm concurrent with rewarming strategies. 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. Among the members of the BLS team, whose role is it to communicate to the code team the patient's status and the care already provided? Incorrect placement, however, can cause an airway obstruction by displacing the tongue to the back of the oropharynx. Two randomized trials from the same center reported improved survival and neurological outcome when steroids were bundled in combination with vasopressin and epinephrine during cardiac arrest and also administered after successful resuscitation from cardiac arrest. Other testing of serum biomarkers, including testing levels over serial time points after arrest, was not evaluated. What is the ideal sequencing of modalities (traditional vasopressors, calcium, glucagon, high-dose 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. . You yell to the medical assistant, "Go get the AED!" A number of key components have been defined for high-quality CPR, including minimizing interruptions in chest compressions, providing compressions of adequate rate and depth, avoiding leaning on the chest between compressions, and avoiding excessive ventilation.1 However, controlled studies are relatively lacking, and observational evidence is at times conflicting. Treatment of atrial fibrillation/flutter depends on the hemodynamic stability of the patient as well as prior history of arrhythmia, comorbidities, and responsiveness to medication. Given that a false-positive test for poor neurological outcome could lead to inappropriate withdrawal of life support from a patient who otherwise would have recovered, the most important test characteristic is specificity. The controlled administration of IV potassium for ventricular arrhythmias due to severe hypokalemia may be useful, but case reports have generally included infusion of potassium and not bolus dosing. Three different types of evidence reviews (systematic reviews, scoping reviews, and evidence updates) were used in the 2020 process. An RCT published in 2019 compared TTM at 33C to 37C for patients who were not following commands after ROSC from cardiac arrest with initial nonshockable rhythm. After immediately initiating the emergency response system, what is the next link in the Adult In-Hospital Cardiac Chain of Survival? The rhythm-control strategy (sometimes called chemical cardioversion) includes antiarrhythmic medications given to convert the rhythm to sinus and/or prevent recurrent atrial fibrillation/flutter (Table 3). A study in critically ill patients who required ventilatory support found that bag-mask ventilation at a rate of 10 breaths per minute decreased hypoxic events before intubation. 2. 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. We recommend TTM for adults who do not follow commands after ROSC from OHCA with any initial rhythm. These recommendations are supported by the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/AHA Task Force on Practice Guidelines and the Heart Rhythm Society18 as well as the focused update of those guidelines published in 2019.2, These recommendations are supported by 2014 AHA, American College of Cardiology, and Heart Rhythm Society Guideline for the Management of Patients With Atrial Fibrillation18 as well as the focused update of those guidelines published in 2019.2. Look for no breathing or only gasping, at the direction of the telecommunicator. 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. How does integrated team performance, as opposed to performance on individual resuscitation skills, 2. Because immediate ROSC cannot always be achieved, local resources for a perimortem cesarean delivery should be summoned as soon as cardiac arrest in a woman in the second half of pregnancy is recognized. A brief introduction or short synopsis is provided to put the recommendations into context with important background information and overarching management or treatment concepts. The BLS TOR rule recommends TOR when all of the following criteria apply before moving to the ambulance for transport: (1) arrest was not witnessed by EMS providers or first responder; (2) no ROSC obtained; and (3) no shocks were delivered. Therefore, the management of bradycardia will depend on both the underlying cause and severity of the clinical presentation. It is preferable to avoid hypotension by maintaining a systolic blood pressure of at least 90 mm Hg and a mean arterial pressure of at least 65 mm Hg in the postresuscitation period. These arrhythmias are common and often coexist, and their treatment recommendations are similar. While hemodynamically stable rhythms afford an opportunity for evaluation and pharmacological treatment, the need for prompt electric cardioversion should be anticipated in the event the arrhythmia proves unresponsive to these measures or rapid decompensation occurs. Clinical trial evidence shows that nondihydropyridine calcium channel antagonists (eg, diltiazem, verapamil), -adrenergic blockers (eg, esmolol, propranolol), amiodarone, and digoxin are all effective for rate control in patients with atrial fibrillation/ flutter. Administration of IV or IO calcium, in the doses suggested for hyperkalemia, may improve hemodynamics in severe magnesium toxicity, supporting its use in cardiac arrest although direct evidence is lacking. Early defibrillation improves outcome from cardiac arrest. In 2018, the AHA, American College of Cardiology, and Heart Rhythm Society published an extensive guideline on the evaluation and management of stable and unstable bradycardia.2 This guideline focuses exclusively on symptomatic bradycardia in the ACLS setting and maintains consistency with the 2018 guideline. 