The AED arrives. . the functional capacity and safety of hospitals and the health-care system at large. Chest compression depth begins to decrease after 90 to 120 seconds of CPR, although compression rates do not decrease significantly over that time window. 2. For synchronized cardioversion of atrial flutter using biphasic energy, an initial energy of 50 to 100 J may be reasonable, depending on the specific biphasic defibrillator being used. Healthcare providers should consider the possibility of a spinal injury before opening the airway. 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. Any staff member may call the team if one of the following criteria is met: Heart rate over 140/min or less than 40/min. Whether treatment of seizure activity on EEG that is not associated with clinically evident seizures affects outcome is currently unknown. The pages provide information for employers and workers across industries, and for workers who will be responding to the emergency. 1. Studies confirm the importance of real-time disaster monitoring systems, emergency response systems, and information systems these days to mitigate devastating impacts on human life, economy, and . The rescuer should then provide high-quality CPR. IV bolus administration of potassium for cardiac arrest in suspected hypokalemia is not recommended. What is the first link in the Pediatric Out-of-Hospital Chain of Survival? Available hemodynamic monitoring modalities in conjunction with manual pulse detection provide an opportunity to confirm myocardial capture and adequate cardiac function. Although the administration of IV magnesium has not been found to be beneficial for VF/VT in the absence of prolonged QT, consideration of its use for cardiac arrest in patients with prolonged QT is advised. What is the correct rate of ventilation delivery for a child or infant in respiratory arrest or failure? This approach results in a protracted hands-off period before shock. Rate control is more common in the emergency setting, using IV administration of a nondihydropyridine calcium channel antagonist (eg, diltiazem, verapamil) or a -adrenergic blocker (eg, metoprolol, esmolol). For each recommendation, the writing group discussed and approved specific recommendation wording and the COR and LOE assignments. 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. Existing evidence, including observational and quasi-RCT data, suggests that pacing by a transcutaneous, transvenous, or transmyocardial approach in cardiac arrest does not improve the likelihood of ROSC or survival, regardless of the timing of pacing administration in established asystole, location of arrest (in-hospital or out-of-hospital), or primary cardiac rhythm (asystole, pulseless electrical activity). 2. 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. Because of the limitation in exhalational air flow, delivery of large tidal volumes at a higher respiratory rate can lead to progressive worsening of air trapping and a decrease in effective ventilation. NATIONAL INCIDENT MANAGEMENT SYSTEM Prior to the inception of NIMS, ICS was the primary response management system in the U.S. Its use was usually restricted to typical emergency response agencies such as fire, police, and EMS, but many other agencies, such as the U.S. Coast Guard, had also adopted ICS. More uniform definitions for status epilepticus, malignant EEG patterns, and other EEG patterns are Nondihydropyridine calcium channel antagonists and IV -adrenergic blockers should not be used in patients with left ventricular systolic dysfunction and decompensated heart failure because these may lead to further hemodynamic compromise. Symptomatic bradycardia may be caused by a number of potentially reversible or treatable causes, including structural heart disease, increased vagal tone, hypoxemia, myocardial ischemia, or medications. The American Heart Association is a qualified 501(c)(3) tax-exempt organization. One benefit to SSEPs is that they are subject to less interference from medications than are other modalities. Rescuers should recognize that multiple approaches may be required to establish an adequate airway. Despite recent gains, only 39.2% of adults receive layperson-initiated CPR, and the general public applied an AED in only 11.9% of cases.1 Survival rates from OHCA vary dramatically between US regions and EMS agencies.2,3 After significant improvements, survival from OHCA has plateaued since 2012. 3. 3. Does hospital-based protocolized discharge planning for cardiac arrest survivors improve access to/ Activation and retrieval of the AED/emergency equipment by the lone healthcare provider or by the second person sent by the rescuer must occur no later than immediately after the check for no normal breathing and no pulse identifies cardiac arrest. 1. After identifying a cardiac arrest, a lone responder should activate the emergency response system first and immediately begin CPR. Recommendations for management of torsades de pointes are also presented in Torsades de Pointes. 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. 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. This topic last received formal evidence review in 2015,8 with an evidence update conducted for the 2020 CoSTR for ALS.2. 1. For patients with cardiac arrest after cardiac surgery, it is reasonable to perform resternotomy early in an appropriately staffed and equipped ICU. What combination of features can identify patients with no chance of survival, even if rewarmed? 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. External chest compressions should be performed if emergency resternotomy is not immediately available. In the presence of known or suspected basal skull fracture or severe coagulopathy, an oral airway is preferred compared with a nasopharyngeal airway. 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. Victims of accidental hypothermia should not be considered dead before rewarming has been provided unless there are signs of obvious death. Should severely hypothermic patients in cardiac arrest receive epinephrine or other resuscitation The suggested timing of the multimodal diagnostics is shown here. 7. Continuous waveform capnography is recommended in addition to clinical assessment as the most reliable method of confirming and monitoring correct placement of an endotracheal tube. 2. Regardless of waveform, successful defibrillation requires that a shock be of sufficient energy to terminate VF/VT. 5. 