1. Based on the training of the rescuers, and only if scene safety can be maintained for the rescuer, sometimes ventilation can be provided in the water (in-water resuscitation), which may lead to improved patient outcomes compared with delaying ventilation until the victim is out of the water. To open a person's airway, do the following: Place your hand on their . decrease pauses in chest compressions and improve outcomes? 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. One RCT in OHCA comparing SGA (with iGel) to ETI in a nonphysician-based EMS system (ETI success, 69%) found no difference in survival or survival with favorable neurological outcome at hospital discharge. Continuous compressions at a rate of 100-120/min Give 1 breath every 6 seconds (10 breaths/min) CPR Compression Rate. That is, when performing CPR on an infant, you perform 30 chest compressions followed by 2 rescue breaths. 2. What are the optimal pharmacological treatment regimens for the management of postarrest seizures? However, ECPR may be considered if there is a potentially reversible cause of an arrest that would benefit from temporary cardiorespiratory support. 1. If an advanced airway is in place, it may be reasonable for the provider to deliver 1 breath every 6 s (10 breaths/min) while continuous chest compressions are being performed. High-dose epinephrine is not recommended for routine use in cardiac arrest. If you have been trained in CPR, go on to opening the airway and rescue breathing. Before appointment, writing group members disclosed all commercial relationships and other potential (including intellectual) conflicts. CPR is recommended until a defibrillator or AED is applied. Do antiarrhythmic drugs, when given in combination for cardiac arrest, improve outcomes from cardiac Based on their greater success in arrhythmia termination, defibrillators using biphasic waveforms are preferred over monophasic defibrillators for treatment of tachyarrhythmias. 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. These procedures are described more fully in Part 2: Evidence Evaluation and Guidelines Development. Disclosure information for writing group members is listed in Appendix 1(link opens in new window). Routine use of sodium bicarbonate is not recommended for patients in cardiac arrest. Seizure prophylaxis in adult postcardiac arrest survivors is not recommended. CPR involves performing chest compressions and, in some cases, rescue ("mouth-to-mouth") breathing. Adenosine is an ultrashort-acting drug that is effective in terminating regular tachycardias when caused by AV reentry. These effects can also precipitate acute coronary syndrome and stroke. 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. 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. In 2013, a trial of over 900 patients compared TTM at 33C to 36C for patients with OHCA and any initial rhythm, excluding unwitnessed asystole, and found that 33C was not superior to 36C. The benefit of any specific target range of glucose management is uncertain in adults with ROSC after cardiac arrest. Patients should be monitored constantly to verify airway patency and adequate ventilation and oxygenation. do they differ from current generic or clinician-derived measures? These recommendations are supported by the 2019 focused update on ACLS guidelines.1. It can be beneficial for rescuers to avoid leaning on the chest between compressions to allow complete chest wall recoil for adults in cardiac arrest. Evidence is limited to case reports and extrapolations from nonfatal cases, interpretation of pathophysiology, and consensus opinion. 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. Like all patients with cardiac arrest, the immediate goal is restoration of perfusion with CPR, initiation of ACLS, and rapid identification and correction of the cause of cardiac arrest. AED indicates automated external defibrillator; and BLS, basic life support. 1. Survival and recovery from adult cardiac arrest depend on a complex system working together to secure the best outcome for the victim. Other recommendations are relevant to persons with more advanced resuscitation training, functioning either with or without access to resuscitation drugs and devices, working either within or outside of a hospital. Once an advanced airway is in place, there is no longer a need to pause compressions to deliver breaths. Disclosure information for peer reviewers is listed in Appendix 2(link opens in new window). 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. In cases of suspected opioid overdose managed by a nonhealthcare provider who is not capable of The evidence for what constitutes optimal CPR continues to evolve as research emerges. These arrhythmias are common and often coexist, and their treatment recommendations are similar. Clinical trials and observational studies since the 2010 Guidelines have yielded no new evidence that routine administration of sodium bicarbonate improves outcomes from undifferentiated cardiac arrest and evidence suggests that it may worsen survival and neurological recovery. Animal studies, case reports, and case series have reported increased heart rate and improved hemodynamics after high-dose insulin administration for -adrenergic blocker toxicity. Data from 1 RCT. 5. . Because of limited evidence, the cornerstone of management of cardiac arrest secondary to anaphylaxis is standard BLS and ACLS, including airway management and early epinephrine. This involves the cannulation of a large vein and artery and initiation of venoarterial extracorporeal circulation and membrane oxygenation (ECMO) (Figure 8). Endotracheal drug administration may be considered when other access routes are not available. arrest with shockable rhythm? 