how is cpr performed differently with advanced airway

These include the high success rate of the first shock with biphasic waveforms (lessening the need for successive shocks), the declining success of immediate second and third serial shocks when the first shock has failed. 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. IV diltiazem or verapamil can be effective for acute treatment in patients with hemodynamically stable SVT at a regular rate. When pacing attempts are not immediately successful, standard ACLS including CPR is indicated. Survivorship plans that address treatment, surveillance, and rehabilitation need to be provided at hospital discharge to optimize transitions of care to the outpatient setting. 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. This topic was previously reviewed by ILCOR in 2015. 2. Agonal breathing is characterized by slow, irregular gasping respirations that are ineffective for ventilation. Neuroprognostication relies on interpreting the results of diagnostic tests and correlating those results with outcome. The Adult Cardiovascular Life Support Writing Group included a diverse group of experts with backgrounds in emergency medicine, critical care, cardiology, toxicology, neurology, EMS, education, research, and public health, along with content experts, AHA staff, and the AHA senior science editors. In cases of prehospital maternal arrest, rapid transport directly to a facility capable of PMCD and neonatal resuscitation, with early activation of the receiving facilitys adult resuscitation, obstetric, and neonatal resuscitation teams, provides the best chance for a successful outcome. 1. Transcutaneous pacing has been studied during cardiac arrest with bradyasystolic cardiac rhythm. For adults in cardiac arrest receiving ventilation, tidal volumes of approximately 500 to 600 mL, or enough to produce visible chest rise, are reasonable. Many cardiac arrest patients who survive the initial event will eventually die because of withdrawal of life-sustaining treatment in the setting of neurological injury. Continuous waveform capnography is recommended in addition to clinical assessment as the most reliable method of confirming and monitoring correct placement of an endotracheal tube. 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. Hemodynamically unstable patients and those with rate-related ischemia should receive urgent electric cardioversion. 1. What are the ideal dose and formulation of IV lipid emulsion therapy? Are glial fibrillary acidic protein, serum tau protein, and neurofilament light chain valuable for Beginning the CPR sequence with compression. Key Numbers for CPR: Ratios, Compression rates & more | AED CPR There are a number of case reports and case series that examined the use of fist pacing during asystolic or life-threatening bradycardic events. 4. If a victim is unconscious/unresponsive, with absent or abnormal breathing (ie, only gasping), the lay rescuer should assume the victim is in cardiac arrest. A 2017 ILCOR systematic review found that a ratio of 30 compressions to 2 breaths was associated with better survival than alternate ratios, a recommendation that was reaffirmed by the AHA in 2018. 4. 1. It is reasonable that TTM be maintained for at least 24 h after achieving target temperature. A randomized trial investigating this question is ongoing (NCT02056236). 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. Both of these considerations support earlier advanced airway management for the pregnant patient. 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. In patients without an advanced airway, it is reasonable to deliver breaths either by mouth or by using bag-mask ventilation. Clinicians must determine if the tachycardia is narrow-complex or wide-complex tachycardia and if it has a regular or irregular rhythm. It is reasonable for healthcare providers to perform chest compressions and ventilation for all adult patients in cardiac arrest from either a cardiac or noncardiac cause. 2. If a victim is unconscious/unresponsive, with absent or abnormal breathing (ie, only gasping), the healthcare provider should check for a pulse for no more than 10 s and, if no definite pulse is felt, should assume the victim is in cardiac arrest. 4. When providing rescue breaths, it may be reasonable to give 1 breath over 1 s, take a regular (not deep) breath, and give a second rescue breath over 1 s. 4. For severe symptomatic bradycardia causing shock, if no IV or IO access is available, immediate transcutaneous pacing while access is being pursued may be undertaken. Adenosine will not typically terminate atrial arrhythmias (such as atrial flutter or atrial tachycardia) but will transiently slow the ventricular rate by blocking conduction of P waves through the AV node, afford their recognition, and help establish the rhythm diagnosis. What is the optimal treatment for hyperkalemia with life-threatening arrhythmia or cardiac arrest? 1. 