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. Because of their negative inotropic effect, nondihydropyridine calcium channel antagonists (eg, diltiazem, verapamil) may further decompensate patients with left ventricular systolic dysfunction and symptomatic heart failure. 1. 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). 1. Cyanide reversibly binds to the ferric ion cytochrome oxidase in the mitochondria and stops cellular respiration and adenosine triphosphate production. In addition, specific recommendations about the training of resuscitation providers are provided in Part 6: Resuscitation Education Science, and recommendations about systems of care are provided in Part 7: Systems of Care.. It is reasonable for a rescuer to use mouth-to-nose ventilation if ventilation through the victims mouth is impossible or impractical. In addition, status myoclonus may have an EEG correlate that is not clearly ictal but may have prognostic meaning, and additional research is needed to delineate these patterns. 2023 American Heart Association, Inc. All rights reserved. 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. Clinical examination findings correlate with poor outcome but are also subject to confounding by TTM and medications, and prior studies have methodological limitations. These recommendations are supported by the 2019 focused update on ACLS guidelines.1. 4. In postcardiac surgery patients who are refractory to standard resuscitation procedures, mechanical circulatory support may be effective in improving outcome. 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. Unfortunately, despite improvements in the design and funding support for resuscitation research, the overall certainty of the evidence base for resuscitation science is low. It may be reasonable to actively prevent fever in comatose patients after TTM. To assure successful maternal resuscitation, all potential stakeholders need to be engaged in the planning and training for cardiac arrest in pregnancy, including the possible need for PMCD. In patients with -adrenergic blocker overdose who are in refractory shock, administration of high-dose insulin with glucose is reasonable. Give 2 breaths. All guidelines were reviewed and approved for publication by the AHA Science Advisory and Coordinating Committee and the AHA Executive Committee. Symptomatic bradycardia may be caused by a number of potentially reversible or treatable causes, including structural heart disease, increased vagal tone, hypoxemia, myocardial ischemia, or medications. AED indicates automated external defibrillator; ALS, advanced life support; BLS, basic life support; and CPR, cardiopulmonary resuscitation. 2. Do steroids improve shock or other outcomes in patients who remain hypotensive after ROSC? If this is not known, defibrillation at the maximal dose may be considered. Cocaine toxicity can cause adverse effects on the cardiovascular system, including dysrhythmia, hypertension, tachycardia and coronary artery vasospasm, and cardiac conduction delays. 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. If an advanced airway is used, a supraglottic airway can be used for adults with OHCA in settings with low tracheal intubation success rates or minimal training opportunities for endotracheal tube placement. It is a treatment technique, which is given when the patient is having a cardiac arrest. The main focus in adult cardiac arrest events includes rapid recognition, prompt provision of CPR, defibrillation of malignant shockable rhythms, and post-ROSC supportive care and treatment of underlying causes. Performance of high-quality CPR includes adequate compression depth and rate while minimizing pauses in compressions. The usefulness of S100 calcium-binding protein (S100B), Tau, neurofilament light chain, and glial fibrillary acidic protein in neuroprognostication is uncertain. outcomes? While you lift the jaw, press firmly and completely around the outside edge of the mask to seal the pocket mask against the face. In patients with -adrenergic blocker overdose who are in shock refractory to pharmacological therapy, ECMO might be considered. Nondihydropyridine calcium channel antagonists and IV -adrenergic blockers should not be used in patients with left ventricular systolic dysfunction and decompensated heart failure because these may lead to further hemodynamic compromise. This protocol is supported by the surgical societies. 1. The precordial thump should not be used routinely for established cardiac arrest. Although not new, this is a 2015 American Heart Association guideline. Though effective for treating a wide-complex tachycardia known to be of supraventricular origin and not involving accessory pathway conduction, verapamils negative inotropic and hypotensive effects can destabilize VT. 1-800-AHA-USA-1 2. Each of the 2020 Guidelines documents were submitted for blinded peer review to 5 subject-matter experts nominated by the AHA. For many patients and families, these plans and resources may be paramount to improved quality of life after cardiac arrest. Its effects are mediated by a different mechanism and are longer lasting than adenosine. Three different types of evidence reviews (systematic reviews, scoping reviews, and evidence updates) were used in the 2020 process. Similar challenges were faced in the 2020 Guidelines process, where a number of critical knowledge gaps were identified in adult cardiac arrest management. Given the potential for the rapid development of oropharyngeal or laryngeal edema, immediate referral to a health professional with expertise in advanced airway placement, including surgical airway management, is recommended. In light of the complexity of postarrest patients, a multidisciplinary team with expertise in cardiac arrest care is preferred, and the development of multidisciplinary protocols is critical to optimize survival and neurological outcome. The trachea, which is sometimes called the windpipe, conducts air down into the lungs through the bronchi, which are smaller tubular branches. In addition, deterioration of fetal status may be an early warning sign of maternal decompensation. These recommendations are supported by the 2018 American College of Cardiology, AHA, and Heart Rhythm Society guideline on the evaluation and management of patients with bradycardia and cardiac conduction delay.16. 4. Simultaneous compressions and ventilation should be avoided,2 but delivery of chest compressions without pausing for ventilation seems a reasonable option.3 The use of SGAs adds to this complexity because efficiency of ventilation during cardiac arrest may be worse than when using an endotracheal tube, though this has not been borne out in recently published RCTs.4,5, This topic last received formal evidence review in 2010.15, These recommendations are supported by the 2017 focused update on adult BLS and CPR quality guidelines.20. Serum biomarkers are blood-based tests that measure the concentration of proteins normally found in the central nervous system (CNS). The AHA has rigorous conflict of interest policies and procedures to minimize the risk of bias or improper influence during the development of guidelines. This is a separate question from the decision of if or when to transport a patient to the hospital with resuscitation ongoing. 