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). Furthermore, the resource intensity required to begin and maintain an ECPR program should be considered in the context of strengthening other links in the Chain of Survival. 3. 4. Early high-quality CPR You are providing care for Mrs. Bove, who has an endotracheal tube in place. It has been shown previously that all rescuers may have difficulty detecting a pulse, leading to delays in CPR, or in some cases CPR not being performed at all for patients in cardiac arrest.3 Recognition of cardiac arrest by lay rescuers, therefore, is determined on the basis of level of consciousness and the respiratory effort of the victim. 3. For a victim with a tracheal stoma who requires rescue breathing, either mouth-to-stoma or face mask (pediatric preferred) tostoma ventilation may be reasonable. The electric characteristics of the VF waveform are known to change over time. General Preparedness and Response This topic last received formal evidence review in 2015.24, Hypoxic-ischemic brain injury is the leading cause of morbidity and mortality in survivors of OHCA and accounts for a smaller but significant portion of poor outcomes after resuscitation from IHCA.1,2 Most deaths attributable to postarrest brain injury are due to active withdrawal of life-sustaining treatment based on a predicted poor neurological outcome. Steps of Emergency Management Prevention, mitigation, preparedness, response and recovery are the five steps of Emergency Management. 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. The 2019 focused update on ACLS guidelines addressed the use of advanced airways in cardiac arrest and noted that either bag-mask ventilation or an advanced airway strategy may be considered during CPR for adult cardiac arrest in any setting.1 Outcomes from advanced airway and bag-mask ventilation interventions are highly dependent on the skill set and experience of the provider (Figure 7). Multiple RCTs have compared high-dose with standard-dose epinephrine, and although some have shown higher rates of ROSC with high-dose epinephrine, none have shown improvement in survival to discharge or any longer-term outcomes. We recommend that the absence of EEG reactivity within 72 h after arrest not be used alone to support a poor neurological prognosis. You are providing care for Mrs. Bove, who has an endotracheal tube in place. A call for help to public emergency services that provides full and accurate information will help the dispatcher send the right responders and equipment. What is the optimal treatment for hyperkalemia with life-threatening arrhythmia or cardiac arrest? Independent of a patients mental status, coronary angiography is reasonable in all postcardiac arrest patients for whom coronary angiography is otherwise indicated. 2. IV Medications Commonly Used for Acute Rate Control in Atrial Fibrillation and Atrial Flutter, CPR & First Aid in Youth Sports Training Kit, Resuscitation Quality Improvement Program (RQI), Coronavirus Resources for CPR & Resuscitation, Advanced Cardiovascular Life Support (ACLS), Resuscitation Quality Improvement Program (RQI), COVID-19 Resources for CPR & Resuscitation, Claiming Your AHA Continuing Education Credits, International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations, extracorporeal cardiopulmonary resuscitation, (partial pressure of) end-tidal carbon dioxide, International Liaison Committee on Resuscitation, arterial partial pressure of carbon dioxide, ST-segment elevation myocardial infarction. Standard BLS and ACLS are the cornerstones of treatment, with airway management and ventilation being of particular importance because of the respiratory cause of arrest. 5. 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. A BLS emergency ambulance shall request an ALS emergency ambulance transport if after assessment on scene determines the need for Conversely, the -adrenergic effects may increase myocardial oxygen demand, reduce subendocardial perfusion, and may be proarrhythmic. However, these case reports are subject to publication bias and should not be used to support its effectiveness. 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. There are no RCTs on the use of ECPR for OHCA or IHCA. If the plot of the reactant concentration versus time is nonlinear, but the concentration drops by 50%50 \%50% every 10 seconds, then the order of the reaction is Since the last review in 2010 of rescue breathing in adult patients, there has been no evidence to support a change in previous recommendations. High-quality CPR is, along with defibrillation for those with shockable rhythms, the most important lifesaving intervention for a patient in cardiac arrest. You suspect that an unresponsive patient has sustained a neck injury. These recommendations are supported by the 2020 CoSTR for BLS.1. ACD-CPR and ITD may act synergistically to enhance venous return during chest decompression and improve blood flow to vital organs during CPR. 2. Poisoning from other cardiac glycosides, such as oleander, foxglove, and digitoxin, have similar effects. 