how is cpr performed differently with advanced airwayhow is cpr performed differently with advanced airway

A wide-complex tachycardia is defined as a rapid rhythm (generally 150 beats/min or more when attributable to an arrhythmia) with a QRS duration of 0.12 seconds or more. Once an advanced airway is emplaced and confirmed, chest compressions should be performed continuously at a rate of at least 100 per minute. 1. In adult cardiac arrest, total preshock and postshock pauses in chest compressions should be as short as possible. Healthcare providers often take too long to check for a pulse. A systematic review of the literature identified 5 small prospective trials, 3 retrospective studies, and multiple case reports and case series with contradictory results. 1. Additional investigations are necessary to evaluate cost-effectiveness, resource allocation, and ethics surrounding the routine use of ECPR in resuscitation. 1. 2. The previous literature was limited by methodological concerns, including around inadequate control for effects of TTM and medications and self-fulfilling prophecies, and there was a lower-than-acceptable false-positive rate (10% to 15%). Cough CPR is described as a repetitive deep inspiration followed by a cough every few seconds before the loss of consciousness. Care Science With Treatment Recommendations (CoSTR).1. Neuroprognostication relies on interpreting the results of diagnostic tests and correlating those results with outcome. This protocol is supported by the surgical societies. 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. 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. There is no evidence that cricoid pressure facilitates ventilation or reduces the risk of aspiration in cardiac arrest patients. If this is not known, defibrillation at the maximal dose may be considered. receiving CPR with ventilation? 4. 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. In cardiac arrest secondary to anaphylaxis, standard resuscitative measures and immediate administration of epinephrine should take priority. Unstable patients require immediate electric cardioversion. ILCOR Consensus on CPR and Emergency Cardiovascular 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. Instead, the compressing rescuer should give continuous chest compressions at a rate of 100 per minute without pauses for ventilation. 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. The use of ECMO for cardiac arrest or refractory shock due to sodium channel blocker/TCA toxicity may be considered. 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. AED indicates automated external defibrillator; and BLS, basic life support. In situations such as nonsurvivable maternal trauma or prolonged pulselessness, in which maternal resuscitative efforts are considered futile, there is no reason to delay performing perimortem cesarean delivery in appropriate patients. 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. Anticoagulation alone is inadequate for patients with fulminant PE. If hemodynamically stable, a presumptive rhythm diagnosis should be attempted by obtaining a 12-lead ECG to evaluate the tachycardias features. 1. Treatment of hemodynamically stable patients with IV diltiazem or verapamil have been shown to convert SVT to normal sinus rhythm in 64% to 98% of patients. 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. 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. A case series suggests that mouth-to-nose ventilation in adults is feasible, safe, and effective. Evidence in humans of the effect of vasopressors or other medications during cardiac arrest in the setting of hypothermia consists of case reports only. 2. On CT, brain edema can be quantified as the GWR, defined as the ratio between the density (measured as Hounsfield units) of the gray matter and the white matter. Nonconvulsive seizures are common after cardiac arrest. The bronchi then divide into smaller and smaller tubules called bronchioles. For each recommendation, the writing group discussed and approved specific recommendation wording and the COR and LOE assignments. If no advanced airway, 30:2 compression-ventilation ratio. The initial phases of resuscitation once cardiac arrest is recognized are similar between lay responders and healthcare providers, with early CPR representing the priority. AED indicates automated external defibrillator; BLS, basic life support; and CPR, cardiopulmonary resuscitation. 3. Although there are no controlled studies, several case reports and small case series have reported improvement in bradycardia and hypotension after glucagon administration. Release the pressure. No randomized RCTs have been performed comparing open-chest with external CPR. Initial management should focus on support of the patients airway and breathing. -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. Bradycardia can be a normal finding, especially for athletes or during sleep. Care of any patient with cardiac arrest in the setting of acute exacerbation of asthma begins with standard BLS. 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. and 2. 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. Check for no breathing or only gasping; if none, begin CPR with compressions. 1. 