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. 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. For asthmatic patients with cardiac arrest, sudden elevation in peak inspiratory pressures or difficulty ventilating should prompt evaluation for tension pneumothorax. Important considerations for determining airway management strategies is provider airway management skill and experience, frequent retraining for providers, and ongoing quality improvement to minimize airway management complications. When an IV line is in place, it is reasonable to consider the IV route for epinephrine in anaphylactic shock, at a dose of 0.05 to 0.1 mg (0.1 mg/mL, aka 1:10 000). 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. There is no evidence that cricoid pressure facilitates ventilation or reduces the risk of aspiration in cardiac arrest patients. CPR indicates cardiopulmonary resuscitation; IHCA, in-hospital cardiac arrest; and OHCA, out-of-hospital cardiac arrest. 4. 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 trachea, which is sometimes called the windpipe, conducts air down into the lungs through the bronchi, which are smaller tubular branches. outcomes? In patients with -adrenergic blocker overdose who are in refractory shock, administration of high-dose insulin with glucose is reasonable. Does preshock waveform analysis lead to improved outcome? The use of an airway adjunct (eg, oropharyngeal and/or nasopharyngeal airway) may be reasonable in unconscious (unresponsive) patients with no cough or gag reflex to facilitate delivery of ventilation with a bag-mask device. 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. 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. 1. Endotracheal drug administration may be considered when other access routes are not available. Recommendation-specific text clarifies the rationale and key study data supporting the recommendations. Historically, the best motor examination in the upper extremities has been used as a prognostic tool, with extensor or absent movement being correlated with poor outcome. 2. The bronchi then divide into smaller and smaller tubules called bronchioles. In a recent meta-analysis of 7 published studies (33 795 patients), only 0.13% (95% CI, 0.03% 0.58%) of patients who fulfilled the BLS termination criteria survived to hospital discharge. 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. Some treatment recommendations involve medical care and decision-making after return of spontaneous circulation (ROSC) or when resuscitation has been unsuccessful. Is the IO route of drug administration safe and efficacious in cardiac arrest, and does efficacy vary by IO site? 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)). ECPR is a complex intervention that requires a highly trained team, specialized equipment, and multidisciplinary support within a healthcare system. The rationale for tracking the overall success rate for systems performing ETI is to make informed decisions as to whether practice should allow for ETI, move toward SGA, or simply use bag-mask ventilation for patients in cardiac arrest; recommendations will vary depending on the overall success rate in a given system. IHCA patients often have invasive monitoring devices in place such as central venous or arterial lines, and personnel to perform advanced procedures such as arterial blood gas analysis or point-of-care ultrasound are often present. 2. 2. The dedicated rescuer who provides manual abdominal compressions will compress the abdomen midway between the xiphoid and the umbilicus during the relaxation phase of chest compression. Patients should be monitored constantly to verify airway patency and adequate ventilation and oxygenation. 3. When 2 or more rescuers are available, it is reasonable to switch chest compressors approximately every 2 min (or after about 5 cycles of compressions and ventilation at a ratio of 30:2) to prevent decreases in the quality of compressions. Cardiac arrest survivors, like many survivors of critical illness, often experience a spectrum of physical, neurological, cognitive, emotional, or social issues, some of which may not become apparent until after hospital discharge. However, the efficacy of IV versus IO drug administration in cardiac arrest remains to be elucidated. If an advanced airway is used, a supraglottic airway can be used for adults with OHCA in settings with low tracheal intubation success rates or minimal training opportunities for endotracheal tube placement. For synchronized cardioversion of atrial fibrillation using biphasic energy, an initial energy of 120 to 200 J is reasonable, depending on the specific biphasic defibrillator being used. 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). Regardless of waveform, successful defibrillation requires that a shock be of sufficient energy to terminate VF/VT. Community reintegration and return to work or other activities may be slow and depend on social support and relationships. It may be reasonable to use a defibrillator in manual mode as compared with automatic mode depending on the skill set of the operator. Unauthorized use prohibited. 