This new link acknowledges the need for the system of care to support recovery, discuss expectations, and provide plans that address treatment, surveillance, and rehabilitation for cardiac arrest survivors and their caregivers as they transition care from the hospital to home and return to role and social function. 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. We recommend that teams caring for comatose cardiac arrest survivors have regular and transparent multidisciplinary discussions with surrogates about the anticipated time course for and uncertainties around neuroprognostication. 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. 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). Should severely hypothermic patients in VF who fail an initial defibrillation attempt receive additional In adult CPR, 100 to 120 chest compressions per minute at a depth of at least 2 inches, but no greater than 2.4 inches, should be provided. Excessive ventilation is unnecessary and can cause gastric inflation, regurgitation, and aspiration. outcomes? When this method is carried out by an inexperienced individual, it can result in serious trauma related to the oropharynx. This topic last received formal evidence review in 2015,8 with an evidence update conducted for the 2020 CoSTR for ALS.2. Dallas, TX 75231, Customer Service Whether treatment of seizure activity on EEG that is not associated with clinically evident seizures affects outcome is currently unknown. Administration of IV amiodarone, procainamide, or sotalol may be considered for the treatment of wide-complex tachycardia. 1. Mouth-to-nose ventilation may be necessary if ventilation through the victims mouth is impossible because of trauma, positioning, or difficulty obtaining a seal. The available evidence suggests no appreciable differences in success or major adverse event rates between calcium channel blockers and adenosine.2. 1. Evidence suggests that patients who are comatose after ROSC benefit from invasive angiography, when indicated, as do patients who are awake. CT indicates computed tomography; EEG, electroencephalogram; MRI, magnetic resonance imaging; NSE, neuron-specific enolase; ROSC, return of spontaneous circulation; SSEP, somatosensory evoked potential; and TTM, targeted temperature management. A large observational cohort study investigating these and other novel serum biomarkers and their performance as prognostic biomarkers would be of high clinical significance. ECPR indicates extracorporeal cardiopulmonary resuscitation. Immediate pacing might be considered in unstable patients with high-degree AV block when IV/IO access is not available. 6. Determining the utility of such physiological monitoring or diagnostic procedures is important. Cardioversion has been shown to be both safe and effective in the prehospital setting for hemodynamically unstable patients with SVT who had failed to respond to vagal maneuvers and IV pharmacological therapies. 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. Chest compressions are the most critical component of CPR, and a chest compressiononly approach is appropriate if lay rescuers are untrained or unwilling to provide respirations. Cough CPR may be considered as a temporizing measure for the witnessed, monitored onset of a hemodynamically significant tachyarrhythmia or bradyarrhythmia before a loss of consciousness without delaying definitive therapy. 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. 6. needed to be able to compare prognostic values across studies. responsible for a large proportion of opioid overdose? 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. The usefulness of S100 calcium-binding protein (S100B), Tau, neurofilament light chain, and glial fibrillary acidic protein in neuroprognostication is uncertain. IV lidocaine, amiodarone, and measures to treat myocardial ischemia may be considered to treat polymorphic VT in the absence of a prolonged QT interval. total time of the compression-plus-decompression cycle)? 3. The trained lay rescuer who feels confident in performing both compressions and ventilation should open the airway using a head tiltchin lift maneuver when no cervical spine injury is suspected. For asthmatic patients with cardiac arrest, sudden elevation in peak inspiratory pressures or difficulty ventilating should prompt evaluation for tension pneumothorax. 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. Although the majority of resuscitation success is achieved by provision of high-quality CPR and defibrillation, other specific treatments for likely underlying causes may be helpful in some cases. 4. Lay and trained responders should not delay activating emergency response systems while awaiting the patients response to naloxone or other interventions. In adult cardiac arrest, total preshock and postshock pauses in chest compressions should be as short as possible. Futility is often defined as less than 1% chance of survival,1 suggesting that for a TOR rule to be valid it should demonstrate high accuracy for predicting futility with the lower confidence limit greater than 99% on external validation. Are glial fibrillary acidic protein, serum tau protein, and neurofilament light chain valuable for 2. and 2. 3. Cognitive impairments after cardiac arrest include difficulty with memory, attention, and executive function. Do prophylactic antiarrhythmic medications on ROSC after successful defibrillation decrease arrhythmia 1. Using a validated TOR rule will help ensure accuracy in determining futile patients (Figures 5 and 6). What is the ideal initial dose of naloxone in a setting where fentanyl and fentanyl analogues are 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.) 2. It is reasonable for providers to first attempt establishing intravenous access for drug administration in cardiac arrest. In 2018, the AHA, American College of Cardiology, and Heart Rhythm Society published an extensive guideline on the evaluation and management of stable and unstable bradycardia.2 This guideline focuses exclusively on symptomatic bradycardia in the ACLS setting and maintains consistency with the 2018 guideline. When oxygen-rich blood cannot get to the brain, brain damage can occur within minutes. If termination of resuscitation (TOR) is being considered, BLS EMS providers should use the BLS termination of resuscitation rule where ALS is not available or may be significantly delayed. A healthcare provider should use the head tiltchin lift maneuver to open the airway of a patient when no cervical spine injury is suspected. It is reasonable that TTM be maintained for at least 24 h after achieving target temperature. 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. Based on the protocols used in clinical trials, it is reasonable to administer epinephrine 1 mg every 3 to 5 min for cardiac arrest. 4. 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. Commercially available defibrillators either provide fixed energy settings or allow for escalating energy settings; both approaches are highly effective in terminating VF/VT. There is some evidence that in noncardiac arrest patients, cricoid pressure may protect against aspiration and gastric insufflation during bag-mask ventilation. No. 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. When providing chest compressions, the rescuer should place the heel of one hand on the center (middle) of the victims chest (the lower half of the sternum) and the heel of the other hand on top of the first so that the hands are overlapped. Vasopressor medications during cardiac arrest. 2. If no advanced airway, 30:2 compression-ventilation ratio. The primary focus of cardiac arrest management for providers is the optimization of all critical steps required to improve outcomes. Immediately begin CPR, and use the AED/ defibrillator when available. 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. Others, such as opioid overdose, are sharply on the rise in the out-of-hospital setting.2 For any cardiac arrest, rescuers are instructed to call for help, perform CPR to restore coronary and cerebral blood flow, and apply an AED to directly treat ventricular fibrillation (VF) or ventricular tachycardia (VT), if present. 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. 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. Survival and recovery from adult cardiac arrest depend on a complex system working together to secure the best outcome for the victim. Extracorporeal CPR is performed with an extracorporeal membrane oxygenation device. In unmonitored cardiac arrest, it is reasonable to provide a brief prescribed period of CPR while a defibrillator is being obtained and readied for use before initial rhythm analysis and possible defibrillation. In patients with -adrenergic blocker overdose who are in shock refractory to pharmacological therapy, ECMO might be considered. Lay rescuers may provide chest compression only CPR to simplify the process and encourage CPR initiation, whereas healthcare providers may provide chest compressions and ventilation (Figures 24). 4. In cardiac arrest secondary to anaphylaxis, standard resuscitative measures and immediate administration of epinephrine should take priority. bradycardia? Vasopressin alone or vasopressin in combination with epinephrine may be considered in cardiac arrest but offers no advantage as a substitute for epinephrine in cardiac arrest.

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