There is a need for further research specifically on the interface between patient factors and the 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. Fist (percussion) pacing may be considered as a temporizing measure in exceptional circumstances such as witnessed, monitored in-hospital arrest (eg, cardiac catheterization laboratory) for bradyasystole before a loss of consciousness and if performed without delaying definitive therapy. Cardiopulmonary Resuscitation During the COVID-19 Pandemic In adult victims of cardiac arrest, it is reasonable for rescuers to perform chest compressions at a rate of 100 to 120/min. 2. 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. 4. -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. When performed with other prognostic tests, it may be reasonable to consider burst suppression on EEG in the absence of sedating medications at 72 h or more after arrest to support the prognosis of poor neurological outcome. Can we identify consistent NSE and S100B thresholds for predicting poor neurological outcome after Although contradictory evidence exists, it may be reasonable to avoid the use of pure -adrenergic blocker medications in the setting of cocaine toxicity. Whether resumption of CPR immediately after shock might reinduce VF/VT is controversial.52-54 This potential concern has not been borne out by any evidence of worsened survival from such a strategy. Neuroprognostication that uses multimodal testing is felt to be better at predicting outcomes than is relying on the results of a single test to predict poor prognosis. It is not uncommon for chest compressions to be paused for rhythm detection and continue to be withheld while the defibrillator is charged and prepared for shock delivery. Early delivery is associated with better maternal and neonatal survival.15 In situations incompatible with maternal survival, early delivery of the fetus may also improve neonatal survival. Explanation: I hope This helps!! 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. Since initial efforts for maternal resuscitation may not be successful, preparation for PMCD should begin early in the resuscitation, since decreased time to PMCD is associated with better maternal and fetal outcomes. In addition to defibrillation, several alternative electric and pseudoelectrical therapies have been explored as possible treatment options during cardiac arrest. Acknowledging these data, the use of mechanical CPR devices by trained personnel may be beneficial in settings where reliable, high-quality manual compressions are not possible or may cause risk to personnel (ie, limited personnel, moving ambulance, angiography suite, prolonged resuscitation, or with concerns for infectious disease exposure). On MRI, cytotoxic injury can be measured as restricted diffusion on diffusion-weighted imaging (DWI) and can be quantified by the ADC. The goal of ECPR is to support end organ perfusion while potentially reversible conditions are addressed. Approximately 1.2% of adults admitted to US hospitals suffer in-hospital cardiac arrest (IHCA).1 Of these patients, 25.8% were discharged from the hospital alive, and 82% of survivors have good functional status at the time of discharge. Although there are no controlled studies, several case reports and small case series have reported improvement in bradycardia and hypotension after glucagon administration. When bradycardia is refractory to medical management and results in severe symptoms, the reasonable next step is placement of a temporary pacing catheter for transvenous pacing. There is no published evidence on the safety, effectiveness, or feasibility of mouth-to-stoma ventilation. The trachea, which is sometimes called the windpipe, conducts air down into the lungs through the bronchi, which are smaller tubular branches. IV lidocaine, amiodarone, and measures to treat myocardial ischemia may be considered to treat polymorphic VT in the absence of a prolonged QT interval. This device provides adequate ventilation comparable to an ET tube. We recommend that the absence of EEG reactivity within 72 h after arrest not be used alone to support a poor neurological prognosis. pharmacological, catheter intervention, or implantable device? We recommend promptly performing and interpreting an electroencephalogram (EEG) for the diagnosis of seizures in all comatose patients after ROSC. For patients with severe hypothermia (less than 30C [86F]) with a perfusing rhythm, core rewarming is often used. 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. Studies of mechanical CPR devices have not demonstrated a benefit when compared with manual CPR, with a suggestion of worse neurological outcome in some studies. Finally, case reports and case series using ECMO in maternal cardiac arrest patients report good maternal survival.16 The treatment of cardiac arrest in late pregnancy represents a major scientific gap. Management of hemodynamically unstable patients with SVT must start with prompt restoration of sinus rhythm through the use of cardioversion. 1. In 2015, approximately 350 000 adults in the United States experienced nontraumatic out-of-hospital cardiac arrest (OHCA) attended by emergency medical services (EMS) personnel.1 Approximately 10.4% of patients with OHCA survive their initial hospitalization, and 8.2% survive with good functional status. 2. Give rescue breaths. 6. 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. 1. neurological outcome? 3. receiving CPR with ventilation? 