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Team planning for cardiac arrest in pregnancy should be done in collaboration with the obstetric, neonatal, emergency, anesthesiology, intensive care, and cardiac arrest services. Interposed abdominal compression CPR is a 3-rescuer technique that includes conventional chest compressions combined with alternating abdominal compressions. 1. Time taken for rhythm analysis also disrupts CPR. affect resuscitation outcomes? 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. The AHA has rigorous conflict of interest policies and procedures to minimize the risk of bias or improper influence during the development of guidelines. 2. Immediately begin CPR, and use the AED/ defibrillator when available. 3. What is the ideal initial dose of naloxone in a setting where fentanyl and fentanyl analogues are Unstable patients require immediate electric cardioversion. 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. 3: Harm. It is reasonable for providers to first attempt establishing intravenous access for drug administration in cardiac arrest. We recommend that the absence of EEG reactivity within 72 h after arrest not be used alone to support a poor neurological prognosis. 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. Survivorship after cardiac arrest is the journey through rehabilitation and recovery and highlights the far-reaching impact on patients, families, healthcare partners, and communities (Figure 11).13. 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. 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. Systematic Review Most studies used young, healthy patients but no current method to identify ideal patients. The administration of flumazenil to patients with undifferentiated coma confers risk and is not recommended. Follow the telecommunicators* instructions. When oxygen-rich blood cannot get to the brain, brain damage can occur within minutes. Lay rescuers may provide chest compression only CPR to simplify the process and encourage CPR initiation, whereas healthcare providers may provide chest compressions and ventilation (Figures 24). What combination of features can identify patients with no chance of survival, even if rewarmed? 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. 2. 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. Of the 250 recommendations in these guidelines, only 2 recommendations are supported by Level A evidence (high-quality evidence from more than 1 randomized controlled trial [RCT], or 1 or more RCT corroborated by high-quality registry studies.) What is the correct order of steps of the Pediatric Out-of-Hospital Chain of Survival? After identifying a cardiac arrest, a lone responder should activate the emergency response system first and immediately begin CPR. Although there are no controlled studies, several case reports and small case series have reported improvement in bradycardia and hypotension after glucagon administration. Nine observational studies evaluated rhythmic/ periodic discharges. If an arterial line is in place, an abrupt increase in diastolic pressure or the presence of an arterial waveform during a rhythm check showing an organized rhythm may indicate ROSC. In patients with confirmed pulmonary embolism as the precipitant of cardiac arrest, thrombolysis, surgical embolectomy, and mechanical embolectomy are reasonable emergency treatment options. Send the second person to retrieve an AED, if one is available. The 2020 ILCOR systematic review evaluated studies that obtained serum biomarkers within the first 7 days after arrest and correlated serum biomarker concentrations with neurological outcome. Much of the published research involves patients whose arrests were presumed to be of cardiac origin and in settings with short EMS response times. Healthcare providers are trained to deliver both compressions and ventilation. Hemodynamically stable patients can be treated with a rate-control or rhythm-control strategy. 5. IV administration of a -adrenergic blocker or nondihydropyridine calcium channel antagonist is recommended to slow the ventricular heart rate in the acute setting in patients with atrial fibrillation or atrial flutter with rapid ventricular response without preexcitation. arrest with shockable rhythm? 3. We recommend treatment of clinically apparent seizures in adult postcardiac arrest survivors. Sparse data have been published addressing this question. 2. For patients with OHCA, use of steroids during CPR is of uncertain benefit. 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. For a patient with suspected opioid overdose who has a definite pulse but no normal breathing or only gasping (ie, a respiratory arrest), in addition to providing standard BLS and/or ACLS care, it is reasonable for responders to administer naloxone. More uniform definitions for status epilepticus, malignant EEG patterns, and other EEG patterns are The theory is that the heart will respond to electric stimuli by producing myocardial contraction and generating forward movement of blood, but clinical trials have not shown pacing to improve patient outcomes. That is, when performing CPR on an infant, you perform 30 chest compressions followed by 2 rescue breaths. 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. 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. Electroencephalography is widely used in clinical practice to evaluate cortical brain activity and diagnose seizures. Nonvasopressor medications during cardiac arrest. Observational studies on TTM for IHCA with any initial rhythm have reported mixed results. Discordance in goals of care between clinicians and families/surrogates has been reported in more than 25% of critically ill patients. However, obtaining IV access under emergent conditions can prove to be challenging based on patient characteristics and operator experience leading to delay in pharmacological treatments. Deliver each breath over 1 second. 