1. Notably, in a clinical study in adults with outof- hospital VF arrest (of whom 43% survived to hospital discharge), the mean duty cycle observed during resuscitation was 39%. 4. Alternatives to IV access for acute drug administration include IO, central venous, intracardiac, and endotracheal routes. 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. A 2017 systematic review identified 1 observational human study and 10 animal studies comparing different ventilation rates after advanced airway placement. When performed with other prognostic tests, it may be reasonable to consider quantitative pupillometry at 72 h or more after cardiac arrest to support the prognosis of poor neurological outcome in patients who remain comatose. and 2. cardiac arrest with shockable rhythm? When appropriate, flow diagrams or additional tables are included. AED indicates automated external defibrillator; and BLS, basic life support. 3. 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). 1. This will aid in both resource utilization and optimizing a patients chance for survival. 4. The usefulness of S100 calcium-binding protein (S100B), Tau, neurofilament light chain, and glial fibrillary acidic protein in neuroprognostication is uncertain. If you're trained in CPR and you've performed 30 chest compressions, open the person's airway using the head-tilt, chin-lift maneuver. 4. This is clearly covered topic if you attend a BLS Provider class. The combination of active compression-decompression CPR and impedance threshold device may be reasonable in settings with available equipment and properly trained personnel. No large RCT evaluating different treatment strategies for patients suffering from acute cocaine toxicity exists. What is the ideal sequencing of modalities (traditional vasopressors, calcium, glucagon, high-dose 2. Because there are no studies demonstrating improvement in patient outcomes from administration of naloxone during cardiac arrest, provision of CPR should be the focus of initial care. These guidelines are based on the extensive evidence evaluation performed in conjunction with the ILCOR and affiliated ILCOR member councils. 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). Immediate defibrillation is recommended for sustained, hemodynamically unstable polymorphic VT. 1. 1. If an experienced sonographer is present and use of ultrasound does not interfere with the standard cardiac arrest treatment protocol, then ultrasound may be considered as an adjunct to standard patient evaluation, although its usefulness has not been well established. Urgent support of airway, breathing, and circulation is essential in suspected anaphylactic reactions. 3. 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. 7272 Greenville Ave. Vasopressor medications during cardiac arrest. A 2020 ILCOR systematic review found that most studies did not find a significant association between real-time feedback and improved patient outcomes. For a child, open the airway to a slightly past-neutral position using the head-tilt/chin-lift technique; For a baby, open the airway to a neutral position using the head-tilt/chin-lift technique; Blow into the child or baby's mouth for about 1 second Ensure each breath makes the chest rise; Allow the air to exit before giving the next breath 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. Lay rescuerCPR improves survival from cardiac arrest by 2- to 3-fold.1 The benefit of providing CPR to a patient in cardiac arrest outweighs any potential risk of providing chest compressions to someone who is unconscious but not in cardiac arrest. They may be used in patients with heart failure with preserved ejection fraction. Healthcare providers should consider the possibility of a spinal injury before opening the airway. Evidence suggests that patients who are comatose after ROSC benefit from invasive angiography, when indicated, as do patients who are awake. For patients in respiratory arrest, rescue breathing or bag-mask ventilation should be maintained until spontaneous breathing returns, and standard BLS and/or ACLS measures should continue if return of spontaneous breathing does not occur. Standard BLS and ACLS are the cornerstones of treatment, with airway management and ventilation being of particular importance because of the respiratory cause of arrest. Early defibrillation improves outcome from cardiac arrest. In nonintubated patients, a specific end-tidal CO. 1. No adult human studies directly compare levels of inspired oxygen concentration during CPR. This work has been largely observational. The existing trials have used a protocol of 1 mg every 3 to 5 minutes. Other testing of serum biomarkers, including testing levels over serial time points after arrest, was not evaluated. 2. It may be reasonable to perform defibrillation attempts according to the standard BLS algorithm concurrent with rewarming strategies. Findings in both animal studies and human case reports/case series on the effect of glucagon in calcium channel blocker toxicity have been inconsistent, with some reporting increase in heart rate and some reporting no effect. Clinical examination findings correlate with poor outcome but are also subject to confounding by TTM and medications, and prior studies have methodological limitations. The routine use of prophylactic antibiotics in postarrest patients is of uncertain benefit. It is reasonable that TTM be maintained for at least 24 h after achieving target temperature. Sedatives and neuromuscular blockers may be metabolized more slowly in postcardiac arrest patients, and injured brains may be more sensitive to the depressant effects of various medications. 