Although abbreviated observation periods may be adequate for patients with fentanyl, morphine, or heroin overdose. Limited data are available from defibrillator threshold testing with backup transthoracic defibrillation, using variable waveforms and energy doses. Despite steady improvement in the rate of survival from IHCA, much opportunity remains. 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. 1. In patients with anaphylactic shock, close hemodynamic monitoring is recommended. The routine use of the impedance threshold device as an adjunct during conventional CPR is not recommended. 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. We recommend structured assessment for anxiety, depression, posttraumatic stress, and fatigue for cardiac arrest survivors and their caregivers. In addition to standard ACLS, several therapies have long been recommended to treat life-threatening hyperkalemia. These topics were identified as not only areas where no information was identified but also where the results of ongoing research could impact the recommendation directly. 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. For many patients and families, these plans and resources may be paramount to improved quality of life after cardiac arrest. In patients who remain comatose after cardiac arrest, we recommend that neuroprognostication involve a multimodal approach and not be based on any single finding. Multiple case series have demonstrated potential benefit from mechanical circulatory support including ECMO and cardiopulmonary bypass in patients who are refractory to standard resuscitation procedures. Based on their greater success in arrhythmia termination, defibrillators using biphasic waveforms are preferred over monophasic defibrillators for treatment of tachyarrhythmias. 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. The key drivers of successful resuscitation from OHCA are lay rescuer cardiopulmonary resuscitation (CPR) and public use of an automated external defibrillator (AED). 2. Do steroids improve shock or other outcomes in patients who remain hypotensive after ROSC? The 2015 Guidelines Update recommended emergent coronary angiography for patients with ST-segment elevation on the post-ROSC ECG. 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. 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). 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. If pharmacological therapy is unsuccessful for the treatment of a hemodynamically stable wide-complex tachycardia, cardioversion or seeking urgent expert consultation is reasonable. IV epinephrine is an appropriate alternative to intramuscular administration in anaphylactic shock when an IV is in place. Applying Class of Recommendation and Level of Evidence to Clinical Strategies, Interventions, Treatments, or Diagnostic Testing in Patient Care (Updated May 2019)*, Table 3. 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. Long-term anticoagulation may be necessary for patients at risk for thromboembolic events based on their CHA2 DS2 - VASc score. 5. The systems-of-care approach to cardiac arrest includes the community and healthcare response to cardiac arrest. Based on the protocols used in clinical trials, it is reasonable to administer epinephrine 1 mg every 3 to 5 min for cardiac arrest. It is reasonable for healthcare providers to perform chest compressions and ventilation for all adult patients in cardiac arrest from either a cardiac or noncardiac cause. 1. We recommend avoiding hypoxemia in all patients who remain comatose after ROSC. CT and MRI findings of brain injury evolve over the first several days after arrest, so the timing of the imaging study of interest is of particular importance as it relates to prognosis. Answer the dispatchers questions, and follow the telecommunicators instructions. The precordial thump should not be used routinely for established cardiac arrest. Since initial efforts for maternal resuscitation may not be successful, preparation for PMCD should begin early in the resuscitation, since decreased time to PMCD is associated with better maternal and fetal outcomes. 2. 1. Like all patients with cardiac arrest, the immediate goal is restoration of perfusion with CPR, initiation of ACLS, and rapid identification and correction of the cause of cardiac arrest. It is likely that a time threshold exists beyond which the absence of ventilation may be harmful, and the generalizability of the findings to all settings must be considered with caution.1, Once an advanced airway has been placed, delivering continuous chest compressions increases the compression fraction but makes it more difficult to deliver adequate ventilation. Refer to the device manufacturers recommended energy for a particular waveform. In the presence of known or suspected basal skull fracture or severe coagulopathy, an oral airway is preferred compared with a nasopharyngeal airway. Benzodiazepine overdose causes CNS and respiratory depression and, particularly when taken with other sedatives (eg, opioids), can cause respiratory arrest and cardiac arrest. Due to the potential effects of intrinsic positive end-expiratory pressure (auto-PEEP) and risk of barotrauma in an asthmatic patient with cardiac arrest, a ventilation strategy of low respiratory rate and tidal volume is reasonable. medications? 