The management of patients with preexcitation syndromes (aka Wolff-Parkinson-White) is covered in the Wide-Complex Tachycardia section. 4. The critical task in preparedness planning is to define the system (how assets are organized) and processes (actions and interactions that must occur) that will guide emergency response and recovery. 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. 3. What should you do? 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. A BLS emergency ambulance shall request an ALS emergency ambulance transport if after assessment on scene determines the need for The evidence for what constitutes optimal CPR continues to evolve as research emerges. Hydroxocobalamin and 100% oxygen, with or without sodium thiosulfate, can be beneficial for cyanide poisoning. Does avoidance of hyperoxia in the postarrest period lead to improved outcomes? 3. Vagal maneuvers are recommended for acute treatment in patients with SVT at a regular rate. In comparison, surveillance and prevention are critical aspects of IHCA. Lay and trained responders should not delay activating emergency response systems while awaiting the patients response to naloxone or other interventions. How is a child defined in terms of CPR/AED care? ACLS indicates advanced cardiovascular life support; and CPR, cardiopulmonary 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. You are working in an OB/GYN office when your patient, Mrs. Tribble, suddenly goes into cardiac arrest. These missions decompose into sets of elemental robot tasks that can be represented individually as standard test methods. 5. A clinical trial studied administration of magnesium in addition to sodium bicarbonate for patients with TCA-induced hypotension, acidosis, and/or QRS prolongation.5 Although overall outcomes were better in the magnesium group, no statistically significant effect was found in mortality, the magnesium patients were significantly less ill than controls at study entry, and methodologic flaws render this work preliminary. It may be reasonable for EMS providers to use a rate of 10 breaths per minute (1 breath every 6 s) to provide asynchronous ventilation during continuous chest compressions before placement of an advanced airway. 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. 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. In addition to assessing level of consciousness and performing basic neurological examination, clinical examination elements may include the pupillary light reflex, pupillometry, corneal reflex, myoclonus, and status myoclonus when assessed within 1 week after cardiac arrest. 2. 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. 3. Look for no breathing or only gasping, at the direction of the telecommunicator. 3. . Transition activities are performed while in a classified event and immediately after termination. For patients with cocaine-induced hypertension, tachycardia, agitation, or chest discomfort, benzodiazepines, alpha blockers, calcium channel blockers, nitroglycerin, and/or morphine can be beneficial. Posting id: 821116570. Clinical Practice Guidelines for the Treatment and Prevention of Drowning: 2019 Update.20. The acute respiratory failure that can precipitate cardiac arrest in asthma patients is characterized by severe obstruction leading to air trapping. 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. 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. Administration of epinephrine may be lifesaving. 2. total time of the compression-plus-decompression cycle)? These arrhythmias are common and often coexist, and their treatment recommendations are similar. 4. Care Science With Treatment Recommendations (CoSTR).1. Three different types of evidence reviews (systematic reviews, scoping reviews, and evidence updates) were used in the 2020 process. No shock waveform has proved to be superior in improving the rate of ROSC or survival. We recommend TTM for adults who do not follow commands after ROSC from OHCA with any initial rhythm. Cough CPR is described as a repetitive deep inspiration followed by a cough every few seconds before the loss of consciousness. The opioid epidemic has resulted in an increase in opioid-associated out-of-hospital cardiac arrest, with the mainstay of care remaining the activation of the emergency response systems and performance of high-quality CPR. The American Heart Association is a qualified 501(c)(3) tax-exempt organization. Available hemodynamic monitoring modalities in conjunction with manual pulse detection provide an opportunity to confirm myocardial capture and adequate cardiac function. 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. The 2020 Guidelines are organized into knowledge chunks, grouped into discrete modules of information on specific topics or management issues.5 Each modular knowledge chunk includes a table of recommendations that uses standard AHA nomenclature of COR and LOE. The prompt initiation of CPR is perhaps the most important intervention to improve survival and neurological outcomes. Care of any patient with cardiac arrest in the setting of acute exacerbation of asthma begins with standard BLS. Taking a regular rather than a deep breath prevents the rescuer from getting dizzy or lightheaded and prevents overinflation of the victims lungs. Multiple agents, including magnesium, coenzyme Q10 (ubiquinol), exanatide, xenon gas, methylphenidate, and amantadine, have been considered as possible agents to either mitigate neurological injury or facilitate patient awakening. arrest with shockable rhythm? We do not recommend the routine use of rapid infusion of cold IV fluids for prehospital cooling of patients after ROSC. Airway, ventilation, and oxygenation are particularly important in the setting of pregnancy because of increased maternal metabolism and decreased functional reserve capacity due to the gravid uterus, making pregnant patients more prone to hypoxia. The National Response System (NRS) is a mechanism routinely and effectively used to respond to a wide range of oil and hazardous substance releases. 