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. A recent systematic review found that no sonographic finding had consistently high sensitivity for clinical outcomes to be used as the sole criterion to terminate cardiac arrest resuscitation. Activation of emergency response system 3. Recognition that all cardiac arrest events are not identical is critical for optimal patient outcome, and specialized management is necessary for many conditions (eg, electrolyte abnormalities, pregnancy, after cardiac surgery). The AHA has rigorous conflict of interest policies and procedures to minimize the risk of bias or improper influence during the development of guidelines. Monitors (ECG, BP cuff, pulse oximeter, et CO2 monitor) Identify: heart rhythm Obtain a 12 lead ECG if possible. A 2017 systematic review identified 1 observational human study and 10 animal studies comparing different ventilation rates after advanced airway placement. These recommendations are supported by the 2015 ACC/AHA/HRS Guideline for the Management of Adult Patients With SVT: A Report of the American College of Cardiology/AHA Task Force on Clinical Practice Guidelines and the Heart Rhythm Society.6, These recommendations are supported by the 2015 American College of Cardiology, AHA, and Heart Rhythm Society Guidelines for the Management of Adult Patients With SVT.6. Rescuers should recognize that multiple approaches may be required to establish an adequate airway. In these cases, this maneuver should be used even in cases of potential spinal injury because the need to open the airway outweighs the risk of further spinal damage in the cardiac arrest patient. Seizure prophylaxis in adult postcardiac arrest survivors is not recommended. In some observational studies, improved outcomes have been noted in victims of cardiac arrest who received conventional CPR (compressions and ventilation) compared with those who received chest compressions only. 1. Advanced airways is a tube which is inserted in the mouth or nose, during this continuous CPR at the rate of 100 per minute is given. 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. 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. The 2020 Guidelines are organized into knowledge chunks, grouped into discrete modules of information on specific topics or management issues.5 Each modular knowledge chunk includes a table of recommendations that uses standard AHA nomenclature of COR and LOE. Rate control is more common in the emergency setting, using IV administration of a nondihydropyridine calcium channel antagonist (eg, diltiazem, verapamil) or a -adrenergic blocker (eg, metoprolol, esmolol). 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. In patients without an advanced airway, it is reasonable to deliver breaths either by mouth or by using bag-mask ventilation. Should there be physiological evidence of return of circulation such as an arterial waveform or abrupt rise in ETCO2 after shock, a pause of chest compressions briefly for confirmatory rhythm analysis may be warranted. In addition to standard ACLS, specific interventions may be lifesaving for cases of hyperkalemia and hypermagnesemia. Arrests without a primary cardiac origin (eg, from respiratory failure, toxic ingestion, pulmonary embolism [PE], or drowning) are also common, however, and in such cases, treatment for reversible underlying causes is important for the rescuer to consider.1 Some noncardiac etiologies may be particularly common in the in-hospital setting. An older systematic review identified 22 case reports of CPR being performed in the prone position (21 in the operating room, 1 in the intensive care unit [ICU]), with 10/22 patients surviving. For adults in cardiac arrest receiving CPR without an advanced airway, it is reasonable to pause compressions to deliver 2 breaths, each given over 1 s. 6. These deliver different peak currents even at the same programmed energy setting, making comparisons of shock efficacy between devices challenging. Conversely, the -adrenergic effects may increase myocardial oxygen demand, reduce subendocardial perfusion, and may be proarrhythmic. Step 2: Open the airway. A wide-complex tachycardia can also be caused by any of these supraventricular arrhythmias when conducted by an accessory pathway (called pre-excited arrhythmias). Although cardiac arrest due to carbon monoxide poisoning is almost always fatal, studies about neurological sequelae from less-severe carbon monoxide poisoning may be relevant. 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. Debriefings and referral for follow-up for emotional support for lay rescuers, EMS providers, and hospital-based healthcare workers after a cardiac arrest event may be beneficial. Dallas, TX 75231, Customer Service However, termination of torsades by shock does not prevent its recurrence, which requires additional measures. What is the optimal approach, vasopressor or transcutaneous pacing, in managing symptomatic 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). 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 OHCA, the care of the victim depends on community engagement and response. Immediate resumption of chest compressions after shock results in a shorter perishock pause and improves the overall hands-on time (chest compression fraction) during resuscitation, which is associated with improved survival from VF arrest.16,48 Even when successful, defibrillation is often followed by a variable (and sometimes protracted) period of asystole or pulseless electrical activity, during which providing CPR while awaiting a return of rhythm and pulse is advisable. Airway management during cardiac arrest usually commences with a basic strategy such as bag-mask ventilation. This topic last underwent formal evidence review in 2010.7, These recommendations are supported by the 2020 CoSTR for BLS.21, This recommendation is supported by the 2020 CoSTR for BLS.21. We recommend that the findings of a best motor response in the upper extremities being either absent or extensor movements not be used alone for predicting a poor neurological outcome in patients who remain comatose after cardiac arrest. Is there benefit to naloxone administration in patients with opioid-associated cardiac arrest who are 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. Hypotension may worsen brain and other organ injury after cardiac arrest by decreasing oxygen delivery to tissues. This involves the cannulation of a large vein and artery and initiation of venoarterial extracorporeal circulation and membrane oxygenation (ECMO) (Figure 8). A recent consensus statement on this topic has been published by the Society of Thoracic Surgeons.9, This topic last received formal evidence review in 2010.35These recommendations were supplemented by a 2017 review published by the Society of Thoracic Surgeons.9. Nonvasopressor medications during cardiac arrest. 