Multiple observational evaluations, primarily in pediatric patients, have demonstrated that decompensation after fresh or salt-water drowning can occur in the first 4 to 6 hours after the event. 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. This Recovery link highlights the enormous recovery and survivorship journey, from the end of acute treatment for critical illness through multimodal rehabilitation (both short- and long-term), for both survivors and families after cardiac arrest. NSE and S100B are the 2 most commonly studied markers, but others are included in this review as well. Unlike most other cardiac arrests, these patients typically develop cardiac arrest in a highly monitored setting such as an ICU, with highly trained staff available to perform rescue therapies. Hydroxocobalamin and 100% oxygen, with or without sodium thiosulfate, can be beneficial for cyanide poisoning. 3. In unmonitored cardiac arrest, it is reasonable to provide a brief prescribed period of CPR while a defibrillator is being obtained and readied for use before initial rhythm analysis and possible defibrillation. 1. Epinephrine is the cornerstone of treatment for anaphylaxis.35, This topic last received formal evidence review in 2010.14. 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. 1 During the prearrest and postarrest periods, the patient will require support of oxygenation and ventilation with tidal volumes and respiratory rates that . When spinal injury is suspected or cannot be ruled out, rescuers should maintain manual spinal motion restriction and not use immobilization devices. 1. 2. Give one breath, blowing for about 1 second, watching for chest rise Your adult friend suddenly collapses at home, and you determine she needs CPR. 1. 1. 1. What is the optimal treatment for hyperkalemia with life-threatening arrhythmia or cardiac arrest? It is reasonable to immediately resume chest compressions after shock delivery for adults in cardiac arrest in any setting. Conversely, polymorphic VT not associated with a long QT is most often due to acute myocardial ischemia.4,5 Other potential causes include catecholaminergic polymorphic VT, a genetic abnormality in which polymorphic VT is provoked by exercise or emotion in the absence of QT prolongation6 ; short QT syndrome, a form of polymorphic VT associated with an unusually short QT interval (corrected QT interval less than 330370 milliseconds)7,8 ; and bidirectional VT seen in digitalis toxicity in which the axis of alternate QRS complexes shifts by 180 degrees.9 Supportive data for the acute pharmacological treatment of polymorphic VT, with and without long corrected QT interval, is largely based on case reports and case series, because no RCTs exist. Observational studies of fibrinolytic therapy for suspected PE were found to have substantial bias and showed mixed results in terms of improvement in outcomes. It may be reasonable to perform defibrillation attempts according to the standard BLS algorithm concurrent with rewarming strategies. This topic last received formal evidence review in 2010.3. 2. 2. For patients with an arterial line in place, does targeting CPR to a particular blood pressure improve Treatment of hemodynamically stable patients with IV diltiazem or verapamil have been shown to convert SVT to normal sinus rhythm in 64% to 98% of patients. Techniques include administration of warm humidified oxygen, warm IV fluids, and intrathoracic or intraperitoneal warm-water lavage. 1. Nonvasopressor medications during cardiac arrest. Emergent coronary angiography and PCI have also been also associated with improved neurological outcomes in patients without STEMI on their post-ROSC resuscitation ECG.4,12 However, a large randomized trial found no improvement in survival in patients resuscitated from OHCA with an initial shockable rhythm in whom no ST-segment elevations or signs of shock were present.13 Multiple RCTs are underway. We recommend that laypersons initiate CPR for presumed cardiac arrest, because the risk of harm to the patient is low if the patient is not in cardiac arrest. Recommendations for the treatment of cardiac arrest due to hyperkalemia, including the use of calcium and sodium bicarbonate, are presented in Electrolyte Abnormalities. When the QRS complex of a VT is of uniform morphology, electric cardioversion with the shock synchronized to the QRS minimizes the risk of provoking VF by a mistimed shock during the vulnerable period of the cardiac cycle (T wave). Full resuscitative measures, including extracorporeal rewarming when available, are recommended for all victims of accidental hypothermia without characteristics that deem them unlikely to survive and without any obviously lethal traumatic injury. intraosseous; IV, intravenous; NSE, neuron-specific enolase; PCI, percutaneous coronary intervention; PMCD, perimortem cesarean delivery; ROSC, return