1. When the victim is hypothermic, pulse and respiratory rates may be slow or difficult to detect. Recommendation-specific text clarifies the rationale and key study data supporting the recommendations. A brief introduction or short synopsis is provided to put the recommendations into context with important background information and overarching management or treatment concepts. Conversely, a regular wide-complex tachycardia could represent monomorphic VT or an aberrantly conducted reentrant paroxysmal SVT, ectopic atrial tachycardia, or atrial flutter. Taking a regular rather than a deep breath prevents the rescuer from getting dizzy or lightheaded and prevents overinflation of the victims lungs. What is the optimal treatment for hyperkalemia with life-threatening arrhythmia or cardiac arrest? 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. management? What is optimal for the CPR duty cycle (the proportion of time spent in compression relative to the CT indicates computed tomography; ROSC, return of spontaneous circulation; and STEMI, ST-segment elevation myocardial infarction. Clinical Practice Guidelines for the Treatment and Prevention of Drowning: 2019 Update.20. response. One expected challenge faced through this process was the lack of data in many areas of cardiac arrest research. 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. 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. 2. It may be reasonable to perform chest compressions so that chest compression and recoil/relaxation times are approximately equal. Care of any patient with cardiac arrest in the setting of acute exacerbation of asthma begins with standard BLS. cardiac arrest with shockable rhythm? 1. A wide-complex tachycardia is defined as a rapid rhythm (generally 150 beats/min or more when attributable to an arrhythmia) with a QRS duration of 0.12 seconds or more. Bradycardia is generally defined as a heart rate less than 60/min. Patients with accidental hypothermia often present with marked CNS and cardiovascular depression and the appearance of death or near death, necessitating the need for prompt full resuscitative measures unless there are signs of obvious death. What is the minimum safe observation period after reversal of respiratory depression from opioid 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. The Level of Evidence (LOE) is based on the quality, quantity, relevance, and consistency of the available evidence. thrombolysis during resuscitation? Distinguishing between these rhythm etiologies is the key to proper drug selection for treatment. In a canine model of anaphylactic shock, a continuous infusion of epinephrine was more effective at treating hypotension than no treatment or bolus epinephrine treatment were. This device provides adequate ventilation comparable to an ET tube. Precharging the defibrillator during ongoing chest compressions shortens the hands-off chest time surrounding defibrillation, without evidence of harm. The immediate cause of death in drowning is hypoxemia. Accurate neurological prognostication in brain-injured cardiac arrest survivors is critically important to ensure that patients with significant potential for recovery are not destined for certain poor outcomes due to care withdrawal. We recommend that cardiac arrest survivors and their caregivers receive comprehensive, multidisciplinary discharge planning, to include medical and rehabilitative treatment recommendations and return to activity/work expectations. Poisoning from other cardiac glycosides, such as oleander, foxglove, and digitoxin, have similar effects. 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. Thirty-seven recommendations are supported by Level B-Randomized Evidence (moderate evidence from 1 or more RCTs) and 57 by Level B-Nonrandomized evidence. 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. 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. 2. The evidence for these recommendations was last reviewed thoroughly in 2010. When the second rescuer arrives, provide 2-rescuer CPR and use the AED/defibrillator. 4. Severe anaphylaxis may cause complete obstruction of the airway and/or cardiovascular collapse from vasogenic shock. 2. 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. 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. 2. 4. A 2006 systematic review involving 7 studies of transcutaneous pacing for symptomatic bradycardia and bradyasystolic cardiac arrest in the prehospital setting did not find a benefit from pacing compared with standard ACLS, although a subgroup analysis from 1 trial suggested a possible benefit in patients with symptomatic bradycardia. Hypotension may worsen brain and other organ injury after cardiac arrest by decreasing oxygen delivery to tissues. Survival and recovery from adult cardiac arrest depend on a complex system working together to secure the best outcome for the victim. These guidelines are not meant to be comprehensive. ALS indicates advanced life support; CPR, cardiopulmonary resuscitation; and EMS, emergency medical services. 1-800-AHA-USA-1 Circulation Obtain IV or IO access. These recommendations are supported by the 2020 CoSTR for BLS.1. 1. CPR should be initiated if pacing is not successful within 1 min. IO access has grown in popularity given the relative ease and speed with which it can be achieved, a higher successful placement rate compared with IV cannulation, and the relatively low procedural risk. 4. This topic last received formal evidence review in 2015,8 with an evidence update conducted for the 2020 CoSTR for ALS.2. What is the best approach to rewarming postarrest patients after treatment with targeted temperature The gravid uterus can compress the inferior vena cava, impeding venous return, thereby reducing stroke volume and cardiac output. 