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1. You are alone caring for a 4-month-old infant who has gone into cardiac arrest. Many cardiac arrest patients who survive the initial event will eventually die because of withdrawal of life-sustaining treatment in the setting of neurological injury. Conversely, when VF/ VT is more protracted, depletion of the hearts energy reserves can compromise the efficacy of defibrillation unless replenished by a prescribed period of CPR before the rhythm analysis. Can point-of-care cardiac ultrasound, in conjunction with other factors, inform termination of An irregularly irregular wide-complex tachycardia with monomorphic QRS complexes suggests atrial fibrillation with aberrancy, whereas pre-excited atrial fibrillation or polymorphic VT are likely when QRS complexes change in their configuration from beat to beat. IV epinephrine is an appropriate alternative to intramuscular administration in anaphylactic shock when an IV is in place. This involves the cannulation of a large vein and artery and initiation of venoarterial extracorporeal circulation and membrane oxygenation (ECMO) (Figure 8). Your adult patient is in respiratory arrest due to an opioid overdose. 1. Resuscitation of the pregnant woman, including PMCD when indicated, is the first priority because it may lead to increased survival of both the woman and the fetus. The routine use of magnesium for cardiac arrest is not recommended. Thus, the ultimate decision of the use, type, and timing of an advanced airway will require consideration of a host of patient and provider characteristics that are not easily defined in a global recommendation. Call Quietly is available in iOS 16.3 and later. Early high-quality CPR You are providing care for Mrs. Bove, who has an endotracheal tube in place. The available evidence suggests no appreciable differences in success or major adverse event rates between calcium channel blockers and adenosine.2. The rationale for a single shock strategy, in which CPR is immediately resumed after the first shock rather than after serial stacked shocks (if required) is based on a number of considerations. Two systematic reviews have identified animal studies, case reports, and human observational studies that have reported increased heart rate and improved hemodynamics after high-dose insulin administration for calcium channel blocker toxicity. The suggested timing of the multimodal diagnostics is shown here. They should perform continuous LUD until the infant is delivered, even if ROSC is achieved. Thirty-seven recommendations are supported by Level B-Randomized Evidence (moderate evidence from 1 or more RCTs) and 57 by Level B-Nonrandomized evidence. A well-conducted human trial showed that administration of propranolol reduces coronary blood flow in patients with cocaine exposure. 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. 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. Rescuers should recognize that multiple approaches may be required to establish an adequate airway. 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. 2. You recognize that a task has been overlooked. What is the most important initial action? There are a number of case reports and case series that examined the use of fist pacing during asystolic or life-threatening bradycardic events. While providing ventilations, you notice that Mr. Sauer moves and appears to be breathing. 1. It can represent any aberrantly conducted supraventricular tachycardia (SVT), including paroxysmal SVT caused by atrioventricular (AV) reentry, aberrantly conducted atrial fibrillation, atrial flutter, or ectopic atrial tachycardia. return of spontaneous circulation. For medical management of a periarrest patient, epinephrine has gained popularity, including IV infusion and utilization of push-dose administration for acute bradycardia and hypotension. Emergent coronary angiography is reasonable for select (eg, electrically or hemodynamically unstable) adult patients who are comatose after OHCA of suspected cardiac origin but without ST-segment elevation on ECG. Early CPR The systematic and continuous approach to providing emergent patient care includes which three elements? These recommendations are supported by the 2020 CoSTR for BLS.1. 2. 1. The primary focus of cardiac arrest management for providers is the optimization of all critical steps required to improve outcomes. CPR is the single-most important intervention for a patient in cardiac arrest, and chest compressions should be provided promptly. Electrolyte abnormalities may cause or contribute to cardiac arrest, hinder resuscitative efforts, and affect hemodynamic recovery after cardiac arrest. will initiate a cluster response which includes providing infection control guidance and recommendations, technical . Opioid overdoses deteriorate to cardiopulmonary arrest because of loss of airway patency and lack of breathing; therefore, addressing the airway and ventilation in a periarrest patient is of the highest priority. The AED arrives. 1. The writing group would also like to acknowledge the outstanding contributions of David J. Magid, MD, MPH. The systems-of-care approach to cardiac arrest includes the community and healthcare response to cardiac arrest. Hemodynamically unstable patients and those with rate-related ischemia should receive urgent electric cardioversion. 2. A BLS emergency ambulance shall request an ALS emergency ambulance transport if after assessment on scene determines the need for 1. This is a separate question from the decision of if or when to transport a patient to the hospital with resuscitation ongoing. Although abbreviated observation periods may be adequate for patients with fentanyl, morphine, or heroin overdose. Which action should you perform first? Epinephrine is the cornerstone of treatment for anaphylaxis.35, This topic last received formal evidence review in 2010.14. When significant CAD is observed during post-ROSC coronary angiography, revascularization can be achieved safely in most cases.5,7,9 Further, successful PCI is associated with improved survival in multiple observational studies.2,6,7,10,11 Additional benefits of evaluation in the cardiac catheterization laboratory include discovery of anomalous coronary anatomy, the opportunity to assess left ventricular function and hemodynamic status, and the potential for insertion of temporary mechanical circulatory support devices. The ILCOR systematic review included studies regardless of TTM status, and findings were correlated with neurological outcome at time points ranging from hospital discharge to 12 months after arrest.4 Quantitative pupillometry is the automated assessment of pupillary reactivity, measured by the percent reduction in pupillary size and the degree of reactivity reported as the neurological pupil index. 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. We recommend avoiding hypoxemia in all patients who remain comatose after ROSC. 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. You yell to the medical assistant, "Go get the AED!" You initiate CPR and correctly perform chest compressions at which rate? 3. On MRI, cytotoxic injury can be measured as restricted diffusion on diffusion-weighted imaging (DWI) and can be quantified by the ADC. 