after immediately initiating the emergency response system after immediately initiating the emergency response system

Does epinephrine, when administered early after cardiac arrest, improve survival with favorable Thus, we recognize that each of these diverse aspects of care contributes to the ultimate functional survival of the cardiac arrest victim. How does this affect compressions and ventilations? If an arterial line is in place, an abrupt increase in diastolic pressure or the presence of an arterial waveform during a rhythm check showing an organized rhythm may indicate ROSC. However, there are several case reports of good maternal and fetal outcome with the use of TTM after cardiac arrest. In addition to standard ACLS, several therapies have long been recommended to treat life-threatening hyperkalemia. 2. Incorrect placement, however, can cause an airway obstruction by displacing the tongue to the back of the oropharynx. This time delay is a consistent issue in OHCA trials. 1. We do not recommend routine use of magnesium for the treatment of polymorphic VT with a normal QT interval. No RCTs of resternotomy timing have been performed. What is the optimal energy needed for cardioversion of atrial fibrillation and atrial flutter? Cocaine toxicity can cause adverse effects on the cardiovascular system, including dysrhythmia, hypertension, tachycardia and coronary artery vasospasm, and cardiac conduction delays. 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. 2. Emergency/Immediate notification is in response to a significant emergency or dangerous situation involving an immediate threat to the health or safety of students or employees occurring on the campus. Because of their longer duration of action, antiarrhythmic agents may also be useful to prevent recurrences of wide-complex tachycardia. For cardiac arrest with known or suspected hyperkalemia, in addition to standard ACLS care, IV calcium should be administered. Based on their greater success in arrhythmia termination, defibrillators using biphasic waveforms are preferred over monophasic defibrillators for treatment of tachyarrhythmias. Emergency Response Plan Revised 8/21/2017 Page 2 of 42 TABLE OF CONTENTS 1. A clinical trial studied administration of magnesium in addition to sodium bicarbonate for patients with TCA-induced hypotension, acidosis, and/or QRS prolongation.5 Although overall outcomes were better in the magnesium group, no statistically significant effect was found in mortality, the magnesium patients were significantly less ill than controls at study entry, and methodologic flaws render this work preliminary. 4. Obtaining EEG in status myoclonus is important to rule out underlying ictal activity. An exposure to patient blood or other body fluid. More research in this area is clearly needed. Evidence in humans of the effect of vasopressors or other medications during cardiac arrest in the setting of hypothermia consists of case reports only. 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. These recommendations are supported by the 2020 Routine use of sodium bicarbonate is not recommended for patients in cardiac arrest. 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.) What are the optimal pharmacological treatment regimens for the management of postarrest seizures? Anaphylaxis causes the immune system to release a flood of chemicals that can cause you to go into shock blood pressure drops suddenly and the airways narrow, blocking breathing. Patients with accidental hypothermia often present with marked CNS and cardiovascular depression and the appearance of death or near death, necessitating the need for prompt full resuscitative measures unless there are signs of obvious death. 1. Atrial fibrillation or flutter with rapid ventricular 2. Two small studies have demonstrated improved hemodynamic effects of open-chest CPR when compared with external chest compressions in cardiac surgery patients. 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. 1. Does preshock waveform analysis lead to improved outcome? This topic last received formal evidence review in 2010.5. -Adrenergic receptor antagonists (-adrenergic blockers) and L-type calcium channel antagonists (calcium channel blockers) are common antihypertensive and cardiac rate control medications. You suspect that an unresponsive patient has sustained a neck injury. In cardiac arrest secondary to anaphylaxis, standard resuscitative measures and immediate administration of epinephrine should take priority. 1. Respiratory rate over 28/min or less than 8/min. While orienting a new medical assistant to the facility, you find a patient who is unresponsive in the exam room. Survival with a favorable neurological outcome (Cerebral Performance Category 12) was higher in the group treated with 33C. CT and MRI findings of brain injury evolve over the first several days after arrest, so the timing of the imaging study of interest is of particular importance as it relates to prognosis. If post emergency response is performed by an employer's own employees who were part of the initial emergency response, it is considered to be part of the . Each of these features can also be useful in making a presumptive rhythm diagnosis. 