It has been shown that the risk of injury from CPR is low in these patients.2. 1. VF is the presenting rhythm in 25% to 50% of cases of cardiac arrest after cardiac surgery. 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. Recovery and survivorship after cardiac arrest. In adult victims of cardiac arrest, it is reasonable for rescuers to perform chest compressions at a rate of 100 to 120/min. Shout for nearby help/activate the resuscitation team; the provider can activate the resuscitation team at this time or after checking for breathing and pulse. 4. 3. 3. Prompt treatment of cardiac glycoside toxicity is imperative to prevent or treat life-threatening arrhythmias. In addition to standard ACLS, several therapies have long been recommended to treat life-threatening hyperkalemia. What is the ideal initial dose of naloxone in a setting where fentanyl and fentanyl analogues are 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. In the 2020 ILCOR systematic review, no randomized trials were identified addressing the treatment of cardiac arrest caused by confirmed PE. 1. 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. Continuous compressions at a rate of 100-120/min Give 1 breath every 6 seconds (10 breaths/min) CPR Compression Rate. If you have been trained in CPR, go on to opening the airway and rescue breathing. Similar challenges were faced in the 2020 Guidelines process, where a number of critical knowledge gaps were identified in adult cardiac arrest management. Care Science With Treatment Recommendations (CoSTR).1. 4. It is reasonable for a rescuer to use mouth-to-nose ventilation if ventilation through the victims mouth is impossible or impractical. 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. Give one breath, blowing for about 1 second, watching for chest rise Your adult friend suddenly collapses at home, and you determine she needs CPR. 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. 3. Based on limited case reports and small case series, there is concern that patients with concomitant preexcitation and atrial fibrillation or atrial flutter may develop VF in response to accelerated ventricular response after the administration of AV nodal blocking agents such as digoxin, nondihydropyridine calcium channel antagonists, -adrenergic blockers, or IV amiodarone. 3. However, with more people surviving cardiac arrest, there is a need to organize discharge planning and long-term rehabilitation care resources. The precordial thump should not be used routinely for established cardiac arrest. CPR indicates cardiopulmonary resuscitation; ET, endotracheal; IO, intraosseous; IV, intravenous; pVT, pulseless ventricular tachycardia; and VF, ventricular fibrillation. 1. Advanced monitoring such as ETCO2 monitoring is being increasingly used. 3. This work has been largely observational. Does the use of point-of-care cardiac ultrasound during cardiac arrest improve outcomes? Bradycardia can be a normal finding, especially for athletes or during sleep. Many of these techniques and devices require specialized equipment and training. We recommend avoiding hypoxemia in all patients who remain comatose after ROSC. Accurate neurological prognostication is important to avoid inappropriate withdrawal of life-sustaining treatment in patients who may otherwise achieve meaningful neurological recovery and also to avoid ineffective treatment when poor outcome is inevitable (Figure 10).3. It is reasonable to place defibrillation paddles or pads on the exposed chest in an anterolateral or anteroposterior position, and to use a paddle or pad electrode diameter more than 8 cm in adults. 2. The pharmacokinetic properties, acute effects, and clinical efficacy of emergency drugs have primarily been described when given intravenously. Send the second person to retrieve an AED, if one is available. 2. -Enough to make the victim's chest rise. Routine administration of calcium for treatment of cardiac arrest is not recommended. We do not recommend the routine use of rapid infusion of cold IV fluids for prehospital cooling of patients after ROSC. Commercially available defibrillators either provide fixed energy settings or allow for escalating energy settings; both approaches are highly effective in terminating VF/VT. Rescue breathing during CPR with an advanced airway: 12-20 breaths per minute Chest compressions should be given continuously at a rate of 100 to 120 per minute. Immediate defibrillation is reasonable for provider-witnessed or monitored VF/pVT of short duration when a defibrillator is already applied or immediately available. Treatment of atrial fibrillation/flutter depends on the hemodynamic stability of the patient as well as prior history of arrhythmia, comorbidities, and responsiveness to medication. 2. What is the most efficacious management approach for postarrest cardiogenic shock, including A recent systematic review found that no sonographic finding had consistently high sensitivity for clinical outcomes to be used as the sole criterion to terminate cardiac arrest resuscitation. Nonvasopressor medications during cardiac arrest. CPR review pt 2 Flashcards | Quizlet Table 1. 