Biphasic and monophasic shock waveforms are likely equivalent in their clinical outcome efficacy. 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. Maintaining a patent airway and providing adequate ventilation and oxygenation are priorities during CPR. Emergent coronary angiography is reasonable for select (eg, electrically or hemodynamically unstable) adult patients who are comatose after OHCA of suspected cardiac origin but without ST-segment elevation on ECG. ACLS Advanced Airway Adjuncts Guide - SaveaLife.com 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. 4. 2. 5. For patients with an arterial line in place, does targeting CPR to a particular blood pressure improve Case reports and at least 1 retrospective observational study have been published on survival after ECMO in patients presenting with refractory shock from -adrenergic blocker overdose. In light of the complexity of postarrest patients, a multidisciplinary team with expertise in cardiac arrest care is preferred, and the development of multidisciplinary protocols is critical to optimize survival and neurological outcome. CPR Quality Push hard (at least 2 inches [5 cm]) and fast (100-120/min) and allow complete chest recoil. The writing group acknowledged that there is no direct evidence that EEG to detect nonconvulsive seizures improves outcomes. 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. maintain proficiency? 3. Adenosine is recommended for acute treatment in patients with SVT at a regular rate. 1. 3. 1. 6. Two RCTs of patients with OHCA with an initially shockable rhythm published in 2002 reported benefit from mild hypothermia when compared with no temperature management. Normal brain has a GWR of approximately 1.3, and this number decreases with edema. There is insufficient evidence to recommend the routine use of extracorporeal CPR (ECPR) for patients with cardiac arrest. When bradycardia occurs secondary to a pathological cause, it can lead to decreased cardiac output with resultant hypotension and tissue hypoperfusion. The AHA has rigorous conflict of interest policies and procedures to minimize the risk of bias or improper influence during the development of guidelines. Because the -adrenergic receptor regulates the activity of the L-type calcium channel,1 overdose of these medications presents similarly, causing life-threatening hypotension and/or bradycardia that may be refractory to standard treatments such as vasopressor infusions.2,3 For patients with refractory hemodynamic instability, therapeutic options include administration of high-dose insulin, IV calcium, or glucagon, and consultation with a medical toxicologist or regional poison center can help determine the optimal therapy. 1. BLS Study Guide - National CPR Association If using a defibrillator capable of escalating energies, higher energy for second and subsequent shocks may be considered for presumed shock-refractory arrhythmias. However, obtaining IV access under emergent conditions can prove to be challenging based on patient characteristics and operator experience leading to delay in pharmacological treatments. Which patients with cardiac arrest due to suspected pulmonary embolism benefit from emergency 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. Epidemiological data suggest that risk factors for It is important for EMS providers to be able to differentiate patients in whom continued resuscitation is futile from patients with a chance of survival who should receive continued resuscitation and transportation to hospital. 1. We recommend that laypersons initiate CPR for presumed cardiac arrest, because the risk of harm to the patient is low if the patient is not in cardiac arrest. 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. CT and MRI findings of brain injury evolve over the first several days after arrest, so the timing of the imaging study of interest is of particular importance as it relates to prognosis. Early activation of the emergency response system is critical for patients with suspected opioid overdose. 2. Case reports have rarely described damage to the heart due to external chest compressions. In adult CPR, 100 to 120 chest compressions per minute at a depth of at least 2 inches, but no greater than 2.4 inches, should be provided. 3. How is CPR performed differently when an advanced airway is in place? Routine stabilization of the cervical spine in the absence of circumstances that suggest a spinal injury is not recommended. A small number of studies has shown that higher Pao, Observational studies have found that increases in ETCO. Table 1. The literature supports prioritizing defibrillation and CPR initially and giving epinephrine if initial attempts with CPR and defibrillation are not successful. 4. Furthermore, many research studies have methodological limitations including small sample sizes, single-center design, lack of blinding, the potential for self-fulfilling prophecies, and the use of outcome at hospital discharge rather than a time point associated with maximal recovery (typically 36 months after arrest).3. What is the ideal sequencing of modalities (traditional vasopressors, calcium, glucagon, high-dose 3. 4. 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. 4. We recommend TTM for adults who do not follow commands after ROSC from IHCA with initial nonshockable rhythm. 1. 5. Patients should be monitored constantly to verify airway patency and adequate ventilation and oxygenation. 2. 4. 