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. She is 28 weeks pregnant and her fundus is above the umbilicus. with hydroxocobalamin? Either bag-mask ventilation or an advanced airway strategy may be considered during CPR for adult cardiac arrest in any setting depending on the situation and skill set of the provider. The majority of recommendations are based on Level C evidence, including those based on limited data (123 recommendations) and expert opinion (31 recommendations). Contact Us, Hours Manual stabilization can decrease movement of the cervical spine during patient care while allowing for proper ventilation and airway control. wastebasket, stove, etc.) The ResQTrial demonstrated that ACD plus ITD was associated with improved survival to hospital discharge with favorable neurological function for OHCA compared with standard CPR, though this study was limited by a lack of blinding, different CPR feedback elements between the study arms (ie, cointervention), lack of CPR quality assessment, and early TOR. All lay rescuers should, at minimum, provide chest compressions for victims of cardiac arrest. The use of an airway adjunct (eg, oropharyngeal and/or nasopharyngeal airway) may be reasonable in unconscious (unresponsive) patients with no cough or gag reflex to facilitate delivery of ventilation with a bag-mask device. Systolic blood pressure greater than 180 mmHg or less than 90 mmHg. A prompt warning to employees to evacuate, shelter or lockdown can save lives. In patients with calcium channel blocker overdose who are in refractory shock, administration of IV glucagon may be considered. Epinephrine did not lead to increased survival with favorable or unfavorable neurological outcome at 3 months, although both of these outcomes occurred slightly more frequently in the epinephrine group.2 Observational data suggest better outcomes when epinephrine is given sooner, and the low survival with favorable neurological outcome in the available trials may be due in part to the median time of 21 minutes from arrest to receipt of epinephrine. 3. 2. Care Science With Treatment Recommendations (CoSTR).1. 4. When evaluated with other prognostic tests, the prognostic value of seizures in patients who remain comatose after cardiac arrest is uncertain. All you have to say is "Someone is unresponsive and not breathing." Be sure to give a specific address and/or description of your location. The benefit of any specific target range of glucose management is uncertain in adults with ROSC after cardiac arrest. The pharmacokinetic properties, acute effects, and clinical efficacy of emergency drugs have primarily been described when given intravenously. What is the minimum safe observation period after reversal of respiratory depression from opioid CPR indicates cardiopulmonary resuscitation; ET, endotracheal; IO, intraosseous; IV, intravenous; PEA, pulseless electrical activity; pVT, pulseless ventricular tachycardia; and VF, ventricular fibrillation. What is the optimal temperature goal for targeted temperature management? Benzodiazepine overdose causes CNS and respiratory depression and, particularly when taken with other sedatives (eg, opioids), can cause respiratory arrest and cardiac arrest. We recommend targeted temperature management for pregnant women who remain comatose after resuscitation from cardiac arrest. Commercially available defibrillators either provide fixed energy settings or allow for escalating energy settings; both approaches are highly effective in terminating VF/VT. You manage the airway while Jake delivers ventilations. 2. Stopping an incident from occurring. Unlike most other cardiac arrests, these patients typically develop cardiac arrest in a highly monitored setting such as an ICU, with highly trained staff available to perform rescue therapies. spontaneous circulation; S100B, S100 calcium binding protein; STEMI, ST-segment elevation myocardial infarction; and VF, ventricular fibrillation. CT and MRI are the 2 most common modalities. 