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. However, obtaining IV access under emergent conditions can prove to be challenging based on patient characteristics and operator experience leading to delay in pharmacological treatments. The gravid uterus can compress the inferior vena cava, impeding venous return, thereby reducing stroke volume and cardiac output. High-quality CPR, defibrillation when appropriate, vasopressors and/or antiarrhythmics, and airway management remain the cornerstones of cardiac arrest resuscitation, but some emerging data suggest that incorporating patient-specific imaging and physiological data into our approach to resuscitation holds some promise. Techniques include administration of warm humidified oxygen, warm IV fluids, and intrathoracic or intraperitoneal warm-water lavage. When performed with other prognostic tests, it may be reasonable to consider bilaterally absent N20 somatosensory evoked potential (SSEP) waves more than 24 h after cardiac arrest to support the prognosis of poor neurological outcome. 4. doi: 10.1161/CIR.0000000000000916, On behalf of the Adult Basic and Advanced Life Support Writing Group. The force from a precordial thump is intended to transmit electric energy to the heart, similar to a low-energy shock, in hope of terminating the underlying tachyarrhythmia. For patients with a sinus tachycardia (heart rate greater than 100/min, P waves), no specific drug treatment is needed, and clinicians should focus on identification and treatment of the underlying cause of the tachycardia (fever, dehydration, pain). The team should provide ventilations at a rate of 1 ventilation every 6 seconds without pausing compressions. Limited animal data and rare case reports suggest possible utility of calcium to improve heart rate and hypotension in -adrenergic blocker toxicity. An IV dose of 0.05 to 0.1 mg (5% to 10% of the epinephrine dose used routinely in cardiac arrest) has been used successfully for anaphylactic shock. It may be reasonable to perform defibrillation attempts according to the standard BLS algorithm concurrent with rewarming strategies. 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). When appropriate, flow diagrams or additional tables are included. However, good outcomes have been observed with rapid resternotomy protocols when performed by experienced providers in an appropriately equipped ICU. There are many alternative CPR techniques being used, and many are unproven. 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. A 12-lead ECG should be obtained as soon as feasible after ROSC to determine whether acute ST-segment elevation is present. Protocols for management of OHCA in pregnancy should be developed to facilitate timely transport to a center with capacity to immediately perform perimortem cesarean delivery while providing ongoing resuscitation. Twelve studies examined the use of naloxone in respiratory arrest, of which 5 compared intramuscular, intravenous, and/or intranasal routes of naloxone administration (2 RCT. Emergency Alerts | Ready.gov WEAs look like text messages but are designed to get your attention with a unique sound and vibration repeated twice. Which mnemonic can help you easily recall and perform assessment? One expected challenge faced through this process was the lack of data in many areas of cardiac arrest research. Atrial flutter is an SVT with a macroreentrant circuit resulting in rapid atrial activation but intermittent ventricular response. The CMT oversees the ERT and the DR team(s). However, these case reports are subject to publication bias and should not be used to support its effectiveness. This topic last received formal evidence review in 2015,8 with an evidence update conducted for the 2020 CoSTR for ALS.2. In patients with persistent hemodynamically unstable bradycardia refractory to medical therapy, temporary transvenous pacing is reasonable to increase heart rate and improve symptoms. A 2017 systematic review identified 1 observational human study and 10 animal studies comparing different ventilation rates after advanced airway placement. 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. Poisoning from other cardiac glycosides, such as oleander, foxglove, and digitoxin, have similar effects. Resuscitation should generally be conducted where the victim is found, as long as high-quality CPR can be administered safely and effectively in that location. 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. This approach recognizes that most sudden cardiac arrest in adults is of cardiac cause, particularly myocardial infarction and electric disturbances. AEDs are highly accurate in their detection of shockable arrhythmias but require a pause in CPR for automated rhythm analysis. 4. 