1. All of these activities require organizational infrastructures to support the education, training, equipment, supplies, and communication that enable each survival. The recommended dose of epinephrine in anaphylaxis is 0.2 to 0.5 mg (1:1000) intramuscularly, to be repeated every 5 to 15 min as needed. Prevention 2. 3. 2. Key topics in postresuscitation care that are not covered in this section, but are discussed later, are targeted temperature management (TTM) (Targeted Temperature Management), percutaneous coronary intervention (PCI) in cardiac arrest (PCI After Cardiac Arrest), neuroprognostication (Neuroprognostication), and recovery (Recovery). Arterial pressure monitoring by arterial line may be used to detect ROSC during chest compressions or when a rhythm check reveals an organized rhythm. The main focus in adult cardiac arrest events includes rapid recognition, prompt provision of CPR, defibrillation of malignant shockable rhythms, and post-ROSC supportive care and treatment of underlying causes. Is there benefit to naloxone administration in patients with opioid-associated cardiac arrest who are AED indicates automated external defibrillator; and BLS, basic life support. Open-chest CPR can be useful if cardiac arrest develops during surgery when the chest or abdomen is already open, or in the early postoperative period after cardiothoracic surgery. Compression rate 3. The value of artifact-filtering algorithms for analysis of electrocardiogram (ECG) rhythms during chest compressions has not been established. Case reports support the use of ECMO for patients with refractory shock due to TCA toxicity. Data from 1 RCT. 1. Other pseudoelectrical therapies, such as cough CPR, fist or percussion pacing, and precordial thump have all been described as temporizing measures in select patients who are either periarrest or in the initial seconds of witnessed cardiac arrest (before losing consciousness in the case of cough CPR) when definitive therapy is not readily available. 3. High-quality CPR, defibrillation when appropriate, vasopressors and/or antiarrhythmics, and airway management remain the cornerstones of cardiac arrest resuscitation, but some emerging data suggest that incorporating patient-specific imaging and physiological data into our approach to resuscitation holds some promise. 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. Several studies demonstrate that patients with known or suspected cyanide toxicity presenting with cardiovascular instability or cardiac arrest who undergo prompt treatment with IV hydroxocobalamin, a cyanide scavenger. In the 2020 ILCOR systematic review, no randomized trials were identified addressing the treatment of cardiac arrest caused by confirmed PE. These arrhythmias are common and often coexist, and their treatment recommendations are similar. These recommendations are supported by the 2015 ACC/AHA/HRS Guideline for the Management of Adult Patients With SVT: A Report of the American College of Cardiology/AHA Task Force on Clinical Practice Guidelines and the Heart Rhythm Society.6, These recommendations are supported by the 2015 American College of Cardiology, AHA, and Heart Rhythm Society Guidelines for the Management of Adult Patients With SVT.6. It may be reasonable to use audiovisual feedback devices during CPR for real-time optimization of CPR performance. Do antiarrhythmic drugs, when given in combination for cardiac arrest, improve outcomes from cardiac Resuscitation should generally be conducted where the victim is found, as long as high-quality CPR can be administered safely and effectively in that location. Healthcare providers often take too long to check for a pulse. On recognition of a cardiac arrest event, a layperson should simultaneously and promptly activate the emergency response system and initiate cardiopulmonary resuscitation (CPR). What are the optimal pharmacological treatment regimens for the management of postarrest seizures? 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. 2. Health care professionals can perform chest. Because there are no studies demonstrating improvement in patient outcomes from administration of naloxone during cardiac arrest, provision of CPR should be the focus of initial care. After identifying a cardiac arrest, a lone responder should activate the emergency response system first and immediately begin CPR. 3. We recommend that cardiac arrest survivors and their caregivers receive comprehensive, multidisciplinary discharge planning, to include medical and rehabilitative treatment recommendations and return to activity/work expectations. treatable/preventable/recoverable? TTM between 32C and 36C for at least 24 hours is currently recommended for all cardiac rhythms in both OHCA and IHCA. Nine observational studies evaluated rhythmic/ periodic discharges. Thus, the ultimate decision of the use, type, and timing of an advanced airway will require consideration of a host of patient and provider characteristics that are not easily defined in a global recommendation. 4. 2. Why is this? In a trained provider-witnessed arrest of a postcardiac surgery patient, immediate defibrillation for VF/VT should be performed. Although not new, this is a 2015 American Heart Association guideline. Is there a role for prophylactic antiarrhythmics after ROSC? No controlled studies examine the effect of IV calcium for calcium channel blocker toxicity. Step 4. 5. All patients with evidence of anaphylaxis require early treatment with epinephrine. 