In addition to standard ACLS, specific interventions may be lifesaving for cases of hyperkalemia and hypermagnesemia. When performed with other prognostic tests, it may be reasonable to consider extensive areas of restricted diffusion on brain MRI at 2 to 7 days after cardiac arrest to support the prognosis of poor neurological outcome in patients who remain comatose. Given the potential for the rapid development of oropharyngeal or laryngeal edema, immediate referral to a health professional with expertise in advanced airway placement, including surgical airway management, is recommended. In patients without an advanced airway, it is reasonable to deliver breaths either by mouth or by using bag-mask ventilation. 1. If using a defibrillator capable of escalating energies, higher energy for second and subsequent shocks may be considered for presumed shock-refractory arrhythmias. Hemodynamically unstable patients with atrial fibrillation or atrial flutter with rapid ventricular response should receive electric cardioversion. There are no data evaluating the use of antidotes to digoxin overdose specifically in the setting of cardiac arrest. Rescuers should provide CPR, including rescue breathing, as soon as an unresponsive submersion victim is removed from the water. 2. TTM between 32C and 36C for at least 24 hours is currently recommended for all cardiac rhythms in both OHCA and IHCA. When providing chest compressions, the rescuer should place the heel of one hand on the center (middle) of the victims chest (the lower half of the sternum) and the heel of the other hand on top of the first so that the hands are overlapped. Amiodarone or lidocaine may be considered for VF/pVT that is unresponsive to defibrillation. Agonal breathing is characterized by slow, irregular gasping respirations that are ineffective for ventilation. 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. Since the last time these recommendations were formally reviewed, The administration of hypertonic (8.4%, 1 mEq/ mL) sodium bicarbonate solution for treatment of sodium channel blockade due to TCAs and other toxicants is supported by human observational studies. In addition to assessing level of consciousness and performing basic neurological examination, clinical examination elements may include the pupillary light reflex, pupillometry, corneal reflex, myoclonus, and status myoclonus when assessed within 1 week after cardiac arrest. The systemic impact of the ischemia-reperfusion injury caused by cardiac arrest and subsequent resuscitation requires postcardiac arrest care to simultaneously support the multiple organ systems that are affected. Twelve observational studies evaluated NSE collected within 72 hours after arrest. Early activation of the emergency response system is critical for patients with suspected opioid overdose. 1. 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. Does this vary based on the opioid involved? Answer the dispatchers questions, and follow the telecommunicators instructions. 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. Due to the potential effects of intrinsic positive end-expiratory pressure (auto-PEEP) and risk of barotrauma in an asthmatic patient with cardiac arrest, a ventilation strategy of low respiratory rate and tidal volume is reasonable. We recommend that the absence of EEG reactivity within 72 h after arrest not be used alone to support a poor neurological prognosis. This topic last received formal evidence review in 2010.3. Furthermore, fetal hypoxia has known detrimental effects. 1. There are no studies comparing different strategies of opening the airway in cardiac arrest patients. Alternatives to IV access for acute drug administration include IO, central venous, intracardiac, and endotracheal routes. 6. Administration of epinephrine may be lifesaving. The usefulness of double sequential defibrillation for refractory shockable rhythm has not been established. Patients with 12-lead identification of ST-segment elevation myocardial infarction (STEMI) should have coronary angiography for possible PCI, highlighting the importance of obtaining an ECG for diagnostic purposes. 1. 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. A recent systematic review of 11 RCTs (overall moderate to low certainty of evidence) found no evidence of improved survival with good neurological outcome with mechanical CPR compared with manual CPR in either OHCA or IHCA.1 Given the perceived logistic advantages related to limited personnel and safety during patient transport, mechanical CPR remains popular among some providers and systems. With respect to timing, for cardiac arrest with a nonshockable rhythm, it is reasonable to administer epinephrine as soon as feasible. What is the optimal treatment for hyperkalemia with life-threatening arrhythmia or cardiac arrest? What is the optimal energy needed for cardioversion of atrial fibrillation and atrial flutter? AEDs are highly accurate in their detection of shockable arrhythmias but require a pause in CPR