3-3 Hurricane Season Preparation Annually, at the beginning of hurricane season (June 1), the H-EOT, the Office of Licensing , R-EOT, and You are providing high-quality CPR on a 6-year-old patient who weighs 44 pounds. 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. You suspect that an unresponsive patient has sustained a neck injury. We recommend selecting and maintaining a constant temperature between 32C and 36C during TTM. We recommend TTM for adults who do not follow commands after ROSC from IHCA with initial shockable rhythm. 2. If no emergency medical services (EMS) or other trained personnel is on the scene, activate the 911 emergency system immediately. Polymorphic VT that is not associated with QT prolongation is often triggered by acute myocardial ischemia and infarction, In the absence of long QT, magnesium has not been shown to be effective in the treatment of polymorphic VT. and 2. 6. Administration of IV amiodarone, procainamide, or sotalol may be considered for the treatment of wide-complex tachycardia. For cardiac arrest with known or suspected hypermagnesemia, in addition to standard ACLS care, it may be reasonable to administer empirical IV calcium. Two randomized trials from the same center reported improved survival and neurological outcome when steroids were bundled in combination with vasopressin and epinephrine during cardiac arrest and also administered after successful resuscitation from cardiac arrest. 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. If necessary, it may order an evacuation. 3. However, termination of torsades by shock does not prevent its recurrence, which requires additional measures. Much of the published research involves patients whose arrests were presumed to be of cardiac origin and in settings with short EMS response times. What is a reason you would choose to perform chest thrusts instead of abdominal thrusts for an adult or child with an obstructed airway? 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. Which statement is true regarding resuscitation for a pregnant patient? Torsades de pointes typically presents in a recurring pattern of self-terminating, hemodynamically unstable polymorphic VT in context of a known or suspected long QT abnormality, often with an associated bradycardia. 6. Administration of epinephrine with concurrent high-quality CPR improves survival, particularly in patients with nonshockable rhythms. The use of mechanical CPR devices may be considered in specific settings where the delivery of high-quality manual compressions may be challenging or dangerous for the provider, as long as rescuers strictly limit interruptions in CPR during deployment and removal of the device. It remains to be tested whether patients with signs of shock benefit from emergent coronary angiography and PCI. Notify the emergency response team Rationale: Activities, such as brushing teeth, can mimic the waveform of VI, so first he client should be assessed (A) to determine if the alarm is accurate. The choice of anticoagulation is beyond the scope of these guidelines. Which action should you perform first? 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. 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. 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. A 7-year-old patient goes into sudden cardiac arrest. The code team has arrived to take over resuscitative efforts. In patients with calcium channel blocker overdose who are in refractory shock, administration of calcium is reasonable. 1. For synchronized cardioversion of atrial flutter using biphasic energy, an initial energy of 50 to 100 J may be reasonable, depending on the specific biphasic defibrillator being used. The duration and severity of hypoxia sustained as a result of drowning is the single most important determinant of outcome. 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. The toxicity of cyanide is predominantly due to the cessation of aerobic cell metabolism. When performed with other prognostic tests, it may be reasonable to consider bilaterally absent corneal reflexes at 72 h or more after cardiac arrest to support the prognosis of poor neurological outcome in patients who remain comatose. Administration of sodium bicarbonate for cardiac arrest or life-threatening cardiac conduction delays (ie, QRS prolongation more than 120 ms) due to sodium channel blocker/tricyclic antidepressant (TCA) overdose can be beneficial. Community reintegration and return to work or other activities may be slow and depend on social support and relationships. A study in critically ill patients who required ventilatory support found that bag-mask ventilation at a rate of 10 breaths per minute decreased hypoxic events before intubation. This protocol is supported by the surgical societies. You and your colleagues are performing CPR on a 6-year-old child. Serum biomarkers are blood-based tests that measure the concentration of proteins normally found in the central nervous system (CNS). 1100 Introduction. This includes identifying P waves and their relationship to QRS complexes and (in the case of patients with a pacemaker) pacing spikes preceding QRS complexes. Independent of a patients mental status, coronary angiography is reasonable in all postcardiac arrest patients for whom coronary angiography is otherwise indicated. When appropriate, flow diagrams or additional tables are included. Responders are normally the first on the scene of an emergency, and range from police, fire, and emergency health personnel, to . It promotes the "rest and digest" response that calms the body down after the danger has passed. 