Evidence is limited to case reports and extrapolations from nonfatal cases, interpretation of pathophysiology, and consensus opinion. ILCOR Consensus on CPR and Emergency Cardiovascular 1. Does this vary based on the opioid involved? The ITD is a pressure-sensitive valve attached to an advanced airway or face mask that limits air entry into the lungs during the decompression phase of CPR, enhancing the negative intrathoracic pressure generated during chest wall recoil and improving venous return and cardiac output during CPR. In a trained provider-witnessed arrest of a postcardiac surgery patient, immediate defibrillation for VF/VT should be performed. 3. These procedures are described more fully in Part 2: Evidence Evaluation and Guidelines Development. Disclosure information for writing group members is listed in Appendix 1(link opens in new window). Part 3: adult basic and advanced life support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. 3. The next steps in care, including the performance of CPR and the administration of naloxone, are discussed in detail below. 1. 3. 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. Cardioversion has been shown to be both safe and effective in the prehospital setting for hemodynamically unstable patients with SVT who had failed to respond to vagal maneuvers and IV pharmacological therapies. This approach recognizes that most sudden cardiac arrest in adults is of cardiac cause, particularly myocardial infarction and electric disturbances. Endotracheal drug administration may be considered when other access routes are not available. Torsades de pointes is a form of polymorphic VT that is associated with a prolonged heart ratecorrected QT interval when the rhythm is normal and VT is not present. The combination of active compression-decompression CPR and impedance threshold device may be reasonable in settings with available equipment and properly trained personnel. Case reports have rarely described damage to the heart due to external chest compressions. However, biphasic waveform defibrillators (which deliver pulses of opposite polarity) expose patients to a much lower peak electric current with equivalent or greater efficacy for terminating atrial. 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). The existing trials have used a protocol of 1 mg every 3 to 5 minutes. 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. If an adult victim with spontaneous circulation (ie, strong and easily palpable pulses) requires support of ventilation, it may be reasonable for the healthcare provider to give rescue breaths at a rate of about 1 breath every 6 s, or about 10 breaths per minute. Conversely, a wide-complex tachycardia can also be due to VT or a rapid ventricular paced rhythm in patients with a pacemaker. Can point-of-care cardiac ultrasound, in conjunction with other factors, inform termination of We do not recommend the routine use of rapid infusion of cold IV fluids for prehospital cooling of patients after ROSC. 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. 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. 1. We recommend promptly performing and interpreting an electroencephalogram (EEG) for the diagnosis of seizures in all comatose patients after ROSC. Nonvasopressor medications during cardiac arrest. In the rare situation when a lone rescuer must leave the victim to dial EMS, the priority should be on prompt EMS activation followed by immediate return to the victim to initiate CPR. 1. Does epinephrine, when administered early after cardiac arrest, improve survival with favorable There are no randomized trials of the use of TTM in pregnancy. This topic was last reviewed in 2010 and identified 2 randomized trials, interposed abdominal compression CPR performed by trained rescuers improved short-term survival. 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. A case series suggests that mouth-to-nose ventilation in adults is feasible, safe, and effective. 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. On MRI, cytotoxic injury can be measured as restricted diffusion on diffusion-weighted imaging (DWI) and can be quantified by the ADC. High-quality CPR, defibrillation when appropriate, vasopressors and/or antiarrhythmics, and airway management remain the cornerstones of cardiac arrest resuscitation, but some emerging data suggest that incorporating patient-specific imaging and physiological data into our approach to resuscitation holds some promise. Interposed abdominal compression CPR may be considered during in-hospital resuscitation when sufficient personnel trained in its use are available. Three different types of evidence reviews (systematic reviews, scoping reviews, and evidence updates) were used in the 2020 process. Based on the protocols used in clinical trials, it is reasonable to administer epinephrine 1 mg every 3 to 5 min for cardiac arrest. The optimal combination of airway techniques, oxygenation and ventilation is uncertain. 