3. Patients who respond to naloxone administration may develop recurrent CNS and/or respiratory depression. Unstable patients require immediate electric cardioversion. The dispatcher will call 911 only after they have spoken with the person who pressed their call button C. The personal emergency response system is activated when the person makes a phone call to the . Initial management should focus on support of the patients airway and breathing. 2. A patent airway is essential to facilitate proper ventilation and oxygenation. Unfortunately, different studies define highly malignant EEG differently or imprecisely, making use of this finding unhelpful. We recommend that teams caring for comatose cardiac arrest survivors have regular and transparent multidisciplinary discussions with surrogates about the anticipated time course for and uncertainties around neuroprognostication. Epinephrine has been hypothesized to have beneficial effects during cardiac arrest primarily because of its -adrenergic effects, leading to increased coronary and cerebral perfusion pressure during CPR. arrest with shockable rhythm? ECPR is a complex intervention that requires a highly trained team, specialized equipment, and multidisciplinary support within a healthcare system. Peer reviewer feedback was provided for guidelines in draft format and again in final format. 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. Prompt treatment of cardiac glycoside toxicity is imperative to prevent or treat life-threatening arrhythmias. There are no RCTs evaluating alternative treatment algorithms for cardiac arrest due to anaphylaxis. A description of the situation (e.g. During targeted temperature management of the pregnant patient, it is recommended that the fetus be continuously monitored for bradycardia as a potential complication, and obstetric and neonatal consultation should be sought. There are differing approaches to charging a manual defibrillator during resuscitation. However, the most critical feature in the diagnosis and treatment of polymorphic VT is not the morphology of rhythm but rather what is known (or suspected) about the patients underlying QT interval. It is reasonable to place defibrillation paddles or pads on the exposed chest in an anterolateral or anteroposterior position, and to use a paddle or pad electrode diameter more than 8 cm in adults. There is insufficient evidence to recommend the routine use of extracorporeal CPR (ECPR) for patients with cardiac arrest. Priorities for the pregnant woman in cardiac arrest should include provision of high-quality CPR and relief of aortocaval compression through left lateral uterine displacement. It is a multi-layered system involving individuals and teams from tribal, local, state, and federal agencies, as well as industry and other organizations. There are some physiological basis and preclinical data for hyperoxemia leading to increased inflammation and exacerbating brain injury in postarrest patients. Apply online instantly. Atrial flutter is an SVT with a macroreentrant circuit resulting in rapid atrial activation but intermittent ventricular response. Is there a consistent threshold value for prognostication for GWR or ADC? response. 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. responsible for a large proportion of opioid overdose? Most opioid-associated deaths also involve the coingestion of multiple drugs or medical and mental health comorbidities.47. 2. No trials to date have found any benefit of either higher-dose epinephrine or other vasopressors over standard-dose epinephrine during CPR. If replenished by a period of CPR before shock, defibrillation success improves significantly. Part 3: adult basic and advanced life support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. The International Liaison Committee on Resuscitation (ILCOR) Formula for Survival emphasizes 3 essential components for good resuscitation outcomes: guidelines based on sound resuscitation science, effective education of the lay public and resuscitation providers, and implementation of a well-functioning Chain of Survival.4, These guidelines contain recommendations for basic life support (BLS) and advanced life support (ALS) for adult patients and are based on the best available resuscitation science. Ask yourself the following questions and use a small blank notebook, writing pad, or other appropriate form(s) to record thoughts and ideas: Should public health become involved in the It can represent any aberrantly conducted supraventricular tachycardia (SVT), including paroxysmal SVT caused by atrioventricular (AV) reentry, aberrantly conducted atrial fibrillation, atrial flutter, or ectopic atrial tachycardia. A wide-complex tachycardia can be regular or irregularly irregular and have uniform (monomorphic) or differing (polymorphic) QRS complexes from beat to beat. EMS systems that perform prehospital intubation should provide a program of ongoing quality improvement to minimize complications and track overall supraglottic airway and endotracheal tube placement success rates. Benefits of this method are a standard and reproducible assessment. 3. However, biphasic waveform defibrillators (which deliver pulses of opposite polarity) expose patients to a much lower peak electric current with equivalent or greater efficacy for terminating atrial. After calling 911, follow the dispatcher's instructions. 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. 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. Nonvasopressor medications during cardiac arrest. Twelve studies examined the use of naloxone in respiratory arrest, of which 5 compared intramuscular, intravenous, and/or intranasal routes of naloxone administration (2 RCT. It is reasonable for providers to first attempt establishing intravenous access for drug administration in cardiac arrest. Survival with a favorable neurological outcome (Cerebral Performance Category 12) was higher in the group treated with 33C. You are alone performing high-quality CPR when a second provider arrives to take over compressions. 1. 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. 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. In patients with -adrenergic blocker overdose who are in refractory shock, administration of IV glucagon is reasonable. Early activation of the emergency response system is critical for patients with suspected opioid overdose. However, termination of torsades by shock does not prevent its recurrence, which requires additional measures. There are no data evaluating the use of antidotes to digoxin overdose specifically in the setting of cardiac arrest. 