That is, when performing CPR on an infant, you perform 30 chest compressions followed by 2 rescue breaths. 1. 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. 4. Current literature is largely observational, and some treatment decisions are based primarily on the physiology of pregnancy and extrapolations from nonarrest pregnancy states.9 High-quality resuscitative and therapeutic interventions that target the most likely cause of cardiac arrest are paramount in this population. Post-cardiac arrest care 6. Futility is often defined as less than 1% chance of survival,1 suggesting that for a TOR rule to be valid it should demonstrate high accuracy for predicting futility with the lower confidence limit greater than 99% on external validation. 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. If no advanced airway, 30:2 compression-ventilation ratio. The ALS TOR rule recommends TOR when all of the following criteria apply before moving to the ambulance for transport: (1) arrest was not witnessed; (2) no bystander CPR was provided; (3) no ROSC after full ALS care in the field; and (4) no AED shocks were delivered. 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. Community reintegration and return to work or other activities may be slow and depend on social support and relationships. 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. 2. 1. Available hemodynamic monitoring modalities in conjunction with manual pulse detection provide an opportunity to confirm myocardial capture and adequate cardiac function. defibrillation? This creates a definitive airway so the air can't escape and end up in the stomach. with hydroxocobalamin? 4. 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. 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. What are the ideal dose and formulation of IV lipid emulsion therapy? Mouth-to-mouth ventilation in the water may be helpful when administered by a trained rescuer if it does not compromise safety. 5. Nine observational studies evaluated rhythmic/ periodic discharges. Send the second person to retrieve an AED, if one is available. 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. For patients in respiratory arrest, rescue breathing or bag-mask ventilation should be maintained until spontaneous breathing returns, and standard BLS and/or ACLS measures should continue if return of spontaneous breathing does not occur. 1. 4. 3. Saturday: 9 a.m. - 5 p.m. CT What do survivor-derived outcome measures of the impact of cardiac arrest survival look like, and how Should there be physiological evidence of return of circulation such as an arterial waveform or abrupt rise in ETCO2 after shock, a pause of chest compressions briefly for confirmatory rhythm analysis may be warranted. All lay rescuers should, at minimum, provide chest compressions for victims of cardiac arrest. Although an advanced airway can be placed without interrupting chest compressions. 4. Intraosseous access may be considered if attempts at intravenous access are unsuccessful or not feasible. Cyanide reversibly binds to the ferric ion cytochrome oxidase in the mitochondria and stops cellular respiration and adenosine triphosphate production. 2. AEDs are highly accurate in their detection of shockable arrhythmias but require a pause in CPR for automated rhythm analysis. 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. 1. Airway, ventilation, and oxygenation are particularly important in the setting of pregnancy because of increased maternal metabolism and decreased functional reserve capacity due to the gravid uterus, making pregnant patients more prone to hypoxia. Does targeted temperature management, compared to strict normothermia, improve outcomes? National Center This recommendation is supported by the 2020 CoSTR for BLS.22, Recommendation 1 is supported by the 2020 CoSTR for ALS.51 Recommendation 2 is supported by a 2020 ILCOR evidence update,51 which found no new information to update the 2010 recommendations.66. 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. 3. It is reasonable for prehospital ALS providers to use the adult ALS TOR rule to terminate resuscitation efforts in the field for adult victims of OHCA. IV amiodarone can be useful for rate control in critically ill patients with atrial fibrillation with rapid ventricular response without preexcitation. Two systematic reviews have identified animal studies, case reports, and human observational studies that have reported increased heart rate and improved hemodynamics after high-dose insulin administration for calcium channel blocker toxicity. Once ROSC is achieved, urgent consultation with a medical toxicologist or regional poison center is suggested. CT and MRI are the 2 most common modalities. Rescue breathing during CPR with an advanced airway: 12-20 breaths per minute Chest compressions should be given continuously at a rate of 100 to 120 per minute. For cardiac arrest with known or suspected hyperkalemia, in addition to standard ACLS care, IV calcium should be administered. In unmonitored cardiac arrest, it is reasonable to provide a brief prescribed period of CPR while a defibrillator is being obtained and readied for use before initial rhythm analysis and possible defibrillation. Does epinephrine, when administered early after cardiac arrest, improve survival with favorable Commercially available defibrillators either provide fixed energy settings or allow for escalating energy settings; both approaches are highly effective in terminating VF/VT. In adult cardiac arrest, it may be reasonable to perform CPR with a chest compression fraction of at least 60%. 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). Adenosine only transiently slows irregularly irregular rhythms, such as atrial fibrillation, rendering it unsuitable for their management. Cough CPR is described as repeated deep breaths followed immediately by a cough every few seconds in an attempt to increase aortic and intracardiac pressures, providing transient hemodynamic support before a loss of consciousness. If you have been trained in CPR, go on to opening the airway and rescue breathing. The 2020 CoSTR recommends that seizures be treated when diagnosed in postarrest patients. 