4. Mechanical CPR devices deliver automated chest compressions, thereby eliminating the need for manual chest compressions. Effective ventilation of the patient with a tracheal stoma may require ventilation through the stoma, either by using mouth-to-stoma rescue breaths or by use of a bag-mask technique that creates a tight seal over the stoma with a round, pediatric face mask. 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. One important consideration is the selection of patients for ECPR and further research is needed to define patients who would most benefit from the intervention. Unfortunately, different studies define highly malignant EEG differently or imprecisely, making use of this finding unhelpful. For cardiotoxicity and cardiac arrest from severe hypomagnesemia, in addition to standard ACLS care, IV magnesium is recommended. 4. The key drivers of successful resuscitation from OHCA are lay rescuer cardiopulmonary resuscitation (CPR) and public use of an automated external defibrillator (AED). The esophageal-tracheal tube (sometimes referred to as a combitube) is an advanced airway alternative to ET intubation. performed by the provider with the most experience with airway management using video-laryngoscopy to minimize the number of attempts and the risk of transmission.3 Third, more data are needed to clarify which pa-tients with COVID-19 are least likely to benefit from CPR. Cardiopulmonary Resuscitation During the COVID-19 Pandemic Based on similarly rare but time-critical interventions, planning, simulation training and mock emergencies will assist in facility preparedness. Hemodynamically unstable patients with atrial fibrillation or atrial flutter with rapid ventricular response should receive electric cardioversion. For a victim with a tracheal stoma who requires rescue breathing, either mouth-to-stoma or face mask (pediatric preferred) tostoma ventilation may be reasonable. Team planning for cardiac arrest in pregnancy should be done in collaboration with the obstetric, neonatal, emergency, anesthesiology, intensive care, and cardiac arrest services. Adult/Child/Infant. These techniques can keep blood flowing to the brain and other organs until medical help arrives. Independent of a patients mental status, coronary angiography is reasonable in all postcardiac arrest patients for whom coronary angiography is otherwise indicated. Intraosseous access may be considered if attempts at intravenous access are unsuccessful or not feasible. 3. The approach to cardiac arrest when PE is suspected but not confirmed is less clear, given that a misdiagnosis could place the patient at risk for bleeding without benefit. 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. A wide-complex tachycardia can also be caused by any of these supraventricular arrhythmias when conducted by an accessory pathway (called pre-excited arrhythmias). Several observational studies have demonstrated improved neurologically favorable survival when early coronary angiography is performed followed by PCI in patients with cardiac arrest who have a STEMI. Because of the limitation in exhalational air flow, delivery of large tidal volumes at a higher respiratory rate can lead to progressive worsening of air trapping and a decrease in effective ventilation. A randomized trial investigating this question is ongoing (NCT02056236). 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. PDF ACLS Cardiac Arrest Algorithm - American Heart Association A small number of studies has shown that higher Pao, Observational studies have found that increases in ETCO. 2. Neuroprognostication relies on interpreting the results of diagnostic tests and correlating those results with outcome. We recommend that the findings of a best motor response in the upper extremities being either absent or extensor movements not be used alone for predicting a poor neurological outcome in patients who remain comatose after cardiac arrest. Rescuers may experience anxiety or posttraumatic stress about providing or not providing BLS. Should severely hypothermic patients in VF who fail an initial defibrillation attempt receive additional The theory is that the heart will respond to electric stimuli by producing myocardial contraction and generating forward movement of blood, but clinical trials have not shown pacing to improve patient outcomes. return of spontaneous circulation. In postcardiac surgery patients with asystole or bradycardic arrest in the ICU with pacing leads in place, pacing can be initiated immediately by trained providers. cardiopulmonary resuscitation; EEG, electroencephalogram; ETCO2, end-tidal carbon dioxide; GWR, gray-white ratio; IHCA, in-hospital cardiac arrest; IO, If someone responds, ensure that the phone is at the side of the victim if at all possible. 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. 3. Do steroids improve shock or other outcomes in patients who remain hypotensive after ROSC? 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. When anaphylaxis produces obstructive airway edema, rapid advanced airway management is critical. 2. Cough CPR is described as a repetitive deep inspiration followed by a cough every few seconds before the loss of consciousness. 1. 1. Airway management during cardiac arrest usually commences with a basic strategy such as bag-mask ventilation. Can artifact-filtering algorithms for analysis of ECG rhythms during CPR in a real-time clinical setting Multiple observational studies have shown an association between emergent coronary angiography and PCI and improved neurological outcomes in patients without ST-segment elevation. What do survivor-derived outcome measures of the impact of cardiac arrest survival look like, and how Shout for nearby help and activate the emergency response system (9-1-1, emergency response). 