of This begins with opening the airway followed by delivery of rescue breaths, ideally with the use of a bag-mask or barrier device. What do survivor-derived outcome measures of the impact of cardiac arrest survival look like, and how After cardiac arrest a combination of basic and advanced airway and ventilation techniques are used during cardiopulmonary resuscitation (CPR) and after a return of spontaneous circulation (ROSC). Step 5. It may be reasonable to charge a manual defibrillator during chest compressions either before or after a scheduled rhythm analysis. Does hospital-based protocolized discharge planning for cardiac arrest survivors improve access to/ Defibrillators (using biphasic or monophasic waveforms) are recommended to treat tachyarrhythmias requiring a shock. No pauses for ventilations - compressions are continuous at 100 to 120/min When providing rescue breaths to an adult victim, you should give 1 breath every 6 seconds What are the correct actions to take for scene safety and assessment? Should severely hypothermic patients in VF who fail an initial defibrillation attempt receive additional Before placement of an advanced airway (supraglottic airway or tracheal tube), it is reasonable for healthcare providers to perform CPR with cycles of 30 compressions and 2 breaths. VF is the presenting rhythm in 25% to 50% of cases of cardiac arrest after cardiac surgery. The Adult Cardiovascular Life Support Writing Group included a diverse group of experts with backgrounds in emergency medicine, critical care, cardiology, toxicology, neurology, EMS, education, research, and public health, along with content experts, AHA staff, and the AHA senior science editors. 2. The Adult OHCA and IHCA Chains of Survival have been updated to better highlight the evolution of systems of care and the critical role of recovery and survivorship with the addition of a new link. Although there is no high-quality evidence favoring one technique over another for establishment and maintenance of a patients airway, rescuers should be aware of the advantages and disadvantages and maintain proficiency in the skills required for each technique. 2. Discharges on EEG were divided into 2 types: rhythmic/periodic and nonrhythmic/periodic. 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)). Although there is no evidence examining the effectiveness of their use during cardiac arrest, oropharyngeal and nasopharyngeal airways can be used to maintain a patent airway and facilitate appropriate ventilation by preventing the tongue from occluding the airway. It may be reasonable to use physiological parameters such as arterial blood pressure or end-tidal CO. 1. In the absence of knowing the manufacturers recommendation for appropriate energy settings, the previous 2010 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care (and reaffirmed in 2015) recommendations for synchronized cardioversion are still applicable [Narrow regular: 50-100 J; Narrow irregular: 120-200 J biphasic or 200 J monophasic; Wide regular: 100 J; Wide irregular: defibrillation dose (not synchronized)]. It can sometimes take the form of intubation. 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. 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. The effectiveness of active compression-decompression CPR is uncertain. In addition to defibrillation, several alternative electric and pseudoelectrical therapies have been explored as possible treatment options during cardiac arrest. 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. 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. Many cardiac arrest patients who survive the initial event will eventually die because of withdrawal of life-sustaining treatment in the setting of neurological injury. Serum biomarkers are blood-based tests that measure the concentration of proteins normally found in the central nervous system (CNS). ALS indicates advanced life support; CPR, cardiopulmonary resuscitation; and EMS, emergency medical services. 2. 4. In adult cardiac arrest, it may be reasonable to perform CPR with a chest compression fraction of at least 60%. Administration of amiodarone or lidocaine to patients with OHCA was last formally reviewed in 2018. 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. 1. 4. When an arrest occurs in the hospital, a strong multidisciplinary approach includes teams of medical professionals who respond, provide CPR, promptly defibrillate, begin ALS measures, and continue post-ROSC care. Synchronized cardioversion is recommended for acute treatment in patients with hemodynamically stable SVT when vagal maneuvers and pharmacological therapy is ineffective or contraindicated. The approach to cardiac arrest when PE is suspected but not confirmed is less clear, given that a misdiagnosis could place the patient at risk for bleeding without benefit. Two RCTs enrolling more than 1000 patients did not find any increase in survival when pausing CPR to analyze rhythm after defibrillation. Care of any patient with cardiac arrest in the setting of acute exacerbation of asthma begins with standard BLS. 