6. neurological outcome? Although the majority of resuscitation success is achieved by provision of high-quality CPR and defibrillation, other specific treatments for likely underlying causes may be helpful in some cases. Observational studies evaluating the utility of cardiac receiving centers suggest that a strong system of care may represent a logical clinical link between successful resuscitation and ultimate survival. 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. 2. 1-800-AHA-USA-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. Is the IO route of drug administration safe and efficacious in cardiac arrest, and does efficacy vary by IO site? Airway and ventilation management during cardiopulmonary resuscitation Adult/Child/Infant. IV epinephrine is an appropriate alternative to intramuscular administration in anaphylactic shock when an IV is in place. In a trained provider-witnessed arrest of a postcardiac surgery patient, immediate defibrillation for VF/VT should be performed. reflex, and myoclonus/status myoclonus? In the rare situation when a lone rescuer must leave the victim to dial EMS, the priority should be on prompt EMS activation followed by immediate return to the victim to initiate CPR. These guidelines are based on the extensive evidence evaluation performed in conjunction with the ILCOR and affiliated ILCOR member councils. This cause of death is especially prominent in those with OHCA but is also frequent after IHCA.1,2 Thus, much of postarrest care focuses on mitigating injury to the brain. 3. It may be reasonable to immediately resume chest compressions after shock administration rather than pause CPR to perform a postshock rhythm check in cardiac arrest patients. and 2. This topic last received formal evidence review in 2015,8 with an evidence update conducted for the 2020 CoSTR for ALS.2. If an advanced airway is used in the in-hospital setting by expert providers trained in these procedures, either a supraglottic airway or an endotracheal tube placement can be used. IV bolus administration of potassium for cardiac arrest in suspected hypokalemia is not recommended. Peer reviewer feedback was provided for guidelines in draft format and again in final format. 4. However, with more people surviving cardiac arrest, there is a need to organize discharge planning and long-term rehabilitation care resources. Healthcare providers often take too long to check for a pulse. Survival with a favorable neurological outcome (Cerebral Performance Category 12) was higher in the group treated with 33C. 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). After cardiac arrest a combination of basic and advanced airway and ventilation techniques are used during cardiopulmonary resuscitation (CPR) and after a return of spontaneous circulation (ROSC). Vasopressor medications during cardiac arrest. The routine use of magnesium for cardiac arrest is not recommended. A healthcare provider should use the head tiltchin lift maneuver to open the airway of a patient when no cervical spine injury is suspected. 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. 3. Immediate defibrillation is reasonable for provider-witnessed or monitored VF/pVT of short duration when a defibrillator is already applied or immediately available. affect resuscitation outcomes? This topic last received formal evidence review in 2015.24, Hypoxic-ischemic brain injury is the leading cause of morbidity and mortality in survivors of OHCA and accounts for a smaller but significant portion of poor outcomes after resuscitation from IHCA.1,2 Most deaths attributable to postarrest brain injury are due to active withdrawal of life-sustaining treatment based on a predicted poor neurological outcome. The potential mechanisms of action of IV lipid emulsion include active shuttling of the local anesthetic drug away from the heart and brain, increased cardiac contractility, vasoconstriction, and cardioprotective effects.1, The reported incidence of LAST ranges from 0 to 2 per 1000 nerve blocks2 but appears to be decreasing as a result of increasing awareness of toxicity and improved techniques.1, This topic last received formal evidence review in 2015.6, Overdose of sodium channelblocking medications, such as TCAs and other drugs (eg, cocaine, flecainide, citalopram), can cause hypotension, dysrhythmia, and death by blockade of cardiac sodium channels, among other mechanisms. If the chest is compressed during ventilations, most of the Continue reading "CPR with an Advanced Airway" When anaphylaxis produces obstructive airway edema, rapid advanced airway management is critical. 1. Toxicity: carbon monoxide, digoxin, and cyanide. medications? Benzodiazepine overdose causes CNS and respiratory depression and, particularly when taken with other sedatives (eg, opioids), can cause respiratory arrest and cardiac arrest. 1. Healthcare providers should consider the possibility of a spinal injury before opening the airway. 1. 2. and 2. The primary focus of cardiac arrest management for providers is the optimization of all critical steps required to improve outcomes. pharmacological, catheter intervention, or implantable device? BLS Study Guide - National CPR Association 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. It may be reasonable to administer IV lipid emulsion, concomitant with standard resuscitative care, to patients with local anesthetic systemic toxicity (LAST), and particularly to patients who have premonitory neurotoxicity or cardiac arrest due to bupivacaine toxicity. Cardiac arrest survivors, like many survivors of critical illness, often experience a spectrum of physical, neurological, cognitive, emotional, or social issues, some of which may not become apparent until after hospital discharge. Why is this? After identifying a cardiac arrest, a lone responder should activate the emergency response system first and immediately begin CPR. 3. resuscitation? The head tiltchin lift has been shown to be effective in establishing an airway in noncardiac arrest and radiological studies. It may be reasonable to perform defibrillation attempts according to the standard BLS algorithm concurrent with rewarming strategies. Copy. When appropriate, flow diagrams or additional tables are included. An older systematic review identified 22 case reports of CPR being performed in the prone position (21 in the operating room, 1 in the intensive care unit [ICU]), with 10/22 patients surviving. Recent evidence, however, suggests that the risk of major bleeding is not significantly higher in cardiac arrest patients receiving thrombolysis. Because of their negative inotropic effect, nondihydropyridine calcium channel antagonists (eg, diltiazem, verapamil) may further decompensate patients with left ventricular systolic dysfunction and symptomatic heart failure. 