For each recommendation, the writing group discussed and approved specific recommendation wording and the COR and LOE assignments. How does this affect compressions and ventilations? ALS indicates advanced life support; CPR, cardiopulmonary resuscitation; and EMS, emergency medical services. The value of VF waveform analysis to guide the acute management of adults with cardiac arrest has not been established. 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. For many patients and families, these plans and resources may be paramount to improved quality of life after cardiac arrest. This concern is especially pertinent in the setting of asphyxial cardiac arrest. Carbon monoxide poisoning reduces the ability of hemoglobin to deliver oxygen and also causes direct cellular damage to the brain and myocardium, leading to death or long-term risk of neurological and myocardial injury. The benefit of any specific target range of glucose management is uncertain in adults with ROSC after cardiac arrest. The ResQTrial demonstrated that ACD plus ITD was associated with improved survival to hospital discharge with favorable neurological function for OHCA compared with standard CPR, though this study was limited by a lack of blinding, different CPR feedback elements between the study arms (ie, cointervention), lack of CPR quality assessment, and early TOR. 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. There is no conclusive evidence of superiority of one biphasic shock waveform over another for defibrillation. The 2019 focused update on ACLS guidelines addressed the use of advanced airways in cardiac arrest and noted that either bag-mask ventilation or an advanced airway strategy may be considered during CPR for adult cardiac arrest in any setting.1 Outcomes from advanced airway and bag-mask ventilation interventions are highly dependent on the skill set and experience of the provider (Figure 7). 1. If increased auto-PEEP or sudden decrease in blood pressure is noted in asthmatics receiving assisted ventilation in a periarrest state, a brief disconnection from the bag mask or ventilator with compression of the chest wall to relieve air-trapping can be effective. It promotes the "rest and digest" response that calms the body down after the danger has passed. 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. After cardiac arrest is recognized, the Chain of Survival continues with activation of the emergency response system and initiation of CPR. A randomized trial investigating this question is ongoing (NCT02056236). We recommend selecting and maintaining a constant temperature between 32C and 36C during TTM. Both of these considerations support earlier advanced airway management for the pregnant patient. Other pseudoelectrical therapies, such as cough CPR, fist or percussion pacing, and precordial thump have all been described as temporizing measures in select patients who are either periarrest or in the initial seconds of witnessed cardiac arrest (before losing consciousness in the case of cough CPR) when definitive therapy is not readily available. Agonal breathing is described by lay rescuers with a variety of terms including, Protracted delays in CPR can occur when checking for a pulse at the outset of resuscitation efforts as well as between successive cycles of CPR. Steps of Emergency Management Prevention, mitigation, preparedness, response and recovery are the five steps of Emergency Management. What is the optimal temperature goal for targeted temperature management? 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. When pacing attempts are not immediately successful, standard ACLS including CPR is indicated. 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. When appropriate, flow diagrams or additional tables are included. 1. A more detailed approach to rhythm management is found elsewhere.13, This topic last received formal evidence review in 2010.17, Polymorphic VT refers to a wide-complex tachycardia of ventricular origin with differing configurations of the QRS complex from beat to beat. The intent of precordial thump is to transmit the mechanical force of the thump to the heart as electric energy analogous to a pacing stimulus or very low-energy shock (depending on its force) and is referred to as, Fist, or percussion, pacing is administered with the goal of stimulating an electric impulse sufficient to cause depolarization and contraction of the myocardium, resulting in a pulse. A 7-year-old patient goes into sudden cardiac arrest. 6. When performed with other prognostic tests, it may be reasonable to consider extensive areas of reduced apparent diffusion coefficient (ADC) on brain MRI at 2 to 7 days after cardiac arrest to support the prognosis of poor neurological outcome in patients who remain comatose. Precordial thump is a single, sharp, high-velocity impact (or punch) to the middle sternum by the ulnar aspect of a tightly clenched fist. An approach using lower tidal volumes, lower respiratory rate, and increased expiratory time may minimize the risk of auto-PEEP and barotrauma. Do double sequential defibrillation and/or alternative defibrillator pad positioning affect outcome in Early high-quality CPR You are providing care for Mrs. Bove, who has an endotracheal tube in place. Standardization of methods for quantifying GWR and ADC would be useful. Futility is often defined as less than 1% chance of survival,1 suggesting that for a TOR rule to be valid it should demonstrate high accuracy for predicting futility with the lower confidence limit greater than 99% on external validation. Vital services such as water, The peripheral IV route has been the traditional approach to vascular access for emergency drug and fluid administration during resuscitation. The overall certainty in the evidence of neurological prognostication studies is low because of biases that limit the internal validity of the studies as well as issues of generalizability that limit their external validity. This is a rare opportunity to gain experience working at one of the most sophisticated Security Alarm monitoring and security command centers in North America and be part of a high-performing team . High-quality CPR is, along with defibrillation for those with shockable rhythms, the most important lifesaving intervention for a patient in cardiac arrest. 