3. Postcardiac arrest care is a critical component of the Chain of Survival. You yell to the medical assistant, "Go get the AED!" 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. 4. Approximately one third of cardiac arrest survivors experience anxiety, depression, or posttraumatic stress. 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. 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. No randomized RCTs have been performed comparing open-chest with external CPR. Twelve observational studies evaluated NSE collected within 72 hours after arrest. It is feasible only at the onset of a hemodynamically significant arrhythmia in a cooperative, conscious patient who has ideally been previously instructed on its performance, and as a bridge to definitive care. Technologies are now in development to diagnose the underlying cardiac rhythm during ongoing CPR and to derive prognostic information from the ventricular waveform that can help guide patient management. In patients with -adrenergic blocker overdose who are in refractory shock, administration of calcium may be considered. It is reasonable to immediately resume chest compressions after shock delivery for adults in cardiac arrest in any setting. 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. 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). 1. Although there are no controlled studies, several case reports and small case series have reported improvement in bradycardia and hypotension after glucagon administration. The healthcare provider should minimize the time taken to check for a pulse (no more than 10 s) during a rhythm check, and if the rescuer does not definitely feel a pulse, chest compressions should be resumed. 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. Due to the potential effects of intrinsic positive end-expiratory pressure (auto-PEEP) and risk of barotrauma in an asthmatic patient with cardiac arrest, a ventilation strategy of low respiratory rate and tidal volume is reasonable. The combination of active compression-decompression CPR and impedance threshold device may be reasonable in settings with available equipment and properly trained personnel. 2. For patients with severe hypothermia (less than 30C [86F]) with a perfusing rhythm, core rewarming is often used. Deterrence operations and surveillance. 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. The reported incidence of cervical spine injury in drowning victims is low (0.009%). The literature supports prioritizing defibrillation and CPR initially and giving epinephrine if initial attempts with CPR and defibrillation are not successful. Recommendation 1 is supported by the 2019 focused update on ACLS guidelines.3 Recommendation 2 last received formal evidence review in 2015.4 Recommendation 3 is supported by the 2020 CoSTR for ALS.11, These recommendations are supported by the 2015 Guidelines Update24 and a 2020 evidence update.11. Ask yourself the following questions and use a small blank notebook, writing pad, or other appropriate form(s) to record thoughts and ideas: Should public health become involved in the It is reasonable that selection of fixed versus escalating energy levels for subsequent shocks for presumed shock-refractory arrhythmias be based on the specific manufacturers instructions for that waveform. The Adult OHCA and IHCA Chains of Survival have been updated to better highlight the evolution of systems of care and the critical role of recovery and survivorship with the addition of a new link. 2. 3. It may be reasonable to use physiological parameters such as arterial blood pressure or end-tidal CO. 1. Neglect the mass and friction of all pulleys and determine the acceleration of each cylinder and the tensions T1T_1T1 and T2T_2T2 in the two cables. Some literature reports good favorable outcomes while others report significant adverse events. Operationally, the timing for prognostication is typically at least 5 days after ROSC for patients treated with TTM (which is about 72 hours after normothermia) and should be conducted under conditions that minimize the confounding effects of sedating medications. 2. Someone from the age of 1 to the onset of puberty. 1. A dispatcher can speak to the person in need through a speaker phone B. 3. 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. You are preparing to deliver ventilations to an adult patient experiencing respiratory arrest. 