You are preparing to deliver ventilations to an adult patient experiencing respiratory arrest. Uncontrolled tachycardia may impair ventricular filling, cardiac output, and coronary perfusion while increasing myocardial oxygen demand. Should severely hypothermic patients in VF who fail an initial defibrillation attempt receive additional 2020;142(suppl 2):S366S468. arrest with shockable rhythm? When bradycardia occurs secondary to a pathological cause, it can lead to decreased cardiac output with resultant hypotension and tissue hypoperfusion. The 2019 focused update on ACLS guidelines1 addressed the use of ECPR for cardiac arrest and noted that there is insufficient evidence to recommend the routine use of ECPR in cardiac arrest. If bradycardia is unresponsive to atropine, IV adrenergic agonists with rate-accelerating effects (eg, epinephrine) or transcutaneous pacing may be effective while the patient is prepared for emergent transvenous temporary pacing if required. 1. Some recommendations are directly relevant to lay rescuers who may or may not have received CPR training and who have little or no access to resuscitation equipment. Limited evidence from case reports and case series demonstrates transient increases in aortic and intracardiac pressure with the use of cough CPR at the onset of tachyarrhythmias or bradyarrhythmias in conscious patients. A case series suggests that mouth-to-nose ventilation in adults is feasible, safe, and effective. Synchronized cardioversion is recommended for acute treatment in patients with hemodynamically stable SVT when vagal maneuvers and pharmacological therapy is ineffective or contraindicated. Stopping an incident from occurring. The BLS team is performing CPR on a patient experiencing cardiac arrest. State the number of significant digits in each of the following measurements. Medical Mini Guardian has the highest monthly fee ($39.95), and Bay Alarm Medical In-Home Preferred has the lowest monthly fee ($29.95) of our best PERS picks. 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. 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. An RCT published in 2019 compared TTM at 33C to 37C for patients who were not following commands after ROSC from cardiac arrest with initial nonshockable rhythm. 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 . Two RCTs of patients with OHCA with an initially shockable rhythm published in 2002 reported benefit from mild hypothermia when compared with no temperature management. 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. 3. 1. Digoxin poisoning can cause severe bradycardia, AV nodal blockade, and life-threatening ventricular arrhythmias. Which is the most appropriate action? 2. Administration of IV or IO calcium, in the doses suggested for hyperkalemia, may improve hemodynamics in severe magnesium toxicity, supporting its use in cardiac arrest although direct evidence is lacking. In the presence of known or suspected basal skull fracture or severe coagulopathy, an oral airway is preferred compared with a nasopharyngeal airway. VF is the presenting rhythm in 25% to 50% of cases of cardiac arrest after cardiac surgery. Chest compression depth begins to decrease after 90 to 120 seconds of CPR, although compression rates do not decrease significantly over that time window. Does avoidance of hyperoxia in the postarrest period lead to improved outcomes? These effects can also precipitate acute coronary syndrome and stroke. Because chest compression fraction of at least 60% is associated with better resuscitation outcomes, compression pauses for ventilation should be as short as possible. The routine use of prophylactic antibiotics in postarrest patients is of uncertain benefit. 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. A victim may also appear clinically dead because of the effects of very low body temperature. 6. What is the most efficacious management approach for postarrest cardiogenic shock, including b. For lay rescuers trained in CPR using chest compressions and ventilation (rescue breaths), it is reasonable to provide ventilation (rescue breaths) in addition to chest compressions for the adult in OHCA. Adenosine only transiently slows irregularly irregular rhythms, such as atrial fibrillation, rendering it unsuitable for their management. Is there a role for prophylactic antiarrhythmics after ROSC? In comparison, surveillance and prevention are critical aspects of IHCA. The AHA has rigorous conflict of interest policies and procedures to minimize the risk of bias or improper influence during the development of guidelines. A well-organized team response when performing high-quality CPR includes ensuring that providers switch off performing compressions every _____ minutes. In addition, 15 recommendations are designated Class 3: No Benefit, and 11 recommendations are Class 3: Harm. Before embarking on empirical drug therapy, obtaining a 12-lead ECG and/or seeking expert consultation for diagnosis is encouraged, if available. The response phase comprises the coordination and management of resources utilizing the Incident Command System. Distinguishing between these rhythm etiologies is the key to proper drug selection for treatment. Along with providing standard BLS and ALS treatment, next steps include preventing additional evaporative heat loss by removing wet garments and insulating the victim from further environmental exposures. 2. Recommendations 1, 2, and 6 last received formal evidence review in 2015.21 Recommendations 3, 4, and 5 are supported by the 2020 CoSTR for BLS.22, This recommendation is supported by a 2020 ILCOR scoping review, which found no new information to update the 2010 recommendations.22,31, This recommendation is supported by a 2020 ILCOR scoping review,22 which found no new information to update the 2010 recommendations.31, Recommendations 1 and 2 are supported by the 2020 CoSTR for BLS.22 Recommendation 3 last received formal evidence review in 2010.46, This recommendation is supported by the 2020 CoSTR for ALS.51. 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. 