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. Compression rate and compression depth, for example, have both been associated with better outcomes, yet these variables have been found to be inversely correlated with each other so that improving one may worsen the other.13 CPR quality interventions are often applied in bundles, making the benefit of any one specific measure difficult to ascertain. For patients with cardiac arrest after cardiac surgery, it is reasonable to perform resternotomy early in an appropriately staffed and equipped ICU. The controlled administration of IV potassium for ventricular arrhythmias due to severe hypokalemia may be useful, but case reports have generally included infusion of potassium and not bolus dosing. 1. Excessive ventilation is unnecessary and can cause gastric inflation, regurgitation, and aspiration. There is a need for further research specifically on the interface between patient factors and the 4. This topic last received formal evidence review in 2010.10, Local anesthetic overdose (also known as local anesthetic systemic toxicity, or LAST) is a life-threatening emergency that can present with neurotoxicity or fulminant cardiovascular collapse.1,2 The most commonly reported agents associated with LAST are bupivacaine, lidocaine, and ropivacaine.2, By definition, LAST is a special circumstance in which alternative approaches should be considered in addition to standard BLS and ALS. There is insufficient evidence to recommend the routine use of extracorporeal CPR (ECPR) for patients with cardiac arrest. 2. 1. Which patients with cardiac arrest due to suspected pulmonary embolism benefit from emergency These recommendations are supported by the 2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay: A Report of the American College of Cardiology/AHA Task Force on Clinical Practice Guidelines and the Heart Rhythm Society.2, These recommendations are supported by the 2018 American College of Cardiology, AHA, and Heart Rhythm Society guideline on the evaluation and management of patients with bradycardia and cardiac conduction delay.2. Injection of epinephrine into the lateral aspect of the thigh produces rapid peak plasma epinephrine concentrations. 4. 1. 2, and 3. Deliver air over 1 second, ensuring that the victim's chest rises. After cardiac arrest is recognized, the Chain of Survival continues with activation of the emergency response system and initiation of CPR. 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. Like all patients with cardiac arrest, the immediate goal is restoration of perfusion with CPR, initiation of ACLS, and rapid identification and correction of the cause of cardiac arrest. 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. Survivorship after cardiac arrest is the journey through rehabilitation and recovery and highlights the far-reaching impact on patients, families, healthcare partners, and communities (Figure 11).13. However, these case reports are subject to publication bias and should not be used to support its effectiveness. cardiac arrest with shockable rhythm? Mechanical CPR devices deliver automated chest compressions, thereby eliminating the need for manual chest compressions. 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. Atropine has been shown to be effective for the treatment of symptomatic bradycardia in both observational studies and in 1 limited RCT. 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. Step 2: Open the airway. Do antiarrhythmic drugs, when given in combination for cardiac arrest, improve outcomes from cardiac Urgent support of airway, breathing, and circulation is essential in suspected anaphylactic reactions. In patients with anaphylactic shock, close hemodynamic monitoring is recommended. The optimal MAP target after ROSC, however, is not clear. Additional investigations are necessary to evaluate cost-effectiveness, resource allocation, and ethics surrounding the routine use of ECPR in resuscitation. No shock waveform has distinguished itself as achieving a consistently higher rate of ROSC or survival. Administration of epinephrine may be lifesaving. Resuscitation from cardiac arrest caused by -adrenergic blocker or calcium channel blocker overdose follows standard resuscitation guidelines. Some EEG-correlated patterns of status myoclonus may have poor prognosis, but there may also be more benign subtypes of status myoclonus with EEG correlates. 1. 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. Neuroprognostication relies on interpreting the results of diagnostic tests and correlating those results with outcome. 2. Anticoagulation alone is inadequate for patients with fulminant PE. Mouth-to-mouth ventilation in the water may be helpful when administered by a trained rescuer if it does not compromise safety. Intraosseous access may be considered if attempts at intravenous access are unsuccessful or not feasible. We recommend TTM for adults who do not follow commands after ROSC from IHCA with initial nonshockable rhythm. Multiple case series have demonstrated potential benefit from mechanical circulatory support including ECMO and cardiopulmonary bypass in patients who are refractory to standard resuscitation procedures. Taking a regular rather than a deep breath prevents the rescuer from getting dizzy or lightheaded and prevents overinflation of the victims lungs. When performed with other prognostic tests, it may be reasonable to consider status myoclonus that occurs within 72 h after cardiac arrest to support the prognosis of poor neurological outcome. After identifying a cardiac arrest, a lone responder should activate the emergency response system first and immediately begin CPR. 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. This Recovery link highlights the enormous recovery and survivorship journey, from the end of acute treatment for critical illness through multimodal rehabilitation (both short- and long-term), for both survivors and families after cardiac arrest. Alternatives to IV access for acute drug administration include IO, central venous, intracardiac, and endotracheal routes. Prompt initiation of targeted temperature management is necessary for all patients who do not follow commands after return of spontaneous circulation to ensure optimal functional and neurological outcome. 2. 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. 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. Once an advanced airway is emplaced and confirmed, chest compressions should be performed continuously at a rate of at least 100 per minute. 1. The electric energy required to successfully cardiovert a patient from atrial fibrillation or atrial flutter to sinus rhythm varies and is generally less in patients with new-onset arrhythmia, thin body habitus, and when biphasic waveform shocks are delivered. 2. The rationale for tracking the overall success rate for systems performing ETI is to make informed decisions as to whether practice should allow for ETI, move toward SGA, or simply use bag-mask ventilation for patients in cardiac arrest; recommendations will vary depending on the overall success rate in a given system. reliably checking a pulse, is initiation of CPR beneficial? Clinical trials in resuscitation are sorely needed.