4. Intra-arterial pressure - If relaxation . 1. 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)). 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. 1. 4. Two studies that included patients enrolled in the AHA Get With The GuidelinesResuscitation registry reported either no benefit or worse outcome from TTM. In patients with -adrenergic blocker overdose who are in refractory shock, administration of high-dose insulin with glucose is reasonable. Deaths from acute asthma have decreased in the United States, but asthma continues to be the acute cause of death for over 3500 adults per year.1,2 Patients with respiratory arrest from asthma develop life-threatening acute respiratory acidosis.3 Both the profound acidemia and the decreased venous return to the heart from elevated intrathoracic pressure are likely causes of cardiac arrest in asthma. This makes it difficult to plan the next step of care and can potentially delay or even misdirect drug therapies if given empirically (blindly) based on the patients presumed, but not actual, underlying rhythm. Atrial fibrillation is an SVT consisting of disorganized atrial electric activation and uncoordinated atrial contraction. 1. 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. If increased auto-PEEP or sudden decrease in blood pressure is noted in asthmatics receiving assisted ventilation in a periarrest state, a brief disconnection from the bag mask or ventilator with compression of the chest wall to relieve air-trapping can be effective. Few patients who develop cardiac arrest from carbon monoxide poisoning survive to hospital discharge, regardless of the treatment administered after ROSC, though rare good outcomes have been described. For patients with severe hypothermia (less than 30C [86F]) with a perfusing rhythm, core rewarming is often used. Agonal breathing is characterized by slow, irregular gasping respirations that are ineffective for ventilation. maintain proficiency? Several studies demonstrate that patients with known or suspected cyanide toxicity presenting with cardiovascular instability or cardiac arrest who undergo prompt treatment with IV hydroxocobalamin, a cyanide scavenger. What is the optimal duration for targeted temperature management before rewarming? 2. Open-chest CPR can be useful if cardiac arrest develops during surgery when the chest or abdomen is already open, or in the early postoperative period after cardiothoracic surgery. 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. 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. 1. In 2013, a trial of over 900 patients compared TTM at 33C to 36C for patients with OHCA and any initial rhythm, excluding unwitnessed asystole, and found that 33C was not superior to 36C. 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). Magnesium may be considered for treatment of polymorphic VT associated with a long QT interval (torsades de pointes). Furthermore, the resource intensity required to begin and maintain an ECPR program should be considered in the context of strengthening other links in the Chain of Survival. pharmacological, catheter intervention, or implantable device? IV infusion of epinephrine may be considered for post-arrest shock in patients with anaphylaxis. All lay rescuers should, at minimum, provide chest compressions for victims of cardiac arrest. do they differ from current generic or clinician-derived measures? Recovery and survivorship after cardiac arrest. These recommendations are supported by the 2019 focused update on ACLS guidelines.1. In intubated patients, failure to achieve an end-tidal CO. 5. insulin) for refractory shock due to -adrenergic blocker or calcium channel blocker overdose? Although an advanced airway can be placed without interrupting chest compressions. 3. What is the ideal timing of PMCD for a pregnant woman in cardiac arrest? Lay and trained responders should not delay activating emergency response systems while awaiting the patients response to naloxone or other interventions. Give rescue breaths. Verapamil should not be administered for any wide-complex tachycardia unless known to be of supraventricular origin and not being conducted by an accessory pathway. 3. The optimal timing of CPR initiation and emergency response system activation was evaluated by an ILCOR systematic review in 2020. A number of key components have been defined for high-quality CPR, including minimizing interruptions in chest compressions, providing compressions of adequate rate and depth, avoiding leaning on the chest between compressions, and avoiding excessive ventilation.1 However, controlled studies are relatively lacking, and observational evidence is at times conflicting. Because pregnant patients are more prone to hypoxia, oxygenation and airway management should be prioritized during resuscitation from cardiac arrest in pregnancy. Monday - Friday: 7 a.m. 7 p.m. CT While amiodarone is typically considered a rhythm-control agent, it can effectively reduce ventricular rate with potential use in patients with congestive heart failure where -adrenergic blockers may not be tolerated and nondihydropyridine calcium channel antagonists are contraindicated. Routine stabilization