2. Clinical trials in resuscitation are sorely needed. If an advanced airway is used, a supraglottic airway can be used for adults with OHCA in settings with low tracheal intubation success rates or minimal training opportunities for endotracheal tube placement. 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 hypothermic heart may be unresponsive to cardiovascular drugs, pacemaker stimulation, and defibrillation; however, the data to support this are essentially theoretical. Long-term anticoagulation may be necessary for patients at risk for thromboembolic events based on their CHA2 DS2 - VASc score. The optimal timing for the performance of PMCD is not well established and must logically vary on the basis of provider skill set and available resources as well as patient and/or cardiac arrest characteristics. The overall certainty in the evidence of neurological prognostication studies is low because of biases that limit the internal validity of the studies as well as issues of generalizability that limit their external validity. 1. Anticoagulation alone is inadequate for patients with fulminant PE. Hyperbaric oxygen therapy may be helpful in the treatment of acute carbon monoxide poisoning in patients with severe toxicity. The effectiveness of agents to mitigate neurological injury in patients who remain comatose after ROSC is uncertain. Standard BLS and ACLS are the cornerstones of treatment, with airway management and ventilation being of particular importance because of the respiratory cause of arrest. 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. Each of these resulted in a description of the literature that facilitated guideline development. We suggest recording EEG in the presence of myoclonus to determine if there is an associated cerebral correlate. 4. The precordial thump may be considered at the onset of a rescuer-witnessed, monitored, unstable ventricular tachyarrhythmia when a defibrillator is not immediately ready for use and is performed without delaying CPR or shock delivery. The routine use of the impedance threshold device as an adjunct during conventional CPR is not recommended. When performed with other prognostic tests, it may be reasonable to consider bilaterally absent N20 somatosensory evoked potential (SSEP) waves more than 24 h after cardiac arrest to support the prognosis of poor neurological outcome. These features make adenosine relatively safe for treating a hemodynamically stable, regular, monomorphic wide-complex tachycardia of unknown type. These recommendations are supported by the 2018 American College of Cardiology, AHA, and Heart Rhythm Society guideline on the evaluation and management of patients with bradycardia and cardiac conduction delay.16. Advanced airways is a tube which is inserted in the mouth or nose, during this continuous CPR at the rate of 100 per minute is given. One large RCT in OHCA comparing bag-mask ventilation with endotracheal intubation (ETI) in a physician-based EMS system showed no significant benefit for either technique for 28-day survival or survival with favorable neurological outcome. 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. 1. Management of hemodynamically unstable patients with SVT must start with prompt restoration of sinus rhythm through the use of cardioversion. In patients with -adrenergic blocker overdose who are in refractory shock, administration of IV glucagon is reasonable. Simultaneous compressions and ventilation should be avoided,2 but delivery of chest compressions without pausing for ventilation seems a reasonable option.3 The use of SGAs adds to this complexity because efficiency of ventilation during cardiac arrest may be worse than when using an endotracheal tube, though this has not been borne out in recently published RCTs.4,5, This topic last received formal evidence review in 2010.15, These recommendations are supported by the 2017 focused update on adult BLS and CPR quality guidelines.20. In patients with -adrenergic blocker overdose who are in shock refractory to pharmacological therapy, ECMO might be considered. Evidence suggests that patients who are comatose after ROSC benefit from invasive angiography, when indicated, as do patients who are awake. No adult human studies directly compare levels of inspired oxygen concentration during CPR. Atrial flutter is an SVT with a macroreentrant circuit resulting in rapid atrial activation but intermittent ventricular response. 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. Existing evidence suggests that the potential harm from CPR in a patient who has been incorrectly identified as having cardiac arrest is low.1 Overall, the benefits of initiation of CPR in cardiac arrest outweigh the relatively low risk of injury for patients not in cardiac arrest. These recommendations are supported by the 2020 CoSTR for BLS.1. At least 1 retrospective study on ECMO use for patients with cardiac arrest or refractory shock in the setting of drug toxicity has reported improved outcomes. Advanced resuscitation 5. Hemodynamically unstable patients and those with rate-related ischemia should receive urgent electric cardioversion. What combination of features can identify patients with no chance of survival, even if rewarmed? 3. In patients who remain comatose after cardiac arrest, we recommend that neuroprognostication involve a multimodal approach and not be based on any single finding. 5. Torsades de pointes typically presents in a recurring pattern of self-terminating, hemodynamically unstable polymorphic VT in context of a known or suspected long QT abnormality, often with an associated bradycardia.