3. ADC indicates apparent diffusion coefficient; CPR, cardiopulmonary resuscitation; CT, computed tomography; ECG, electrocardiogram; ECPR, extracorporeal These include activation of the emergency response, provision of high-quality CPR and early defibrillation, ALS interventions, effective post-ROSC care including careful prognostication, and support during recovery and survivorship. For patients with severe hypothermia (less than 30C [86F]) with a perfusing rhythm, core rewarming is often used. National Center You are providing compressions on a 6-month-old who weighs 17 pounds. A wide-complex tachycardia can also be caused by any of these supraventricular arrhythmias when conducted by an accessory pathway (called pre-excited arrhythmias). This topic last received formal evidence review in 2015,8 with an evidence update conducted for the 2020 CoSTR for ALS.2. Priorities for the pregnant woman in cardiac arrest should include provision of high-quality CPR and relief of aortocaval compression through left lateral uterine displacement. Based on limited case reports and small case series, there is concern that patients with concomitant preexcitation and atrial fibrillation or atrial flutter may develop VF in response to accelerated ventricular response after the administration of AV nodal blocking agents such as digoxin, nondihydropyridine calcium channel antagonists, -adrenergic blockers, or IV amiodarone. Intraosseous access may be considered if attempts at intravenous access are unsuccessful or not feasible. A recent consensus statement on this topic has been published by the Society of Thoracic Surgeons.9, This topic last received formal evidence review in 2010.35These recommendations were supplemented by a 2017 review published by the Society of Thoracic Surgeons.9. The 2020 CoSTR recommends that seizures be treated when diagnosed in postarrest patients. Which term refers to clearly and rationally identifying the connection between information and actions? Response. This new link acknowledges the need for the system of care to support recovery, discuss expectations, and provide plans that address treatment, surveillance, and rehabilitation for cardiac arrest survivors and their caregivers as they transition care from the hospital to home and return to role and social function. Cyanide reversibly binds to the ferric ion cytochrome oxidase in the mitochondria and stops cellular respiration and adenosine triphosphate production. Defibrillators (using biphasic or monophasic waveforms) are recommended to treat tachyarrhythmias requiring a shock. Epinephrine has been hypothesized to have beneficial effects during cardiac arrest primarily because of its -adrenergic effects, leading to increased coronary and cerebral perfusion pressure during CPR. There are no RCTs evaluating alternative treatment algorithms for cardiac arrest due to anaphylaxis. In an emergency, the individual can press a call button to signal for help. Many of these techniques and devices require specialized equipment and training. Although contradictory evidence exists, it may be reasonable to avoid the use of pure -adrenergic blocker medications in the setting of cocaine toxicity. Acute asthma management was reviewed in detail in the 2010 Guidelines.4 For 2020, the writing group focused attention on additional ACLS considerations specific to asthma patients in the immediate periarrest period. There is no conclusive evidence of superiority of one biphasic shock waveform over another for defibrillation. What are the ideal dose and formulation of IV lipid emulsion therapy? 3. Nondihydropyridine calcium channel antagonists and IV -adrenergic blockers should not be used in patients with left ventricular systolic dysfunction and decompensated heart failure because these may lead to further hemodynamic compromise. Verapamil is a calcium channel blocking agent that slows AV node conduction, shortens the refractory period of accessory pathways, and acts as a negative inotrope and vasodilator. Success rates for the Valsalva maneuver in terminating SVT range from 19% to 54%. Since the last review in 2010 of rescue breathing in adult patients, there has been no evidence to support a change in previous recommendations. It is reasonable that selection of fixed versus escalating energy levels for subsequent shocks for presumed shock-refractory arrhythmias be based on the specific manufacturers instructions for that waveform. 3. after initiating CPR you and 2 nurses have been performing CPR on a 72 year old patient, Ben Phillips. 4. 1. 5. For cardiac arrest with known or suspected hyperkalemia, in addition to standard ACLS care, IV calcium should be administered. Soon after the AED pads have been placed, the device alerts, "Shock advised." In postcardiac surgery patients who are refractory to standard resuscitation procedures, mechanical circulatory support may be effective in improving outcome. recurrence and improve outcome? If no emergency medical services (EMS) or other trained personnel is on the scene, activate the 911 emergency system immediately. 1. For a patient with suspected opioid overdose who has a definite pulse but no normal breathing or only gasping (ie, a respiratory arrest), in addition to providing standard BLS and/or ACLS care, it is reasonable for responders to administer naloxone. 