for automated rhythm analysis. Each recommendation was developed and formally approved by the writing group. The combination of adenosines short-lived slowing of AV node conduction, shortening of refractoriness in the myocardium and accessory pathways, and hypotensive effects make it unsuitable in hemodynamically unstable patients and for treating irregularly irregular and polymorphic wide-complex tachycardias. An RCT published in 2019 compared TTM at 33C to 37C for patients who were not following commands after ROSC from cardiac arrest with initial nonshockable rhythm. When performed with other prognostic tests, it may be reasonable to consider burst suppression on EEG in the absence of sedating medications at 72 h or more after arrest to support the prognosis of poor neurological outcome. Recommendations 1 and 2 are supported by the 2020 CoSTR for ALS.22 Recommendations 3 and 4 last received formal evidence review in 2010.20. In patients without an advanced airway, it is reasonable to deliver breaths either by mouth or by using bag-mask ventilation. See answer (1) Best Answer. 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. 4. 1. CPR provides a small but critical amount of blood flow to the heart and brain. Survival with a favorable neurological outcome (Cerebral Performance Category 12) was higher in the group treated with 33C. The clinical signs associated with severe hyperkalemia (more than 6.5 mmol/L) include flaccid paralysis, paresthesia, depressed deep tendon reflexes, or shortness of breath.13 The early electrocardiographic signs include peaked T waves on the ECG followed by flattened or absent T waves, prolonged PR interval, widened QRS complex, deepened S waves, and merging of S and T waves.4,5 As hyperkalemia progresses, the ECG can develop idioventricular rhythms, form a sine-wave pattern, and develop into an asystolic cardiac arrest.4,5 Severe hypokalemia is less common but can occur in the setting of gastrointestinal or renal losses and can lead to life-threatening ventricular arrhythmias.68 Severe hypermagnesemia is most likely to occur in the obstetric setting in patients being treated with IV magnesium for preeclampsia or eclampsia. Immediately begin CPR, and use the AED/ defibrillator when available. CPR is Cardiopulmonary resuscitation. needed to be able to compare prognostic values across studies. 1. 1. 5. It is reasonable for healthcare providers to perform chest compressions and ventilation for all adult patients in cardiac arrest from either a cardiac or noncardiac cause. Along with providing standard BLS and ALS treatment, next steps include preventing additional evaporative heat loss by removing wet garments and insulating the victim from further environmental exposures. In patients with -adrenergic blocker overdose who are in refractory shock, administration of calcium may be considered. 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. Finally, case reports and case series using ECMO in maternal cardiac arrest patients report good maternal survival.16 The treatment of cardiac arrest in late pregnancy represents a major scientific gap. In some cases, emergency cricothyroidotomy or tracheostomy may be required. Atrial fibrillation is an SVT consisting of disorganized atrial electric activation and uncoordinated atrial contraction. Because immediate ROSC cannot always be achieved, local resources for a perimortem cesarean delivery should be summoned as soon as cardiac arrest in a woman in the second half of pregnancy is recognized. 3. In adult cardiac arrest, total preshock and postshock pauses in chest compressions should be as short as possible. 3. This recommendation is based on expert consensus and pathophysiologic rationale. The management of patients with preexcitation syndromes (aka Wolff-Parkinson-White) is covered in the Wide-Complex Tachycardia section. 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. 3. ! These guidelines are not meant to be comprehensive. When bradycardia is refractory to medical management and results in severe symptoms, the reasonable next step is placement of a temporary pacing catheter for transvenous pacing. In addition, deterioration of fetal status may be an early warning sign of maternal decompensation. Multiple agents, including magnesium, coenzyme Q10 (ubiquinol), exanatide, xenon gas, methylphenidate, and amantadine, have been considered as possible agents to either mitigate neurological injury or facilitate patient awakening. A single shock strategy is reasonable in preference to stacked shocks for defibrillation in the setting of unmonitored cardiac arrest. IO access has grown in popularity given the relative ease and speed with which it can be achieved, a higher successful placement rate compared with IV cannulation, and the relatively low procedural risk. If you have been trained in CPR, go on to opening the airway and rescue breathing. Studies of mechanical CPR devices have not demonstrated a benefit when compared with manual CPR, with a suggestion of worse neurological outcome in some studies. In patients with calcium channel blocker overdose who are in refractory shock, administration of calcium is reasonable. In situations such as nonsurvivable maternal trauma or prolonged pulselessness, in which maternal resuscitative efforts are considered futile, there is no reason to delay performing perimortem cesarean delivery in appropriate patients. ADC indicates apparent diffusion coefficient; CPR, cardiopulmonary resuscitation; CT, computed tomography; ECG, electrocardiogram; ECPR, extracorporeal Does avoidance of hyperoxia in the postarrest period lead to improved outcomes? Sparse data have been published addressing this question. Many alternatives and adjuncts to conventional CPR have been developed. 