2. While you lift the jaw, press firmly and completely around the outside edge of the mask to seal the pocket mask against the face. The evidence for these recommendations was last reviewed thoroughly in 2010. A wide-complex tachycardia is defined as a rapid rhythm (generally 150 beats/min or more when attributable to an arrhythmia) with a QRS duration of 0.12 seconds or more. What is the correct order of steps of the Pediatric Out-of-Hospital Chain of Survival? Patients in anaphylactic shock are critically ill, and cardiovascular and respiratory status can change quickly, making close monitoring imperative. The 2019 focused update on ACLS guidelines addressed the use of advanced airways in cardiac arrest and noted that either bag-mask ventilation or an advanced airway strategy may be considered during CPR for adult cardiac arrest in any setting.1 Outcomes from advanced airway and bag-mask ventilation interventions are highly dependent on the skill set and experience of the provider (Figure 7). No shock waveform has distinguished itself as achieving a consistently higher rate of ROSC or survival. The 2020 CoSTR recommends that seizures be treated when diagnosed in postarrest patients. Routine stabilization of the cervical spine in the absence of circumstances that suggest a spinal injury is not recommended. 2. 4. thrombolysis during resuscitation? ECPR indicates extracorporeal cardiopulmonary resuscitation. When evaluated with other prognostic tests after arrest, the usefulness of rhythmic periodic discharges to support the prognosis of poor neurological outcome is uncertain. 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. In addition, 15 recommendations are designated Class 3: No Benefit, and 11 recommendations are Class 3: Harm. 2. 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. What is the specific type, amount, and interval between airway management training experiences to What is the optimal energy needed for cardioversion of atrial fibrillation and atrial flutter? A recent systematic review of 11 RCTs (overall moderate to low certainty of evidence) found no evidence of improved survival with good neurological outcome with mechanical CPR compared with manual CPR in either OHCA or IHCA.1 Given the perceived logistic advantages related to limited personnel and safety during patient transport, mechanical CPR remains popular among some providers and systems. 1-800-AHA-USA-1 Evidence in humans of the effect of vasopressors or other medications during cardiac arrest in the setting of hypothermia consists of case reports only. When pacing attempts are not immediately successful, standard ACLS including CPR is indicated. 2. The suggested timing of the multimodal diagnostics is shown here. If a victim is unconscious/unresponsive, with absent or abnormal breathing (ie, only gasping), the healthcare provider should check for a pulse for no more than 10 s and, if no definite pulse is felt, should assume the victim is in cardiac arrest. There are also no specific alterations to ACLS for patients with cardiac arrest from asthma, although airway management and ventilation increase in importance given the likelihood of an underlying respiratory cause of arrest. This topic last received formal evidence review in 2015.7. Advanced resuscitation 5. Animal studies, case reports, and case series have reported increased heart rate and improved hemodynamics after high-dose insulin administration for -adrenergic blocker toxicity. Epinephrine should be administered early by intramuscular injection (or autoinjector) to all patients with signs of a systemic allergic reaction, especially hypotension, airway swelling, or difficulty breathing. It includes a venous cannula, a pump, an oxygenator, and an arterial cannula. Fever after ROSC is associated with poor neurological outcome in patients not treated with TTM, although this finding is reported less consistently in patients treated with TTM. The value of VF waveform analysis to guide the acute management of adults with cardiac arrest has not been established. 2. The prompt initiation of CPR is perhaps the most important intervention to improve survival and neurological outcomes. Polymorphic VT that is not associated with QT prolongation is often triggered by acute myocardial ischemia and infarction, In the absence of long QT, magnesium has not been shown to be effective in the treatment of polymorphic VT. and 2. Point-of-care cardiac ultrasound can identify cardiac tamponade or other potentially reversible causes of cardiac arrest and identify cardiac motion in pulseless electrical activity. Phone or ask someone to phone 9-1-1 (the phone or caller with the phone remains at the victim's side, with the phone on speaker mode). Does sodium thiosulfate provide additional benefit to patients with cyanide poisoning who are treated Thirty-seven recommendations are supported by Level B-Randomized Evidence (moderate evidence from 1 or more RCTs) and 57 by Level B-Nonrandomized evidence. The key drivers of successful resuscitation from OHCA are lay rescuer cardiopulmonary resuscitation (CPR) and public use of an automated external defibrillator (AED). It is preferred to perform CPR on a firm surface and with the victim in the supine position, when feasible. Should severely hypothermic patients in cardiac arrest receive epinephrine or other resuscitation The provision of rescue breaths for apneic patients with a pulse is essential. 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. 3. 2. There are no randomized trials of the use of TTM in pregnancy. If using a defibrillator capable of escalating energies, higher energy for second and subsequent shocks may be considered for presumed shock-refractory arrhythmias. 2. 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. 