1. Limited animal data and rare case reports suggest possible utility of calcium to improve heart rate and hypotension in -adrenergic blocker toxicity. In addition to defibrillation, several alternative electric and pseudoelectrical therapies have been explored as possible treatment options during cardiac arrest. Step 1: Power on the AED if needed - Follow the prompts (as a guide to next steps) Step 2: Choose adult pads for victim 8 years of age and older - Attack the adhesive AED pads to the victim's bare chest - Follow the diagrams on the pads Step 3: When AED prompts you, clear the victim during analysis. Applying Class of Recommendation and Level of Evidence to Clinical Strategies, Interventions, Treatments, or Diagnostic Testing in Patient Care (Updated May 2019)*, Table 3. Prompt treatment of cardiac glycoside toxicity is imperative to prevent or treat life-threatening arrhythmias. A lone healthcare provider should commence with chest compressions rather than with ventilation. CPR Flashcards | Quizlet 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. However, termination of torsades by shock does not prevent its recurrence, which requires additional measures. Follow the telecommunicators* instructions. No RCTs of TTM have included IHCA patients with an initial shockable rhythm, and this recommendation is therefore based largely on extrapolation from OHCA studies and the study of patients with initially nonshockable rhythms that included IHCA patients. The paucity of information on the efficacy of IO drug administration during CPR was acknowledged in 2010, but since then the IO route has grown in popularity. When evaluated with other prognostic tests, the prognostic value of seizures in patients who remain comatose after cardiac arrest is uncertain. 1. 1. Emergent electric cardioversion and defibrillation are highly effective at terminating VF/VT and other tachyarrhythmias. 1. 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. 2. These include the high success rate of the first shock with biphasic waveforms (lessening the need for successive shocks), the declining success of immediate second and third serial shocks when the first shock has failed. Each of these features can also be useful in making a presumptive rhythm diagnosis. The routine use of mechanical CPR devices is not recommended. 1. 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. Others, such as opioid overdose, are sharply on the rise in the out-of-hospital setting.2 For any cardiac arrest, rescuers are instructed to call for help, perform CPR to restore coronary and cerebral blood flow, and apply an AED to directly treat ventricular fibrillation (VF) or ventricular tachycardia (VT), if present. 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. 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. Evidence suggests that patients who are comatose after ROSC benefit from invasive angiography, when indicated, as do patients who are awake. Before embarking on empirical drug therapy, obtaining a 12-lead ECG and/or seeking expert consultation for diagnosis is encouraged, if available. 5. When performed with other prognostic tests, it may be reasonable to consider bilaterally absent corneal reflexes at 72 h or more after cardiac arrest to support the prognosis of poor neurological outcome in patients who remain comatose. We recommend TTM for adults who do not follow commands after ROSC from OHCA with any initial rhythm. 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. Determining the utility of such physiological monitoring or diagnostic procedures is important. Does avoidance of hyperoxia in the postarrest period lead to improved outcomes? The routine use of prophylactic antibiotics in postarrest patients is of uncertain benefit. 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. Obtaining EEG in status myoclonus is important to rule out underlying ictal activity. If a jaw thrust and/or insertion of an airway adjunct are ineffective in opening the airway and allowing ventilation to occur, a head tiltchin lift may be the only way to open the airway. Evidence in humans of the effect of vasopressors or other medications during cardiac arrest in the setting of hypothermia consists of case reports only. 3. 3. 3. Arrests without a primary cardiac origin (eg, from respiratory failure, toxic ingestion, pulmonary embolism [PE], or drowning) are also common, however, and in such cases, treatment for reversible underlying causes is important for the rescuer to consider.1 Some noncardiac etiologies may be particularly common in the in-hospital setting. These recommendations are supported by the 2019 focused update on ACLS guidelines.1. What is the optimal approach, vasopressor or transcutaneous pacing, in managing symptomatic Based on the protocols used in clinical trials, it is reasonable to administer epinephrine 1 mg every 3 to 5 min for cardiac arrest. However, there are several case reports of good maternal and fetal outcome with the use of TTM after cardiac arrest. Recommendations 1, 2, and 3 are supported by the 2020 CoSTR for BLS.4 Recommendation 4 last received formal evidence review in 2010.17, Recommendations 1 and 4 are supported by the 2020 CoSTR for BLS.4 Recommendations 2, 3, 5, and 6 last received formal evidence review in 2015.31, Recommendations 1, 2, and 3 are supported by the 2020 CoSTR for BLS.4 Recommendation 4 last received formal evidence review in 2010.44, These recommendations are supported by the 2020 CoSTRs for BLS and ALS.4,49. 