1100 Introduction. If advanced airway placement will interrupt chest compressions, providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or obtains ROSC. 2. and 2. Synchronized cardioversion is recommended for acute treatment in patients with hemodynamically unstable SVT. The potential mechanisms of action of IV lipid emulsion include active shuttling of the local anesthetic drug away from the heart and brain, increased cardiac contractility, vasoconstriction, and cardioprotective effects.1, The reported incidence of LAST ranges from 0 to 2 per 1000 nerve blocks2 but appears to be decreasing as a result of increasing awareness of toxicity and improved techniques.1, This topic last received formal evidence review in 2015.6, Overdose of sodium channelblocking medications, such as TCAs and other drugs (eg, cocaine, flecainide, citalopram), can cause hypotension, dysrhythmia, and death by blockade of cardiac sodium channels, among other mechanisms. We suggest recording EEG in the presence of myoclonus to determine if there is an associated cerebral correlate. Evacuation of the gravid uterus relieves aortocaval compression and may increase the likelihood of ROSC. Can artifact-filtering algorithms for analysis of ECG rhythms during CPR in a real-time clinical setting Bradycardia is generally defined as a heart rate less than 60/min. 1. 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. Multiple case reports have observed intracranial placement of nasopharyngeal airways in patients with basilar skull fractures. 2. 5. Limited animal data and rare case reports suggest possible utility of calcium to improve heart rate and hypotension in -adrenergic blocker toxicity. Based on similarly rare but time-critical interventions, planning, simulation training and mock emergencies will assist in facility preparedness. In patients who remain comatose after cardiac arrest, we recommend that neuroprognostication be delayed until adequate time has passed to ensure avoidance of confounding by medication effect or a transiently poor examination in the early postinjury period. 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. 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. The key drivers of successful resuscitation from OHCA are lay rescuer cardiopulmonary resuscitation (CPR) and public use of an automated external defibrillator (AED). Rapidly intervening with patients admitted through emergency department triage C. Responding to patients during a disaster or multiple-patient situation D. Responding to patients after activation of the emergency response system The ALS TOR rule recommends TOR when all of the following criteria apply before moving to the ambulance for transport: (1) arrest was not witnessed; (2) no bystander CPR was provided; (3) no ROSC after full ALS care in the field; and (4) no AED shocks were delivered. In what situations is attempted resuscitation of the drowning victim futile? Of 16 observational studies on timing in the recent systematic review, all found an association between earlier epinephrine and ROSC for patients with nonshockable rhythms, although improvements in survival were not universally seen. When Mr. Phillips shows signs of ROSC, where should you perform the pulse check? ECPR refers to the initiation of cardiopulmonary bypass during the resuscitation of a patient in cardiac arrest. 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. When supplemental oxygen is available, it may be reasonable to use the maximal feasible inspired oxygen concentration during CPR. A pediatric critical care physician whose areas of specialty include trauma care, emergency medical services, and disaster medicine, Cantwell also has seen the response to disasters change since the Sept. 11 attacks. 1. Resuscitation from cardiac arrest caused by -adrenergic blocker or calcium channel blocker overdose follows standard resuscitation guidelines. All outside signs both to me as a person and as a medic said it was no biggie. 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. Opioid-associated resuscitative emergencies are defined by the presence of cardiac arrest, respiratory arrest, or severe life-threatening instability (such as severe CNS or respiratory depression, hypotension, or cardiac arrhythmia) that is suspected to be due to opioid toxicity. 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. Early high-quality CPR The nurse assesses a responsive adult and determines she is choking. 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. experience, training, tools, and skills of the provider when choosing an approach to airway management. 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. cardiopulmonary resuscitation; EEG, electroencephalogram; ETCO2, end-tidal carbon dioxide; GWR, gray-white ratio; IHCA, in-hospital cardiac arrest; IO, 2. To avoid hypoxia in adults with ROSC in the immediate postarrest period, it is reasonable to use the highest available oxygen concentration until the arterial oxyhemoglobin saturation or the partial pressure of arterial oxygen can be measured reliably. Soon after the AED pads have been placed, the device alerts, "Shock advised." What is the ideal timing of PMCD for a pregnant woman in cardiac arrest? Julie S Snyder, Linda Lilley, Shelly Collins, Foundations for Population Health in Community and Public Health Nursing, BIOL 1407-007 Chapter 37: The Endocrine Syste, Constitutional Law: Federalism, Structure of. This makes it difficult to plan the next step of care and can potentially delay or even misdirect drug therapies if given empirically (blindly) based on the patients presumed, but not actual, underlying rhythm. 