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. How is CPR performed differently when an advanced airway is in place? Explanation: Success rates for the Valsalva maneuver in terminating SVT range from 19% to 54%. Which patients with cardiac arrest due to suspected pulmonary embolism benefit from emergency SSEPs are obtained by stimulating the median nerve and evaluating for the presence of a cortical N20 wave. 1. Techniques include administration of warm humidified oxygen, warm IV fluids, and intrathoracic or intraperitoneal warm-water lavage. Immediate defibrillation is the treatment of choice when torsades is sustained or degenerates to VF. 6. Initial management should focus on support of the patients airway and breathing. 1. The previous literature was limited by methodological concerns, including around inadequate control for effects of TTM and medications and self-fulfilling prophecies, and there was a lower-than-acceptable false-positive rate (10% to 15%). If bradycardia is unresponsive to atropine, IV adrenergic agonists with rate-accelerating effects (eg, epinephrine) or transcutaneous pacing may be effective while the patient is prepared for emergent transvenous temporary pacing if required. 1. Epinephrine is the cornerstone of treatment for anaphylaxis.35, This topic last received formal evidence review in 2010.14. With respect to timing, for cardiac arrest with a nonshockable rhythm, it is reasonable to administer epinephrine as soon as feasible. Pulseless electrical activity is the presenting rhythm in 36% to 53% of PE-related cardiac arrests, while primary shockable rhythms are uncommon.35. No shock waveform has distinguished itself as achieving a consistently higher rate of ROSC or survival. Although not new, this is a 2015 American Heart Association guideline. All patients with evidence of anaphylaxis require early treatment with epinephrine. We suggest against the use of point-of-care ultrasound for prognostication during CPR. A victim may also appear clinically dead because of the effects of very low body temperature. 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. 1. If cardiac arrest develops as the result of cocaine toxicity, there is no evidence to suggest deviation from standard BLS and ALS guidelines, with specific treatment strategies used in the postcardiac arrest phase as needed if there is evidence of severe cardiotoxicity or neurotoxicity. Fist (or percussion) pacing is the delivery of a serial, rhythmic, relatively low-velocity impact to the sternum by a closed fist.1 Fist pacing is administered in an attempt to stimulate an electric impulse sufficient to cause myocardial depolarization. When VF/VT has been present for more than a few minutes, myocardial reserves of oxygen and other energy substrates are rapidly depleted. 5. The 2020 CoSTR recommends that seizures be treated when diagnosed in postarrest patients. This makes it difficult to plan the next step of care and can potentially delay or even misdirect drug therapies if given empirically (blindly) based on the patients presumed, but not actual, underlying rhythm. 1. The choice of anticoagulation is beyond the scope of these guidelines. In cases of prehospital maternal arrest, rapid transport directly to a facility capable of PMCD and neonatal resuscitation, with early activation of the receiving facilitys adult resuscitation, obstetric, and neonatal resuscitation teams, provides the best chance for a successful outcome. Artifact-filtering and other innovative techniques to disclose the underlying rhythm beneath ongoing CPR can surmount these challenges and minimize interruptions in chest compressions while offering a diagnostic advantage to better direct therapies. Vasopressin alone or vasopressin in combination with epinephrine may be considered in cardiac arrest but offers no advantage as a substitute for epinephrine in cardiac arrest. Once an advanced airway is emplaced and confirmed, chest compressions should be performed continuously at a rate of at least 100 per minute. 5. Few patients who develop cardiac arrest from carbon monoxide poisoning survive to hospital discharge, regardless of the treatment administered after ROSC, though rare good outcomes have been described. 3. A wide-complex tachycardia can be regular or irregularly irregular and have uniform (monomorphic) or differing (polymorphic) QRS complexes from beat to beat. 4. The relative contribution of assisted ventilation for patients in cardiac arrest is more controversial. In patients with narrow-complex tachycardia who are refractory to the measures described, this may indicate a more complicated rhythm abnormality for which expert consultation may be advisable. Immediate resumption of chest compressions after shock results in a shorter perishock pause and improves the overall hands-on time (chest compression fraction) during resuscitation, which is associated with improved survival from VF arrest.16,48 Even when successful, defibrillation is often followed by a variable (and sometimes protracted) period of asystole or pulseless electrical activity, during which providing CPR while awaiting a return of rhythm and pulse is advisable. Electric cardioversion can be useful either as firstline treatment or for drug-refractory wide-complex tachycardia due to reentry rhythms (such as atrial fibrillation, atrial flutter, AV reentry, and VT). Thus, the confidence in the prognostication of the diagnostic tests studied is also low. Activation of emergency response system 3. 3. 1. Rescuers should recognize that multiple approaches may be required to establish an adequate airway. 1. Determining the utility of such physiological monitoring or diagnostic procedures is important. Are NSE and S100B helpful when checked later than 72 h after ROSC? 