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. However, these case reports are subject to publication bias and should not be used to support its effectiveness. In some observational studies, improved outcomes have been noted in victims of cardiac arrest who received conventional CPR (compressions and ventilation) compared with those who received chest compressions only. The Adult OHCA and IHCA Chains of Survival have been updated to better highlight the evolution of systems of care and the critical role of recovery and survivorship with the addition of a new link. 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. This approach is supported by animal studies and human case reports and has recently been systematically reviewed.4. What combination of features can identify patients with no chance of survival, even if rewarmed? 2. Does sodium thiosulfate provide additional benefit to patients with cyanide poisoning who are treated 1. Its effects are mediated by a different mechanism and are longer lasting than adenosine. 1. Two RCTs compared a strategy of targeting highnormal Paco2 (4446 mmHg) with one targeting low-normal Paco. Patient selection, evaluation, timing, drug selection, and anticoagulation for patients undergoing rhythm control are beyond the scope of these guidelines and are presented elsewhere.1,2. An updated systematic review on several aspects of this important topic is needed once currently ongoing clinical trials have been completed. In a trained provider-witnessed arrest of a postcardiac surgery patient, immediate defibrillation for VF/VT should be performed. These recommendations are supported by the 2020 CoSTR for ALS,4 which supplements the last comprehensive review of this topic conducted in 2015.7. Hemodynamically stable patients can be treated with a rate-control or rhythm-control strategy. 1. Care of any patient with cardiac arrest in the setting of acute exacerbation of asthma begins with standard BLS. Furthermore, fetal hypoxia has known detrimental effects. Urgent support of airway, breathing, and circulation is essential in suspected anaphylactic reactions. 2. For adults in cardiac arrest receiving CPR without an advanced airway, it is reasonable to pause compressions to deliver 2 breaths, each given over 1 s. 6. 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. Advanced resuscitation 5. During manual CPR, rescuers should perform chest compressions to a depth of at least 2 inches, or 5 cm, for an average adult while avoiding excessive chest compression depths (greater than 2.4 inches, or 6 cm). receiving CPR with ventilation? 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. The risk for developing torsades increases when the corrected QT interval is greater than 500 milliseconds and accompanied by bradycardia.1 Torsades can be due to an inherited genetic abnormality2 and can also be caused by drugs and electrolyte imbalances that cause lengthening of the QT interval.3. Airway management during cardiac arrest usually commences with a basic strategy such as bag-mask ventilation. Activation and retrieval of the AED/emergency equipment by the lone healthcare provider or by the second person sent by the rescuer must occur no later than immediately after the check for no normal breathing and no pulse identifies cardiac arrest. No studies were found that specifically examined the use of ETCO. Adenosine only transiently slows irregularly irregular rhythms, such as atrial fibrillation, rendering it unsuitable for their management. 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. Recognition that all cardiac arrest events are not identical is critical for optimal patient outcome, and specialized management is necessary for many conditions (eg, electrolyte abnormalities, pregnancy, after cardiac surgery). 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. In adult cardiac arrest, total preshock and postshock pauses in chest compressions should be as short as possible. However, the efficacy of IV versus IO drug administration in cardiac arrest remains to be elucidated. Immediate defibrillation is recommended for sustained, hemodynamically unstable polymorphic VT. 1. Cardiac arrest occurs after 1% to 8% of cardiac surgery cases.18 Etiologies include tachyarrhythmias such as VT or VF, bradyarrhythmias such as heart block or asystole, obstructive causes such as tamponade or pneumothorax, technical factors such as dysfunction of a new valve, occlusion of a grafted artery, or bleeding. In patients presenting with acute symptomatic bradycardia, evaluation and treatment of reversible causes is recommended. Manual stabilization can decrease movement of the cervical spine during patient care while allowing for proper ventilation and airway control. neuroprognostication? Electroencephalography is widely used in clinical practice to evaluate cortical brain activity and diagnose seizures. In patients with calcium channel blocker overdose who are in refractory shock, administration of IV glucagon may be considered. 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. The goal of ECPR is to support end organ perfusion while potentially reversible conditions are addressed. 2. In a trial that compared esmolol with diltiazem, diltiazem was more effective in terminating SVT. doi: 10.1161/CIR.0000000000000916, On behalf of the Adult Basic and Advanced Life Support Writing Group. C-EO. Therefore, the management of bradycardia will depend on both the underlying cause and severity of the clinical presentation. It may be reasonable to use physiological parameters such as arterial blood pressure or end-tidal CO. 1. 