-Perform a head tilt- chin lift to open the airway. 3. Historically, the best motor examination in the upper extremities has been used as a prognostic tool, with extensor or absent movement being correlated with poor outcome. 3. The American Heart Association requests that this document be cited as follows: Panchal AR, Bartos JA, Cabaas JG, Donnino MW, Drennan IR, Hirsch KG, Kudenchuk PJ, Kurz MC, Lavonas EJ, Morley PT, ONeil BJ, Peberdy MA, Rittenberger JC, Rodriguez AJ, Sawyer KN, Berg KM; on behalf of the Adult Basic and Advanced Life Support Writing Group. If this is not known, defibrillation at the maximal dose may be considered. Emergent electric cardioversion and defibrillation are highly effective at terminating VF/VT and other tachyarrhythmias. In cardiac arrest secondary to anaphylaxis, standard resuscitative measures and immediate administration of epinephrine should take priority. 1. We recommend targeted temperature management for pregnant women who remain comatose after resuscitation from cardiac arrest. The suggestion to administer epinephrine was strengthened to a recommendation based on a systematic review and meta-analysis. Step 1: Power on the AED if needed - Follow the prompts (as a guide to next steps) Step 2: Choose adult pads for victim 8 years of age and older - Attack the adhesive AED pads to the victim's bare chest - Follow the diagrams on the pads Step 3: When AED prompts you, clear the victim during analysis. 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. Many of the tests considered are subject to error because of the effects of medications, organ dysfunction, and temperature. 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. These guidelines are not meant to be comprehensive. When the second rescuer arrives, provide 2-rescuer CPR and use the AED/defibrillator. CPR is Cardiopulmonary resuscitation. Injection of epinephrine into the lateral aspect of the thigh produces rapid peak plasma epinephrine concentrations. 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). It is preferable to avoid hypotension by maintaining a systolic blood pressure of at least 90 mm Hg and a mean arterial pressure of at least 65 mm Hg in the postresuscitation period. 1. This topic last received formal evidence review in 2015,8 with an evidence update conducted for the 2020 CoSTR for ALS.2. The initial phases of resuscitation once cardiac arrest is recognized are similar between lay responders and healthcare providers, with early CPR representing the priority. Cough CPR may be considered as a temporizing measure for the witnessed, monitored onset of a hemodynamically significant tachyarrhythmia or bradyarrhythmia before a loss of consciousness without delaying definitive therapy. Benzodiazepine overdose causes CNS and respiratory depression and, particularly when taken with other sedatives (eg, opioids), can cause respiratory arrest and cardiac arrest. 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. After identifying a cardiac arrest, a lone responder should activate the emergency response system first and immediately begin CPR. Synchronized cardioversion is recommended for acute treatment in patients with hemodynamically unstable SVT. Advanced monitoring such as ETCO2 monitoring is being increasingly used. 2. Vasopressor medications during cardiac arrest. In some cases, emergency cricothyroidotomy or tracheostomy may be required. For patients with severe hypothermia (less than 30C [86F]) with a perfusing rhythm, core rewarming is often used. However, electric cardioversion may not be effective for automatic tachycardias (such as ectopic atrial tachycardias), entails risks associated with sedation, and does not prevent recurrences of the wide-complex tachycardia. 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. 4. 1. Studies on push-dose epinephrine for bradycardia specifically are lacking, although limited data support its use for hypotension. Antidigoxin Fab antibodies should be administered to patients with severe cardiac glycoside toxicity. Phone or ask someone to phone 9-1-1 (the phone or caller with the phone remains at the victim's side, with the phone on speaker mode). One benefit to SSEPs is that they are subject to less interference from medications than are other modalities. 3. Electroencephalography is widely used in clinical practice to evaluate cortical brain activity and diagnose seizures. 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. 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. Limited evidence from case reports and case series demonstrates transient increases in aortic and intracardiac pressure with the use of cough CPR at the onset of tachyarrhythmias or bradyarrhythmias in conscious patients. If this is not known, defibrillation at the maximal dose may be considered. Transcutaneous pacing has been studied during cardiac arrest with bradyasystolic cardiac rhythm. 4. In intubated patients, failure to achieve an end-tidal CO. 5. 4. 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. 