4. humidified oxygen? Hyperbaric oxygen therapy may be helpful in the treatment of acute carbon monoxide poisoning in patients with severe toxicity. This topic last received formal evidence review in 2015.7. 1. Do neuroprotective agents improve favorable neurological outcome after arrest? 1. Evidence is limited to case reports and extrapolations from nonfatal cases, interpretation of pathophysiology, and consensus opinion. Which statement about bag-valve-mask (BVM) resuscitators is true? To accomplish delivery early, ideally within 5 min after the time of arrest, it is reasonable to immediately prepare for perimortem cesarean delivery while initial BLS and ACLS interventions are being performed. 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. Emergency response and disaster recovery. 1. referral to rehabilitation services or patient outcomes? Persons who enter the Main Accumulation Areas test the system by initiating a two-way conversation with Security each time they enter. 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. 1. Energy setting specifications for cardioversion also differ between defibrillators. 2. If the patient presents with SVT, the primary goal of treatment is to quickly identify and treat patients who are hemodynamically unstable (ischemic chest pain, altered mental status, shock, hypotension, acute heart failure) or symptomatic due to the arrhythmia. . A small number of studies has shown that higher Pao, Observational studies have found that increases in ETCO. You and your co-worker Jake are operating a BVM during multiple-provider CPR for an adult. In addition to standard ACLS, specific interventions may be lifesaving for cases of hyperkalemia and hypermagnesemia. Electric cardioversion can be useful either as firstline treatment or for drug-refractory wide-complex tachycardia due to reentry rhythms (such as atrial fibrillation, atrial flutter, AV reentry, and VT). 4. 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). 4. Commercially available defibrillators either provide fixed energy settings or allow for escalating energy settings; both approaches are highly effective in terminating VF/VT. How does integrated team performance, as opposed to performance on individual resuscitation skills, Overall outcomes from out-of-hospital cardiac arrest (OHCA), both in terms of survival and neurologic and functional ability, are poor: only 11 percent of patients treated by emergency medical services (EMS) personnel survive to discharge (Daya et al., 2015; Vellano et al., 2015). Mitigation Case reports and at least 1 retrospective observational study have been published on survival after ECMO in patients presenting with refractory shock from -adrenergic blocker overdose. No large RCT evaluating different treatment strategies for patients suffering from acute cocaine toxicity exists. 1. 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.) After symptoms have been identified and a bystander has called 9-1-1 or an equivalent emergency response system, the next step in the chain of survival is to immediately begin cardiopulmonary resuscitation or CPR. In light of the complexity of postarrest patients, a multidisciplinary team with expertise in cardiac arrest care is preferred, and the development of multidisciplinary protocols is critical to optimize survival and neurological outcome. ADC indicates apparent diffusion coefficient; CPR, cardiopulmonary resuscitation; CT, computed tomography; ECG, electrocardiogram; ECPR, extracorporeal management? 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. The systems-of-care approach to cardiac arrest includes the community and healthcare response to cardiac arrest. 3. Do steroids improve shock or other outcomes in patients who remain hypotensive after ROSC? At least 1 retrospective study on ECMO use for patients with cardiac arrest or refractory shock in the setting of drug toxicity has reported improved outcomes. Turn Call with Hold and Release, Call with 5 Button Presses, or Call Quietly on. Recommendations for management of torsades de pointes are also presented in Torsades de Pointes. 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. 4. These recommendations are supported by Cardiac Arrest in Pregnancy: a Scientific Statement From the AHA9 and a 2020 evidence update.30, This topic was reviewed in an ILCOR systematic review for 2020.1 PE is a potentially reversible cause of shock and cardiac arrest. To maintain provider skills from initial training, frequent retraining is important. What is the specific type, amount, and interval between airway management training experiences to 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. Since the last time these recommendations were formally reviewed, The administration of hypertonic (8.4%, 1 mEq/ mL) sodium bicarbonate solution for treatment of sodium channel blockade due to TCAs and other toxicants is supported by human observational studies. 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. Urgent support of airway, breathing, and circulation is essential in suspected anaphylactic reactions. You initiate CPR and correctly perform chest compressions at which rate? Digoxin poisoning can cause severe bradycardia, AV nodal blockade, and life-threatening ventricular arrhythmias. When the second rescuer arrives, provide 2-rescuer CPR and use the AED/defibrillator. 