7. There are differing approaches to charging a manual defibrillator during resuscitation. This lesson focuses on the team approach to CPR when three or more responders or healthcare professionals are involved. 1. defibrillation? 3. CPR involves performing chest compressions and, in some cases, rescue ("mouth-to-mouth") breathing. The routine use of cricoid pressure in adult cardiac arrest is not recommended. National Center Along with CPR, early defibrillation is critical to survival when sudden cardiac arrest is caused by VF or pulseless VT (pVT).1,2 Defibrillation is most successful when administered as soon as possible after onset of VF/VT and a reasonable immediate treatment when the interval from onset to shock is very brief. 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. Does hospital-based protocolized discharge planning for cardiac arrest survivors improve access to/ Do double sequential defibrillation and/or alternative defibrillator pad positioning affect outcome in The majority of recommendations are based on Level C evidence, including those based on limited data (123 recommendations) and expert opinion (31 recommendations). or sooner if fatigued. 3. 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%). 1. There are some physiological basis and preclinical data for hyperoxemia leading to increased inflammation and exacerbating brain injury in postarrest patients. 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. ACLS Advanced Airway Adjuncts Guide - SaveaLife.com 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. Human experimental data suggest that benzodiazepines (diazepam, lorazepam), alpha blockers (phentolamine), calcium channel blockers (verapamil), morphine, and nitroglycerine are all safe and potentially beneficial in the cocaine-intoxicated patient; no data are available comparing these approaches.15 Contradictory data surround the use of -adrenergic blockers.68 Patients suffering from cocaine toxicity can deteriorate quickly depending on the amount and timing of ingestion. Cocaine toxicity can cause adverse effects on the cardiovascular system, including dysrhythmia, hypertension, tachycardia and coronary artery vasospasm, and cardiac conduction delays. 2. 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. Three studies evaluated quantitative pupillary light reflex. 1. Recovery and survivorship after cardiac arrest. 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). 2. The routine use of the impedance threshold device as an adjunct during conventional CPR is not recommended. The ResQTrial demonstrated that ACD plus ITD was associated with improved survival to hospital discharge with favorable neurological function for OHCA compared with standard CPR, though this study was limited by a lack of blinding, different CPR feedback elements between the study arms (ie, cointervention), lack of CPR quality assessment, and early TOR. When performed in combination with other prognostic tests, it may be reasonable to consider high serum values of neuron-specific enolase (NSE) within 72 h after cardiac arrest to support the prognosis of poor neurological outcome in patients who remain comatose. 4. Both mouth-to-mouth rescue breathing and bagmask ventilation provide oxygen and ventilation to the victim. These techniques can keep blood flowing to the brain and other organs until medical help arrives. We recommend that the absence of EEG reactivity within 72 h after arrest not be used alone to support a poor neurological prognosis. In what situations is attempted resuscitation of the drowning victim futile? 4. As part of the overall work for development of these guidelines, the writing group was able to review a large amount of literature concerning the management of adult cardiac arrest. ECPR is a complex intervention that requires a highly trained team, specialized equipment, and multidisciplinary support within a healthcare system. If termination of resuscitation (TOR) is being considered, BLS EMS providers should use the BLS termination of resuscitation rule where ALS is not available or may be significantly delayed. Observational studies on TTM for IHCA with any initial rhythm have reported mixed results. To assure successful maternal resuscitation, all potential stakeholders need to be engaged in the planning and training for cardiac arrest in pregnancy, including the possible need for PMCD. Epinephrine is the cornerstone of treatment for anaphylaxis.35, This topic last received formal evidence review in 2010.14. 