2. There is concern that delivery of chest compressions without assisted ventilation for prolonged periods could be less effective than conventional CPR (compressions plus breaths) because the arterial oxygen content will decrease as CPR duration increases. Given the potential for the rapid development of oropharyngeal or laryngeal edema, immediate referral to a health professional with expertise in advanced airway placement, including surgical airway management, is recommended. 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. A systematic review of the literature identified 5 small prospective trials, 3 retrospective studies, and multiple case reports and case series with contradictory results. Administration of sodium bicarbonate for cardiac arrest or life-threatening cardiac conduction delays (ie, QRS prolongation more than 120 ms) due to sodium channel blocker/tricyclic antidepressant (TCA) overdose can be beneficial. Severe anaphylaxis may cause complete obstruction of the airway and/or cardiovascular collapse from vasogenic shock. Providers should perform high-quality CPR and continuous left uterine displacement (LUD). Hyperkalemia is commonly caused by renal failure and can precipitate cardiac arrhythmias and cardiac arrest. 4. The suggested timing of the multimodal diagnostics is shown here. Peer reviewer feedback was provided for guidelines in draft format and again in final format. 2023 American Heart Association, Inc. All rights reserved. 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. The effectiveness of agents to mitigate neurological injury in patients who remain comatose after ROSC is uncertain. You administered the recommended dose of naloxone. A recent systematic review of 11 RCTs (overall moderate to low certainty of evidence) found no evidence of improved survival with good neurological outcome with mechanical CPR compared with manual CPR in either OHCA or IHCA.1 Given the perceived logistic advantages related to limited personnel and safety during patient transport, mechanical CPR remains popular among some providers and systems. The controlled administration of IV potassium for ventricular arrhythmias due to severe hypokalemia may be useful, but case reports have generally included infusion of potassium and not bolus dosing. This topic last received formal evidence review in 2010.3. Using a validated TOR rule will help ensure accuracy in determining futile patients (Figures 5 and 6). experience, training, tools, and skills of the provider when choosing an approach to airway management. When the victim is hypothermic, pulse and respiratory rates may be slow or difficult to detect. While an expeditious trial of medications and/or fluids may be appropriate in some cases, unstable patients or patients with ongoing cardiac ischemia with atrial fibrillation or atrial flutter need to be cardioverted promptly. 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. 1. However, electric cardioversion may not be effective for automatic tachycardias (such as ectopic atrial tachycardias), entails risks associated with sedation, and does not prevent recurrences of the wide-complex tachycardia. Because any single method of neuroprognostication has an intrinsic error rate and may be subject to confounding, multiple modalities should be used to improve decision-making accuracy. Anterolateral, anteroposterior, anterior-left infrascapular, and anterior-right infrascapular electrode placements are comparably effective for treating supraventricular and ventricular arrhythmias. What is the ideal timing of PMCD for a pregnant woman in cardiac arrest? When bradycardia is refractory to medical management and results in severe symptoms, the reasonable next step is placement of a temporary pacing catheter for transvenous pacing. Operationally, administering epinephrine every second cycle of CPR, after the initial dose, may also be reasonable. 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. A 2020 ILCOR systematic review identified 3 studies involving 57 total patients that investigated the effect of hand positioning on resuscitation process and outcomes. Sodium thiosulfate enhances the effectiveness of nitrites by enhancing the detoxification of cyanide, though its role in patients treated with hydroxocobalamin is less certain.4 Novel antidotes are in development. Additional investigations are necessary to evaluate cost-effectiveness, resource allocation, and ethics surrounding the routine use of ECPR in resuscitation. Immediately initiate chest compressions. For patients with an arterial line in place, does targeting CPR to a particular blood pressure improve Research on building emergency communications provides useful guidance on ways to communicate emergency information to improve public response and safety. The usefulness of double sequential defibrillation for refractory shockable rhythm has not been established. Mission's redesigned, quick registration process reduced the number of questions asked immediately upon patient presentation to the ED from 17 to three: name, date of birth, and chief complaint. 