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. In the ASPIRE trial (1071 patients), use of the load-distributing band device was associated with similar odds of survival to hospital discharge (adjusted odds ratio [aOR], 0.56; CI, 0.311.00; A 2013 Cochrane review of 10 trials comparing ACD-CPR with standard CPR found no differences in mortality and neurological function in adults with OHCA or IHCA. 1. These procedures are described more fully in Part 2: Evidence Evaluation and Guidelines Development. Disclosure information for writing group members is listed in Appendix 1(link opens in new window). 2. 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). 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. Are you performing all of the required ITM on your Emergency Power Supply System? Which term refers to clearly and rationally identifying the connection between information and actions? The benefit of any specific target range of glucose management is uncertain in adults with ROSC after cardiac arrest. This approach results in a protracted hands-off period before shock. Ideally, activation of the emergency response system and initiation of CPR occur simultaneously. Clinical trial evidence shows that nondihydropyridine calcium channel antagonists (eg, diltiazem, verapamil), -adrenergic blockers (eg, esmolol, propranolol), amiodarone, and digoxin are all effective for rate control in patients with atrial fibrillation/ flutter. Should severely hypothermic patients receive intubation and mechanical ventilation or simply warm You are alone caring for a 4-month-old infant who has gone into cardiac arrest. Multiple observational studies have shown an association between emergent coronary angiography and PCI and improved neurological outcomes in patients without ST-segment elevation. These arrhythmias are common and often coexist, and their treatment recommendations are similar. The optimal timing of CPR initiation and emergency response system activation was evaluated by an ILCOR systematic review in 2020. You and your colleagues are performing CPR on a 6-year-old child. Soon after the AED pads have been placed, the device alerts, "Shock advised." There is no evidence that cricoid pressure facilitates ventilation or reduces the risk of aspiration in cardiac arrest patients. When performed with other prognostic tests, it may be reasonable to consider burst suppression on EEG in the absence of sedating medications at 72 h or more after arrest to support the prognosis of poor neurological outcome. Poisoning from other cardiac glycosides, such as oleander, foxglove, and digitoxin, have similar effects. Cardiac arrest occurs after 1% to 8% of cardiac surgery cases.18 Etiologies include tachyarrhythmias such as VT or VF, bradyarrhythmias such as heart block or asystole, obstructive causes such as tamponade or pneumothorax, technical factors such as dysfunction of a new valve, occlusion of a grafted artery, or bleeding. Many alternatives and adjuncts to conventional CPR have been developed. 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. You are providing high-quality CPR on a 6-year-old patient who weighs 44 pounds. 3. 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. This topic last received formal evidence review in 2010.4. This approach is supported by animal studies and human case reports and has recently been systematically reviewed.4. 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. A wide-complex tachycardia can be regular or irregularly irregular and have uniform (monomorphic) or differing (polymorphic) QRS complexes from beat to beat. 1. 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. How does this affect compressions and ventilations? Acute increase in right ventricular pressure due to pulmonary artery obstruction and release of vasoactive mediators produces cardiogenic shock that may rapidly progress to cardiovascular collapse. Recommendations 1 and 2 are supported by the 2020 CoSTR for ALS.22 Recommendations 3 and 4 last received formal evidence review in 2010.20. When bradycardia occurs secondary to a pathological cause, it can lead to decreased cardiac output with resultant hypotension and tissue hypoperfusion. The World Health Organization Regional Office for Europe has developed the Hospital emergency response checklist to assist hospital administrators and emergency managers in responding effectively to the most likely disaster scenarios. Initial management should focus on support of the patients airway and breathing. Which patients with cardiac arrest due to suspected pulmonary embolism benefit from emergency 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. 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. 1. 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. Approximately 1.2% of adults admitted to US hospitals suffer in-hospital cardiac arrest (IHCA).1 Of these patients, 25.8% were discharged from the hospital alive, and 82% of survivors have good functional status at the time of discharge. 3. Two RCTs compared a strategy of targeting highnormal Paco2 (4446 mmHg) with one targeting low-normal Paco. These recommendations are supported by the 2020 CoSTR for ALS,4 which supplements the last comprehensive review of this topic conducted in 2015.7. Postcardiac arrest care is a critical component of the Chain of Survival and demands a comprehensive, structured, multidisciplinary system that requires consistent implementation for optimal patient outcomes. 