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. This includes identifying P waves and their relationship to QRS complexes and (in the case of patients with a pacemaker) pacing spikes preceding QRS complexes. To maintain provider skills from initial training, frequent retraining is important. Postcardiac arrest care is a critical component of the Chain of Survival. Incorrect placement, however, can cause an airway obstruction by displacing the tongue to the back of the oropharynx. External chest compressions should be performed if emergency resternotomy is not immediately available. Regardless of the underlying QT interval, all forms of polymorphic VT tend to be hemodynamically and electrically unstable. outcomes? In adult victims of cardiac arrest, it is reasonable for rescuers to perform chest compressions at a rate of 100 to 120/min. Electric pacing is not recommended for routine use in established cardiac arrest. 3. Does avoidance of hyperoxia in the postarrest period lead to improved outcomes? Much of the evidence examining the effectiveness of airway strategies comes from radiographic and cadaver studies. 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. The clinical manifestations of bradycardia can range from an absence of symptoms to symptomatic bradycardia (bradycardia associated with acutely altered mental status, ischemic chest discomfort, acute heart failure, hypotension, or other signs of shock that persist despite adequate airway and breathing). When performed with other prognostic tests, it may be reasonable to consider persistent status epilepticus 72 h or more after cardiac arrest to support the prognosis of poor neurological outcome. IV amiodarone can be useful for rate control in critically ill patients with atrial fibrillation with rapid ventricular response without preexcitation. Resuscitation of the pregnant woman, including PMCD when indicated, is the first priority because it may lead to increased survival of both the woman and the fetus. and 2. 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. Some literature reports good favorable outcomes while others report significant adverse events. 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. No randomized RCTs have been performed comparing open-chest with external CPR. In small case series, IV magnesium has been effective in suppressing and preventing recurrences of. 4. Severe anaphylaxis may cause complete obstruction of the airway and/or cardiovascular collapse from vasogenic shock. Early activation of the emergency response system is critical for patients with suspected opioid overdose. A 2017 ILCOR systematic review found that a ratio of 30 compressions to 2 breaths was associated with better survival than alternate ratios, a recommendation that was reaffirmed by the AHA in 2018. When performed with other prognostic tests, it may be reasonable to consider status myoclonus that occurs within 72 h after cardiac arrest to support the prognosis of poor neurological outcome. Resuscitation from cardiac arrest caused by -adrenergic blocker or calcium channel blocker overdose follows standard resuscitation guidelines. 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. Recommendations 1, 3, and 5 last received formal evidence review in 2015.10Recommendation 2 last received formal evidence review in 2015,10 with an evidence update completed in 2020.11 Recommendation 4 last received formal evidence review in 2010.12. Available hemodynamic monitoring modalities in conjunction with manual pulse detection provide an opportunity to confirm myocardial capture and adequate cardiac function. 6. Each of the 2020 Guidelines documents were submitted for blinded peer review to 5 subject-matter experts nominated by the AHA. The treatment of nonconvulsive seizures (diagnosed by EEG only) may be considered. For cardiotoxicity and cardiac arrest from severe hypomagnesemia, in addition to standard ACLS care, IV magnesium is recommended. CPR indicates cardiopulmonary resuscitation; ET, endotracheal; IO, intraosseous; IV, intravenous; pVT, pulseless ventricular tachycardia; and VF, ventricular fibrillation. What is the optimal approach, vasopressor or transcutaneous pacing, in managing symptomatic Thirty-seven recommendations are supported by Level B-Randomized Evidence (moderate evidence from 1 or more RCTs) and 57 by Level B-Nonrandomized evidence. 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. 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. 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. Because of potential interference with maternal resuscitation, fetal monitoring should not be undertaken during cardiac arrest in pregnancy. This begins with opening the airway followed by delivery of rescue breaths, ideally with the use of a bag-mask or barrier device. We recommend targeted temperature management for pregnant women who remain comatose after resuscitation from cardiac arrest. 3. 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. How long after mild drowning events should patients be observed for late-onset respiratory effects? What are the ideal dose and formulation of IV lipid emulsion therapy? 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 Adult Cardiovascular Life Support Writing Group included a diverse group of experts with backgrounds in emergency medicine, critical care, cardiology, toxicology, neurology, EMS, education, research, and public health, along with content experts, AHA staff, and the AHA senior science editors. 1. Administration of IV amiodarone, procainamide, or sotalol may be considered for the treatment of wide-complex tachycardia. Recovery What is the correct order of steps in the Out-of-Hospital Chain of Survival for adults? There is no evidence that cricoid pressure facilitates ventilation or reduces the risk of aspiration in cardiac arrest patients. This link is provided for convenience only and is not an endorsement of either the linked-to entity or any product or service. A small number of studies has shown that higher Pao, Observational studies have found that increases in ETCO. Interposed abdominal compression CPR may be considered during in-hospital resuscitation when sufficient personnel trained in its use are available. In some cases, emergency cricothyroidotomy or tracheostomy may be required. This lesson focuses on the team approach to CPR when three or more responders or healthcare professionals are involved. 