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. Findings in both animal studies and human case reports/case series on the effect of glucagon in calcium channel blocker toxicity have been inconsistent, with some reporting increase in heart rate and some reporting no effect. Before embarking on empirical drug therapy, obtaining a 12-lead ECG and/or seeking expert consultation for diagnosis is encouraged, if available. Recommendations 1 and 2 are supported by the 2020 CoSTR for ALS.22 Recommendations 3 and 4 last received formal evidence review in 2010.20. What is the interrater agreement for physical examination findings such as pupillary light reflex, corneal The writing group acknowledges the following contributors: Julie Arafeh, RN, MSN; Justin L. Benoit, MD, MS; Maureen Chase; MD, MPH; Antonio Fernandez; Edison Ferreira de Paiva, MD, PhD; Bryan L. Fischberg, NRP; Gustavo E. Flores, MD, EMT-P; Peter Fromm, MPH, RN; Raul Gazmuri, MD, PhD; Blayke Courtney Gibson, MD; Theresa Hoadley, MD, PhD; Cindy H. Hsu, MD, PhD; Mahmoud Issa, MD; Adam Kessler, DO; Mark S. Link, MD; David J. Magid, MD, MPH; Keith Marrill, MD; Tonia Nicholson, MBBS; Joseph P. Ornato, MD; Garrett Pacheco, MD; Michael Parr, MB; Rahul Pawar, MBBS, MD; James Jaxton, MD; Sarah M. Perman, MD, MSCE; James Pribble, MD; Derek Robinett, MD; Daniel Rolston, MD; Comilla Sasson, MD, PhD; Sree Veena Satyapriya, MD; Travis Sharkey, MD, PhD; Jasmeet Soar, MA, MB, BChir; Deb Torman, MBA, MEd, AT, ATC, EMT-P; Benjamin Von Schweinitz; Anezi Uzendu, MD; and Carolyn M. Zelop, MD. Bradycardia is generally defined as a heart rate less than 60/min. 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. There is concern that delivery of chest compressions without assisted ventilation for prolonged periods could be less effective than conventional CPR (compressions plus breaths) because the arterial oxygen content will decrease as CPR duration increases. Look for no breathing or only gasping, at the direction of the telecommunicator. The AED was attached, and ''no shock'' was advised. 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. Although the administration of IV magnesium has not been found to be beneficial for VF/VT in the absence of prolonged QT, consideration of its use for cardiac arrest in patients with prolonged QT is advised. Can point-of-care cardiac ultrasound, in conjunction with other factors, inform termination of Emergent coronary angiography is reasonable for select (eg, electrically or hemodynamically unstable) adult patients who are comatose after OHCA of suspected cardiac origin but without ST-segment elevation on ECG. Existing evidence, including observational and quasi-RCT data, suggests that pacing by a transcutaneous, transvenous, or transmyocardial approach in cardiac arrest does not improve the likelihood of ROSC or survival, regardless of the timing of pacing administration in established asystole, location of arrest (in-hospital or out-of-hospital), or primary cardiac rhythm (asystole, pulseless electrical activity). However, the most critical feature in the diagnosis and treatment of polymorphic VT is not the morphology of rhythm but rather what is known (or suspected) about the patients underlying QT interval. Because of their longer duration of action, antiarrhythmic agents may also be useful to prevent recurrences of wide-complex tachycardia. In patients with anaphylactic shock, close hemodynamic monitoring is recommended. If no advanced airway, 30:2 compression-ventilation ratio. Key topics in postresuscitation care that are not covered in this section, but are discussed later, are targeted temperature management (TTM) (Targeted Temperature Management), percutaneous coronary intervention (PCI) in cardiac arrest (PCI After Cardiac Arrest), neuroprognostication (Neuroprognostication), and recovery (Recovery). 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. 2. 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. 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. Given that a false-positive test for poor neurological outcome could lead to inappropriate withdrawal of life support from a patient who otherwise would have recovered, the most important test characteristic is specificity. 3. There is no proven benefit from the use of antihistamines, inhaled beta agonists, and IV corticosteroids during anaphylaxis-induced cardiac arrest. IV bolus administration of potassium for cardiac arrest in suspected hypokalemia is not recommended. 3. 3. Immediately begin CPR, and use the AED/ defibrillator when available. In postcardiac surgery patients who are refractory to standard resuscitation procedures, mechanical circulatory support may be effective in improving outcome. Recommendations 1, 2, and 3 are supported by the 2020 CoSTR for BLS.4 Recommendation 4 last received formal evidence review in 2010.17, Recommendations 1 and 4 are supported by the 2020 CoSTR for BLS.4 Recommendations 2, 3, 5, and 6 last received formal evidence review in 2015.31, Recommendations 1, 2, and 3 are supported by the 2020 CoSTR for BLS.4 Recommendation 4 last received formal evidence review in 2010.44, These recommendations are supported by the 2020 CoSTRs for BLS and ALS.4,49. In the absence of knowing the manufacturers recommendation for appropriate energy settings, the previous 2010 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care (and reaffirmed in 2015) recommendations for synchronized cardioversion are still applicable [Narrow regular: 50-100 J; Narrow irregular: 120-200 J biphasic or 200 J monophasic; Wide regular: 100 J; Wide irregular: defibrillation dose (not synchronized)]. A 2017 systematic review identified 1 observational human study and 10 animal studies comparing different ventilation rates after advanced airway placement. What is the validity and reliability of ETCO. Several RCTs have compared a titrated approach to oxygen administration with an approach of administering 100% oxygen in the first 1 to 2 hours after ROSC. It may be reasonable to perform chest compressions so that chest compression and recoil/relaxation times are approximately equal. 1. 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. 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. spontaneous circulation; S100B, S100 calcium binding protein; STEMI, ST-segment elevation myocardial infarction; and VF, ventricular fibrillation. 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. A recent meta-analysis of 13 RCTs (990 evaluable patients) found that adverse events and serious adverse events were more common in patients who were randomized to receive flumazenil than placebo (number needed to harm: 5.5 for all adverse events and 50 for serious adverse events). 