1. Fire . We recommend TTM for adults who do not follow commands after ROSC from IHCA with initial shockable rhythm. The team is delivering 1 ventilation every 6 seconds. Care of any patient with cardiac arrest in the setting of acute exacerbation of asthma begins with standard BLS. Manual stabilization can decrease movement of the cervical spine during patient care while allowing for proper ventilation and airway control. Immediately Initiate Your Emergency Response Plan Immediately initiating your organization's emergency response plans' predefined series of notifications is essential in getting people to safety and minimizing the impacts of emergency situations. 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. IV infusion of epinephrine may be considered for post-arrest shock in patients with anaphylaxis. Routine stabilization of the cervical spine in the absence of circumstances that suggest a spinal injury is not recommended. In a recent meta-analysis of 2 published studies (10 178 patients), only 0.01% (95% CI, 0.00%0.07%) of patients who fulfilled the ALS termination criteria survived to hospital discharge. When pacing attempts are not immediately successful, standard ACLS including CPR is indicated. These guidelines are based on the extensive evidence evaluation performed in conjunction with the ILCOR and affiliated ILCOR member councils. The suggested timing of the multimodal diagnostics is shown here. Administration of IV amiodarone, procainamide, or sotalol may be considered for the treatment of wide-complex tachycardia. Multiple randomized trials have been performed in various domains of TTM and were summarized in a systematic review published in 2015.1 Subsequent to the 2015 recommendations, additional randomized trials have evaluated TTM for nonshockable rhythms as well as TTM duration. For cardiac arrest with known or suspected hyperkalemia, in addition to standard ACLS care, IV calcium should be administered. 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 Which term refers to clearly and rationally identifying the connection between information and actions? All victims of drowning who require any form of resuscitation (including rescue breathing alone) should be transported to the hospital for evaluation and monitoring, even if they appear to be alert and demonstrate effective cardiorespiratory function at the scene. In a trained provider-witnessed arrest of a postcardiac surgery patient where pacer wires are already in place, we recommend immediate pacing in an asystolic or bradycardic arrest. Its use as a neuroprognostic tool is promising, but the literature is limited by several factors: lack of standardized terminology and definitions, relatively small sample sizes, single center study design, lack of blinding, subjectivity in the interpretation, and lack of accounting for effects of medications. 1. CPR obscures interpretation of the underlying rhythm because of the artifact created by chest compressions on the ECG. Alternatives to IV access for acute drug administration include IO, central venous, intracardiac, and endotracheal routes. What is the validity and reliability of ETCO. A 7-year-old patient goes into sudden cardiac arrest. 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. What is the compression-to-ventilation ratio during multiple-provider CPR? It has been shown that the risk of injury from CPR is low in these patients.2. We recommend that epinephrine be administered for patients in cardiac arrest. Does preshock waveform analysis lead to improved outcome? Does hospital-based protocolized discharge planning for cardiac arrest survivors improve access to/ 4. 3. 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%). A description of the situation (e.g. authorized emergency ambulance dispatch center for specific MPDS determinants in accordance with EMS Policy No. Signs and symptoms include a rapid, weak pulse; a skin rash; and nausea and vomiting. smell of smoke, visible flames, etc.) 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. Excessive ventilation is unnecessary and can cause gastric inflation, regurgitation, and aspiration. 1. It may be reasonable to use physiological parameters such as arterial blood pressure or end-tidal CO. 1. Your adult patient is in respiratory arrest due to an opioid overdose. 2. Early delivery is associated with better maternal and neonatal survival.15 In situations incompatible with maternal survival, early delivery of the fetus may also improve neonatal survival. Early high-quality CPR You are providing care for Mrs. Bove, who has an endotracheal tube in place. Which mnemonic can help you easily recall and perform assessment? Which intervention should the nurse implement? 