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. AEDs are highly accurate in their detection of shockable arrhythmias but require a pause in CPR for automated rhythm analysis. Although an advanced airway can be placed without interrupting chest compressions. Can artifact-filtering algorithms for analysis of ECG rhythms during CPR in a real-time clinical setting A 2020 ILCOR systematic review found that most studies did not find a significant association between real-time feedback and improved patient outcomes. Should there be physiological evidence of return of circulation such as an arterial waveform or abrupt rise in ETCO2 after shock, a pause of chest compressions briefly for confirmatory rhythm analysis may be warranted. Before embarking on empirical drug therapy, obtaining a 12-lead ECG and/or seeking expert consultation for diagnosis is encouraged, if available. 2. with hydroxocobalamin? Distinguishing between these rhythm etiologies is the key to proper drug selection for treatment. How does integrated team performance, as opposed to performance on individual resuscitation skills, needed to be able to compare prognostic values across studies. 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). The cause of the bradycardia may dictate the severity of the presentation. 3. Maintaining a patent airway and providing adequate ventilation and oxygenation are priorities during CPR. Therefore, the management of bradycardia will depend on both the underlying cause and severity of the clinical presentation. Acute asthma management was reviewed in detail in the 2010 Guidelines.4 For 2020, the writing group focused attention on additional ACLS considerations specific to asthma patients in the immediate periarrest period. 1. The initial phases of resuscitation once cardiac arrest is recognized are similar between lay responders and healthcare providers, with early CPR representing the priority. 1. We recommend that cardiac arrest survivors have multimodal rehabilitation assessment and treatment for physical, neurological, cardiopulmonary, and cognitive impairments before discharge from the hospital. 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. Recognition that all cardiac arrest events are not identical is critical for optimal patient outcome, and specialized management is necessary for many conditions (eg, electrolyte abnormalities, pregnancy, after cardiac surgery). One study of patients with laryngectomies showed that a pediatric face mask created a better peristomal seal than a standard ventilation mask. Atrial flutter is an SVT with a macroreentrant circuit resulting in rapid atrial activation but intermittent ventricular response. 2. A large observational cohort study investigating these and other novel serum biomarkers and their performance as prognostic biomarkers would be of high clinical significance. The duration and severity of hypoxia sustained as a result of drowning is the single most important determinant of outcome. After identifying a cardiac arrest, a lone responder should activate the emergency response system first and immediately begin CPR. Evidence suggests that patients who are comatose after ROSC benefit from invasive angiography, when indicated, as do patients who are awake. Recommendations 1, 3, and 5 last received formal evidence review in 2015.10Recommendation 2 last received formal evidence review in 2015,10 with an evidence update completed in 2020.11 Recommendation 4 last received formal evidence review in 2010.12. Additional investigations are necessary to evaluate cost-effectiveness, resource allocation, and ethics surrounding the routine use of ECPR in resuscitation. Evidence in humans of the effect of vasopressors or other medications during cardiac arrest in the setting of hypothermia consists of case reports only. What is the optimal approach, vasopressor or transcutaneous pacing, in managing symptomatic 3. Observational studies on TTM for IHCA with any initial rhythm have reported mixed results. Mechanical CPR devices deliver automated chest compressions, thereby eliminating the need for manual chest compressions. Does avoidance of hyperoxia in the postarrest period lead to improved outcomes? Based on their greater success in arrhythmia termination, defibrillators using biphasic waveforms are preferred over monophasic defibrillators for treatment of tachyarrhythmias. There is insufficient evidence to recommend the routine use of extracorporeal CPR (ECPR) for patients with cardiac arrest. and 2. As more and more centers and EMS systems are using feedback devices and collecting data on CPR measures such as compression depth and chest compression fraction, these data will enable ongoing updates to these recommendations. CPR involves performing chest compressions and, in some cases, rescue ("mouth-to-mouth") breathing. Administration of epinephrine with concurrent high-quality CPR improves survival, particularly in patients with nonshockable rhythms. A single shock strategy is reasonable in preference to stacked shocks for defibrillation in the setting of unmonitored cardiac arrest. CPR duty cycle refers to the proportion of time spent in compression relative to the total time of the compression plus decompression cycle. 