3. One study of patients with laryngectomies showed that a pediatric face mask created a better peristomal seal than a standard ventilation mask. When VF/VT has been present for more than a few minutes, myocardial reserves of oxygen and other energy substrates are rapidly depleted. It is reasonable for providers to first attempt establishing intravenous access for drug administration in cardiac arrest. Survivorship plans help guide the patient, caregivers, and primary care providers and include a summary of the inpatient course, recommended follow-up appointments, and postdischarge recovery expectations (Figure 12). Individual test modalities may be obtained earlier and the results integrated into the multimodality assessment synthesized at least 72 hours after normothermia. This Part of the 2020 American Heart Association (AHA) Guidelines for CPR and Emergency Cardiovascular Care includes recommendations for clinical care of adults with cardiac arrest, including those with life-threatening conditions in whom cardiac arrest is imminent, and after successful resuscitation from 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. Care of any patient with cardiac arrest in the setting of acute exacerbation of asthma begins with standard BLS. 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. 2. Digoxin poisoning can cause severe bradycardia, AV nodal blockade, and life-threatening ventricular arrhythmias. Artifact-filtering and other innovative techniques to disclose the underlying rhythm beneath ongoing CPR can surmount these challenges and minimize interruptions in chest compressions while offering a diagnostic advantage to better direct therapies. AED indicates automated external defibrillator; ALS, advanced life support; BLS, basic life support; and CPR, cardiopulmonary resuscitation. Neurologic prognostication incorporates multiple diagnostic tests which are synthesized into a comprehensive multimodal assessment at least 72 hours after return to normothermia and with sedation and analgesia limited as possible. Adult/Child/Infant. 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. How is CPR performed differently when an advanced airway is in place? Unstable patients require immediate electric cardioversion. Each of the 2020 Guidelines documents were submitted for blinded peer review to 5 subject-matter experts nominated by the AHA. Synchronized cardioversion or drugs or both may be used to control unstable or symptomatic regular narrow-complex tachycardia. In cardiac arrest secondary to anaphylaxis, standard resuscitative measures and immediate administration of epinephrine should take priority. Common causes of maternal cardiac arrest are hemorrhage, heart failure, amniotic fluid embolism, sepsis, aspiration pneumonitis, venous thromboembolism, preeclampsia/eclampsia, and complications of anesthesia.1,4,6. Gently lift their chin forward with your other hand. Health care professionals can perform chest. Cardiac arrest survivors, their families, and families of nonsurvivors may be powerful advocates for community response to cardiac arrest and patient-centered outcomes. Fever after ROSC is associated with poor neurological outcome in patients not treated with TTM, although this finding is reported less consistently in patients treated with TTM. Evidence suggests that patients who are comatose after ROSC benefit from invasive angiography, when indicated, as do patients who are awake. However, an oral airway is preferred because of the risk of trauma with a nasopharyngeal airway. Finally, case reports and case series using ECMO in maternal cardiac arrest patients report good maternal survival.16 The treatment of cardiac arrest in late pregnancy represents a major scientific gap. Should severely hypothermic patients in VF who fail an initial defibrillation attempt receive additional Because immediate ROSC cannot always be achieved, local resources for a perimortem cesarean delivery should be summoned as soon as cardiac arrest in a woman in the second half of pregnancy is recognized. 1. 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. To open a person's airway, do the following: Place your hand on their . In cases where the initial shock fails to terminate VF/VT, subsequent shocks may be effective when repeated at the same or an escalating energy setting. affect resuscitation outcomes? When performed with other prognostic tests, it may be reasonable to consider extensive areas of restricted diffusion on brain MRI at 2 to 7 days after cardiac arrest to support the prognosis of poor neurological outcome in patients who remain comatose. While hemodynamically stable rhythms afford an opportunity for evaluation and pharmacological treatment, the need for prompt electric cardioversion should be anticipated in the event the arrhythmia proves unresponsive to these measures or rapid decompensation occurs. 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. 2. 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. If pharmacological therapy is unsuccessful for the treatment of a hemodynamically stable wide-complex tachycardia, cardioversion or seeking urgent expert consultation is reasonable. Although abbreviated observation periods may be adequate for patients with fentanyl, morphine, or heroin overdose. 5. IV lidocaine, amiodarone, and measures to treat myocardial ischemia may be considered to treat polymorphic VT in the absence of a prolonged QT interval. 