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. Neuroimaging may be helpful after arrest to detect and quantify structural brain injury. These recommendations are supported by the 2020 CoSTR for ALS.11, Recommendation 1 last received formal evidence review in 2010 and is supported by the Guidelines for the Use of an Insulin Infusion for the Management of Hyperglycemia in Critically Ill Patients from the Society for Critical Care Medicine.49 Recommendation 2 is supported by the 2020 CoSTR for ALS.11 Recommendations 3 and 4 last received formal evidence review in 2015.24. A well-conducted human trial showed that administration of propranolol reduces coronary blood flow in patients with cocaine exposure. Three different types of evidence reviews (systematic reviews, scoping reviews, and evidence updates) were used in the 2020 process. On CT, brain edema can be quantified as the GWR, defined as the ratio between the density (measured as Hounsfield units) of the gray matter and the white matter. Many of the tests considered are subject to error because of the effects of medications, organ dysfunction, and temperature. with hydroxocobalamin? 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. One RCT including 355 patients found no difference in outcome between TTM for 24 and 48 hours. 1. Limited animal data and rare case reports suggest possible utility of calcium to improve heart rate and hypotension in -adrenergic blocker toxicity. 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. 1. 2. These recommendations are supported by the 2019 focused update on ACLS guidelines.1. This is a separate question from the decision of if or when to transport a patient to the hospital with resuscitation ongoing. For cardiac arrest with known or suspected hypermagnesemia, in addition to standard ACLS care, it may be reasonable to administer empirical IV calcium. This may include vasopressor agents such as epinephrine (discussed in Vasopressor Medications During Cardiac Arrest) as well as drugs without direct hemodynamic effects (nonpressors) such as antiarrhythmic medications, magnesium, sodium bicarbonate, calcium, or steroids (discussed here). ILCOR Consensus on CPR and Emergency Cardiovascular 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. 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. At very elevated levels, hypermagnesemia can lead to altered consciousness, bradycardia or ventricular arrhythmias, and cardiac arrest.9,10 Hypomagnesemia can occur in the setting of gastrointestinal illness or malnutrition, among other causes, and, when significant, can lead to both atrial and ventricular arrhythmias.11, The ongoing opioid epidemic has resulted in an increase in opioid-associated OHCA, leading to approximately 115 deaths per day in the United States and predominantly impacting patients from 25 to 65 years old.13 Initially, isolated opioid toxicity is associated with CNS and respiratory depression that progresses to respiratory arrest followed by cardiac arrest. 1. 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. 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. The primary focus of cardiac arrest management for providers is the optimization of all critical steps required to improve outcomes. 4. Mouth-to-nose ventilation may be necessary if ventilation through the victims mouth is impossible because of trauma, positioning, or difficulty obtaining a seal. Whether resumption of CPR immediately after shock might reinduce VF/VT is controversial.52-54 This potential concern has not been borne out by any evidence of worsened survival from such a strategy. 2. It is reasonable to immediately resume chest compressions after shock delivery for adults in cardiac arrest in any setting. The paucity of information on the efficacy of IO drug administration during CPR was acknowledged in 2010, but since then the IO route has grown in popularity. Recovery expectations and survivorship plans that address treatment, surveillance, and rehabilitation need to be provided to cardiac arrest survivors and their caregivers at hospital discharge to optimize transitions of care to home and to the outpatient setting. 4. Which populations are most likely to benefit from ECPR? While you lift the jaw, ensure that you are sealing the mask all the way around the outside edge of the mask to obtain a good seal against the victim's face. Although abbreviated observation periods may be adequate for patients with fentanyl, morphine, or heroin overdose. The effectiveness of active compression-decompression CPR is uncertain. IV bolus administration of potassium for cardiac arrest in suspected hypokalemia is not recommended. This is clearly covered topic if you attend a BLS Provider class. 2. 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. An updated systematic review on several aspects of this important topic is needed once currently ongoing clinical trials have been completed. 3. TTM between 32C and 36C for at least 24 hours is currently recommended for all cardiac rhythms in both OHCA and IHCA. 