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. Instead, the compressing rescuer should give continuous chest compressions at a rate of 100 per minute without pauses for ventilation. 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. The electric energy required to successfully cardiovert a patient from atrial fibrillation or atrial flutter to sinus rhythm varies and is generally less in patients with new-onset arrhythmia, thin body habitus, and when biphasic waveform shocks are delivered. . Unauthorized use prohibited. A victim may also appear clinically dead because of the effects of very low body temperature. IV Medications Commonly Used for Acute Rate Control in Atrial Fibrillation and Atrial Flutter, CPR & First Aid in Youth Sports Training Kit, Resuscitation Quality Improvement Program (RQI), Coronavirus Resources for CPR & Resuscitation, Advanced Cardiovascular Life Support (ACLS), Resuscitation Quality Improvement Program (RQI), COVID-19 Resources for CPR & Resuscitation, Claiming Your AHA Continuing Education Credits, International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations, extracorporeal cardiopulmonary resuscitation, (partial pressure of) end-tidal carbon dioxide, International Liaison Committee on Resuscitation, arterial partial pressure of carbon dioxide, ST-segment elevation myocardial infarction. In contrast, a patient who develops third-degree heart block but is otherwise well compensated might experience relatively low blood pressure but otherwise be stable. Each of these resulted in a description of the literature that facilitated guideline development. Adenosine is an ultrashort-acting drug that is effective in terminating regular tachycardias when caused by AV reentry. 3. Monitors (ECG, BP cuff, pulse oximeter, et CO2 monitor) Identify: heart rhythm Obtain a 12 lead ECG if possible. These effects can also precipitate acute coronary syndrome and stroke. 1. It is important for EMS providers to be able to differentiate patients in whom continued resuscitation is futile from patients with a chance of survival who should receive continued resuscitation and transportation to hospital. 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). The American Heart Association is a qualified 501(c)(3) tax-exempt organization. Pharmacological and mechanical therapies to rapidly reverse pulmonary artery occlusion and restore adequate pulmonary and systemic circulation have emerged as primary therapies for massive PE, including fulminant PE.2,6 Current advanced treatment options include systemic thrombolysis, surgical or percutaneous mechanical embolectomy, and ECPR. No controlled studies examine the effect of IV calcium for calcium channel blocker toxicity. Thus, the confidence in the prognostication of the diagnostic tests studied is also low. Using a validated TOR rule will help ensure accuracy in determining futile patients (Figures 5 and 6). 2b. In patients with confirmed pulmonary embolism as the precipitant of cardiac arrest, thrombolysis, surgical embolectomy, and mechanical embolectomy are reasonable emergency treatment options. return of spontaneous circulation. These recommendations are supported by the 2019 AHA Focused Update on Advanced Cardiovascular Life Support: Use of Advanced Airways, Vasopressors, and Extracorporeal CPR During Cardiac Arrest: An Update to the AHA Guidelines for CPR and Emergency Cardiovascular Care.12. The key drivers of successful resuscitation from OHCA are lay rescuer cardiopulmonary resuscitation (CPR) and public use of an automated external defibrillator (AED). 1. 3. arrest with shockable rhythm? Although contradictory evidence exists, it may be reasonable to avoid the use of pure -adrenergic blocker medications in the setting of cocaine toxicity. Hyperlinked references are provided to facilitate quick access and review. 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. Breath stacking in an asthma patient with limited ability to exhale can lead to increases in intrathoracic pressure, decreases in venous return and coronary perfusion pressure, and cardiac arrest. High-quality CPR is, along with defibrillation for those with shockable rhythms, the most important lifesaving intervention for a patient in cardiac arrest. 