2. One RCT including 355 patients found no difference in outcome between TTM for 24 and 48 hours. Although abbreviated observation periods may be adequate for patients with fentanyl, morphine, or heroin overdose. Lay rescuerCPR improves survival from cardiac arrest by 2- to 3-fold.1 The benefit of providing CPR to a patient in cardiac arrest outweighs any potential risk of providing chest compressions to someone who is unconscious but not in cardiac arrest. These recommendations are supported by the 2019 AHA Focused Update on Advanced Cardiovascular Life Support: Use of Advanced Airways, Vasopressors, and Extracorporeal CPR During Cardiac Arrest: An Update to the AHA Guidelines for CPR and Emergency Cardiovascular Care.12. When this method is carried out by an inexperienced individual, it can result in serious trauma related to the oropharynx. It may be reasonable to use physiological parameters such as arterial blood pressure or end-tidal CO. 1. 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. When bradycardia occurs secondary to a pathological cause, it can lead to decreased cardiac output with resultant hypotension and tissue hypoperfusion. To maintain provider skills from initial training, frequent retraining is important. It is critical for community members to recognize cardiac arrest, phone 9-1-1 (or the local emergency response number), perform CPR (including, for untrained lay rescuers, compression-only CPR), and use an AED.3,4 Emergency medical personnel are then called to the scene, continue resuscitation, and transport the patient for stabilization and definitive management. The routine use of cricoid pressure in adult cardiac arrest is not recommended. 1. This is a separate question from the decision of if or when to transport a patient to the hospital with resuscitation ongoing. A 2020 ILCOR systematic review found 2 RCTs and a small number of observational studies evaluating the effect of prophylactic antibiotics on outcomes in postarrest patients. 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. More uniform definitions for status epilepticus, malignant EEG patterns, and other EEG patterns are Based on similarly rare but time-critical interventions, planning, simulation training and mock emergencies will assist in facility preparedness. Routine administration of calcium for treatment of cardiac arrest is not recommended. The clinical manifestations of bradycardia can range from an absence of symptoms to symptomatic bradycardia (bradycardia associated with acutely altered mental status, ischemic chest discomfort, acute heart failure, hypotension, or other signs of shock that persist despite adequate airway and breathing). 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). If an experienced sonographer is present and use of ultrasound does not interfere with the standard cardiac arrest treatment protocol, then ultrasound may be considered as an adjunct to standard patient evaluation, although its usefulness has not been well established. ADC indicates apparent diffusion coefficient; CPR, cardiopulmonary resuscitation; CT, computed tomography; ECG, electrocardiogram; ECPR, extracorporeal Clinical Practice Guidelines for the Treatment and Prevention of Drowning: 2019 Update.20. It is not uncommon for chest compressions to be paused for rhythm detection and continue to be withheld while the defibrillator is charged and prepared for shock delivery. However, electric cardioversion may not be effective for automatic tachycardias (such as ectopic atrial tachycardias), entails risks associated with sedation, and does not prevent recurrences of the wide-complex tachycardia. The reported incidence of cervical spine injury in drowning victims is low (0.009%). Many alternatives and adjuncts to conventional CPR have been developed. 3. The systems-of-care approach to cardiac arrest includes the community and healthcare response to cardiac arrest. Can artifact-filtering algorithms for analysis of ECG rhythms during CPR in a real-time clinical setting Each recommendation was developed and formally approved by the writing group. 1. Airway management during cardiac arrest usually commences with a basic strategy such as bag-mask ventilation. 6. It can sometimes take the form of intubation. Much of the published research involves patients whose arrests were presumed to be of cardiac origin and in settings with short EMS response times. 2. We recommend TTM for adults who do not follow commands after ROSC from IHCA with initial shockable rhythm. Studies on push-dose epinephrine for bradycardia specifically are lacking, although limited data support its use for hypotension. 1. The presence of undifferentiated myoclonic movements after cardiac arrest should not be used to support a poor neurological prognosis. Instead, the compressing rescuer should give continuous chest compressions at a rate of 100 per minute without pauses for ventilation. 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. Data from 1 RCT. It is important to underscore that while cough CPR by definition cannot be used for an unconscious patient, it can be harmful in any setting if diverting time, effort, and attention from performing high-quality CPR. It remains to be tested whether patients with signs of shock benefit from emergent coronary angiography and PCI. In cases of suspected opioid overdose managed by a nonhealthcare provider who is not capable of 2. IV lidocaine, amiodarone, and measures to treat myocardial ischemia may be considered to treat polymorphic VT in the absence of a prolonged QT interval. Closed on Sundays. 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. 