3. The intent of precordial thump is to transmit the mechanical force of the thump to the heart as electric energy analogous to a pacing stimulus or very low-energy shock (depending on its force) and is referred to as, Fist, or percussion, pacing is administered with the goal of stimulating an electric impulse sufficient to cause depolarization and contraction of the myocardium, resulting in a pulse. Prompt initiation of targeted temperature management is necessary for all patients who do not follow commands after return of spontaneous circulation to ensure optimal functional and neurological outcome. 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. Routine measurement of arterial blood gases during CPR has uncertain value. and 2. These still require further testing and validation before routine use. 2. 3. Can artifact-filtering algorithms for analysis of ECG rhythms during CPR in a real-time clinical setting What are the optimal pharmacological treatment regimens for the management of postarrest seizures? Of 16 observational studies on timing in the recent systematic review, all found an association between earlier epinephrine and ROSC for patients with nonshockable rhythms, although improvements in survival were not universally seen. What is the optimal approach to advanced airway management for IHCA? This is a separate question from the decision of if or when to transport a patient to the hospital with resuscitation ongoing. The optimal combination of airway techniques, oxygenation and ventilation is uncertain. Shout for nearby help and activate the emergency response system (9-1-1, emergency response). Limited animal data and rare case reports suggest possible utility of calcium to improve heart rate and hypotension in -adrenergic blocker toxicity. This topic was previously reviewed by ILCOR in 2015. Postcardiac arrest care is a critical component of the Chain of Survival and demands a comprehensive, structured, multidisciplinary system that requires consistent implementation for optimal patient outcomes. Deliver each breath over 1 second. Does the treatment of nonconvulsive seizures, common in postarrest patients, improve patient 2. Place 2 fingers on the lower half of the breastbone in the middle of the chest and press down by one-third of the depth of the chest (you may need to use one hand to do CPR depending on the size of the infant). Which patients with cyanide poisoning benefit from antidotal therapy? On CT, brain edema can be quantified as the GWR, defined as the ratio between the density (measured as Hounsfield units) of the gray matter and the white matter. When an IV line is in place, it is reasonable to consider the IV route for epinephrine in anaphylactic shock, at a dose of 0.05 to 0.1 mg (0.1 mg/mL, aka 1:10 000). No. Distinguishing between these rhythm etiologies is the key to proper drug selection for treatment. These arrhythmias are common and often coexist, and their treatment recommendations are similar. There are no RCTs evaluating alternative treatment algorithms for cardiac arrest due to anaphylaxis. or sooner if fatigued. Recovery What is the correct order of steps in the Out-of-Hospital Chain of Survival for adults? 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. A brief introduction or short synopsis is provided to put the recommendations into context with important background information and overarching management or treatment concepts. 2. In patients with -adrenergic blocker overdose who are in refractory shock, administration of calcium may be considered. More research in this area is clearly needed. 3. Two randomized, placebo-controlled trials, enrolling over 8500 patients, evaluated the efficacy of epinephrine for OHCA.1,2 A systematic review and meta-analysis of these and other studies3 concluded that epinephrine significantly increased ROSC and survival to hospital discharge. There is some evidence that in noncardiac arrest patients, cricoid pressure may protect against aspiration and gastric insufflation during bag-mask ventilation. 1. These techniques can keep blood flowing to the brain and other organs until medical help arrives. 3. A number of case reports have shown good outcomes in patients who received double sequential defibrillation. receiving CPR with ventilation? In adult cardiac arrest, it may be reasonable to perform CPR with a chest compression fraction of at least 60%. However, these case reports are subject to publication bias and should not be used to support its effectiveness. There are no studies comparing cough CPR to standard resuscitation care. 2. This link is provided for convenience only and is not an endorsement of either the linked-to entity or any product or service. For patients with cardiac arrest after cardiac surgery, it is reasonable to perform resternotomy early in an appropriately staffed and equipped ICU. Most opioid-associated deaths also involve the coingestion of multiple drugs or medical and mental health comorbidities.47. 1. 1. providers are skilled and can implement it quickly. OT indicates occupational therapy; PT, physical therapy; PTSD, posttraumatic stress disorder; and SLP, speech-language pathologist, Severe accidental environmental hypothermia (body temperature less than 30C [86F]) causes marked decrease in both heart rate and respiratory rate and may make it difficult to determine if a patient is truly in cardiac arrest. 