3. Advanced airways is a tube which is inserted in the mouth or nose, during this continuous CPR at the rate of 100 per minute is given. The key drivers of successful resuscitation from OHCA are lay rescuer cardiopulmonary resuscitation (CPR) and public use of an automated external defibrillator (AED). Standardization of methods for quantifying GWR and ADC would be useful. Because of potential interference with maternal resuscitation, fetal monitoring should not be undertaken during cardiac arrest in pregnancy. The 2019 focused update on ACLS guidelines1 addressed the use of ECPR for cardiac arrest and noted that there is insufficient evidence to recommend the routine use of ECPR in cardiac arrest. 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. 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. 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. In patients who remain comatose after cardiac arrest, we recommend that neuroprognostication be delayed until adequate time has passed to ensure avoidance of confounding by medication effect or a transiently poor examination in the early postinjury period. To avoid hypoxia in adults with ROSC in the immediate postarrest period, it is reasonable to use the highest available oxygen concentration until the arterial oxyhemoglobin saturation or the partial pressure of arterial oxygen can be measured reliably. Neuroprognostication relies on interpreting the results of diagnostic tests and correlating those results with outcome. 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. 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. How long after mild drowning events should patients be observed for late-onset respiratory effects? There are some physiological basis and preclinical data for hyperoxemia leading to increased inflammation and exacerbating brain injury in postarrest patients. All guidelines were reviewed and approved for publication by the AHA Science Advisory and Coordinating Committee and the AHA Executive Committee. External chest compressions should be performed if emergency resternotomy is not immediately available. 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. What is the ideal sequencing of modalities (traditional vasopressors, calcium, glucagon, high-dose 1. 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. The immediate cause of death in drowning is hypoxemia. 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. Many of the tests considered are subject to error because of the effects of medications, organ dysfunction, and temperature. 2b. Unfortunately, despite improvements in the design and funding support for resuscitation research, the overall certainty of the evidence base for resuscitation science is low. Obtaining EEG in status myoclonus is important to rule out underlying ictal activity. 1. A patent airway is essential to facilitate proper ventilation and oxygenation. 2. 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. The combitube has two separate balloons that must be inflated and two separate ports. If an advanced airway is used in the in-hospital setting by expert providers trained in these procedures, either a supraglottic airway or an endotracheal tube placement can be used. When the second rescuer arrives, provide 2-rescuer CPR and use the AED/defibrillator. Deliver air over 1 second, ensuring that the victim's chest rises. In a tiered ALS- and BLS-provider system, the use of the BLS TOR rule can avoid confusion at the scene of a cardiac arrest without compromising diagnostic accuracy. ACD-CPR is performed by using a handheld device with a suction cup applied to the midsternum, actively lifting up the chest during decompressions, thereby enhancing the negative intrathoracic pressure generated by chest recoil and increasing venous return and cardiac output during the next chest compression. This topic last received formal evidence review in 2010.4. Patients in anaphylactic shock are critically ill, and cardiovascular and respiratory status can change quickly, making close monitoring imperative. The benefit of an oropharyngeal compared with a nasopharyngeal airway in the presence of a known or suspected basilar skull fracture or severe coagulopathy has not been assessed in clinical trials. 3. Given the potential for the rapid development of oropharyngeal or laryngeal edema, immediate referral to a health professional with expertise in advanced airway placement, including surgical airway management, is recommended. What is the interrater agreement for physical examination findings such as pupillary light reflex, corneal Epinephrine did not lead to increased survival with favorable or unfavorable neurological outcome at 3 months, although both of these outcomes occurred slightly more frequently in the epinephrine group.2 Observational data suggest better outcomes when epinephrine is given sooner, and the low survival with favorable neurological outcome in the available trials may be due in part to the median time of 21 minutes from arrest to receipt of epinephrine. The goal of ECPR is to support end organ perfusion while potentially reversible conditions are addressed. 3. 