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. That is, when performing CPR on an infant, you perform 30 chest compressions followed by 2 rescue breaths. 2. The routine use of mechanical CPR devices is not recommended. 4. External chest compressions should be performed if emergency resternotomy is not immediately available. 3. 1. IV infusion of epinephrine is a reasonable alternative to IV boluses for treatment of anaphylaxis in patients not in cardiac arrest. After successful maternal resuscitation, the undelivered fetus remains susceptible to the effects of hypothermia, acidosis, hypoxemia, and hypotension, all of which can occur in the setting of post-ROSC care with TTM. A study in critically ill patients who required ventilatory support found that bag-mask ventilation at a rate of 10 breaths per minute decreased hypoxic events before intubation. Its effects are mediated by a different mechanism and are longer lasting than adenosine. The administration of flumazenil to patients with undifferentiated coma confers risk and is not recommended. Prognostication of neurological recovery is complex and limited by uncertainty in most cases. Given that a false-positive test for poor neurological outcome could lead to inappropriate withdrawal of life support from a patient who otherwise would have recovered, the most important test characteristic is specificity. Does hospital-based protocolized discharge planning for cardiac arrest survivors improve access to/ A case series suggests that mouth-to-nose ventilation in adults is feasible, safe, and effective. Pressing down and releasing is 1 compression. 1. We recommend structured assessment for anxiety, depression, posttraumatic stress, and fatigue for cardiac arrest survivors and their caregivers. We recommend avoiding hypoxemia in all patients who remain comatose after ROSC. Unauthorized use prohibited. Debriefings and referral for follow-up for emotional support for lay rescuers, EMS providers, and hospital-based healthcare workers after a cardiac arrest event may be beneficial. Manual stabilization can decrease movement of the cervical spine during patient care while allowing for proper ventilation and airway control. This new link acknowledges the need for the system of care to support recovery, discuss expectations, and provide plans that address treatment, surveillance, and rehabilitation for cardiac arrest survivors and their caregivers as they transition care from the hospital to home and return to role and social function. The half-life of flumazenil is shorter than many benzodiazepines, necessitating close monitoring after flumazenil administration.2 An alternative to flumazenil administration is respiratory support with bag-mask ventilation followed by ETI and mechanical ventilation until the benzodiazepine has been metabolized. CPR involves performing chest compressions and, in some cases, rescue ("mouth-to-mouth") breathing. ILCOR Consensus on CPR and Emergency Cardiovascular 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. An updated systematic review on several aspects of this important topic is needed once currently ongoing clinical trials have been completed. 2. Aggressive rewarming, possibly including invasive techniques, may be required and may necessitate transport to the hospital sooner than would be done in other OHCA circumstances.1 The specific care of patients who are victims of an avalanche are not included in these guidelines but can be found elsewhere.2, This topic last received formal evidence review in 2010.1, Between 1.6% and 5.1% of US adults have suffered anaphylaxis.1 Approximately 200 Americans die from anaphylaxis annually, mostly from adverse reactions to medication.2 Although anaphylaxis is a multisystem disease, life-threatening manifestations most often involve the respiratory tract (edema, bronchospasm) and/or the circulatory system (vasodilatory shock). IV diltiazem or verapamil can be effective for acute treatment in patients with hemodynamically stable SVT at a regular rate. Opioid-associated resuscitative emergencies are defined by the presence of cardiac arrest, respiratory arrest, or severe life-threatening instability (such as severe CNS or respiratory depression, hypotension, or cardiac arrhythmia) that is suspected to be due to opioid toxicity. Can