3. Limited animal data and rare case reports suggest possible utility of calcium to improve heart rate and hypotension in -adrenergic blocker toxicity. Case reports support the use of ECMO for patients with refractory shock due to TCA toxicity. Prognostication of neurological recovery is complex and limited by uncertainty in most cases. 1. do they differ from current generic or clinician-derived measures? Rescuers may experience anxiety or posttraumatic stress about providing or not providing BLS. 2. 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. Emergency Response Plan (ERP) WRITTEN . Incorrect placement, however, can cause an airway obstruction by displacing the tongue to the back of the oropharynx. Multiple observational studies have shown an association between emergent coronary angiography and PCI and improved neurological outcomes in patients without ST-segment elevation. The American Heart Association is a qualified 501(c)(3) tax-exempt organization. However, ECPR may be considered if there is a potentially reversible cause of an arrest that would benefit from temporary cardiorespiratory support. You are providing high-quality CPR on a 6-year-old patient who weighs 44 pounds. A measure of the stiffness of a linear actuator system is the amount of force required to cause a certain linear deflection. Healthcare providers are trained to deliver both compressions and ventilation. 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. Team planning for cardiac arrest in pregnancy should be done in collaboration with the obstetric, neonatal, emergency, anesthesiology, intensive care, and cardiac arrest services. 2. Advanced monitoring such as ETCO2 monitoring is being increasingly used. This protocol is supported by the surgical societies. A wide-complex tachycardia can also be caused by any of these supraventricular arrhythmias when conducted by an accessory pathway (called pre-excited arrhythmias). 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. Drug administration by central venous access (by internal jugular or subclavian vein) achieves higher peak concentrations and more rapid circulation times than drugs administered by peripheral IV do, Endotracheal drug administration is regarded as the least-preferred route of drug administration because it is associated with unpredictable (but generally low) drug concentrations. o Ensuring HVAC systems are in good working order, and ventilation has been increased, where possible. ILCOR Consensus on CPR and Emergency Cardiovascular 2. Rescuers should provide CPR, including rescue breathing, as soon as an unresponsive submersion victim is removed from the water. AEDs are highly accurate in their detection of shockable arrhythmias but require a pause in CPR for automated rhythm analysis. The writing group would also like to acknowledge the outstanding contributions of David J. Magid, MD, MPH. 5. 1. Limited evidence for this intervention consists largely of observational studies, many of which have focused on indications and the relatively high complication rate (including bloodstream infections and pneumothorax, among others). In addition to standard ACLS, specific interventions may be lifesaving for cases of hyperkalemia and hypermagnesemia. 3. 2. 1. IV amiodarone can be useful for rate control in critically ill patients with atrial fibrillation with rapid ventricular response without preexcitation. Cough CPR may be considered as a temporizing measure for the witnessed, monitored onset of a hemodynamically significant tachyarrhythmia or bradyarrhythmia before a loss of consciousness without delaying definitive therapy. 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. 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. 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. You are providing care for Mrs. Bove, who has an endotracheal tube in place. This topic was last reviewed in 2010 and identified 2 randomized trials, interposed abdominal compression CPR performed by trained rescuers improved short-term survival. 2. Which statement is true regarding resuscitation for a pregnant patient? 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. A 2020 ILCOR systematic review. This approach is supported by animal studies and human case reports and has recently been systematically reviewed.4. 2. This topic last received formal evidence review in 2010.22. The most common cause of ventilation difficulty is an improperly opened airway. Emergency drills are conducted in accordance with CF OP 215-4. Adenosine only transiently slows irregularly irregular rhythms, such as atrial fibrillation, rendering it unsuitable for their management. When performed with other prognostic tests, it may be reasonable to consider bilaterally absent pupillary light reflex at 72 h or more after cardiac arrest to support the prognosis of poor neurological outcome in patients who remain comatose. Techniques include administration of warm humidified oxygen, warm IV fluids, and intrathoracic or intraperitoneal warm-water lavage. When bradycardia occurs secondary to a pathological cause, it can lead to decreased cardiac output with resultant hypotension and tissue hypoperfusion. Although theoretically attractive and of some proven benefit in animal studies, none of the latter therapies has been definitively proved to improve overall survival after cardiac arrest, although some may have possible benefit in selected populations and/or special circumstances. A pediatric critical care physician whose areas of specialty include trauma care, emergency medical services, and