4. Thirty-seven recommendations are supported by Level B-Randomized Evidence (moderate evidence from 1 or more RCTs) and 57 by Level B-Nonrandomized evidence. There are no studies comparing different strategies of opening the airway in cardiac arrest patients. No shock waveform has proved to be superior in improving the rate of ROSC or survival. Patients in anaphylactic shock are critically ill, and cardiovascular and respiratory status can change quickly, making close monitoring imperative. For asthmatic patients with cardiac arrest, sudden elevation in peak inspiratory pressures or difficulty ventilating should prompt evaluation for tension pneumothorax. In 2013, a trial of over 900 patients compared TTM at 33C to 36C for patients with OHCA and any initial rhythm, excluding unwitnessed asystole, and found that 33C was not superior to 36C. The choice of anticoagulation is beyond the scope of these guidelines. These guidelines are not meant to be comprehensive. This is a separate question from the decision of if or when to transport a patient to the hospital with resuscitation ongoing. How is a child defined in terms of CPR/AED care? It may be reasonable for EMS providers to use a rate of 10 breaths per minute (1 breath every 6 s) to provide asynchronous ventilation during continuous chest compressions before placement of an advanced airway. The clinical signs associated with severe hyperkalemia (more than 6.5 mmol/L) include flaccid paralysis, paresthesia, depressed deep tendon reflexes, or shortness of breath.13 The early electrocardiographic signs include peaked T waves on the ECG followed by flattened or absent T waves, prolonged PR interval, widened QRS complex, deepened S waves, and merging of S and T waves.4,5 As hyperkalemia progresses, the ECG can develop idioventricular rhythms, form a sine-wave pattern, and develop into an asystolic cardiac arrest.4,5 Severe hypokalemia is less common but can occur in the setting of gastrointestinal or renal losses and can lead to life-threatening ventricular arrhythmias.68 Severe hypermagnesemia is most likely to occur in the obstetric setting in patients being treated with IV magnesium for preeclampsia or eclampsia. We recommend TTM for adults who do not follow commands after ROSC from IHCA with initial nonshockable rhythm. A 12-lead ECG should be obtained as soon as feasible after ROSC to determine whether acute ST-segment elevation is present. Magnesium may be considered for treatment of polymorphic VT associated with a long QT interval (torsades de pointes). CPR indicates cardiopulmonary resuscitation; IHCA, in-hospital cardiac arrest; and OHCA, out-of-hospital cardiac arrest. In patients with calcium channel blocker overdose who are in refractory shock, administration of IV glucagon may be considered. Neuroprognostication relies on interpreting the results of diagnostic tests and correlating those results with outcome. 6. Artifact-filtering and other innovative techniques to disclose the underlying rhythm beneath ongoing CPR can surmount these challenges and minimize interruptions in chest compressions while offering a diagnostic advantage to better direct therapies. Based on the training of the rescuers, and only if scene safety can be maintained for the rescuer, sometimes ventilation can be provided in the water (in-water resuscitation), which may lead to improved patient outcomes compared with delaying ventilation until the victim is out of the water. What are the optimal pharmacological treatment regimens for the management of postarrest seizures? Anticoagulation alone is inadequate for patients with fulminant PE. External chest compressions should be performed if emergency resternotomy is not immediately available. 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. 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). What is the ideal initial dose of naloxone in a setting where fentanyl and fentanyl analogues are 64.01 fm c. 80.001 m d. 0.720g0.720 \mu g0.720g e. 2.40106kg2.40 \times 10^{6} \mathrm{kg}2.40106kg f. 6108kg6 \times 10^{8} \mathrm{kg}6108kg g. 4.071016m4.07 \times 10^{16} \mathrm{m}4.071016m. Interposed abdominal compression CPR is a 3-rescuer technique that includes conventional chest compressions combined with alternating abdominal compressions. Rescuers cannot be certain that the persons clinical condition is due to opioid-induced respiratory depression alone. 3. IV diltiazem or verapamil can be effective for acute treatment in patients with hemodynamically stable SVT at a regular rate. Emergency Response and Recovery. Because the -adrenergic receptor regulates the activity of the L-type calcium channel,1 overdose of these medications presents similarly, causing life-threatening hypotension and/or bradycardia that may be refractory to standard treatments such as vasopressor infusions.2,3 For patients with refractory hemodynamic instability, therapeutic options include administration of high-dose insulin, IV calcium, or glucagon, and consultation with a medical toxicologist or regional poison center can help determine the optimal therapy. Intraosseous access may be considered if attempts at intravenous access are unsuccessful or not feasible. Healthcare providers often take too long to check for a pulse. 1. Answer: Perform cardiopulmonary resuscitation Explanation: According to the Adult In-Hospital Cardiac Chain of Survival after immediately starting the emergency response system, you should immediately start a cardiopulmonary resuscitation with an emphasis on chest compressions. Each recommendation was developed and formally approved by the writing group. 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. Based on their greater success in arrhythmia termination, defibrillators using biphasic waveforms are preferred over monophasic defibrillators for treatment of tachyarrhythmias.