artifact-filtering algorithms for analysis of ECG rhythms during CPR in a real-time clinical setting The controlled administration of IV potassium for ventricular arrhythmias due to severe hypokalemia may be useful, but case reports have generally included infusion of potassium and not bolus dosing. IV lidocaine, amiodarone, and measures to treat myocardial ischemia may be considered to treat polymorphic VT in the absence of a prolonged QT interval. In patients presenting with acute symptomatic bradycardia, evaluation and treatment of reversible causes is recommended. It is feasible only at the onset of a hemodynamically significant arrhythmia in a cooperative, conscious patient who has ideally been previously instructed on its performance, and as a bridge to definitive care. Conversely, when VF/ VT is more protracted, depletion of the hearts energy reserves can compromise the efficacy of defibrillation unless replenished by a prescribed period of CPR before the rhythm analysis. For asthmatic patients with cardiac arrest, sudden elevation in peak inspiratory pressures or difficulty ventilating should prompt evaluation for tension pneumothorax. . 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. 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. doi: 10.1161/CIR.0000000000000916, On behalf of the Adult Basic and Advanced Life Support Writing Group. Observational studies on TTM for IHCA with any initial rhythm have reported mixed results. 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. A wide-complex tachycardia can also be caused by any of these supraventricular arrhythmias when conducted by an accessory pathway (called pre-excited arrhythmias). 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. If so, what dose and schedule should be used? Individual test modalities may be obtained earlier and the results integrated into the multimodality assessment synthesized at least 72 hours after normothermia. 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. We recommend that cardiac arrest survivors have multimodal rehabilitation assessment and treatment for physical, neurological, cardiopulmonary, and cognitive impairments before discharge from the hospital. Recovery expectations and survivorship plans that address treatment, surveillance, and rehabilitation need to be provided to cardiac arrest survivors and their caregivers at hospital discharge to optimize transitions of care to home and to the outpatient setting. A more detailed approach to rhythm management is found elsewhere.13, This topic last received formal evidence review in 2010.17, Polymorphic VT refers to a wide-complex tachycardia of ventricular origin with differing configurations of the QRS complex from beat to beat. These arrhythmias are common and often coexist, and their treatment recommendations are similar. Thrombolysis may be considered when cardiac arrest is suspected to be caused by pulmonary embolism. Toxicity: carbon monoxide, digoxin, and cyanide. Atrial flutter is an SVT with a macroreentrant circuit resulting in rapid atrial activation but intermittent ventricular response. 3. IV bolus administration of potassium for cardiac arrest in suspected hypokalemia is not recommended. What is the optimal duration for targeted temperature management before rewarming? 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. Clinicians must determine if the tachycardia is narrow-complex or wide-complex tachycardia and if it has a regular or irregular rhythm. Advanced resuscitation 5. Outcomes from IHCA are overall superior to those from OHCA,5 likely because of reduced delays in initiation of effective resuscitation. 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. The pharmacokinetic properties, acute effects, and clinical efficacy of emergency drugs have primarily been described when given intravenously. Although not new, this is a 2015 American Heart Association guideline. 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. Airway: Open the airway. Transcutaneous pacing has been studied during cardiac arrest with bradyasystolic cardiac rhythm. 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). The only time you should do continuous compressions is when you have secured an advanced airway such as an ET tube. Can we identify consistent NSE and S100B thresholds for predicting poor neurological outcome after Recommendations 1, 2, and 6 last received formal evidence review in 2015.21 Recommendations 3, 4, and 5 are supported by the 2020 CoSTR for BLS.22, This recommendation is supported by a 2020 ILCOR scoping review, which found no new information to update the 2010 recommendations.22,31, This recommendation is supported by a 2020 ILCOR scoping review,22 which found no new information to update the 2010 recommendations.31, Recommendations 1 and 2 are supported by the 2020 CoSTR for BLS.22 Recommendation 3 last received formal evidence review in 2010.46, This recommendation is supported by the 2020 CoSTR for ALS.51. Initial management should focus on support of the patients airway and breathing. However, good outcomes have been observed with rapid resternotomy protocols when performed by experienced providers in an appropriately equipped ICU. This work has been largely observational. 