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. Although there are no controlled studies, several case reports and small case series have reported improvement in bradycardia and hypotension after glucagon administration. 3. Operationally, administering epinephrine every second cycle of CPR, after the initial dose, may also be reasonable. 2. 3. Bradycardia is generally defined as a heart rate less than 60/min. 2. The effectiveness of CPR appears to be maximized with the victim in a supine position and the rescuer kneeling beside the victims chest (eg, out-of-hospital) or standing beside the bed (eg, in-hospital). Activation of emergency response system 3. When significant CAD is observed during post-ROSC coronary angiography, revascularization can be achieved safely in most cases.5,7,9 Further, successful PCI is associated with improved survival in multiple observational studies.2,6,7,10,11 Additional benefits of evaluation in the cardiac catheterization laboratory include discovery of anomalous coronary anatomy, the opportunity to assess left ventricular function and hemodynamic status, and the potential for insertion of temporary mechanical circulatory support devices. Once reliable measurement of peripheral blood oxygen saturation is available, avoiding hyperoxemia by titrating the fraction of inspired oxygen to target an oxygen saturation of 92% to 98% may be reasonable in patients who remain comatose after ROSC. For patients with cocaine-induced hypertension, tachycardia, agitation, or chest discomfort, benzodiazepines, alpha blockers, calcium channel blockers, nitroglycerin, and/or morphine can be beneficial. 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. with hydroxocobalamin? 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. In patients with -adrenergic blocker overdose who are in refractory shock, administration of IV glucagon is reasonable. 5. 1. 5. It may be reasonable to actively prevent fever in comatose patients after TTM. Peer reviewer feedback was provided for guidelines in draft format and again in final format. A single shock strategy is reasonable in preference to stacked shocks for defibrillation in the setting of unmonitored cardiac arrest. Immediate defibrillation by a trained provider presents distinct advantages in these patients, whereas the morbidity associated with external chest compressions or resternotomy may substantially impact recovery. It may be reasonable for EMS providers to use a rate of 10 breaths per minute (1 breath every 6 s) to provide asynchronous ventilation during continuous chest compressions before placement of an advanced airway. If this is not known, defibrillation at the maximal dose may be considered. Evidence is limited to case reports and extrapolations from nonfatal cases, interpretation of pathophysiology, and consensus opinion. What is the optimal approach to advanced airway management for IHCA? On MRI, cytotoxic injury can be measured as restricted diffusion on diffusion-weighted imaging (DWI) and can be quantified by the ADC. 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. An updated systematic review on several aspects of this important topic is needed once currently ongoing clinical trials have been completed. ILCOR Consensus on CPR and Emergency Cardiovascular 3. In postcardiac surgery patients with asystole or bradycardic arrest in the ICU with pacing leads in place, pacing can be initiated immediately by trained providers. Before placement of an advanced airway (supraglottic airway or tracheal tube), it is reasonable for healthcare providers to perform CPR with cycles of 30 compressions and 2 breaths. 3. CPR indicates cardiopulmonary resuscitation; ET, endotracheal; IO, intraosseous; IV, intravenous; PEA, pulseless electrical activity; pVT, pulseless ventricular tachycardia; and VF, ventricular fibrillation. Routine use of sodium bicarbonate is not recommended for patients in cardiac arrest. The next steps in care, including the performance of CPR and the administration of naloxone, are discussed in detail below. 1. Taking a regular rather than a deep breath prevents the rescuer from getting dizzy or lightheaded and prevents overinflation of the victims lungs. 3. 1. The evidence for what constitutes optimal CPR continues to evolve as research emerges. How to Perform CPR: Hands-Only and Mouth-to-Mouth - Healthline Adenosine only transiently slows irregularly irregular rhythms, such as atrial fibrillation, rendering it unsuitable for their management. This may include vasopressor agents such as epinephrine (discussed in Vasopressor Medications During Cardiac Arrest) as well as drugs without direct hemodynamic effects (nonpressors) such as antiarrhythmic medications, magnesium, sodium bicarbonate, calcium, or steroids (discussed here). 2. Cough CPR is described as a repetitive deep inspiration followed by a cough every few seconds before the loss of consciousness. In addition to standard ACLS, several therapies have long been recommended to treat life-threatening hyperkalemia. When VF/VT has been present for more than a few minutes, myocardial reserves of oxygen and other energy substrates are rapidly depleted. 1. Unauthorized use prohibited. What combination of features can identify patients with no chance of survival, even if rewarmed? What is the specific type, amount, and interval between airway management training experiences to The head tiltchin lift has been shown to be effective in establishing an airway in noncardiac arrest and radiological studies.

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