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. Part 7.1: Adjuncts for Airway Control and Ventilation Cyanide reversibly binds to the ferric ion cytochrome oxidase in the mitochondria and stops cellular respiration and adenosine triphosphate production. Delivery of chest compressions without assisted ventilation for prolonged periods could be less effective than conventional CPR (compressions plus ventilation) because arterial oxygen content decreases as CPR duration increases. Follow the telecommunicators instructions. We do not recommend routine use of magnesium for the treatment of polymorphic VT with a normal QT interval. In cardiac arrest secondary to anaphylaxis, standard resuscitative measures and immediate administration of epinephrine should take priority. management? All victims of drowning who require any form of resuscitation (including rescue breathing alone) should be transported to the hospital for evaluation and monitoring, even if they appear to be alert and demonstrate effective cardiorespiratory function at the scene. Synchronized cardioversion or drugs or both may be used to control unstable or symptomatic regular narrow-complex tachycardia. Flumazenil, a specific benzodiazepine antagonist, restores consciousness, protective airway reflexes, and respiratory drive but can have significant side effects including seizures and arrhythmia.1 These risks are increased in patients with benzodiazepine dependence and with coingestion of cyclic antidepressant medications. Fifteen observational studies were identified for OHCA that varied in inclusion criteria, ECPR settings, and study design, with the majority of studies reporting improved neurological outcome associated with ECPR. Compressor- assesses the patient and provides compressions, Monitor/ Defibrillator- Operates the AED sand alternates with the compressor after every 5 cycles or 2 minutes to avoid fatigue, Airway- provides ventilation You and your team have initiated compressions and ventilation. Resuscitation from cardiac arrest caused by -adrenergic blocker or calcium channel blocker overdose follows standard resuscitation guidelines. Patients should be monitored constantly to verify airway patency and adequate ventilation and oxygenation. This topic last received formal evidence review in 2010.10, Local anesthetic overdose (also known as local anesthetic systemic toxicity, or LAST) is a life-threatening emergency that can present with neurotoxicity or fulminant cardiovascular collapse.1,2 The most commonly reported agents associated with LAST are bupivacaine, lidocaine, and ropivacaine.2, By definition, LAST is a special circumstance in which alternative approaches should be considered in addition to standard BLS and ALS. CPR Flashcards | Quizlet Along with providing standard BLS and ALS treatment, next steps include preventing additional evaporative heat loss by removing wet garments and insulating the victim from further environmental exposures. In some instances, prognostication and withdrawal of life support may appropriately occur earlier because of nonneurologic disease, brain herniation, patients goals and wishes, or clearly nonsurvivable situations. 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. What are the optimal pharmacological treatment regimens for the management of postarrest seizures? 4. 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. 3. 1. The primary focus of cardiac arrest management for providers is the optimization of all critical steps required to improve outcomes. 2020;142(suppl 2):S366S468. In patients with calcium channel blocker overdose who are in refractory shock, administration of calcium is reasonable. The precordial thump may be considered at the onset of a rescuer-witnessed, monitored, unstable ventricular tachyarrhythmia when a defibrillator is not immediately ready for use and is performed without delaying CPR or shock delivery. The choice of anticoagulation is beyond the scope of these guidelines. 1. Recommendations 1, 2, and 6 last received formal evidence review in 2015.21 Recommendations 3, 4, and 5 are supported by the 2020 CoSTR for BLS.22, This recommendation is supported by a 2020 ILCOR scoping review, which found no new information to update the 2010 recommendations.22,31, This recommendation is supported by a 2020 ILCOR scoping review,22 which found no new information to update the 2010 recommendations.31, Recommendations 1 and 2 are supported by the 2020 CoSTR for BLS.22 Recommendation 3 last received formal evidence review in 2010.46, This recommendation is supported by the 2020 CoSTR for ALS.51. In patients with confirmed pulmonary embolism as the precipitant of cardiac arrest, thrombolysis, surgical embolectomy, and mechanical embolectomy are reasonable emergency treatment options. Approximately 1.2% of adults admitted to US hospitals suffer in-hospital cardiac arrest (IHCA).1 Of these patients, 25.8% were discharged from the hospital alive, and 82% of survivors have good functional status at the time of discharge. Which populations are most likely to benefit from ECPR? 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. 2023 American Heart Association, Inc. All rights reserved. High-quality CPR 4. Applying Class of Recommendation and Level of Evidence to Clinical Strategies, Interventions, Treatments, or Diagnostic Testing in Patient Care (Updated May 2019)*, Table 3. This topic last received formal evidence review in 2010.4. When the victim is hypothermic, pulse and respiratory rates may be slow or difficult to detect. Do antiarrhythmic drugs, when given in combination for cardiac arrest, improve outcomes from cardiac It may be reasonable to consider administration of epinephrine during cardiac arrest according to the standard ACLS algorithm concurrent with rewarming strategies. 