1. The rhythm-control strategy (sometimes called chemical cardioversion) includes antiarrhythmic medications given to convert the rhythm to sinus and/or prevent recurrent atrial fibrillation/flutter (Table 3). If pharmacological therapy is unsuccessful for the treatment of a hemodynamically stable wide-complex tachycardia, cardioversion or seeking urgent expert consultation is reasonable. Follow the telecommunicators* instructions. When providing rescue breaths, it may be reasonable to give 1 breath over 1 s, take a regular (not deep) breath, and give a second rescue breath over 1 s. 4. reflex, and myoclonus/status myoclonus? Obtaining EEG in status myoclonus is important to rule out underlying ictal activity. 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. In accordance with the BSEE Safety and Environment Management System II, an Emergency Action Plan (EAP) should be in place. Symptoms typically occur within minutes, and findings may include arrhythmias, apnea, hypotension with bradycardia, seizures, and cardiovascular collapse.1 Lactic acidosis is a sensitive and specific finding.2,3 Immediate antidotes include hydroxocobalamin and nitrites; however, the former has a much better safety profile. total time of the compression-plus-decompression cycle)? 2. CPR should be initiated if defibrillation is not successful within 1 min. Fist (percussion) pacing may be considered as a temporizing measure in exceptional circumstances such as witnessed, monitored in-hospital arrest (eg, cardiac catheterization laboratory) for bradyasystole before a loss of consciousness and if performed without delaying definitive therapy. 3. Both mouth-to-mouth rescue breathing and bagmask ventilation provide oxygen and ventilation to the victim. 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. The management of patients with preexcitation syndromes (aka Wolff-Parkinson-White) is covered in the Wide-Complex Tachycardia section. 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. After immediately initiating the emergency response system, what is the next link in the Adult In-Hospital Cardiac Chain of Survival? 1. 1. They may repeatedly recur and remit spontaneously, become sustained, or degenerate to VF, for which electric shock may be required. Immediately begin CPR, and use the AED/ defibrillator when available. 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. When the victim is hypothermic, pulse and respiratory rates may be slow or difficult to detect. Many of these were reviewed in an evidence update provided in the 2020 COSTR for ALS.2 Many uncertainties within the topic of TTM remain, including whether temperature should vary on the basis of patient characteristics, how long TTM should be maintained, and how quickly it should be started. 4. 3. This tool comprises current It may be reasonable to actively prevent fever in comatose patients after TTM. A well-conducted human trial showed that administration of propranolol reduces coronary blood flow in patients with cocaine exposure. 3. thrombolysis during resuscitation? These recommendations are supported by a 2020 ILCOR systematic review.1. 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). When performed with other prognostic tests, it may be reasonable to consider extensive areas of reduced apparent diffusion coefficient (ADC) on brain MRI at 2 to 7 days after cardiac arrest to support the prognosis of poor neurological outcome in patients who remain comatose. 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. What is the effect of hypocarbia or hypercarbia on outcome after cardiac arrest? 2. 3. The duration and severity of hypoxia sustained as a result of drowning is the single most important determinant of outcome. Operationally, the timing for prognostication is typically at least 5 days after ROSC for patients treated with TTM (which is about 72 hours after normothermia) and should be conducted under conditions that minimize the confounding effects of sedating medications. If advanced airway placement will interrupt chest compressions, providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or obtains ROSC. Hyperlinked references are provided to facilitate quick access and review. In patients with acute bradycardia associated with hemodynamic compromise, administration of atropine is reasonable to increase heart rate. Other testing of serum biomarkers, including testing levels over serial time points after arrest, was not evaluated. You and your co-worker Jake are operating a BVM during multiple-provider CPR for an adult. The key drivers of successful resuscitation from OHCA are lay rescuer cardiopulmonary resuscitation (CPR) and public use of an automated external defibrillator (AED). CPR should be initiated if pacing is not successful within 1 min. You perform a rapid assessment and determine that your patient is experiencing cardiac arrest. There is also inconsistency in definitions used to describe specific findings and patterns. Individual test modalities may be obtained earlier and the results integrated into the multimodality assessment synthesized at least 72 hours after normothermia. In OHCA, the care of the victim depends on community engagement and response. 2. 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. You and two nurses have been performing CPR on a 72-year-old patient, Ben Phillips. The college is equipped with emergency equipment for use in the event of a release. You are alone and caring for a 9-month-old infant with an obstructed airway who becomes unresponsive. Management of acute PE is determined by disease severity.2 Fulminant PE, characterized by cardiac arrest or severe hemodynamic instability, defines the subset of massive PE that is the focus of these recommendations. Which term refers to clearly and rationally identifying the connection between information and actions? IV infusion of epinephrine is a reasonable alternative to IV boluses for treatment of anaphlaxis in patients not in cardiac arrest. Regardless of the underlying QT interval, all forms of polymorphic VT tend to be hemodynamically and electrically unstable. Minimizing disruptions in CPR surrounding shock administration is also a high priority. 4. You are providing care for Mrs. Bove, who has an endotracheal tube in place. Outcomes from IHCA are overall superior to those from OHCA,5 likely because of reduced delays in initiation of effective resuscitation.