2. Amiodarone or lidocaine may be considered for VF/pVT that is unresponsive to defibrillation. What are the optimal pharmacological treatment regimens for the management of postarrest seizures? During manual CPR, rescuers should perform chest compressions to a depth of at least 2 inches, or 5 cm, for an average adult while avoiding excessive chest compression depths (greater than 2.4 inches, or 6 cm). One RCT including 355 patients found no difference in outcome between TTM for 24 and 48 hours. 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. For a victim with a tracheal stoma who requires rescue breathing, either mouth-to-stoma or face mask (pediatric preferred) tostoma ventilation may be reasonable. 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. This recommendation is based on the fact that nonconvulsive seizures are common in postarrest patients and that the presence of seizures may be important prognostically, although whether treatment of nonconvulsive seizures affects outcome in this setting remains uncertain. A recent meta-analysis of 13 RCTs (990 evaluable patients) found that adverse events and serious adverse events were more common in patients who were randomized to receive flumazenil than placebo (number needed to harm: 5.5 for all adverse events and 50 for serious adverse events). What is the most efficacious management approach for postarrest cardiogenic shock, including 4. Look for no breathing or only gasping, at the direction of the telecommunicator. providers are skilled and can implement it quickly. 2. 1. 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. The routine use of cricoid pressure in adult cardiac arrest is not recommended. 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). In addition, it may be helpful for providers to master an advanced airway strategy as well as a second (backup) strategy for use if they are unable to establish the first-choice airway adjunct. In some observational studies, improved outcomes have been noted in victims of cardiac arrest who received conventional CPR (compressions and ventilation) compared with those who received chest compressions only. *Red Dress DHHS, Go Red AHA ; National Wear Red Day is a registered trademark. 2. These include the high success rate of the first shock with biphasic waveforms (lessening the need for successive shocks), the declining success of immediate second and third serial shocks when the first shock has failed. 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. 2, and 3. Routine administration of calcium for treatment of cardiac arrest is not recommended. No adult human studies directly compare levels of inspired oxygen concentration during CPR. Immediate defibrillation is reasonable for provider-witnessed or monitored VF/pVT of short duration when a defibrillator is already applied or immediately available. 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. 3. 4. There is no evidence that cricoid pressure facilitates ventilation or reduces the risk of aspiration in cardiac arrest patients. IV infusion of epinephrine is a reasonable alternative to IV boluses for treatment of anaphylaxis in patients not in cardiac arrest. Electroencephalography is widely used in clinical practice to evaluate cortical brain activity and diagnose seizures. Continuous compressions at a rate of 100-120/min Give 1 breath every 6 seconds (10 breaths/min) CPR Compression Rate. A 2020 ILCOR systematic review found 2 RCTs and a small number of observational studies evaluating the effect of prophylactic antibiotics on outcomes in postarrest patients. Severe exacerbations of asthma can lead to profound respiratory distress, retention of carbon dioxide, and air trapping, resulting in acute respiratory acidosis and high intrathoracic pressure. Before appointment, all peer reviewers were required to disclose relationships with industry and any other conflicts of interest, and all disclosures were reviewed by AHA staff. 1. IV diltiazem or verapamil can be effective for acute treatment in patients with hemodynamically stable SVT at a regular rate. This approach recognizes that most sudden cardiac arrest in adults is of cardiac cause, particularly myocardial infarction and electric disturbances. The optimal combination of airway techniques, oxygenation and ventilation is uncertain. 1. 7. The immediate cause of death in drowning is hypoxemia. It may be reasonable to consider administration of epinephrine during cardiac arrest according to the standard ACLS algorithm concurrent with rewarming strategies. It is reasonable for providers to first attempt establishing intravenous access for drug administration in cardiac arrest. 2. CPR prolongs the time VF is present and increases the likelihood that a shock will terminate VF (defibrillate the heart) and allow the heart to resume an effective rhythm and effective systemic perfusion.
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