1. When providing chest compressions, the rescuer should place the heel of one hand on the center (middle) of the victims chest (the lower half of the sternum) and the heel of the other hand on top of the first so that the hands are overlapped. Because any single method of neuroprognostication has an intrinsic error rate and may be subject to confounding, multiple modalities should be used to improve decision-making accuracy. The American Heart Association requests that this document be cited as follows: Panchal AR, Bartos JA, Cabaas JG, Donnino MW, Drennan IR, Hirsch KG, Kudenchuk PJ, Kurz MC, Lavonas EJ, Morley PT, ONeil BJ, Peberdy MA, Rittenberger JC, Rodriguez AJ, Sawyer KN, Berg KM; on behalf of the Adult Basic and Advanced Life Support Writing Group. Atrial fibrillation is an SVT consisting of disorganized atrial electric activation and uncoordinated atrial contraction. 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. Case reports and animal data have suggested that IV lipid emulsion may be of benefit.25 LAST results in profound inhibition of voltage-gated channels (especially sodium transduction) in the cell membrane. 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. It is reasonable to immediately resume chest compressions after shock delivery for adults in cardiac arrest in any setting. Which term refers to clearly and rationally identifying the connection between information and actions? 2. Administration of sodium bicarbonate for cardiac arrest or life-threatening cardiac conduction delays (ie, QRS prolongation more than 120 ms) due to sodium channel blocker/tricyclic antidepressant (TCA) overdose can be beneficial. CPR indicates cardiopulmonary resuscitation. It has been shown previously that all rescuers may have difficulty detecting a pulse, leading to delays in CPR, or in some cases CPR not being performed at all for patients in cardiac arrest.3 Recognition of cardiac arrest by lay rescuers, therefore, is determined on the basis of level of consciousness and the respiratory effort of the victim. It has been shown that the risk of injury from CPR is low in these patients.2. The effect of individual CPR quality metrics or interventions is difficult to evaluate because so many happen concurrently and may interact with each other in their effect. What is the optimal energy needed for cardioversion of atrial fibrillation and atrial flutter? Two small studies have demonstrated improved hemodynamic effects of open-chest CPR when compared with external chest compressions in cardiac surgery patients. and 2. Lay rescuers may provide chest compression only CPR to simplify the process and encourage CPR initiation, whereas healthcare providers may provide chest compressions and ventilation (Figures 24). The goal of ECPR is to support end organ perfusion while potentially reversible conditions are addressed. ACD-CPR is performed by using a handheld device with a suction cup applied to the midsternum, actively lifting up the chest during decompressions, thereby enhancing the negative intrathoracic pressure generated by chest recoil and increasing venous return and cardiac output during the next chest compression. If using a defibrillator capable of escalating energies, higher energy for second and subsequent shocks may be considered for presumed shock-refractory arrhythmias. Do neuroprotective agents improve favorable neurological outcome after arrest? 2. cardiac arrest with shockable rhythm? The team should provide ventilations at a rate of 1 ventilation every 6 seconds without pausing compressions. 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. CPR is recommended until a defibrillator or AED is applied. Based on similarly rare but time-critical interventions, planning, simulation training and mock emergencies will assist in facility preparedness. In a trained provider-witnessed arrest of a postcardiac surgery patient, immediate defibrillation for VF/VT should be performed. 4. Because the duration of action of naloxone may be shorter than the respiratory depressive effect of the opioid, particularly long-acting formulations, repeat doses of naloxone, or a naloxone infusion may be required. Obtaining EEG in status myoclonus is important to rule out underlying ictal activity. Continuous waveform capnography is recommended in addition to clinical assessment as the most reliable method of confirming and monitoring correct placement of an endotracheal tube. 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. You perform a rapid assessment and determine that your patient is experiencing cardiac arrest. 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. If hemodynamically stable, a presumptive rhythm diagnosis should be attempted by obtaining a 12-lead ECG to evaluate the tachycardias features. Check for no breathing or only gasping and check pulse (ideally simultaneously). Two randomized, placebo-controlled trials, enrolling over 8500 patients, evaluated the efficacy of epinephrine for OHCA.1,2 A systematic review and meta-analysis of these and other studies3 concluded that epinephrine significantly increased ROSC and survival to hospital discharge. No controlled studies examine the effect of IV calcium for calcium channel blocker toxicity. Conversely, when VF/ VT is more protracted, depletion of the hearts energy reserves can compromise the efficacy of defibrillation unless replenished by a prescribed period of CPR before the rhythm analysis.