disaster medicine, Cantwell also has seen the response to disasters change since the Sept. 11 attacks. If any of these occur, take the following steps: Wash needlesticks and cuts with soap and water Flush splashes to the nose, mouth, or skin with water Irrigate eyes with clean water, saline, or sterile irrigants Report the incident to your supervisor Immediately seek medical treatment Vagal maneuvers are recommended for acute treatment in patients with SVT at a regular rate. You and your colleagues have been providing high-quality CPR for and using the AED on Mr. Sauer. What is the ideal sequencing of modalities (traditional vasopressors, calcium, glucagon, high-dose Evidence suggests that patients who are comatose after ROSC benefit from invasive angiography, when indicated, as do patients who are awake. Operationally, the timing for prognostication is typically at least 5 days after ROSC for patients treated with TTM (which is about 72 hours after normothermia) and should be conducted under conditions that minimize the confounding effects of sedating medications. 2. What is the validity and reliability of ETCO. The clinical signs associated with severe hyperkalemia (more than 6.5 mmol/L) include flaccid paralysis, paresthesia, depressed deep tendon reflexes, or shortness of breath.13 The early electrocardiographic signs include peaked T waves on the ECG followed by flattened or absent T waves, prolonged PR interval, widened QRS complex, deepened S waves, and merging of S and T waves.4,5 As hyperkalemia progresses, the ECG can develop idioventricular rhythms, form a sine-wave pattern, and develop into an asystolic cardiac arrest.4,5 Severe hypokalemia is less common but can occur in the setting of gastrointestinal or renal losses and can lead to life-threatening ventricular arrhythmias.68 Severe hypermagnesemia is most likely to occur in the obstetric setting in patients being treated with IV magnesium for preeclampsia or eclampsia. Mechanical CPR devices deliver automated chest compressions, thereby eliminating the need for manual chest compressions. 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. You and your colleagues are performing CPR on a 6-year-old child. 4. Which patients develop affective/psychological disorders of well-being after cardiac arrest, and are they Immediately begin CPR, and use the AED/ defibrillator when available. IV infusion of epinephrine may be considered for post-arrest shock in patients with anaphylaxis. 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. The optimal MAP target after ROSC, however, is not clear. Are there in-hospital interventions that can reduce or prevent physical impairment after cardiac arrest? Anticoagulation alone is inadequate for patients with fulminant PE. cardiac arrest? All outside signs both to me as a person and as a medic said it was no biggie. MEMPHIS, Tenn. Two Memphis Fire Department emergency medical technicians who were fired and had their licenses suspended for failing to . Priorities for the pregnant woman in cardiac arrest should include provision of high-quality CPR and relief of aortocaval compression through left lateral uterine displacement. Active compression-decompression CPR might be considered for use when providers are adequately trained and monitored. 3. It is reasonable that TTM be maintained for at least 24 h after achieving target temperature. Community reintegration and return to work or other activities may be slow and depend on social support and relationships. When the victim cannot be placed in the supine position, it may be reasonable for rescuers to provide CPR with the victim in the prone position, particularly in hospitalized patients with an advanced airway in place. The ALS TOR rule recommends TOR when all of the following criteria apply before moving to the ambulance for transport: (1) arrest was not witnessed; (2) no bystander CPR was provided; (3) no ROSC after full ALS care in the field; and (4) no AED shocks were delivered. A 2015 systematic review reported significant heterogeneity among studies, with some studies, but not all, reporting better rates of survival to hospital discharge associated with higher chest compression fractions. Lifesaving procedures, including standard BLS and ACLS, are therefore important to continue until a patient is rewarmed unless the victim is obviously dead (eg, rigor mortis or nonsurvivable traumatic injury). Most opioid-associated deaths also involve the coingestion of multiple drugs or medical and mental health comorbidities.47. 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. 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. Administration of IV amiodarone, procainamide, or sotalol may be considered for the treatment of wide-complex tachycardia. Immediate defibrillation is the treatment of choice when torsades is sustained or degenerates to VF. It may be reasonable to administer IV lipid emulsion, concomitant with standard resuscitative care, to patients with local anesthetic systemic toxicity (LAST), and particularly to patients who have premonitory neurotoxicity or cardiac arrest due to bupivacaine toxicity. Thrombolysis may be considered when cardiac arrest is suspected to be caused by pulmonary embolism. When Mr. Phillips shows signs of ROSC, where should you perform the pulse check? A former Memphis Fire Department emergency medical technician has told a Tennessee board that officers "impeded patient care" by refusing to remove Tyre Nichols' handcuffs, which would have . 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. When VF/VT has been present for more than a few minutes, myocardial reserves of oxygen and other energy substrates are rapidly depleted. You are providing compressions on a 6-month-old who weighs 17 pounds. With respect to timing, for cardiac arrest with a shockable rhythm, it may be reasonable to administer epinephrine after initial defibrillation attempts have failed. 