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. No RCTs of resternotomy timing have been performed. Each of these features can also be useful in making a presumptive rhythm diagnosis. National Center Immediate defibrillation is recommended for sustained, hemodynamically unstable polymorphic VT. 1. The systems-of-care approach to cardiac arrest includes the community and healthcare response to cardiac arrest. However, termination of torsades by shock does not prevent its recurrence, which requires additional measures. A clinical trial studied administration of magnesium in addition to sodium bicarbonate for patients with TCA-induced hypotension, acidosis, and/or QRS prolongation.5 Although overall outcomes were better in the magnesium group, no statistically significant effect was found in mortality, the magnesium patients were significantly less ill than controls at study entry, and methodologic flaws render this work preliminary. do they differ from current generic or clinician-derived measures? Recommendations for the treatment of cardiac arrest due to hyperkalemia, including the use of calcium and sodium bicarbonate, are presented in Electrolyte Abnormalities. However, an oral airway is preferred because of the risk of trauma with a nasopharyngeal airway. 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. 4. Clinicians must determine if the tachycardia is narrow-complex or wide-complex tachycardia and if it has a regular or irregular rhythm. Since last addressed by the 2010 Guidelines, a 2013 systematic review found little evidence to support the routine use of calcium in undifferentiated cardiac arrest, though the evidence is very weak due calcium as a last resort medication in refractory cardiac arrest. What is the most efficacious management approach for postarrest cardiogenic shock, including Cardiac arrest results in heterogeneous injury; thus, death can also result from multiorgan dysfunction or shock. 1. outcomes? Point-of-care cardiac ultrasound can identify cardiac tamponade or other potentially reversible causes of cardiac arrest and identify cardiac motion in pulseless electrical activity. Advanced resuscitation 5. 2. needed to be able to compare prognostic values across studies. These deliver different peak currents even at the same programmed energy setting, making comparisons of shock efficacy between devices challenging. The 2015 Guidelines Update recommended emergent coronary angiography for patients with ST-segment elevation on the post-ROSC ECG. How is cpr performed differently when an advanced airway is in place See answer Advertisement 4631001552 Answer: Once an advanced airway is in place rescuers are no longer delivering cycles of CPR. 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. 1. The peripheral IV route has been the traditional approach to vascular access for emergency drug and fluid administration during resuscitation. The BLS care of adolescents follows adult guidelines. medications? In postcardiac surgery patients with asystole or bradycardic arrest in the ICU with pacing leads in place, pacing can be initiated immediately by trained providers. External chest compressions should be performed if emergency resternotomy is not immediately available. Thus, the ultimate decision of the use, type, and timing of an advanced airway will require consideration of a host of patient and provider characteristics that are not easily defined in a global recommendation. Drug administration by central venous access (by internal jugular or subclavian vein) achieves higher peak concentrations and more rapid circulation times than drugs administered by peripheral IV do, Endotracheal drug administration is regarded as the least-preferred route of drug administration because it is associated with unpredictable (but generally low) drug concentrations. 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. 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. 4. Quantitative waveform capnography - If Petco 2 <10 mm Hg, attempt to improve CPR quality. Can we identify consistent NSE and S100B thresholds for predicting poor neurological outcome after 2. CPR provides a small but critical amount of blood flow to the heart and brain. Whether resumption of CPR immediately after shock might reinduce VF/VT is controversial.52-54 This potential concern has not been borne out by any evidence of worsened survival from such a strategy. Patients in anaphylactic shock are critically ill, and cardiovascular and respiratory status can change quickly, making close monitoring imperative. The rationale for a single shock strategy, in which CPR is immediately resumed after the first shock rather than after serial stacked shocks (if required) is based on a number of considerations. It is not uncommon for chest compressions to be paused for rhythm detection and continue to be withheld while the defibrillator is charged and prepared for shock delivery. Clinical examination findings correlate with poor outcome but are also subject to confounding by TTM and medications, and prior studies have methodological limitations. 3. 