1. The routine use of magnesium for cardiac arrest is not recommended. If atropine is ineffective, either alternative agents to increase heart rate and blood pressure or transcutaneous pacing are reasonable next steps. Opioid overdoses deteriorate to cardiopulmonary arrest because of loss of airway patency and lack of breathing; therefore, addressing the airway and ventilation in a periarrest patient is of the highest priority. 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. 7. Initial management of wide-complex tachycardia requires a rapid assessment of the patients hemodynamic stability. When performed with other prognostic tests, it may be reasonable to consider burst suppression on EEG in the absence of sedating medications at 72 h or more after arrest to support the prognosis of poor neurological outcome. 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. If someone responds, ensure that the phone is at the side of the victim if at all possible. Anticoagulation alone is inadequate for patients with fulminant PE. Robert Long, whose license was suspended for failing to give aid to Nichols and who has also been fired, appeared by . 3. The process will be determined by the size of the team. bradycardia? EEG patterns that were evaluated in the 2020 ILCOR systematic review include unreactive EEG, epileptiform discharges, seizures, status epilepticus, burst suppression, and highly malignant EEG. 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. The nurse assesses a responsive adult and determines she is choking. 1. Part 3: adult basic and advanced life support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Early delivery is associated with better maternal and neonatal survival.15 In situations incompatible with maternal survival, early delivery of the fetus may also improve neonatal survival. 3. This topic last received formal evidence review in 2010.5. -Adrenergic receptor antagonists (-adrenergic blockers) and L-type calcium channel antagonists (calcium channel blockers) are common antihypertensive and cardiac rate control medications. ECPR indicates extracorporeal cardiopulmonary resuscitation. do they differ from current generic or clinician-derived measures? The provision of rescue breaths for apneic patients with a pulse is essential. Cough CPR is described as repeated deep breaths followed immediately by a cough every few seconds in an attempt to increase aortic and intracardiac pressures, providing transient hemodynamic support before a loss of consciousness. Studies of mechanical CPR devices have not demonstrated a benefit when compared with manual CPR, with a suggestion of worse neurological outcome in some studies. A randomized trial investigating this question is ongoing (NCT02056236). Which statement about bag-valve-mask (BVM) resuscitators is true? 2. 3. 3. The actions taken in the initial minutes of an emergency are critical. A two-person technique is the preferred methodology for bag-valve-mask (BVM) ventilations as it provides better seal and ventilation volume. IV lidocaine, amiodarone, and measures to treat myocardial ischemia may be considered to treat polymorphic VT in the absence of a prolonged QT interval. Since the last time these recommendations were formally reviewed, The administration of hypertonic (8.4%, 1 mEq/ mL) sodium bicarbonate solution for treatment of sodium channel blockade due to TCAs and other toxicants is supported by human observational studies. It is reasonable for a rescuer to use mouth-to-nose ventilation if ventilation through the victims mouth is impossible or impractical. In February 2003, President Bush issued . Check for no breathing or only gasping and check pulse (ideally simultaneously). 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. Studies confirm the importance of real-time disaster monitoring systems, emergency response systems, and information systems these days to mitigate devastating impacts on human life, economy, and . Hyperlinked references are provided to facilitate quick access and review. Which statement correctly describes the appropriate technique for operating the BVM? This is accomplished through the development of an effective EOP (see below for suggested EOP formats). Shout for nearby help and activate the emergency response system (9-1-1, emergency response). The traditional approach for giving emergency pharmacotherapy is by the peripheral IV route. One RCT in OHCA comparing SGA (with iGel) to ETI in a nonphysician-based EMS system (ETI success, 69%) found no difference in survival or survival with favorable neurological outcome at hospital discharge. the functional capacity and safety of hospitals and the health-care system at large. For cardiac arrest with known or suspected hyperkalemia, in addition to standard ACLS care, IV calcium should be administered. When supplemental oxygen is available, it may be reasonable to use the maximal feasible inspired oxygen concentration during CPR. Synchronized cardioversion is recommended for acute treatment in patients with hemodynamically unstable SVT. and 2. Evacuation of the gravid uterus relieves aortocaval compression and may increase the likelihood of ROSC. 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). 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. 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. Are NSE and S100B helpful when checked later than 72 h after ROSC? Critical knowledge gaps are summarized in Table 4. Outcomes from IHCA are overall superior to those from OHCA,5 likely because of reduced delays in initiation of effective resuscitation. Victims of accidental hypothermia should not be considered dead before rewarming has been provided unless there are signs of obvious death. In patients with narrow-complex tachycardia who are refractory to the measures described, this may indicate a more complicated rhythm abnormality for which expert consultation may be advisable. In patients with calcium channel blocker overdose who are in refractory shock, administration of IV glucagon may be considered. Which is the next appropriate action? 