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. 1. Cardiac arrest survivors, their families, and families of nonsurvivors may be powerful advocates for community response to cardiac arrest and patient-centered outcomes. These recommendations are supported by a 2020 ILCOR systematic review.1. 1. The next steps in care, including the performance of CPR and the administration of naloxone, are discussed in detail below. These arrhythmias are common and often coexist, and their treatment recommendations are similar. Based on their greater success in arrhythmia termination, defibrillators using biphasic waveforms are preferred over monophasic defibrillators for treatment of tachyarrhythmias. Multiple RCTs have compared high-dose with standard-dose epinephrine, and although some have shown higher rates of ROSC with high-dose epinephrine, none have shown improvement in survival to discharge or any longer-term outcomes. Before appointment, writing group members disclosed all commercial relationships and other potential (including intellectual) conflicts. 4. 1. Based on the training of the rescuers, and only if scene safety can be maintained for the rescuer, sometimes ventilation can be provided in the water (in-water resuscitation), which may lead to improved patient outcomes compared with delaying ventilation until the victim is out of the water. Although an advanced airway can be placed without interrupting chest compressions. Epinephrine has been hypothesized to have beneficial effects during cardiac arrest primarily because of its -adrenergic effects, leading to increased coronary and cerebral perfusion pressure during CPR. This makes it difficult to plan the next step of care and can potentially delay or even misdirect drug therapies if given empirically (blindly) based on the patients presumed, but not actual, underlying rhythm. What is the interrater agreement for physical examination findings such as pupillary light reflex, corneal Epinephrine should be administered early by intramuscular injection (or autoinjector) to all patients with signs of a systemic allergic reaction, especially hypotension, airway swelling, or difficulty breathing. Deliver air over 1 second, ensuring that the victim's chest rises. 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. Although data specific to patients with ROSC after cardiac arrest from anaphylaxis was not identified, an observational study of anaphylactic shock suggests that IV infusion of epinephrine (515 g/min), along with other resuscitative measures such as volume resuscitation, can be successful in the treatment of anaphylactic shock. 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. Patients in anaphylactic shock are critically ill, and cardiovascular and respiratory status can change quickly, making close monitoring imperative. Observational studies on TTM for IHCA with any initial rhythm have reported mixed results. No RCTs of resternotomy timing have been performed. Manual stabilization can decrease movement of the cervical spine during patient care while allowing for proper ventilation and airway control. 1. When pacing attempts are not immediately successful, standard ACLS including CPR is indicated. Adult CPR Team Approach - ProCPR Magnesium may be considered for treatment of polymorphic VT associated with a long QT interval (torsades de pointes). Does preshock waveform analysis lead to improved outcome? For patients known or suspected to be in cardiac arrest, in the absence of a proven benefit from the use of naloxone, standard resuscitative measures should take priority over naloxone administration, with a focus on high-quality CPR (compressions plus ventilation). 3. This topic last received formal evidence review in 2015.7. 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. Adenosine should not be administered for hemodynamically unstable, irregularly irregular, or polymorphic wide-complex tachycardias. While an expeditious trial of medications and/or fluids may be appropriate in some cases, unstable patients or patients with ongoing cardiac ischemia with atrial fibrillation or atrial flutter need to be cardioverted promptly. overdose with naloxone? Unstable patients require immediate electric cardioversion. There are differing approaches to charging a manual defibrillator during resuscitation. They may repeatedly recur and remit spontaneously, become sustained, or degenerate to VF, for which electric shock may be required. Some treatment recommendations involve medical care and decision-making after return of spontaneous circulation (ROSC) or when resuscitation has been unsuccessful. Operationally, administering epinephrine every second cycle of CPR, after the initial dose, may also be reasonable. National Center Should severely hypothermic patients receive intubation and mechanical ventilation or simply warm When the victim is hypothermic, pulse and respiratory rates may be slow or difficult to detect. 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. OT indicates occupational therapy; PT, physical therapy; PTSD, posttraumatic stress disorder; and SLP, speech-language pathologist, Severe accidental environmental hypothermia (body temperature less than 30C [86F]) causes marked decrease in both heart rate and respiratory rate and may make it difficult to determine if a patient is truly in cardiac arrest.