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). Epidemiological data suggest that risk factors for The writing group would also like to acknowledge the outstanding contributions of David J. Magid, MD, MPH. -Perform a head tilt- chin lift to open the airway. Observational studies of fibrinolytic therapy for suspected PE were found to have substantial bias and showed mixed results in terms of improvement in outcomes. NSE and S100B are the 2 most commonly studied markers, but others are included in this review as well. 1. For severe symptomatic bradycardia causing shock, if no IV or IO access is available, immediate transcutaneous pacing while access is being pursued may be undertaken. It is reasonable to immediately resume chest compressions after shock delivery for adults in cardiac arrest in any setting. Mouth-to-nose ventilation may be necessary if ventilation through the victims mouth is impossible because of trauma, positioning, or difficulty obtaining a seal. The routine use of magnesium for cardiac arrest is not recommended. AED indicates automated external defibrillator; BLS, basic life support; and CPR, cardiopulmonary resuscitation. 1. Which patients with cardiac arrest due to suspected pulmonary embolism benefit from emergency CPR is Cardiopulmonary resuscitation. Simultaneously . What defines optimal hospital care for patients with ROSC after cardiac arrest is not completely known, but there is increasing interest in identifying and optimizing practices that are likely to improve outcomes. 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. 1. 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. 3. If advanced airway placement will interrupt chest compressions, providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or obtains ROSC. VF is the presenting rhythm in 25% to 50% of cases of cardiac arrest after cardiac surgery. 2. Debriefings and referral for follow-up for emotional support for lay rescuers, EMS providers, and hospital-based healthcare workers after a cardiac arrest event may be beneficial. 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. Success rates for the Valsalva maneuver in terminating SVT range from 19% to 54%. When appropriate, flow diagrams or additional tables are included. 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. ALS indicates advanced life support; CPR, cardiopulmonary resuscitation; and EMS, emergency medical services. The hypothermic heart may be unresponsive to cardiovascular drugs, pacemaker stimulation, and defibrillation; however, the data to support this are essentially theoretical. During cardiac arrest, if the pregnant woman with a fundus height at or above the umbilicus has not achieved ROSC with usual resuscitation measures plus manual left lateral uterine displacement, it is advisable to prepare to evacuate the uterus while resuscitation continues. Resuscitation should generally be conducted where the victim is found, as long as high-quality CPR can be administered safely and effectively in that location. A recent consensus statement on this topic has been published by the Society of Thoracic Surgeons.9, This topic last received formal evidence review in 2010.35These recommendations were supplemented by a 2017 review published by the Society of Thoracic Surgeons.9. 2. neurological outcome? In the supine position, aortocaval compression can occur for singleton pregnancies starting at approximately 20 weeks of gestational age or when the fundal height is at or above the level of the umbilicus. 1. 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. Give rescue breaths. 3. 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. Disclosure information for peer reviewers is listed in Appendix 2(link opens in new window). Recognition of cardiac arrest by healthcare providers includes a pulse check, but the importance of not prolonging efforts to detect a pulse is emphasized. The routine use of cricoid pressure in adult cardiac arrest is not recommended. 6. 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). Although the majority of resuscitation success is achieved by provision of high-quality CPR and defibrillation, other specific treatments for likely underlying causes may be helpful in some cases. To accomplish delivery early, ideally within 5 min after the time of arrest, it is reasonable to immediately prepare for perimortem cesarean delivery while initial BLS and ACLS interventions are being performed. In patients with atrial fibrillation and atrial flutter in the setting of preexcitation, digoxin, nondihydropyridine calcium channel antagonists, -adrenergic blockers, and IV amiodarone should not be administered because they may increase the ventricular response and result in VF. When performed with other prognostic tests, it may be reasonable to consider reduced gray-white ratio (GWR) on brain computed tomography (CT) after cardiac arrest to support the prognosis of poor neurological outcome in patients who remain comatose. 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. The effectiveness of active compression-decompression CPR is uncertain. 2. A randomized trial investigating this question is ongoing (NCT02056236). The prompt initiation of CPR is perhaps the most important intervention to improve survival and neurological outcomes.

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