3. Healthcare providers are trained to deliver both compressions and ventilation. 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. When pacing attempts are not immediately successful, standard ACLS including CPR is indicated. The rationale for tracking the overall success rate for systems performing ETI is to make informed decisions as to whether practice should allow for ETI, move toward SGA, or simply use bag-mask ventilation for patients in cardiac arrest; recommendations will vary depending on the overall success rate in a given system. 3. Are you performing all of the required ITM on your Emergency Power Supply System? Any staff member may call the team if one of the following criteria is met: Heart rate over 140/min or less than 40/min. 1. These recommendations are supported by the 2020 CoSTR for ALS.11, Recommendation 1 last received formal evidence review in 2010 and is supported by the Guidelines for the Use of an Insulin Infusion for the Management of Hyperglycemia in Critically Ill Patients from the Society for Critical Care Medicine.49 Recommendation 2 is supported by the 2020 CoSTR for ALS.11 Recommendations 3 and 4 last received formal evidence review in 2015.24. Survivorship plans help guide the patient, caregivers, and primary care providers and include a summary of the inpatient course, recommended follow-up appointments, and postdischarge recovery expectations (Figure 12). at a facility for initiating effective emergency response and control, addressing emergency reporting and response requirements, and compliance with all applicable governmental . spontaneous circulation; S100B, S100 calcium binding protein; STEMI, ST-segment elevation myocardial infarction; and VF, ventricular fibrillation. Cyanide poisoning may result from smoke inhalation, industrial exposures, self-poisoning, terrorism, or the administration of sodium nitroprusside. What is the optimal approach to advanced airway management for IHCA? 6. 2. No large RCT evaluating different treatment strategies for patients suffering from acute cocaine toxicity exists. This recommendation is based on the fact that nonconvulsive seizures are common in postarrest patients and that the presence of seizures may be important prognostically, although whether treatment of nonconvulsive seizures affects outcome in this setting remains uncertain. 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. 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. These guidelines are not meant to be comprehensive. 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. Taking a regular rather than a deep breath prevents the rescuer from getting dizzy or lightheaded and prevents overinflation of the victims lungs. Which statement is true regarding CPR and AED use for a pregnant patient? channel blockers. You enter Ms. Evers's room and notice she is slumped over in her chair and appears unresponsive and cyanotic. 1. Critical knowledge gaps are summarized in Table 4. Flumazenil, a specific benzodiazepine antagonist, restores consciousness, protective airway reflexes, and respiratory drive but can have significant side effects including seizures and arrhythmia.1 These risks are increased in patients with benzodiazepine dependence and with coingestion of cyclic antidepressant medications. AED indicates automated external defibrillator; BLS, basic life support; and CPR, cardiopulmonary resuscitation. ACLS indicates advanced cardiovascular life support; BLS, basic life support; CPR, cardiopulmonary resuscitation; ET, endotracheal; IV, intravenous; and ROSC, needed to be able to compare prognostic values across studies. TTM between 32C and 36C for at least 24 hours is currently recommended for all cardiac rhythms in both OHCA and IHCA. The suggested timing of the multimodal diagnostics is shown here. total time of the compression-plus-decompression cycle)? 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. Open-chest CPR can be useful if cardiac arrest develops during surgery when the chest or abdomen is already open, or in the early postoperative period after cardiothoracic surgery. Multiple observational studies have shown an association between emergent coronary angiography and PCI and improved neurological outcomes in patients without ST-segment elevation. Rescuers cannot be certain that the persons clinical condition is due to opioid-induced respiratory depression alone.