2. In addition to assessing level of consciousness and performing basic neurological examination, clinical examination elements may include the pupillary light reflex, pupillometry, corneal reflex, myoclonus, and status myoclonus when assessed within 1 week after cardiac arrest. Studies on push-dose epinephrine for bradycardia specifically are lacking, although limited data support its use for hypotension. A more comprehensive description of these methods is provided in Part 2: Evidence Evaluation and Guidelines Development.. One RCT in OHCA comparing SGA (with iGel) to ETI in a nonphysician-based EMS system (ETI success, 69%) found no difference in survival or survival with favorable neurological outcome at hospital discharge. The combination of adenosines short-lived slowing of AV node conduction, shortening of refractoriness in the myocardium and accessory pathways, and hypotensive effects make it unsuitable in hemodynamically unstable patients and for treating irregularly irregular and polymorphic wide-complex tachycardias. 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. CPR indicates cardiopulmonary resuscitation; IHCA, in-hospital cardiac arrest; and OHCA, out-of-hospital cardiac arrest. IV amiodarone can be useful for rate control in critically ill patients with atrial fibrillation with rapid ventricular response without preexcitation. 3. Recommendations 1 and 5 are supported by the 2018 focused update on ACLS guidelines.1 Recommendation 2 last received formal evidence review in 2015.20 Recommendations 3 and 4 last received formal evidence review in 2010.21. Observational studies evaluating the utility of cardiac receiving centers suggest that a strong system of care may represent a logical clinical link between successful resuscitation and ultimate survival. In what situations is attempted resuscitation of the drowning victim futile? Important considerations for determining airway management strategies is provider airway management skill and experience, frequent retraining for providers, and ongoing quality improvement to minimize airway management complications. Because of limited evidence, the cornerstone of management of cardiac arrest secondary to anaphylaxis is standard BLS and ACLS, including airway management and early epinephrine. When the second rescuer arrives, provide 2-rescuer CPR and use the AED/defibrillator. When oxygen-rich blood cannot get to the brain, brain damage can occur within minutes. Urgent support of airway, breathing, and circulation is essential in suspected anaphylactic reactions. 3. If someone responds, ensure that the phone is at the side of the victim if at all possible. This recommendation is supported by the 2020 CoSTR for BLS.22, Recommendation 1 is supported by the 2020 CoSTR for ALS.51 Recommendation 2 is supported by a 2020 ILCOR evidence update,51 which found no new information to update the 2010 recommendations.66. 3. Send the second person to retrieve an AED, if one is available. There is also inconsistency in definitions used to describe specific findings and patterns. 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. 2, and 3. 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. Cardiac arrest survivors, their families, and families of nonsurvivors may be powerful advocates for community response to cardiac arrest and patient-centered outcomes. This recommendation is based on expert consensus and pathophysiologic rationale. Two randomized, placebo-controlled trials, enrolling over 8500 patients, evaluated the efficacy of epinephrine for OHCA.1,2 A systematic review and meta-analysis of these and other studies3 concluded that epinephrine significantly increased ROSC and survival to hospital discharge. 1. What is the most efficacious management approach for postarrest cardiogenic shock, including pharmacological, catheter intervention, or implantable device? When performed in combination with other prognostic tests, it may be reasonable to consider high serum values of neuron-specific enolase (NSE) within 72 h after cardiac arrest to support the prognosis of poor neurological outcome in patients who remain comatose. Each year, drowning is responsible for approximately 0.7% of deaths worldwide, or more than 500 000 deaths per year.1,2 A recent study using data from the United States reported a survival rate of 13% after cardiac arrest associated with drowning.3 People at increased risk for drowning include children, those with seizure disorders, and those intoxicated with alcohol or other drugs.1 Although survival is uncommon after prolonged submersion, successful resuscitations have been reported.49 For this reason, scene resuscitation should be initiated and the victim transported to the hospital unless there are obvious signs of death. needed to be able to compare prognostic values across studies. 2. Prompt systemic anticoagulation is generally indicated for patients with massive and submassive PE to prevent clot propagation and support endogenous clot dissolution over weeks. A 2020 ILCOR systematic review identified 3 studies involving 57 total patients that investigated the effect of hand positioning on resuscitation process and outcomes. There are no data evaluating the use of antidotes to digoxin overdose specifically in the setting of cardiac arrest. In patients who remain comatose after cardiac arrest, it is reasonable to perform multimodal neuroprognostication at a minimum of 72 hours after normothermia, though individual prognostic tests may be obtained earlier than this. VF is the presenting rhythm in 25% to 50% of cases of cardiac arrest after cardiac surgery. 