4. CPR / AED Study Guide: Part 2 - National CPR Association We recommend that cardiac arrest survivors have multimodal rehabilitation assessment and treatment for physical, neurological, cardiopulmonary, and cognitive impairments before discharge from the hospital. An approach using lower tidal volumes, lower respiratory rate, and increased expiratory time may minimize the risk of auto-PEEP and barotrauma. Approximately one third of cardiac arrest survivors experience anxiety, depression, or posttraumatic stress. Emergent electric cardioversion and defibrillation are highly effective at terminating VF/VT and other tachyarrhythmias. Both of these considerations support earlier advanced airway management for the pregnant patient. 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. 1. These deliver different peak currents even at the same programmed energy setting, making comparisons of shock efficacy between devices challenging. What are the optimal pharmacological treatment regimens for the management of postarrest seizures? 4. Conversely, a wide-complex tachycardia can also be due to VT or a rapid ventricular paced rhythm in patients with a pacemaker. Two small studies have demonstrated improved hemodynamic effects of open-chest CPR when compared with external chest compressions in cardiac surgery patients. Coronary artery disease (CAD) is prevalent in the setting of cardiac arrest.14 Patients with cardiac arrest due to shockable rhythms have demonstrated particularly high rates of severe CAD: up to 96% of patients with STEMI on their postresuscitation ECG,2,5 up to 42% for patients without ST-segment elevation,2,57 and 85% of refractory out-of-hospital VF/VT arrest patients have severe CAD.8 The role of CAD in cardiac arrest with nonshockable rhythms is unknown. 6. 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. If you're trained in CPR and you've performed 30 chest compressions, open the person's airway using the head-tilt, chin-lift maneuver. CT and MRI are the 2 most common modalities. Airway and ventilation management during cardiopulmonary resuscitation Normal brain has a GWR of approximately 1.3, and this number decreases with edema. In a trained provider-witnessed arrest of a postcardiac surgery patient, immediate defibrillation for VF/VT should be performed. Rescuers should provide CPR, including rescue breathing, as soon as an unresponsive submersion victim is removed from the water. Discharges on EEG were divided into 2 types: rhythmic/periodic and nonrhythmic/periodic. Severe anaphylaxis may cause complete obstruction of the airway and/or cardiovascular collapse from vasogenic shock. Notably, when the QRS complex is of uniform morphology, shock synchronized to the QRS is encouraged because this minimizes the risk of provoking VF by a mistimed shock during the vulnerable period of the cardiac cycle (T wave). CPR is the single-most important intervention for a patient in cardiac arrest and should be provided until a defibrillator is applied to minimize interruptions in compressions. If a spinal injury is suspected or cannot be ruled out, providers should open the airway by using a jaw thrust instead of head tiltchin lift. One expected challenge faced through this process was the lack of data in many areas of cardiac arrest research. With respect to timing, for cardiac arrest with a nonshockable rhythm, it is reasonable to administer epinephrine as soon as feasible. Patients who respond to naloxone administration may develop recurrent CNS and/or respiratory depression. In the 2020 ILCOR systematic review, no randomized trials were identified addressing the treatment of cardiac arrest caused by confirmed PE. IV antiarrhythmic medications may be considered in stable patients with wide-complex tachycardia, particularly if suspected to be VT or having failed adenosine. Observational studies of fibrinolytic therapy for suspected PE were found to have substantial bias and showed mixed results in terms of improvement in outcomes. 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. Some literature reports good favorable outcomes while others report significant adverse events. Hemodynamically unstable patients with atrial fibrillation or atrial flutter with rapid ventricular response should receive electric cardioversion. 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. 1. 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. 5. While amiodarone is typically considered a rhythm-control agent, it can effectively reduce ventricular rate with potential use in patients with congestive heart failure where -adrenergic blockers may not be tolerated and nondihydropyridine calcium channel antagonists are contraindicated. Disclosure information for peer reviewers is listed in Appendix 2(link opens in new window). In the supine position, aortocaval compression can occur for singleton pregnancies starting at approximately 20 weeks of gestational age or when the fundal height is at or above the level of the umbilicus. 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. Shout for nearby help and activate the emergency response system (9-1-1, emergency response). Cough CPR may be considered as a temporizing measure for the witnessed, monitored onset of a hemodynamically significant tachyarrhythmia or bradyarrhythmia before a loss of consciousness without delaying definitive therapy. We recommend selecting and maintaining a constant temperature between 32C and 36C during TTM. DWI/ADC is a sensitive measure of injury, with normal values ranging between 700 and 800106 mm2 /s and values decreasing with injury. 1. Do double sequential defibrillation and/or alternative defibrillator pad positioning affect outcome in Additional recommendations about opioid overdose response education are provided in Part 6: Resuscitation Education Science., AED indicates automated external defibrillator; CPR, cardiopulmonary resuscitation; and EMS, emergency medical services, These recommendations are supported by the 2020 AHA scientific statement on opioid-associated OHCA.3, Approximately 1 in 12 000 admissions for delivery in the United States results in a maternal cardiac arrest.1 Although it remains a rare event, the incidence has been increasing.2 Reported maternal and fetal/neonatal survival rates vary widely.38 Invariably, the best outcomes for both mother and fetus are through successful maternal resuscitation. This approach results in a protracted hands-off period before shock. 