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. As part of the overall work for development of these guidelines, the writing group was able to review a large amount of literature concerning the management of adult cardiac arrest. Neuroprognostication relies on interpreting the results of diagnostic tests and correlating those results with outcome. It promotes the "rest and digest" response that calms the body down after the danger has passed. Many of the tests considered are subject to error because of the effects of medications, organ dysfunction, and temperature. In an emergency, the individual can press a call button to signal for help. Answers Emergency 911 and non-emergency telephone calls for police, security, and technical support events and services. We suggest recording EEG in the presence of myoclonus to determine if there is an associated cerebral correlate. Beginning the CPR sequence with compression. wastebasket, stove, etc.) Common causes of maternal cardiac arrest are hemorrhage, heart failure, amniotic fluid embolism, sepsis, aspiration pneumonitis, venous thromboembolism, preeclampsia/eclampsia, and complications of anesthesia.1,4,6. Which is the most appropriate action? See Metrics for High-Quality CPR for recommendations on physiological monitoring during CPR. It does not have a pediatric setting and includes only adult AED pads. 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. Bradycardia is generally defined as a heart rate less than 60/min. After immediately initiating the emergency response system, what is the next link in the Adult In-Hospital Cardiac Chain of Survival? smell of smoke, visible flames, etc.) Status myoclonus is commonly defined as spontaneous or sound-sensitive, repetitive, irregular brief jerks in both face and limb present most of the day within 24 hours after cardiac arrest.8 Status myoclonus differs from myoclonic status epilepticus; myoclonic status epilepticus is defined as status epilepticus with physical manifestation of persistent myoclonic movements and is considered a subtype of status epilepticus for these guidelines. Hyperkalemia is commonly caused by renal failure and can precipitate cardiac arrhythmias and cardiac arrest. If an adult victim with spontaneous circulation (ie, strong and easily palpable pulses) requires support of ventilation, it may be reasonable for the healthcare provider to give rescue breaths at a rate of about 1 breath every 6 s, or about 10 breaths per minute. In addition to standard ACLS, several therapies have long been recommended to treat life-threatening hyperkalemia. 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. Serum biomarkers are blood-based tests that measure the concentration of proteins normally found in the central nervous system (CNS). What is the compression-to-ventilation ratio during multiple-provider CPR? Although abbreviated observation periods may be adequate for patients with fentanyl, morphine, or heroin overdose. Since the last time these recommendations were formally reviewed, The administration of hypertonic (8.4%, 1 mEq/ mL) sodium bicarbonate solution for treatment of sodium channel blockade due to TCAs and other toxicants is supported by human observational studies. 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. Case reports and at least 1 retrospective observational study have been published on survival after ECMO in patients presenting with refractory shock from -adrenergic blocker overdose. 1. 1. We recommend promptly performing and interpreting an electroencephalogram (EEG) for the diagnosis of seizures in all comatose patients after ROSC. No RCTs of resternotomy timing have been performed. While providing ventilations, you notice that Mr. Sauer moves and appears to be breathing. The reported incidence of cervical spine injury in drowning victims is low (0.009%). Before appointment, writing group members disclosed all commercial relationships and other potential (including intellectual) conflicts. This concern is especially pertinent in the setting of asphyxial cardiac arrest. We recommend that the absence of EEG reactivity within 72 h after arrest not be used alone to support a poor neurological prognosis. Perimortem cesarean delivery (PMCD) at or greater than 20 weeks uterine size, sometimes referred to as resuscitative hysterotomy, appears to improve outcomes of maternal cardiac arrest when resuscitation does not rapidly result in ROSC (Figure 15).1014 Further, shorter time intervals from arrest to delivery appear to lead to improved maternal and neonatal outcomes.15 However, the clinical decision to perform PMCDand its timing with respect to maternal cardiac arrestis complex because of the variability in level of practitioner and team training, patient factors (eg, etiology of arrest, gestational age), and system resources. If hemodynamically stable, a presumptive rhythm diagnosis should be attempted by obtaining a 12-lead ECG to evaluate the tachycardias features. Multiple observational studies have shown an association between emergent coronary angiography and PCI and improved neurological outcomes in patients without ST-segment elevation. 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. In 2015, approximately 350 000 adults in the United States experienced nontraumatic out-of-hospital cardiac arrest (OHCA) attended by emergency medical services (EMS) personnel.1 Approximately 10.4% of patients with OHCA survive their initial hospitalization, and 8.2% survive with good functional status. 6. Which patients with cardiac arrest due to suspected pulmonary embolism benefit from emergency Each of these features can also be useful in making a presumptive rhythm diagnosis. 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. Prompt treatment of cardiac glycoside toxicity is imperative to prevent or treat life-threatening arrhythmias. 1. How often may this dose be repeated? Cognitive impairments after cardiac arrest include difficulty with memory, attention, and executive function. 3. In patients without an advanced airway, it is reasonable to deliver breaths either by mouth or by using bag-mask ventilation. This protocol is supported by the surgical societies. 