3. This begins with opening the airway followed by delivery of rescue breaths, ideally with the use of a bag-mask or barrier device. 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. Gently lift their chin forward with your other hand. Intra-arterial pressure - If relaxation . 1. 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. 2. The rationale for a single shock strategy, in which CPR is immediately resumed after the first shock rather than after serial stacked shocks (if required) is based on a number of considerations. NSE and S100B are the 2 most commonly studied markers, but others are included in this review as well. It is reasonable for prehospital ALS providers to use the adult ALS TOR rule to terminate resuscitation efforts in the field for adult victims of OHCA. A wide-complex tachycardia can be regular or irregularly irregular and have uniform (monomorphic) or differing (polymorphic) QRS complexes from beat to beat. 1. Although there is no evidence examining the effectiveness of their use during cardiac arrest, oropharyngeal and nasopharyngeal airways can be used to maintain a patent airway and facilitate appropriate ventilation by preventing the tongue from occluding the airway. What is the validity and reliability of ETCO. 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. Two studies that included patients enrolled in the AHA Get With The GuidelinesResuscitation registry reported either no benefit or worse outcome from TTM. Do prophylactic antiarrhythmic medications on ROSC after successful defibrillation decrease arrhythmia There are many alternative CPR techniques being used, and many are unproven. Critical knowledge gaps are summarized in Table 4. Arterial pressure monitoring by arterial line may be used to detect ROSC during chest compressions or when a rhythm check reveals an organized rhythm. Interposed abdominal compression CPR is a 3-rescuer technique that includes conventional chest compressions combined with alternating abdominal compressions. Clinical trials and observational studies since the 2010 Guidelines have yielded no new evidence that routine administration of sodium bicarbonate improves outcomes from undifferentiated cardiac arrest and evidence suggests that it may worsen survival and neurological recovery. Should severely hypothermic patients in cardiac arrest receive epinephrine or other resuscitation Once ROSC is achieved, urgent consultation with a medical toxicologist or regional poison center is suggested. The half-life of flumazenil is shorter than many benzodiazepines, necessitating close monitoring after flumazenil administration.2 An alternative to flumazenil administration is respiratory support with bag-mask ventilation followed by ETI and mechanical ventilation until the benzodiazepine has been metabolized. Furthermore, fetal hypoxia has known detrimental effects. Cyanide poisoning may result from smoke inhalation, industrial exposures, self-poisoning, terrorism, or the administration of sodium nitroprusside. 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. During manual CPR, rescuers should perform chest compressions to a depth of at least 2 inches, or 5 cm, for an average adult while avoiding excessive chest compression depths (greater than 2.4 inches, or 6 cm). There is a need for further research specifically on the interface between patient factors and the The Level of Evidence (LOE) is based on the quality, quantity, relevance, and consistency of the available evidence. 1. For cardiac arrest with known or suspected hypermagnesemia, in addition to standard ACLS care, it may be reasonable to administer empirical IV calcium. 1. Adenosine is recommended for acute treatment in patients with SVT at a regular rate. Agonal breathing is characterized by slow, irregular gasping respirations that are ineffective for ventilation. When available, expert consultation can be helpful to assist in the diagnosis and management of treatment-refractory wide-complex tachycardia. Cardiac arrest survivors, like many survivors of critical illness, often experience a spectrum of physical, neurological, cognitive, emotional, or social issues, some of which may not become apparent until after hospital discharge. 2. Injection of epinephrine into the lateral aspect of the thigh produces rapid peak plasma epinephrine concentrations. A large observational cohort study investigating these and other novel serum biomarkers and their performance as prognostic biomarkers would be of high clinical significance. Healthcare providers are trained to deliver both compressions and ventilation. 2. We recommend that laypersons initiate CPR for presumed cardiac arrest, because the risk of harm to the patient is low if the patient is not in cardiac arrest. Look for no breathing or only gasping, at the direction of the telecommunicator. In patients with calcium channel blocker overdose who are in shock refractory to pharmacological therapy, ECMO might be considered. This Part of the 2020 American Heart Association (AHA) Guidelines for CPR and Emergency Cardiovascular Care includes recommendations for clinical care of adults with cardiac arrest, including those with life-threatening conditions in whom cardiac arrest is imminent, and after successful resuscitation from cardiac arrest. The dedicated rescuer who provides manual abdominal compressions will compress the abdomen midway between the xiphoid and the umbilicus during the relaxation phase of chest compression. -Enough to make the victim's chest rise. humidified oxygen? *Red Dress DHHS, Go Red AHA ; National Wear Red Day is a registered trademark.