2, and 3. 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. When providing rescue breaths, it may be reasonable to give 1 breath over 1 s, take a regular (not deep) breath, and give a second rescue breath over 1 s. 4. CPR indicates cardiopulmonary resuscitation; ET, endotracheal; IO, intraosseous; IV, intravenous; PEA, pulseless electrical activity; pVT, pulseless ventricular tachycardia; and VF, ventricular fibrillation. 1. There are no studies comparing different strategies of opening the airway in cardiac arrest patients. b. smell of smoke, visible flames, etc.) Other recommendations are relevant to persons with more advanced resuscitation training, functioning either with or without access to resuscitation drugs and devices, working either within or outside of a hospital. The location of the emergency (e.g. Observational studies of fibrinolytic therapy for suspected PE were found to have substantial bias and showed mixed results in terms of improvement in outcomes. ECPR is a complex intervention that requires a highly trained team, specialized equipment, and multidisciplinary support within a healthcare system. 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. An approach using lower tidal volumes, lower respiratory rate, and increased expiratory time may minimize the risk of auto-PEEP and barotrauma. Mitigation 2. Immediate defibrillation is recommended for sustained, hemodynamically unstable polymorphic VT. 1. Can point-of-care cardiac ultrasound, in conjunction with other factors, inform termination of Assess the situation Initiate the response by assessing the situation. Several studies demonstrate that patients with known or suspected cyanide toxicity presenting with cardiovascular instability or cardiac arrest who undergo prompt treatment with IV hydroxocobalamin, a cyanide scavenger. DWI/ADC is a sensitive measure of injury, with normal values ranging between 700 and 800106 mm2 /s and values decreasing with injury. 2. Emergent coronary angiography and PCI have also been also associated with improved neurological outcomes in patients without STEMI on their post-ROSC resuscitation ECG.4,12 However, a large randomized trial found no improvement in survival in patients resuscitated from OHCA with an initial shockable rhythm in whom no ST-segment elevations or signs of shock were present.13 Multiple RCTs are underway. The key drivers of successful resuscitation from OHCA are lay rescuer cardiopulmonary resuscitation (CPR) and public use of an automated external defibrillator (AED). Limited data are available from defibrillator threshold testing with backup transthoracic defibrillation, using variable waveforms and energy doses. You manage the airway while Jake delivers ventilations. Time to drug in IHCA is generally much shorter, and the effect of epinephrine on outcomes in the IHCA population may therefore be different. Your adult patient is in respiratory arrest due to an opioid overdose. It may be reasonable to charge a manual defibrillator during chest compressions either before or after a scheduled rhythm analysis. The goal of ECPR is to support end organ perfusion while potentially reversible conditions are addressed. You initiate CPR and correctly perform chest compressions at which rate? 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. For synchronized cardioversion of atrial flutter using biphasic energy, an initial energy of 50 to 100 J may be reasonable, depending on the specific biphasic defibrillator being used. In adult victims of cardiac arrest, it is reasonable for rescuers to perform chest compressions at a rate of 100 to 120/min. 2. Neuroprognostication that uses multimodal testing is felt to be better at predicting outcomes than is relying on the results of a single test to predict poor prognosis. The team is delivering 1 ventilation every 6 seconds. 1. You are providing high-quality CPR on a 6-year-old patient who weighs 44 pounds. Healthcare providers often take too long to check for a pulse. What should you do? The theory is that the heart will respond to electric stimuli by producing myocardial contraction and generating forward movement of blood, but clinical trials have not shown pacing to improve patient outcomes. In a tiered ALS- and BLS-provider system, the use of the BLS TOR rule can avoid confusion at the scene of a cardiac arrest without compromising diagnostic accuracy. 