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. The systems-of-care approach to cardiac arrest includes the community and healthcare response to cardiac arrest. 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. Biphasic and monophasic shock waveforms are likely equivalent in their clinical outcome efficacy. No. For each recommendation, the writing group discussed and approved specific recommendation wording and the COR and LOE assignments. Three different types of evidence reviews (systematic reviews, scoping reviews, and evidence updates) were used in the 2020 process. In patients with -adrenergic blocker overdose who are in shock refractory to pharmacological therapy, ECMO might be considered. Limitations to their prognostic utility include variability in testing methods on the basis of site and laboratory, between-laboratory inconsistency in levels, susceptibility to additional uncertainty due to hemolysis, and potential extracerebral sources of the proteins. Full resuscitative measures, including extracorporeal rewarming when available, are recommended for all victims of accidental hypothermia without characteristics that deem them unlikely to survive and without any obviously lethal traumatic injury. A systematic review of the literature identified 5 small prospective trials, 3 retrospective studies, and multiple case reports and case series with contradictory results. 2. and 2. We do not recommend routine use of magnesium for the treatment of polymorphic VT with a normal QT interval. Conversely, a wide-complex tachycardia can also be due to VT or a rapid ventricular paced rhythm in patients with a pacemaker. Emergent coronary angiography and PCI have also been also associated with improved neurological outcomes in patients without STEMI on their post-ROSC resuscitation ECG.4,12 However, a large randomized trial found no improvement in survival in patients resuscitated from OHCA with an initial shockable rhythm in whom no ST-segment elevations or signs of shock were present.13 Multiple RCTs are underway. Victims of accidental hypothermia should not be considered dead before rewarming has been provided unless there are signs of obvious death. A number of key components have been defined for high-quality CPR, including minimizing interruptions in chest compressions, providing compressions of adequate rate and depth, avoiding leaning on the chest between compressions, and avoiding excessive ventilation.1 However, controlled studies are relatively lacking, and observational evidence is at times conflicting. 2. During cardiac arrest, if the pregnant woman with a fundus height at or above the umbilicus has not achieved ROSC with usual resuscitation measures plus manual left lateral uterine displacement, it is advisable to prepare to evacuate the uterus while resuscitation continues. 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. Benefits of this method are a standard and reproducible assessment. When bradycardia occurs secondary to a pathological cause, it can lead to decreased cardiac output with resultant hypotension and tissue hypoperfusion. 3. 1. What is the most efficacious management approach for postarrest cardiogenic shock, including 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. ACLS indicates advanced cardiovascular life support; BLS, basic life support; CPR, cardiopulmonary resuscitation; ET, endotracheal; IV, intravenous; and ROSC, 2. These techniques can keep blood flowing to the brain and other organs until medical help arrives. There is concern that delivery of chest compressions without assisted ventilation for prolonged periods could be less effective than conventional CPR (compressions plus breaths) because the arterial oxygen content will decrease as CPR duration increases. CT indicates computed tomography; ROSC, return of spontaneous circulation; and STEMI, ST-segment elevation myocardial infarction. 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. 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. If someone responds, ensure that the phone is at the side of the victim if at all possible. In patients with calcium channel blocker overdose who are in refractory shock, administration of IV glucagon may be considered. 1. In patients with acute bradycardia associated with hemodynamic compromise, administration of atropine is reasonable to increase heart rate. Verapamil is a calcium channel blocking agent that slows AV node conduction, shortens the refractory period of accessory pathways, and acts as a negative inotrope and vasodilator. The topic of neuroprotective agents was last reviewed in detail in 2010. More uniform definitions for status epilepticus, malignant EEG patterns, and other EEG patterns are The provision of rescue breaths for apneic patients with a pulse is essential. In patients who remain comatose after cardiac arrest, it is reasonable to perform multimodal neuroprognostication at a minimum of 72 hours after normothermia, though individual prognostic tests may be obtained earlier than this. Case reports and animal data have suggested that IV lipid emulsion may be of benefit.25 LAST results in profound inhibition of voltage-gated channels (especially sodium transduction) in the cell membrane. 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. These evidence- review methods, including specific criteria used to determine COR and LOE, are described more fully in Part 2: Evidence Evaluation and Guidelines Development. The Adult Basic and Advanced Life Support Writing Group members had final authority over and formally approved these recommendations. 1. This approach is supported by animal studies and human case reports and has recently been systematically reviewed.4.

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