2. Although cardiac arrest due to carbon monoxide poisoning is almost always fatal, studies about neurological sequelae from less-severe carbon monoxide poisoning may be relevant. Time to drug in IHCA is generally much shorter, and the effect of epinephrine on outcomes in the IHCA population may therefore be different. These still require further testing and validation before routine use. This topic last received formal evidence review in 2015,8 with an evidence update conducted for the 2020 CoSTR for ALS.2. Your lungs are spongy, air-filled sacs, with one lung located on either side of the chest. 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. 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. Prevention 2. 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. 1. There are some physiological basis and preclinical data for hyperoxemia leading to increased inflammation and exacerbating brain injury in postarrest patients. Shout for nearby help. The routine use of magnesium for cardiac arrest is not recommended. If a regular wide-complex tachycardia is suspected to be paroxysmal SVT, vagal maneuvers can be considered before initiating pharmacological therapies (see Regular Narrow-Complex Tachycardia). 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. 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. Community reintegration and return to work or other activities may be slow and depend on social support and relationships. No trials to date have found any benefit of either higher-dose epinephrine or other vasopressors over standard-dose epinephrine during CPR. With respect to timing, for cardiac arrest with a shockable rhythm, it may be reasonable to administer epinephrine after initial defibrillation attempts have failed. The toxicity of cyanide is predominantly due to the cessation of aerobic cell metabolism. Minimizing disruptions in CPR surrounding shock administration is also a high priority. Clinical Practice Guidelines for the Treatment and Prevention of Drowning: 2019 Update.20. Bradycardia can be a normal finding, especially for athletes or during sleep. 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. Before appointment, writing group members disclosed all commercial relationships and other potential (including intellectual) conflicts. Because the duration of action of naloxone may be shorter than the respiratory depressive effect of the opioid, particularly long-acting formulations, repeat doses of naloxone, or a naloxone infusion may be required. No RCTs of resternotomy timing have been performed. The Chain of Survival, introduced in Major Concepts, is now expanded to emphasize the important component of survivorship during recovery from cardiac arrest, requires coordinated efforts from medical professionals in a variety of disciplines and, in the case of OHCA, from lay rescuers, emergency dispatchers, and first responders. For each recommendation, the writing group discussed and approved specific recommendation wording and the COR and LOE assignments. Immediate defibrillation is reasonable for provider-witnessed or monitored VF/pVT of short duration when a defibrillator is already applied or immediately available. After return of spontaneous breathing, patients should be observed in a healthcare setting until the risk of recurrent opioid toxicity is low and the patients level of consciousness and vital signs have normalized. Post-cardiac arrest care 6. There is no proven benefit from the use of antihistamines, inhaled beta agonists, and IV corticosteroids during anaphylaxis-induced cardiac arrest. Other pseudoelectrical therapies, such as cough CPR, fist or percussion pacing, and precordial thump have all been described as temporizing measures in select patients who are either periarrest or in the initial seconds of witnessed cardiac arrest (before losing consciousness in the case of cough CPR) when definitive therapy is not readily available. 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. 2. Hemodynamically unstable patients with atrial fibrillation or atrial flutter with rapid ventricular response should receive electric cardioversion. When this method is carried out by an inexperienced individual, it can result in serious trauma related to the oropharynx. The 2019 focused update on ACLS guidelines addressed the use of advanced airways in cardiac arrest and noted that either bag-mask ventilation or an advanced airway strategy may be considered during CPR for adult cardiac arrest in any setting.1 Outcomes from advanced airway and bag-mask ventilation interventions are highly dependent on the skill set and experience of the provider (Figure 7). If so, what dose and schedule should be used? 3. It is reasonable for a rescuer to use mouth-to-nose ventilation if ventilation through the victims mouth is impossible or impractical. 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. 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). Recovery and survivorship after cardiac arrest. As with all AHA guidelines, each 2020 recommendation is assigned a Class of Recommendation (COR) based on the strength and consistency of the evidence, alternative treatment options, and the impact on patients and society (Table 1(link opens in new window)). A systematic review of the literature evaluated all case reports of cardiac arrest in pregnancy about the timing of PMCD, but the wide range of case heterogeneity and reporting bias does not allow for conclusions. IV amiodarone can be useful for rate control in critically ill patients with atrial fibrillation with rapid ventricular response without preexcitation. 