3. CPR is recommended until a defibrillator or AED is applied. In addition, 15 recommendations are designated Class 3: No Benefit, and 11 recommendations are Class 3: Harm. AED indicates automated external defibrillator; and BLS, basic life support. Naloxone is safe to administer if the patient is not breathing and you cannot identify the drug overdosed. Each of these features can also be useful in making a presumptive rhythm diagnosis. It does not have a pediatric setting and includes only adult AED pads. 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. What is the sixth link in the Adult In-Hospital Cardiac Chain of Survival? Rescuers should avoid excessive ventilation (too many breaths or too large a volume) during CPR. 5. The next steps in care, including the performance of CPR and the administration of naloxone, are discussed in detail below. Routine use of sodium bicarbonate is not recommended for patients in cardiac arrest. Although the vast majority of cardiac arrest trials have been conducted in OHCA, IHCA comprises almost half of the arrests that occur in the United States annually, and many OHCA resuscitations continue into the emergency department. Since the last review in 2010 of rescue breathing in adult patients, there has been no evidence to support a change in previous recommendations. Atrial fibrillation or flutter with rapid ventricular 3. In 2018, the AHA, American College of Cardiology, and Heart Rhythm Society published an extensive guideline on the evaluation and management of stable and unstable bradycardia.2 This guideline focuses exclusively on symptomatic bradycardia in the ACLS setting and maintains consistency with the 2018 guideline. Notably, when the QRS complex is of uniform morphology, shock synchronized to the QRS is encouraged because this minimizes the risk of provoking VF by a mistimed shock during the vulnerable period of the cardiac cycle (T wave). 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. 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. Prompt systemic anticoagulation is generally indicated for patients with massive and submassive PE to prevent clot propagation and support endogenous clot dissolution over weeks. Which technique should you use to open the patient's airway? There is no evidence that cricoid pressure facilitates ventilation or reduces the risk of aspiration in cardiac arrest patients. The trained lay rescuer who feels confident in performing both compressions and ventilation should open the airway using a head tiltchin lift maneuver when no cervical spine injury is suspected. In patients with calcium channel blocker overdose who are in refractory shock, administration of high-dose insulin with glucose is reasonable. At minimum, one drill per year must be completed for each type of emergency response: evacuation, shelter in place, and hide/run/fight. 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. Which response by the medical assistant demonstrates closed-loop communication? Both mouth-to-mouth rescue breathing and bagmask ventilation provide oxygen and ventilation to the victim. IV infusion of epinephrine is a reasonable alternative to IV boluses for treatment of anaphlaxis in patients not in cardiac arrest. Thirty-seven recommendations are supported by Level B-Randomized Evidence (moderate evidence from 1 or more RCTs) and 57 by Level B-Nonrandomized evidence. Can artifact-filtering algorithms for analysis of ECG rhythms during CPR in a real-time clinical setting 1. Post emergency response means that portion of an emergency response performed after the immediate threat of a release has been stabilized or eliminated and clean-up of the site has begun. 1. 1. When performed with other prognostic tests, it may be reasonable to consider bilaterally absent N20 somatosensory evoked potential (SSEP) waves more than 24 h after cardiac arrest to support the prognosis of poor neurological outcome. 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. 1. Characteristic ECG findings include tachycardia and QRS prolongation with a right bundle branch pattern.1,2 TCA toxicity can mimic a Brugada type 1 ECG pattern.3, The standard therapy for hypotension or cardiotoxicity from sodium channel blocker poisoning consists of sodium boluses and serum alkalization, typically achieved through administration of sodium bicarbonate boluses. The 2010 Guidelines recommended a 50% duty cycle, in which the time spent in compression and decompression was equal, mainly on the basis of its perceived ease of being achieved in practice. 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. Resuscitation of the pregnant woman, including PMCD when indicated, is the first priority because it may lead to increased survival of both the woman and the fetus. 1. These guidelines are designed primarily for North American healthcare providers who are looking for an up-to-date summary for BLS and ALS for adults as well as for those who are seeking more in-depth information on resuscitation science and gaps in current knowledge. In determining the COR, the writing group considered the LOE and other factors, including systems issues, economic factors, and ethical factors such as equity, acceptability, and feasibility. Hemodynamically unstable patients and those with rate-related ischemia should receive urgent electric cardioversion. Intracardiac drug administration was discouraged in the 2000 AHA Guidelines for CPR and Emergency Cardiovascular Care given its highly specialized skill set, potential morbidity, and other available options for access.1,2 Endotracheal drug administration results in low blood concentrations and unpredictable pharmacological effect and has also largely fallen into disuse given other access options. "The push has been to build up the experience of state teams to be able to respond quickly," she said. 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.