3. This may include vasopressor agents such as epinephrine (discussed in Vasopressor Medications During Cardiac Arrest) as well as drugs without direct hemodynamic effects (nonpressors) such as antiarrhythmic medications, magnesium, sodium bicarbonate, calcium, or steroids (discussed here). This topic last received formal evidence review in 2010.5. -Adrenergic receptor antagonists (-adrenergic blockers) and L-type calcium channel antagonists (calcium channel blockers) are common antihypertensive and cardiac rate control medications. Arterial pressure monitoring by arterial line may be used to detect ROSC during chest compressions or when a rhythm check reveals an organized rhythm. The AED was attached, and ''no shock'' was advised. In patients with atrial fibrillation and atrial flutter in the setting of preexcitation, digoxin, nondihydropyridine calcium channel antagonists, -adrenergic blockers, and IV amiodarone should not be administered because they may increase the ventricular response and result in VF. The force from a precordial thump is intended to transmit electric energy to the heart, similar to a low-energy shock, in hope of terminating the underlying tachyarrhythmia. Sodium thiosulfate enhances the effectiveness of nitrites by enhancing the detoxification of cyanide, though its role in patients treated with hydroxocobalamin is less certain.4 Novel antidotes are in development. Emergent coronary angiography is reasonable for select (eg, electrically or hemodynamically unstable) adult patients who are comatose after OHCA of suspected cardiac origin but without ST-segment elevation on ECG. The optimal timing of CPR initiation and emergency response system activation was evaluated by an ILCOR systematic review in 2020. 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. IV infusion of epinephrine may be considered for post-arrest shock in patients with anaphylaxis. 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. 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. Because pregnant patients are more prone to hypoxia, oxygenation and airway management should be prioritized during resuscitation from cardiac arrest in pregnancy. 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. 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. See Metrics for High-Quality CPR for recommendations on physiological monitoring during CPR. IHCA patients often have invasive monitoring devices in place such as central venous or arterial lines, and personnel to perform advanced procedures such as arterial blood gas analysis or point-of-care ultrasound are often present. The routine use of prophylactic antibiotics in postarrest patients is of uncertain benefit. 1. What is the optimal timing for head CT for prognostication? There is no published evidence on the safety, effectiveness, or feasibility of mouth-to-stoma ventilation. resuscitation? The 2010 Guidelines recommended a 50% duty cycle, in which the time spent in compression and decompression was equal, mainly on the basis of its perceived ease of being achieved in practice. spontaneous circulation; S100B, S100 calcium binding protein; STEMI, ST-segment elevation myocardial infarction; and VF, ventricular fibrillation. Individual test modalities may be obtained earlier and the results integrated into the multimodality assessment synthesized at least 72 hours after normothermia. 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. Adenosine will not typically terminate atrial arrhythmias (such as atrial flutter or atrial tachycardia) but will transiently slow the ventricular rate by blocking conduction of P waves through the AV node, afford their recognition, and help establish the rhythm diagnosis. Accurate neurological prognostication is important to avoid inappropriate withdrawal of life-sustaining treatment in patients who may otherwise achieve meaningful neurological recovery and also to avoid ineffective treatment when poor outcome is inevitable (Figure 10).3. 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. CT and MRI are the 2 most common modalities. Amiodarone or lidocaine may be considered for VF/pVT that is unresponsive to defibrillation. The immediate cause of death in drowning is hypoxemia. Cardioversion has been shown to be both safe and effective in the prehospital setting for hemodynamically unstable patients with SVT who had failed to respond to vagal maneuvers and IV pharmacological therapies. Clinical trials in resuscitation are sorely needed. IV antiarrhythmic medications may be considered in stable patients with wide-complex tachycardia, particularly if suspected to be VT or having failed adenosine. The majority of recommendations are based on Level C evidence, including those based on limited data (123 recommendations) and expert opinion (31 recommendations). 1. 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. 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. Administration of amiodarone or lidocaine to patients with OHCA was last formally reviewed in 2018. The topic of neuroprotective agents was last reviewed in detail in 2010. We recommend that the findings of a best motor response in the upper extremities being either absent or extensor movements not be used alone for predicting a poor neurological outcome in patients who remain comatose after cardiac arrest. 3. In nonintubated patients, a specific end-tidal CO. 1. AED indicates automated external defibrillator; ALS, advanced life support; BLS, basic life support; and CPR, cardiopulmonary resuscitation. 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. It may be reasonable to initially use minimally interrupted chest compressions (ie, delayed ventilation) for witnessed shockable OHCA as part of a bundle of care.