of the cervical spine in the absence of circumstances that suggest a spinal injury is not recommended. How long after mild drowning events should patients be observed for late-onset respiratory effects? This approach recognizes that most sudden cardiac arrest in adults is of cardiac cause, particularly myocardial infarction and electric disturbances. Should severely hypothermic patients in VF who fail an initial defibrillation attempt receive additional In creating these recommendations, the writing group considered the difficulty in accurately differentiating opioid-associated resuscitative emergencies from other causes of cardiac and respiratory arrest. What is the optimal approach to advanced airway management for IHCA? In a small clinical trial and several observational studies, waveform capnography was 100% specific for confirming endotracheal tube position during cardiac arrest. 5. Cardiac arrest occurs after 1% to 8% of cardiac surgery cases.18 Etiologies include tachyarrhythmias such as VT or VF, bradyarrhythmias such as heart block or asystole, obstructive causes such as tamponade or pneumothorax, technical factors such as dysfunction of a new valve, occlusion of a grafted artery, or bleeding. Recommendations 1, 2, 3, and 5 are supported by the 2020 CoSTRs for BLS and ALS.13,14 Recommendations 4 and 6 last received formal evidence review in 2015.15. 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. 1. The main focus in adult cardiac arrest events includes rapid recognition, prompt provision of CPR, defibrillation of malignant shockable rhythms, and post-ROSC supportive care and treatment of underlying causes. It is feasible only at the onset of a hemodynamically significant arrhythmia in a cooperative, conscious patient who has ideally been previously instructed on its performance, and as a bridge to definitive care. Patients should be monitored constantly to verify airway patency and adequate ventilation and oxygenation. Available hemodynamic monitoring modalities in conjunction with manual pulse detection provide an opportunity to confirm myocardial capture and adequate cardiac function. This topic last underwent formal evidence review in 2010.7, These recommendations are supported by the 2020 CoSTR for BLS.21, This recommendation is supported by the 2020 CoSTR for BLS.21. Community reintegration and return to work or other activities may be slow and depend on social support and relationships. Resuscitation causes, processes, and outcomes are very different for OHCA and IHCA, which are reflected in their respective Chains of Survival (Figure 1). It may be reasonable to use a defibrillator in manual mode as compared with automatic mode depending on the skill set of the operator. 2. CPR Quality Push hard (at least 2 inches [5 cm]) and fast (100-120/min) and allow complete chest recoil. 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. Because of potential interference with maternal resuscitation, fetal monitoring should not be undertaken during cardiac arrest in pregnancy. In patients with calcium channel blocker overdose who are in refractory shock, administration of high-dose insulin with glucose is reasonable. 2. 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. A randomized trial investigating this question is ongoing (NCT02056236). Lifesaving procedures, including standard BLS and ACLS, are therefore important to continue until a patient is rewarmed unless the victim is obviously dead (eg, rigor mortis or nonsurvivable traumatic injury). For patients known or suspected to be in cardiac arrest, in the absence of a proven benefit from the use of naloxone, standard resuscitative measures should take priority over naloxone administration, with a focus on high-quality CPR (compressions plus ventilation). The previous literature was limited by methodological concerns, including around inadequate control for effects of TTM and medications and self-fulfilling prophecies, and there was a lower-than-acceptable false-positive rate (10% to 15%). The drugs hypotensive and tissue refractorinessshortening effects can accelerate ventricular rates in polymorphic VT and, when atrial fibrillation or flutter are conducted by an accessory pathway, risk degeneration to VF. These arrhythmias are common and often coexist, and their treatment recommendations are similar. In patients with -adrenergic blocker overdose who are in shock refractory to pharmacological therapy, ECMO might be considered. Shout for nearby help/activate the resuscitation team; the provider can activate the resuscitation team at this time or after checking for breathing and pulse. Once ROSC is achieved, urgent consultation with a medical toxicologist or regional poison center is suggested. A large observational cohort study investigating these and other novel serum biomarkers and their performance as prognostic biomarkers would be of high clinical significance. Endotracheal drug administration may be considered when other access routes are not available. Conversely, the -adrenergic effects may increase myocardial oxygen demand, reduce subendocardial perfusion, and may be proarrhythmic. and 2. 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.) 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. One study found no difference in survival with good neurological outcome at 3 months in patients monitored with routine (one to two 20-minute EEGs over 24 hours) versus continuous (for 1824 hours) EEG.