1. A two-person technique is the preferred methodology for BVM ventilations as it provides better seal and ventilation volume, A well-organized team response when performing high-quality CPR includes ensuring that providers switch off performing compressions every _____ minutes. 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. Immediate defibrillation is the treatment of choice when torsades is sustained or degenerates to VF. Emergent electric cardioversion and defibrillation are highly effective at terminating VF/VT and other tachyarrhythmias. This topic last received formal evidence review in 2010.12, These recommendations are supported by the 2018 focused update on ACLS guidelines.21, Management of SVTs is the subject of a recent joint treatment guideline from the AHA, the American College of Cardiology, and the Heart Rhythm Society.1, Narrow-complex tachycardia represents a range of tachyarrhythmias originating from a circuit or focus involving the atria or the AV node. 1. Each of the 2020 Guidelines documents were submitted for blinded peer review to 5 subject-matter experts nominated by the AHA. 2. When the victim is hypothermic, pulse and respiratory rates may be slow or difficult to detect. Coronary artery disease (CAD) is prevalent in the setting of cardiac arrest.14 Patients with cardiac arrest due to shockable rhythms have demonstrated particularly high rates of severe CAD: up to 96% of patients with STEMI on their postresuscitation ECG,2,5 up to 42% for patients without ST-segment elevation,2,57 and 85% of refractory out-of-hospital VF/VT arrest patients have severe CAD.8 The role of CAD in cardiac arrest with nonshockable rhythms is unknown. You are alone performing high-quality CPR when a second provider arrives to take over compressions. AED indicates automated external defibrillator; and BLS, basic life support. Although contradictory evidence exists, it may be reasonable to avoid the use of pure -adrenergic blocker medications in the setting of cocaine toxicity. CPR is recommended until a defibrillator or AED is applied. 1. Conversely, the -adrenergic effects may increase myocardial oxygen demand, reduce subendocardial perfusion, and may be proarrhythmic. For patients with cocaine-induced hypertension, tachycardia, agitation, or chest discomfort, benzodiazepines, alpha blockers, calcium channel blockers, nitroglycerin, and/or morphine can be beneficial. 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. Limitations to their prognostic utility include variability in testing methods on the basis of site and laboratory, between-laboratory inconsistency in levels, susceptibility to additional uncertainty due to hemolysis, and potential extracerebral sources of the proteins. In 2013, a trial of over 900 patients compared TTM at 33C to 36C for patients with OHCA and any initial rhythm, excluding unwitnessed asystole, and found that 33C was not superior to 36C. When switching roles, you should minimize interruptions in chest compressions to less than how many seconds? It is important for EMS providers to be able to differentiate patients in whom continued resuscitation is futile from patients with a chance of survival who should receive continued resuscitation and transportation to hospital. In addition, it may be helpful for providers to master an advanced airway strategy as well as a second (backup) strategy for use if they are unable to establish the first-choice airway adjunct. Long-term anticoagulation may be necessary for patients at risk for thromboembolic events based on their CHA2 DS2 - VASc score. 4. Hyperlinked references are provided to facilitate quick access and review. Phone or ask someone to phone 9-1-1 (the phone or caller with the phone remains at the victim's side, with the phone on speaker mode). Taking a regular rather than a deep breath prevents the rescuer from getting dizzy or lightheaded and prevents overinflation of the victims lungs. needed to be able to compare prognostic values across studies. Routine measurement of arterial blood gases during CPR has uncertain value. 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. The AED arrives. Acute asthma management was reviewed in detail in the 2010 Guidelines.4 For 2020, the writing group focused attention on additional ACLS considerations specific to asthma patients in the immediate periarrest period. -Adrenergic blockers may be used in compensated patients with cardiomyopathy; however, they should be used with caution or avoided altogether in patients with decompensated heart failure. Acknowledging these data, the use of mechanical CPR devices by trained personnel may be beneficial in settings where reliable, high-quality manual compressions are not possible or may cause risk to personnel (ie, limited personnel, moving ambulance, angiography suite, prolonged resuscitation, or with concerns for infectious disease exposure). Determining the utility of such physiological monitoring or diagnostic procedures is important. . Which statement correctly describes the appropriate technique for operating the BVM? Is there a consistent threshold value for prognostication for GWR or ADC? do they differ from current generic or clinician-derived measures? 2. If replenished by a period of CPR before shock, defibrillation success improves significantly. The average cost of a personal emergency response system is $25-$50 per month, depending on the brand and model chosen. The presence of undifferentiated myoclonic movements after cardiac arrest should not be used to support a poor neurological prognosis. Interposed abdominal compression CPR may be considered during in-hospital resuscitation when sufficient personnel trained in its use are available. 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. cardiac arrest? You and your colleagues are performing CPR on a 6-year-old child. When evaluated with other prognostic tests, the prognostic value of seizures in patients who remain comatose after cardiac arrest is uncertain. 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.
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