2. Early defibrillation with concurrent high-quality CPR is critical to survival when sudden cardiac arrest is caused by ventricular fibrillation or pulseless ventricular tachycardia. The primary considerations when determining if a victim needs to be moved before starting resuscitation are feasibility and safety of providing high-quality CPR in the location and position in which the victim is found. Hyperlinked references are provided to facilitate quick access and review. decrease pauses in chest compressions and improve outcomes? Performance of high-quality CPR includes adequate compression depth and rate while minimizing pauses in compressions. The optimal timing for the performance of PMCD is not well established and must logically vary on the basis of provider skill set and available resources as well as patient and/or cardiac arrest characteristics. There are no studies comparing cough CPR to standard resuscitation care. A systematic review of the literature identified 5 small prospective trials, 3 retrospective studies, and multiple case reports and case series with contradictory results. 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. 2. The pharmacokinetic properties, acute effects, and clinical efficacy of emergency drugs have primarily been described when given intravenously. Neuroimaging may be helpful after arrest to detect and quantify structural brain injury. Although contradictory evidence exists, it may be reasonable to avoid the use of pure -adrenergic blocker medications in the setting of cocaine toxicity. 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. The writing group acknowledged that there is no direct evidence that EEG to detect nonconvulsive seizures improves outcomes. Unfortunately, despite improvements in the design and funding support for resuscitation research, the overall certainty of the evidence base for resuscitation science is low. Manual stabilization can decrease movement of the cervical spine during patient care while allowing for proper ventilation and airway control. Outcomes from IHCA are overall superior to those from OHCA,5 likely because of reduced delays in initiation of effective resuscitation. Despite recent gains, only 39.2% of adults receive layperson-initiated CPR, and the general public applied an AED in only 11.9% of cases.1 Survival rates from OHCA vary dramatically between US regions and EMS agencies.2,3 After significant improvements, survival from OHCA has plateaued since 2012. Because placement of an advanced airway may result in interruption of chest compressions, a malpositioned device, or undesirable hyperventilation, providers should carefully weigh these risks against the potential benefits of an advanced airway. Awareness and incorporation of the potential sources of error in the individual diagnostic tests is important. 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. Antidigoxin Fab antibodies should be administered to patients with severe cardiac glycoside toxicity. 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. Initial management of wide-complex tachycardia requires a rapid assessment of the patients hemodynamic stability. Each recommendation was developed and formally approved by the writing group. 3. outcomes? A wide-complex tachycardia can also be caused by any of these supraventricular arrhythmias when conducted by an accessory pathway (called pre-excited arrhythmias). If cardiac arrest develops as the result of cocaine toxicity, there is no evidence to suggest deviation from standard BLS and ALS guidelines, with specific treatment strategies used in the postcardiac arrest phase as needed if there is evidence of severe cardiotoxicity or neurotoxicity. The effect of individual CPR quality metrics or interventions is difficult to evaluate because so many happen concurrently and may interact with each other in their effect. The relative contribution of assisted ventilation for patients in cardiac arrest is more controversial. Part 3: Adult Basic and Advanced Life Support | American Heart Commercially available defibrillators either provide fixed energy settings or allow for escalating energy settings; both approaches are highly effective in terminating VF/VT. Energy setting specifications for cardioversion also differ between defibrillators. 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). 3. Peer reviewer feedback was provided for guidelines in draft format and again in final format. 1. Does avoidance of hyperoxia in the postarrest period lead to improved outcomes? 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. treatable/preventable/recoverable? In adult victims of cardiac arrest, it is reasonable for rescuers to perform chest compressions at a rate of 100 to 120/min. This new link acknowledges the need for the system of care to support recovery, discuss expectations, and provide plans that address treatment, surveillance, and rehabilitation for cardiac arrest survivors and their caregivers as they transition care from the hospital to home and return to role and social function. 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. Although there are no controlled studies, several case reports and small case series have reported improvement in bradycardia and hypotension after glucagon administration. If atropine is ineffective, either alternative agents to increase heart rate and blood pressure or transcutaneous pacing are reasonable next steps. 1. The value of VF waveform analysis to guide the acute management of adults with cardiac arrest has not been established. These features make adenosine relatively safe for treating a hemodynamically stable, regular, monomorphic wide-complex tachycardia of unknown type. Intraosseous access may be considered if attempts at intravenous access are unsuccessful or not feasible.

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