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). 1. Lay rescuerCPR improves survival from cardiac arrest by 2- to 3-fold.1 The benefit of providing CPR to a patient in cardiac arrest outweighs any potential risk of providing chest compressions to someone who is unconscious but not in cardiac arrest. channel blockers. 3. If this is not known, defibrillation at the maximal dose may be considered. Seizure prophylaxis in adult postcardiac arrest survivors is not recommended. For lay rescuers trained in CPR using chest compressions and ventilation (rescue breaths), it is reasonable to provide ventilation (rescue breaths) in addition to chest compressions for the adult in OHCA. The primary focus of cardiac arrest management for providers is the optimization of all critical steps required to improve outcomes. 1. For cardiotoxicity and cardiac arrest from severe hypomagnesemia, in addition to standard ACLS care, IV magnesium is recommended. 3. Active compression-decompression CPR might be considered for use when providers are adequately trained and monitored. Conversely, a wide-complex tachycardia can also be due to VT or a rapid ventricular paced rhythm in patients with a pacemaker. Which patients with cardiac arrest due to suspected pulmonary embolism benefit from emergency 1. 1. The combination of active compression-decompression CPR and impedance threshold device may be reasonable in settings with available equipment and properly trained personnel. The writing group acknowledged that there is no direct evidence that EEG to detect nonconvulsive seizures improves outcomes. These recommendations are supported by Cardiac Arrest in Pregnancy: a Scientific Statement From the AHA9 and a 2020 evidence update.30, This topic was reviewed in an ILCOR systematic review for 2020.1 PE is a potentially reversible cause of shock and cardiac arrest. referral to rehabilitation services or patient outcomes? The writing group acknowledges the following contributors: Julie Arafeh, RN, MSN; Justin L. Benoit, MD, MS; Maureen Chase; MD, MPH; Antonio Fernandez; Edison Ferreira de Paiva, MD, PhD; Bryan L. Fischberg, NRP; Gustavo E. Flores, MD, EMT-P; Peter Fromm, MPH, RN; Raul Gazmuri, MD, PhD; Blayke Courtney Gibson, MD; Theresa Hoadley, MD, PhD; Cindy H. Hsu, MD, PhD; Mahmoud Issa, MD; Adam Kessler, DO; Mark S. Link, MD; David J. Magid, MD, MPH; Keith Marrill, MD; Tonia Nicholson, MBBS; Joseph P. Ornato, MD; Garrett Pacheco, MD; Michael Parr, MB; Rahul Pawar, MBBS, MD; James Jaxton, MD; Sarah M. Perman, MD, MSCE; James Pribble, MD; Derek Robinett, MD; Daniel Rolston, MD; Comilla Sasson, MD, PhD; Sree Veena Satyapriya, MD; Travis Sharkey, MD, PhD; Jasmeet Soar, MA, MB, BChir; Deb Torman, MBA, MEd, AT, ATC, EMT-P; Benjamin Von Schweinitz; Anezi Uzendu, MD; and Carolyn M. Zelop, MD. 3. A 2020 ILCOR systematic review. Prompt treatment of cardiac glycoside toxicity is imperative to prevent or treat life-threatening arrhythmias. Early defibrillation improves outcome from cardiac arrest. There are no RCTs on the use of ECPR for OHCA or IHCA. The opioid epidemic has resulted in an increase in opioid-associated out-of-hospital cardiac arrest, with the mainstay of care remaining the activation of the emergency response systems and performance of high-quality CPR. Survival and recovery from adult cardiac arrest depend on a complex system working together to secure the best outcome for the victim. VF is the presenting rhythm in 25% to 50% of cases of cardiac arrest after cardiac surgery. If a victim is unconscious/unresponsive, with absent or abnormal breathing (ie, only gasping), the healthcare provider should check for a pulse for no more than 10 s and, if no definite pulse is felt, should assume the victim is in cardiac arrest. Although abbreviated observation periods may be adequate for patients with fentanyl, morphine, or heroin overdose. The trachea, which is sometimes called the windpipe, conducts air down into the lungs through the bronchi, which are smaller tubular branches. -Enough to make the victim's chest rise. affect resuscitation outcomes? with hydroxocobalamin? Although case reports describe good outcomes after the use of ECMO6 and IV lipid emulsion therapy710 for severe sodium channel blocker cardiotoxicity, no controlled human studies could be found, and limited animal data do not support lipid emulsion efficacy.11, No human controlled studies were found evaluating treatment of cardiac arrest due to TCA toxicity, although 1 study demonstrated termination of amitriptyline-induced VT in dogs.12, This topic last received formal evidence review in 2010.25. decrease pauses in chest compressions and improve outcomes? 5. What is the best approach to rewarming postarrest patients after treatment with targeted temperature
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