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. What is the best approach to rewarming postarrest patients after treatment with targeted temperature Atrial fibrillation or flutter with rapid ventricular In adult victims of cardiac arrest, it is reasonable for rescuers to perform chest compressions at a rate of 100 to 120/min. 1. The suggested timing of the multimodal diagnostics is shown here. Healthcare providers often take too long to check for a pulse. 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. Your adult patient is in respiratory arrest due to an opioid overdose. We recommend that the absence of EEG reactivity within 72 h after arrest not be used alone to support a poor neurological prognosis. 2. 1. 3. This recommendation is based on expert consensus and pathophysiologic rationale. 2. 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. Conversely, a regular wide-complex tachycardia could represent monomorphic VT or an aberrantly conducted reentrant paroxysmal SVT, ectopic atrial tachycardia, or atrial flutter. Technologies are now in development to diagnose the underlying cardiac rhythm during ongoing CPR and to derive prognostic information from the ventricular waveform that can help guide patient management. Unfortunately, despite improvements in the design and funding support for resuscitation research, the overall certainty of the evidence base for resuscitation science is low. A description of the situation (e.g. 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. 1. Robert Long, whose license was suspended for failing to give aid to Nichols and who has also been fired, appeared by . An IV dose of 0.05 to 0.1 mg (5% to 10% of the epinephrine dose used routinely in cardiac arrest) has been used successfully for anaphylactic shock. 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. What are the optimal pharmacological treatment regimens for the management of postarrest seizures? 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. After return of spontaneous breathing, patients should be observed in a healthcare setting until the risk of recurrent opioid toxicity is low and the patients level of consciousness and vital signs have normalized. The management of patients with preexcitation syndromes (aka Wolff-Parkinson-White) is covered in the Wide-Complex Tachycardia section. When performed with other prognostic tests, it may be reasonable to consider persistent status epilepticus 72 h or more after cardiac arrest to support the prognosis of poor neurological outcome. Acute increase in right ventricular pressure due to pulmonary artery obstruction and release of vasoactive mediators produces cardiogenic shock that may rapidly progress to cardiovascular collapse. 1. One study found no difference in survival with good neurological outcome at 3 months in patients monitored with routine (one to two 20-minute EEGs over 24 hours) versus continuous (for 1824 hours) EEG. Chest compressions are the most critical component of CPR, and a chest compressiononly approach is appropriate if lay rescuers are untrained or unwilling to provide respirations. 1. EMS systems that perform prehospital intubation should provide a program of ongoing quality improvement to minimize complications and track overall supraglottic airway and endotracheal tube placement success rates. Atrial fibrillation is an SVT consisting of disorganized atrial electric activation and uncoordinated atrial contraction. ADRIAN SAINZ Associated Press. The treatment of nonconvulsive seizures (diagnosed by EEG only) may be considered. Evidence in humans of the effect of vasopressors or other medications during cardiac arrest in the setting of hypothermia consists of case reports only. DWI/ADC is a sensitive measure of injury, with normal values ranging between 700 and 800106 mm2 /s and values decreasing with injury. Management of hemodynamically unstable patients with SVT must start with prompt restoration of sinus rhythm through the use of cardioversion. A single shock strategy is reasonable in preference to stacked shocks for defibrillation in the setting of unmonitored cardiac arrest. Early defibrillation improves outcome from cardiac arrest. Multiple case reports have observed intracranial placement of nasopharyngeal airways in patients with basilar skull fractures. Discharges on EEG were divided into 2 types: rhythmic/periodic and nonrhythmic/periodic. In the setting of head and neck trauma, a head tiltchin lift maneuver should be performed if the airway cannot be opened with a jaw thrust and airway adjunct insertion. CPR duty cycle refers to the proportion of time spent in compression relative to the total time of the compression plus decompression cycle. The systemic impact of the ischemia-reperfusion injury caused by cardiac arrest and subsequent resuscitation requires postcardiac arrest care to simultaneously support the multiple organ systems that are affected. Look for no breathing or only gasping, at the direction of the telecommunicator. What is the optimal treatment for hyperkalemia with life-threatening arrhythmia or cardiac arrest? 2. Poisoning from other cardiac glycosides, such as oleander, foxglove, and digitoxin, have similar effects. You are alone caring for a 4-month-old infant who has gone into cardiac arrest. Although a few EMS systems have demonstrated the ability to significantly increase survival rates (Nichol et al . Transcutaneous pacing has been studied during cardiac arrest with bradyasystolic cardiac rhythm. The same anticonvulsant regimens used for the treatment of seizures caused by other etiologies may be considered for seizures detected after cardiac arrest. In accordance with the BSEE Safety and Environment Management System II, an Emergency Action Plan (EAP) should be in place. You are preparing to deliver ventilations to an adult patient experiencing respiratory arrest. 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.
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