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. Place 2 fingers on the lower half of the breastbone in the middle of the chest and press down by one-third of the depth of the chest (you may need to use one hand to do CPR depending on the size of the infant). The traditional approach for giving emergency pharmacotherapy is by the peripheral IV route. How long after mild drowning events should patients be observed for late-onset respiratory effects? Two systematic reviews have identified animal studies, case reports, and human observational studies that have reported increased heart rate and improved hemodynamics after high-dose insulin administration for calcium channel blocker toxicity. 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. AED indicates automated external defibrillator; BLS, basic life support; and CPR, cardiopulmonary resuscitation. No randomized RCTs have been performed comparing open-chest with external CPR. insulin) for refractory shock due to -adrenergic blocker or calcium channel blocker overdose? If using a defibrillator capable of escalating energies, higher energy for second and subsequent shocks may be considered for presumed shock-refractory arrhythmias. On recognition of a cardiac arrest event, a layperson should simultaneously and promptly activate the emergency response system and initiate cardiopulmonary resuscitation (CPR). Excessive ventilation is unnecessary and can cause gastric inflation, regurgitation, and aspiration. Cyanide poisoning may result from smoke inhalation, industrial exposures, self-poisoning, terrorism, or the administration of sodium nitroprusside. 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. 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. 1. 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). Instead, the compressing rescuer should give continuous chest compressions at a rate of 100 per minute without pauses for ventilation. Nonconvulsive seizures are common after cardiac arrest. One benefit to SSEPs is that they are subject to less interference from medications than are other modalities. Biphasic and monophasic shock waveforms are likely equivalent in their clinical outcome efficacy. 3. Simultaneously . Three studies evaluated quantitative pupillary light reflex. It has been shown previously that all rescuers may have difficulty detecting a pulse, leading to delays in CPR, or in some cases CPR not being performed at all for patients in cardiac arrest.3 Recognition of cardiac arrest by lay rescuers, therefore, is determined on the basis of level of consciousness and the respiratory effort of the victim. 7. The 2015 American College of Cardiology, AHA, and Heart Rhythm Society Guidelines evaluated and recommended adenosine as a first-line treatment for regular SVT because of its effectiveness, extremely short half-life, and favorable side-effect profile. 1. 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. 1. thrombolysis during resuscitation? Administration of IV or IO calcium, in the doses suggested for hyperkalemia, may improve hemodynamics in severe magnesium toxicity, supporting its use in cardiac arrest although direct evidence is lacking. 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. Many of these were reviewed in an evidence update provided in the 2020 COSTR for ALS.2 Many uncertainties within the topic of TTM remain, including whether temperature should vary on the basis of patient characteristics, how long TTM should be maintained, and how quickly it should be started. Is there a role for prophylactic antiarrhythmics after ROSC? Operationally, administering epinephrine every second cycle of CPR, after the initial dose, may also be reasonable. Maintaining the arterial partial pressure of carbon dioxide (Paco2) within a normal physiological range (generally 3545 mm Hg) may be reasonable in patients who remain comatose after ROSC. IV infusion of epinephrine is a reasonable alternative to IV boluses for treatment of anaphylaxis in patients not in cardiac arrest. 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. Status myoclonus is commonly defined as spontaneous or sound-sensitive, repetitive, irregular brief jerks in both face and limb present most of the day within 24 hours after cardiac arrest.8 Status myoclonus differs from myoclonic status epilepticus; myoclonic status epilepticus is defined as status epilepticus with physical manifestation of persistent myoclonic movements and is considered a subtype of status epilepticus for these guidelines. No RCTs of resternotomy timing have been performed. 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. For cardiotoxicity and cardiac arrest from severe hypomagnesemia, in addition to standard ACLS care, IV magnesium is recommended. CT and MRI are the 2 most common modalities. 3. These recommendations are supported by a 2020 ILCOR systematic review.1. 4. 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. 1. Conversely, when VF/ VT is more protracted, depletion of the hearts energy reserves can compromise the efficacy of defibrillation unless replenished by a prescribed period of CPR before the rhythm analysis. The writing group would also like to acknowledge the outstanding contributions of David J. Magid, MD, MPH.