1. Multiple case series have demonstrated potential benefit from mechanical circulatory support including ECMO and cardiopulmonary bypass in patients who are refractory to standard resuscitation procedures. CPR Ratio Chart and Key Numbers | SureFire CPR Nonconvulsive seizures are common after cardiac arrest. These include mechanical CPR, impedance threshold devices (ITD), active compression-decompression (ACD) CPR, and interposed abdominal compression CPR. There is no evidence that cricoid pressure facilitates ventilation or reduces the risk of aspiration in cardiac arrest patients. How is cpr performed when an advanced airway is in place - Brainly Limited evidence for this intervention consists largely of observational studies, many of which have focused on indications and the relatively high complication rate (including bloodstream infections and pneumothorax, among others). This topic last underwent formal evidence review in 2010.7, These recommendations are supported by the 2020 CoSTR for BLS.21, This recommendation is supported by the 2020 CoSTR for BLS.21. This topic last received formal evidence review in 2015.7. A comprehensive, structured, multidisciplinary system of care should be implemented in a consistent manner for the treatment of postcardiac arrest patients. Recommendation 1 is supported by the 2019 focused update on ACLS guidelines.3 Recommendation 2 last received formal evidence review in 2015.4 Recommendation 3 is supported by the 2020 CoSTR for ALS.11, These recommendations are supported by the 2015 Guidelines Update24 and a 2020 evidence update.11. Community reintegration and return to work or other activities may be slow and depend on social support and relationships. The traditional approach for giving emergency pharmacotherapy is by the peripheral IV route. High-dose epinephrine is not recommended for routine use 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. Hyperlinked references are provided to facilitate quick access and review. In cardiac arrest secondary to anaphylaxis, standard resuscitative measures and immediate administration of epinephrine should take priority. 5. Since the last review in 2010 of rescue breathing in adult patients, there has been no evidence to support a change in previous recommendations. 1. 3. Routine use of sodium bicarbonate is not recommended for patients in cardiac arrest. There should be no pause in chest compressions for delivery of ventilations (Class IIa). 1. In determining the COR, the writing group considered the LOE and other factors, including systems issues, economic factors, and ethical factors such as equity, acceptability, and feasibility. ACD-CPR and ITD may act synergistically to enhance venous return during chest decompression and improve blood flow to vital organs during CPR. It can represent any aberrantly conducted supraventricular tachycardia (SVT), including paroxysmal SVT caused by atrioventricular (AV) reentry, aberrantly conducted atrial fibrillation, atrial flutter, or ectopic atrial tachycardia. Do prophylactic antiarrhythmic medications on ROSC after successful defibrillation decrease arrhythmia The systems-of-care approach to cardiac arrest includes the community and healthcare response to cardiac arrest. The management of patients with preexcitation syndromes (aka Wolff-Parkinson-White) is covered in the Wide-Complex Tachycardia section. All of these activities require organizational infrastructures to support the education, training, equipment, supplies, and communication that enable each survival. 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. Perimortem cesarean delivery (PMCD) at or greater than 20 weeks uterine size, sometimes referred to as resuscitative hysterotomy, appears to improve outcomes of maternal cardiac arrest when resuscitation does not rapidly result in ROSC (Figure 15).1014 Further, shorter time intervals from arrest to delivery appear to lead to improved maternal and neonatal outcomes.15 However, the clinical decision to perform PMCDand its timing with respect to maternal cardiac arrestis complex because of the variability in level of practitioner and team training, patient factors (eg, etiology of arrest, gestational age), and system resources. neurological outcome? Adenosine is an ultrashort-acting drug that is effective in terminating regular tachycardias when caused by AV reentry. In contrast, a patient who develops third-degree heart block but is otherwise well compensated might experience relatively low blood pressure but otherwise be stable. Should severely hypothermic patients in cardiac arrest receive epinephrine or other resuscitation The 2015 American College of Cardiology, AHA, and Heart Rhythm Society Guidelines evaluated and recommended adenosine as a first-line treatment for regular SVT because of its effectiveness, extremely short half-life, and favorable side-effect profile. They may be used in patients with heart failure with preserved ejection fraction. Each year, drowning is responsible for approximately 0.7% of deaths worldwide, or more than 500 000 deaths per year.1,2 A recent study using data from the United States reported a survival rate of 13% after cardiac arrest associated with drowning.3 People at increased risk for drowning include children, those with seizure disorders, and those intoxicated with alcohol or other drugs.1 Although survival is uncommon after prolonged submersion, successful resuscitations have been reported.49 For this reason, scene resuscitation should be initiated and the victim transported to the hospital unless there are obvious signs of death. Hemodynamically unstable patients and those with rate-related ischemia should receive urgent electric cardioversion. This involves the cannulation of a large vein and artery and initiation of venoarterial extracorporeal circulation and membrane oxygenation (ECMO) (Figure 8). What is the optimal timing for head CT for prognostication? Is there an ideal time in the CPR cycle for defibrillator charging? 