4. 5. Rate control is more common in the emergency setting, using IV administration of a nondihydropyridine calcium channel antagonist (eg, diltiazem, verapamil) or a -adrenergic blocker (eg, metoprolol, esmolol). 2. All guidelines were reviewed and approved for publication by the AHA Science Advisory and Coordinating Committee and the AHA Executive Committee. The clinical signs associated with severe hyperkalemia (more than 6.5 mmol/L) include flaccid paralysis, paresthesia, depressed deep tendon reflexes, or shortness of breath.13 The early electrocardiographic signs include peaked T waves on the ECG followed by flattened or absent T waves, prolonged PR interval, widened QRS complex, deepened S waves, and merging of S and T waves.4,5 As hyperkalemia progresses, the ECG can develop idioventricular rhythms, form a sine-wave pattern, and develop into an asystolic cardiac arrest.4,5 Severe hypokalemia is less common but can occur in the setting of gastrointestinal or renal losses and can lead to life-threatening ventricular arrhythmias.68 Severe hypermagnesemia is most likely to occur in the obstetric setting in patients being treated with IV magnesium for preeclampsia or eclampsia. To assure successful maternal resuscitation, all potential stakeholders need to be engaged in the planning and training for cardiac arrest in pregnancy, including the possible need for PMCD. Frequent experience or frequent retraining is recommended for providers who perform endotracheal intubation. In some instances, prognostication and withdrawal of life support may appropriately occur earlier because of nonneurologic disease, brain herniation, patients goals and wishes, or clearly nonsurvivable situations. Limited evidence from case reports and case series demonstrates transient increases in aortic and intracardiac pressure with the use of cough CPR at the onset of tachyarrhythmias or bradyarrhythmias in conscious patients. 5. There is also inconsistency in definitions used to describe specific findings and patterns. 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. 7272 Greenville Ave. Healthcare providers often take too long to check for a pulse. In adult cardiac arrest, it may be reasonable to perform CPR with a chest compression fraction of at least 60%. Opioid overdoses deteriorate to cardiopulmonary arrest because of loss of airway patency and lack of breathing; therefore, addressing the airway and ventilation in a periarrest patient is of the highest priority. 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. IV Medications Commonly Used for Acute Rate Control in Atrial Fibrillation and Atrial Flutter, CPR & First Aid in Youth Sports Training Kit, Resuscitation Quality Improvement Program (RQI), Coronavirus Resources for CPR & Resuscitation, Advanced Cardiovascular Life Support (ACLS), Resuscitation Quality Improvement Program (RQI), COVID-19 Resources for CPR & Resuscitation, Claiming Your AHA Continuing Education Credits, International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations, extracorporeal cardiopulmonary resuscitation, (partial pressure of) end-tidal carbon dioxide, International Liaison Committee on Resuscitation, arterial partial pressure of carbon dioxide, ST-segment elevation myocardial infarction. Many of the tests considered are subject to error because of the effects of medications, organ dysfunction, and temperature. Enhancing survivorship and recovery after cardiac arrest needs to be a systematic priority, aligned with treatment recommendations for patients surviving stroke, cancer, and other critical illnesses.35, These recommendations are supported by Sudden Cardiac Arrest Survivorship: a Scientific Statement From the AHA.3. Look for no breathing or only gasping, at the direction of the telecommunicator. All lay rescuers should, at minimum, provide chest compressions for victims of cardiac arrest. This topic was last reviewed in 2010 and identified 2 randomized trials, interposed abdominal compression CPR performed by trained rescuers improved short-term survival. Extracorporeal CPR is performed with an extracorporeal membrane oxygenation device. 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. EEG patterns that were evaluated in the 2020 ILCOR systematic review include unreactive EEG, epileptiform discharges, seizures, status epilepticus, burst suppression, and highly malignant EEG. National Center In a small clinical trial and several observational studies, waveform capnography was 100% specific for confirming endotracheal tube position during cardiac arrest. *Telecommunicator and dispatcher are terms often used interchangeably. 1. In these situations, the mainstay of care remains the early recognition of an emergency followed by the activation of the emergency response systems (Figures 13 and 14). The treatment of nonconvulsive seizures (diagnosed by EEG only) may be considered. This approach is supported by animal studies and human case reports and has recently been systematically reviewed.4. Does emergent PCI for patients with ROSC after VF/VT cardiac arrest and no STEMI but with signs of The topic of neuroprotective agents was last reviewed in detail in 2010. What defines optimal hospital care for patients with ROSC after cardiac arrest is not completely known, but there is increasing interest in identifying and optimizing practices that are likely to improve outcomes.