4. Arterial pressure monitoring by arterial line may be used to detect ROSC during chest compressions or when a rhythm check reveals an organized rhythm. 2. 3. Tension pneumothorax is a rare life-threatening complication of asthma and a potentially reversible cause of arrest. IV diltiazem or verapamil can be effective for acute treatment in patients with hemodynamically stable SVT at a regular rate. 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. Answer the dispatchers questions, and follow the telecommunicators instructions. Advanced airway (or advanced airway management) is a practice used by medical professionals to support breathing such as an endotracheal tube, a laryngeal mask airway, or an esophageal-tracheal combitube. This concern is especially pertinent in the setting of asphyxial cardiac arrest. 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. High-dose epinephrine is not recommended for routine use in cardiac arrest. 1. Is there benefit to naloxone administration in patients with opioid-associated cardiac arrest who are These recommendations are supported by the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/AHA Task Force on Practice Guidelines and the Heart Rhythm Society18 as well as the focused update of those guidelines published in 2019.2, These recommendations are supported by 2014 AHA, American College of Cardiology, and Heart Rhythm Society Guideline for the Management of Patients With Atrial Fibrillation18 as well as the focused update of those guidelines published in 2019.2. 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. Should severely hypothermic patients in VF who fail an initial defibrillation attempt receive additional A patent airway is essential to facilitate proper ventilation and oxygenation. It may be reasonable to use a defibrillator in manual mode as compared with automatic mode depending on the skill set of the operator. 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. Pharmacological treatment of cardiac arrest is typically deployed when CPR with or without attempted defibrillation fails to achieve ROSC. Case reports support the use of ECMO for patients with refractory shock due to TCA toxicity. 4. Emergent electric cardioversion and defibrillation are highly effective at terminating VF/VT and other tachyarrhythmias. 3. 1. Discharges on EEG were divided into 2 types: rhythmic/periodic and nonrhythmic/periodic. In intubated patients, failure to achieve an end-tidal CO. 5. The routine use of mechanical CPR devices is not recommended. Monday - Friday: 7 a.m. 7 p.m. CT ECPR indicates extracorporeal cardiopulmonary resuscitation. Carbon monoxide poisoning reduces the ability of hemoglobin to deliver oxygen and also causes direct cellular damage to the brain and myocardium, leading to death or long-term risk of neurological and myocardial injury. We recommend targeted temperature management for pregnant women who remain comatose after resuscitation from cardiac arrest. 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. 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. 3. The esophageal-tracheal tube (sometimes referred to as a combitube) is an advanced airway alternative to ET intubation. 1. It has been shown previously that all rescuers may have difficulty detecting a pulse, leading to delays in CPR, or in some cases CPR not being performed at all for patients in cardiac arrest.3 Recognition of cardiac arrest by lay rescuers, therefore, is determined on the basis of level of consciousness and the respiratory effort of the victim. Care Science With Treatment Recommendations (CoSTR).1. and 2. 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. In patients with persistent hemodynamically unstable bradycardia refractory to medical therapy, temporary transvenous pacing is reasonable to increase heart rate and improve symptoms. If pharmacological therapy is unsuccessful for the treatment of a hemodynamically stable wide-complex tachycardia, cardioversion or seeking urgent expert consultation is reasonable. This time delay is a consistent issue in OHCA trials. Immediate defibrillation is recommended for sustained, hemodynamically unstable polymorphic VT. 1. If no advanced airway, 30:2 compression-ventilation ratio. The 2015 Guidelines Update recommended emergent coronary angiography for patients with ST-segment elevation on the post-ROSC ECG. Beginning the CPR sequence with compression. Agonal breathing is described by lay rescuers with a variety of terms including, Protracted delays in CPR can occur when checking for a pulse at the outset of resuscitation efforts as well as between successive cycles of CPR. Others, such as opioid overdose, are sharply on the rise in the out-of-hospital setting.2 For any cardiac arrest, rescuers are instructed to call for help, perform CPR to restore coronary and cerebral blood flow, and apply an AED to directly treat ventricular fibrillation (VF) or ventricular tachycardia (VT), if present. The available evidence suggests no appreciable differences in success or major adverse event rates between calcium channel blockers and adenosine.2. 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. Case reports and at least 1 retrospective observational study have been published on survival after ECMO in patients presenting with refractory shock from -adrenergic blocker overdose. 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. 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. In addition to defibrillation, several alternative electric and pseudoelectrical therapies have been explored as possible treatment options during cardiac arrest. 1. While an expeditious trial of medications and/or fluids may be appropriate in some cases, unstable patients or patients with ongoing cardiac ischemia with atrial fibrillation or atrial flutter need to be cardioverted promptly.

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