1. Deaths from acute asthma have decreased in the United States, but asthma continues to be the acute cause of death for over 3500 adults per year.1,2 Patients with respiratory arrest from asthma develop life-threatening acute respiratory acidosis.3 Both the profound acidemia and the decreased venous return to the heart from elevated intrathoracic pressure are likely causes of cardiac arrest in asthma. The optimal combination of airway techniques, oxygenation and ventilation is uncertain. The 2020 ILCOR systematic review evaluated studies that obtained serum biomarkers within the first 7 days after arrest and correlated serum biomarker concentrations with neurological outcome. Recent evidence, however, suggests that the risk of major bleeding is not significantly higher in cardiac arrest patients receiving thrombolysis. 2. Most opioid-associated deaths also involve the coingestion of multiple drugs or medical and mental health comorbidities.47. Can we identify consistent NSE and S100B thresholds for predicting poor neurological outcome after Although there are no controlled studies, several case reports and small case series have reported improvement in bradycardia and hypotension after glucagon administration. These still require further testing and validation before routine use. 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. When available, expert consultation can be helpful to assist in the diagnosis and management of treatment-refractory wide-complex tachycardia. Coronary angiography should be performed emergently for all cardiac arrest patients with suspected cardiac cause of arrest and ST-segment elevation on ECG. This challenge was faced in both the 2010 Guidelines and 2015 Guidelines Update processes, where only a small percent of guideline recommendations (1%) were based on high-grade LOE (A) and nearly three quarters were based on low-grade LOE (C).1. The AHA has rigorous conflict of interest policies and procedures to minimize the risk of bias or improper influence during the development of guidelines. 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. IV amiodarone can be useful for rate control in critically ill patients with atrial fibrillation with rapid ventricular response without preexcitation. 1. No shock waveform has proved to be superior in improving the rate of ROSC or survival. responsible for a large proportion of opioid overdose? Drug administration by central venous access (by internal jugular or subclavian vein) achieves higher peak concentrations and more rapid circulation times than drugs administered by peripheral IV do, Endotracheal drug administration is regarded as the least-preferred route of drug administration because it is associated with unpredictable (but generally low) drug concentrations. 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. 2. Chest compressions are the most critical component of CPR, and a chest compressiononly approach is appropriate if lay rescuers are untrained or unwilling to provide respirations. 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. Resuscitation causes, processes, and outcomes are very different for OHCA and IHCA, which are reflected in their respective Chains of Survival (Figure 1). 1. Although contradictory evidence exists, it may be reasonable to avoid the use of pure -adrenergic blocker medications in the setting of cocaine toxicity. 4. 2. 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. The writing group would also like to acknowledge the outstanding contributions of David J. Magid, MD, MPH. In cases of suspected opioid overdose managed by a nonhealthcare provider who is not capable of Some recommendations are directly relevant to lay rescuers who may or may not have received CPR training and who have little or no access to resuscitation equipment. When 2 or more rescuers are available, it is reasonable to switch chest compressors approximately every 2 min (or after about 5 cycles of compressions and ventilation at a ratio of 30:2) to prevent decreases in the quality of compressions. All lay rescuers should, at minimum, provide chest compressions for victims of cardiac arrest. 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. Once an advanced airway is in place, there is no longer a need to pause compressions to deliver breaths. If the patient presents with SVT, the primary goal of treatment is to quickly identify and treat patients who are hemodynamically unstable (ischemic chest pain, altered mental status, shock, hypotension, acute heart failure) or symptomatic due to the arrhythmia. Of the 250 recommendations in these guidelines, only 2 recommendations are supported by Level A evidence (high-quality evidence from more than 1 randomized controlled trial [RCT], or 1 or more RCT corroborated by high-quality registry studies.)
