Individual test modalities may be obtained earlier and the results integrated into the multimodality assessment synthesized at least 72 hours after normothermia. The AED was attached, and ''no shock'' was advised. Peer reviewer feedback was provided for guidelines in draft format and again in final format. The relative contribution of assisted ventilation for patients in cardiac arrest is more controversial. 2. When bradycardia occurs secondary to a pathological cause, it can lead to decreased cardiac output with resultant hypotension and tissue hypoperfusion. 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. VF is the presenting rhythm in 25% to 50% of cases of cardiac arrest after cardiac surgery. We recommend that the absence of EEG reactivity within 72 h after arrest not be used alone to support a poor neurological prognosis. During cardiac arrest, if the pregnant woman with a fundus height at or above the umbilicus has not achieved ROSC with usual resuscitation measures plus manual left lateral uterine displacement, it is advisable to prepare to evacuate the uterus while resuscitation continues. In a trained provider-witnessed arrest of a postcardiac surgery patient where pacer wires are already in place, we recommend immediate pacing in an asystolic or bradycardic arrest. Obtaining EEG in status myoclonus is important to rule out underlying ictal activity. 2. Interposed abdominal compression CPR is a 3-rescuer technique that includes conventional chest compressions combined with alternating abdominal compressions. . Thrombolysis may be considered when cardiac arrest is suspected to be caused by pulmonary embolism. Anticoagulation alone is inadequate for patients with fulminant PE. 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). Similar challenges were faced in the 2020 Guidelines process, where a number of critical knowledge gaps were identified in adult cardiac arrest management. 2. 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. Two studies that included patients enrolled in the AHA Get With The GuidelinesResuscitation registry reported either no benefit or worse outcome from TTM. Arterial pressure monitoring by arterial line may be used to detect ROSC during chest compressions or when a rhythm check reveals an organized rhythm. Can point-of-care cardiac ultrasound, in conjunction with other factors, inform termination of Are NSE and S100B helpful when checked later than 72 h after ROSC? To effectively give rescue breaths, it's essential that the person's airway is open and clear. Thus, the ultimate decision of the use, type, and timing of an advanced airway will require consideration of a host of patient and provider characteristics that are not easily defined in a global recommendation. In patients with calcium channel blocker overdose who are in shock refractory to pharmacological therapy, ECMO might be considered. The American Heart Association is a qualified 501(c)(3) tax-exempt organization. The opioid epidemic has resulted in an increase in opioid-associated out-of-hospital cardiac arrest, with the mainstay of care remaining the activation of the emergency response systems and performance of high-quality CPR. It may be reasonable to immediately resume chest compressions after shock administration rather than pause CPR to perform a postshock rhythm check in cardiac arrest patients. While amiodarone is typically considered a rhythm-control agent, it can effectively reduce ventricular rate with potential use in patients with congestive heart failure where -adrenergic blockers may not be tolerated and nondihydropyridine calcium channel antagonists are contraindicated. 2. What is optimal for the CPR duty cycle (the proportion of time spent in compression relative to the 3. 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. We recommend selecting and maintaining a constant temperature between 32C and 36C during TTM. affect resuscitation outcomes? Because of their longer duration of action, antiarrhythmic agents may also be useful to prevent recurrences of wide-complex tachycardia. Thirty-seven recommendations are supported by Level B-Randomized Evidence (moderate evidence from 1 or more RCTs) and 57 by Level B-Nonrandomized evidence. Approximately 1.2% of adults admitted to US hospitals suffer in-hospital cardiac arrest (IHCA).1 Of these patients, 25.8% were discharged from the hospital alive, and 82% of survivors have good functional status at the time of discharge. 2. The value of VF waveform analysis to guide the acute management of adults with cardiac arrest has not been established. Is there a consistent threshold value for prognostication for GWR or ADC? A brief introduction or short synopsis is provided to put the recommendations into context with important background information and overarching management or treatment concepts. It may be reasonable to use audiovisual feedback devices during CPR for real-time optimization of CPR performance. or sooner if fatigued. 1. 2. Should severely hypothermic patients in VF who fail an initial defibrillation attempt receive additional Does emergent PCI for patients with ROSC after VF/VT cardiac arrest and no STEMI but with signs of How do you ventilate During CPR with an advanced airway in place? The literature supports prioritizing defibrillation and CPR initially and giving epinephrine if initial attempts with CPR and defibrillation are not successful. 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. 1. No adult human studies directly compare levels of inspired oxygen concentration during CPR. intraosseous; IV, intravenous; NSE, neuron-specific enolase; PCI, percutaneous coronary intervention; PMCD, perimortem cesarean delivery; ROSC, return of These guidelines are based on the extensive evidence evaluation performed in conjunction with the ILCOR and affiliated ILCOR member councils. 3. Mouth-to-nose ventilation may be necessary if ventilation through the victims mouth is impossible because of trauma, positioning, or difficulty obtaining a seal. This cause of death is especially prominent in those with OHCA but is also frequent after IHCA.1,2 Thus, much of postarrest care focuses on mitigating injury to the brain. Opioid overdoses deteriorate to cardiopulmonary arrest because of loss of airway patency and lack of breathing; therefore, addressing the airway and ventilation in a periarrest patient is of the highest priority. The initial phases of resuscitation once cardiac arrest is recognized are similar between lay responders and healthcare providers, with early CPR representing the priority. What are the optimal pharmacological treatment regimens for the management of postarrest seizures? 4. This topic was last reviewed in 2010 and identified 2 randomized trials, interposed abdominal compression CPR performed by trained rescuers improved short-term survival. One large RCT in OHCA comparing bag-mask ventilation with endotracheal intubation (ETI) in a physician-based EMS system showed no significant benefit for either technique for 28-day survival or survival with favorable neurological outcome. 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. Evidence suggests that patients who are comatose after ROSC benefit from invasive angiography, when indicated, as do patients who are awake. In patients with anaphylactic shock, close hemodynamic monitoring is recommended. The suggested timing of the multimodal diagnostics is shown here. IV infusion of epinephrine is a reasonable alternative to IV boluses for treatment of anaphylaxis in patients not in cardiac arrest. For a patient with suspected opioid overdose who has a definite pulse but no normal breathing or only gasping (ie, a respiratory arrest), in addition to providing standard BLS and/or ACLS care, it is reasonable for responders to administer naloxone. Routine measurement of arterial blood gases during CPR has uncertain value. 5. 2. What is the optimal duration for targeted temperature management before rewarming? The precordial thump should not be used routinely for established cardiac arrest. Normal brain has a GWR of approximately 1.3, and this number decreases with edema. Management of hemodynamically unstable patients with SVT must start with prompt restoration of sinus rhythm through the use of cardioversion. CPR is Cardiopulmonary resuscitation. 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. All lay rescuers should, at minimum, provide chest compressions for victims of cardiac arrest. Mouth-to-mouth ventilation in the water may be helpful when administered by a trained rescuer if it does not compromise safety. In a trained provider-witnessed arrest of a postcardiac surgery patient, immediate defibrillation for VF/VT should be performed. In a recent meta-analysis of 2 published studies (10 178 patients), only 0.01% (95% CI, 0.00%0.07%) of patients who fulfilled the ALS termination criteria survived to hospital discharge. 2. 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.
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