1. Registration staff asked the remaining questions at the patient bedside during their ED stay, reducing unnecessary delays in registration and more . She is 28 weeks pregnant and her fundus is above the umbilicus. The management of patients with preexcitation syndromes (aka Wolff-Parkinson-White) is covered in the Wide-Complex Tachycardia section. Administration of IV amiodarone, procainamide, or sotalol may be considered for the treatment of wide-complex tachycardia. Shout for nearby help/activate the resuscitation team; the provider can activate the resuscitation team at this time or after checking for breathing and pulse. Vasopressor medications during cardiac arrest. Does sodium thiosulfate provide additional benefit to patients with cyanide poisoning who are treated On MRI, cytotoxic injury can be measured as restricted diffusion on diffusion-weighted imaging (DWI) and can be quantified by the ADC. insulin) for refractory shock due to -adrenergic blocker or calcium channel blocker overdose? Public Health Emergency Response Guide Version 2.0 12 Immediate Response: Hours 0 - 2 1. The usefulness of S100 calcium-binding protein (S100B), Tau, neurofilament light chain, and glial fibrillary acidic protein in neuroprognostication is uncertain. *Telecommunicator and dispatcher are terms often used interchangeably. 5. 1. CPR should be initiated if pacing is not successful within 1 min. The critical task in preparedness planning is to define the system (how assets are organized) and processes (actions and interactions that must occur) that will guide emergency response and recovery. A well-organized team response when performing high-quality CPR includes ensuring that providers switch off performing compressions every _____ minutes. Do prophylactic antiarrhythmic medications on ROSC after successful defibrillation decrease arrhythmia Saturday: 9 a.m. - 5 p.m. CT Seizure prophylaxis in adult postcardiac arrest survivors is not recommended. Taking a regular rather than a deep breath prevents the rescuer from getting dizzy or lightheaded and prevents overinflation of the victims lungs. 1. The risk for developing torsades increases when the corrected QT interval is greater than 500 milliseconds and accompanied by bradycardia.1 Torsades can be due to an inherited genetic abnormality2 and can also be caused by drugs and electrolyte imbalances that cause lengthening of the QT interval.3. Precharging the defibrillator during ongoing chest compressions shortens the hands-off chest time surrounding defibrillation, without evidence of harm. Hang up only after the Emergency Operator has done so, or told you to. It is reasonable that TTM be maintained for at least 24 h after achieving target temperature. Maintaining the arterial partial pressure of carbon dioxide (Paco2) within a normal physiological range (generally 3545 mm Hg) may be reasonable in patients who remain comatose after ROSC. When Mr. Phillips shows signs of ROSC, where should you perform the pulse check? Three studies evaluated quantitative pupillary light reflex. 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. High-quality CPR is, along with defibrillation for those with shockable rhythms, the most important lifesaving intervention for a patient in cardiac arrest. 3. 1. No trials to date have found any benefit of either higher-dose epinephrine or other vasopressors over standard-dose epinephrine during CPR. 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. 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. In patients with calcium channel blocker overdose who are in refractory shock, administration of high-dose insulin with glucose is reasonable. Does targeted temperature management, compared to strict normothermia, improve outcomes? 1. This topic last received formal evidence review in 2010.4. 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. The 2015 American College of Cardiology, AHA, and Heart Rhythm Society Guidelines evaluated and recommended adenosine as a first-line treatment for regular SVT because of its effectiveness, extremely short half-life, and favorable side-effect profile. Given that a false-positive test for poor neurological outcome could lead to inappropriate withdrawal of life support from a patient who otherwise would have recovered, the most important test characteristic is specificity. 2. In the absence of conclusive evidence that one biphasic waveform is superior to another in termination of VF, it is reasonable to use the manufacturers recommended energy dose for the first shock. Are you performing all of the required ITM on your Emergency Power Supply System? We recommend treatment of clinically apparent seizures in adult postcardiac arrest survivors. The same anticonvulsant regimens used for the treatment of seizures caused by other etiologies may be considered for seizures detected after cardiac arrest. To maintain provider skills from initial training, frequent retraining is important. CT and MRI are the 2 most common modalities. During targeted temperature management of the pregnant patient, it is recommended that the fetus be continuously monitored for bradycardia as a potential complication, and obstetric and neonatal consultation should be sought. Based on similarly rare but time-critical interventions, planning, simulation training and mock emergencies will assist in facility preparedness. 1. 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. Studies of mechanical CPR devices have not demonstrated a benefit when compared with manual CPR, with a suggestion of worse neurological outcome in some studies.