2. 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. Based on their greater success in arrhythmia termination, defibrillators using biphasic waveforms are preferred over monophasic defibrillators for treatment of tachyarrhythmias. It may be reasonable to perform defibrillation attempts according to the standard BLS algorithm concurrent with rewarming strategies. If a spinal injury is suspected or cannot be ruled out, providers should open the airway by using a jaw thrust instead of head tiltchin lift. Each of these features can also be useful in making a presumptive rhythm diagnosis. Copy. Recovery and survivorship after cardiac arrest. No shock waveform has distinguished itself as achieving a consistently higher rate of ROSC or survival. It is reasonable for providers to first attempt establishing intravenous access for drug administration in cardiac arrest. 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. 3. Digoxin poisoning can cause severe bradycardia, AV nodal blockade, and life-threatening ventricular arrhythmias. Patients who respond to naloxone administration may develop recurrent CNS and/or respiratory depression. More research in this area is clearly needed. This topic last received formal evidence review in 2015,8 with an evidence update conducted for the 2020 CoSTR for ALS.2. The 2015 Guidelines Update recommended emergent coronary angiography for patients with ST-segment elevation on the post-ROSC ECG. In patients with -adrenergic blocker overdose who are in refractory shock, administration of IV glucagon is reasonable. All guidelines were reviewed and approved for publication by the AHA Science Advisory and Coordinating Committee and the AHA Executive Committee. 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. Does targeted temperature management, compared to strict normothermia, improve outcomes? AEDs are highly accurate in their detection of shockable arrhythmias but require a pause in CPR for automated rhythm analysis. 4. What is the optimal duration for targeted temperature management before rewarming? It may be reasonable to charge a manual defibrillator during chest compressions either before or after a scheduled rhythm analysis. If an advanced airway is used, either a supraglottic airway or endotracheal intubation can be used for adults with OHCA in settings with high tracheal intubation success rates or optimal training opportunities for endotracheal tube placement. 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. The pharmacokinetic properties, acute effects, and clinical efficacy of emergency drugs have primarily been described when given intravenously. 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. This involves the cannulation of a large vein and artery and initiation of venoarterial extracorporeal circulation and membrane oxygenation (ECMO) (Figure 8). IV -adrenergic blockers are reasonable for acute treatment in patients with hemodynamically stable SVT at a regular rate. Both mouth-to-mouth rescue breathing and bagmask ventilation provide oxygen and ventilation to the victim. Before appointment, writing group members disclosed all commercial relationships and other potential (including intellectual) conflicts. Is there a consistent threshold value for prognostication for GWR or ADC? In small case series, IV magnesium has been effective in suppressing and preventing recurrences of. 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. 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. There are 2 different types of mechanical CPR devices: a load-distributing compression band that compresses the entire thorax circumferentially and a pneumatic piston device that compresses the chest in an anteroposterior direction. IV amiodarone can be useful for rate control in critically ill patients with atrial fibrillation with rapid ventricular response without preexcitation. Normal brain has a GWR of approximately 1.3, and this number decreases with edema. Extracorporeal CPR is performed with an extracorporeal membrane oxygenation device. These deliver different peak currents even at the same programmed energy setting, making comparisons of shock efficacy between devices challenging. The same anticonvulsant regimens used for the treatment of seizures caused by other etiologies may be considered for seizures detected after cardiac arrest. 1. 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. In patients with confirmed pulmonary embolism as the precipitant of cardiac arrest, thrombolysis, surgical embolectomy, and mechanical embolectomy are reasonable emergency treatment options. Point-of-care cardiac ultrasound can identify cardiac tamponade or other potentially reversible causes of cardiac arrest and identify cardiac motion in pulseless electrical activity. 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. If replenished by a period of CPR before shock, defibrillation success improves significantly. 4. 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. Early defibrillation improves outcome from cardiac arrest. 1. ACLS indicates advanced cardiovascular life support; BLS, basic life support; CPR, cardiopulmonary resuscitation; ET, endotracheal; IV, intravenous; and ROSC, For shockable rhythms, trial protocols have directed that epinephrine be given after the third shock. Thus, the confidence in the prognostication of the diagnostic tests studied is also low. Of the 250 recommendations in these guidelines, only 2 recommendations are supported by Level A evidence (high-quality evidence from more than 1 randomized controlled trial [RCT], or 1 or more RCT corroborated by high-quality registry studies.) 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.

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