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. You are providing care for Mrs. Bove, who has an endotracheal tube in place. Although case reports describe good outcomes after the use of ECMO6 and IV lipid emulsion therapy710 for severe sodium channel blocker cardiotoxicity, no controlled human studies could be found, and limited animal data do not support lipid emulsion efficacy.11, No human controlled studies were found evaluating treatment of cardiac arrest due to TCA toxicity, although 1 study demonstrated termination of amitriptyline-induced VT in dogs.12, This topic last received formal evidence review in 2010.25. What is the optimal duration for targeted temperature management before rewarming? There is also inconsistency in definitions used to describe specific findings and patterns. Someone from the age of 1 to the onset of puberty. When the QRS complex of a VT is of uniform morphology, electric cardioversion with the shock synchronized to the QRS minimizes the risk of provoking VF by a mistimed shock during the vulnerable period of the cardiac cycle (T wave). The combination of active compression-decompression CPR and impedance threshold device may be reasonable in settings with available equipment and properly trained personnel. 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. However, with more people surviving cardiac arrest, there is a need to organize discharge planning and long-term rehabilitation care resources. Because the duration of action of naloxone may be shorter than the respiratory depressive effect of the opioid, particularly long-acting formulations, repeat doses of naloxone, or a naloxone infusion may be required. No RCTs of resternotomy timing have been performed. You perform a rapid assessment and determine that your patient is experiencing cardiac arrest. When 2 or more rescuers are available, it is reasonable to switch chest compressors approximately every 2 min (or after about 5 cycles of compressions and ventilation at a ratio of 30:2) to prevent decreases in the quality of compressions. 4. 2. Shout for nearby help. These recommendations are supported by the 2018 American College of Cardiology, AHA, and Heart Rhythm Society guideline on the evaluation and management of patients with bradycardia and cardiac conduction delay.16. A. Identifying and treating early clinical deterioration B. A 2017 systematic review identified 1 observational human study and 10 animal studies comparing different ventilation rates after advanced airway placement. The emergency should not be terminated until a Recovery Plan Outline has been developed and a Recovery Organization identified. In some cases, emergency cricothyroidotomy or tracheostomy may be required. Several observational studies have demonstrated improved neurologically favorable survival when early coronary angiography is performed followed by PCI in patients with cardiac arrest who have a STEMI. Acts as the on-call coordinator on an as needed basis, and responds immediately when on call; Directs personnel in the operational procedures to complete assignments and understand manpower and equipment requirements to complete field service projects and emergency responses; Acts as office liaison for the field service personnel in the field; What is the correct rate of ventilation delivery for a child or infant in respiratory arrest or failure? Lay and trained responders should not delay activating emergency response systems while awaiting the patients response to naloxone or other interventions. 3. For adults in cardiac arrest receiving ventilation, tidal volumes of approximately 500 to 600 mL, or enough to produce visible chest rise, are reasonable. CT and MRI are the 2 most common modalities. Historically, the best motor examination in the upper extremities has been used as a prognostic tool, with extensor or absent movement being correlated with poor outcome. When anaphylaxis produces obstructive airway edema, rapid advanced airway management is critical. These guidelines are not meant to be comprehensive. 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. In an emergency, the individual can press a call button to signal for help. 1. 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. After identifying a cardiac arrest, a lone responder should activate the emergency response system first and immediately begin CPR. A large observational cohort study investigating these and other novel serum biomarkers and their performance as prognostic biomarkers would be of high clinical significance. We recommend selecting and maintaining a constant temperature between 32C and 36C during TTM. 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. Precordial thump is a single, sharp, high-velocity impact (or punch) to the middle sternum by the ulnar aspect of a tightly clenched fist. 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. Some EEG-correlated patterns of status myoclonus may have poor prognosis, but there may also be more benign subtypes of status myoclonus with EEG correlates. 5. In addition to defibrillation, several alternative electric and pseudoelectrical therapies have been explored as possible treatment options during cardiac arrest. Residual sedation or paralysis can confound the accuracy of clinical examinations. Rescuers may experience anxiety or posttraumatic stress about providing or not providing BLS. Immediately begin CPR, and use the AED/ defibrillator when available. Adenosine is an ultrashort-acting drug that is effective in terminating regular tachycardias when caused by AV reentry. You are alone and caring for a 9-month-old infant with an obstructed airway who becomes unresponsive. After initial stabilization, care of critically ill postarrest patients hinges on hemodynamic support, mechanical ventilation, temperature management, diagnosis and treatment of underlying causes, diagnosis and treatment of seizures, vigilance for and treatment of infection, and management of the critically ill state of the patient. Was this Article Helpful ? Hemodynamically unstable patients with atrial fibrillation or atrial flutter with rapid ventricular response should receive electric cardioversion. Does avoidance of hyperoxia in the postarrest period lead to improved outcomes? 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. It consists of actions which are aimed at saving lives, reducing economic losses and alleviating suffering. The routine use of cricoid pressure in adult cardiac arrest is not recommended. The CMT oversees the ERT and the DR team(s). Debriefings and referral for follow-up for emotional support for lay rescuers, EMS providers, and hospital-based healthcare workers after a cardiac arrest event may be beneficial. Vasopressor medications during cardiac arrest. This topic last received formal evidence review in 2015.7. 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). 2. Routine measurement of arterial blood gases during CPR has uncertain value. needed to be able to compare prognostic values across studies. Does the use of point-of-care cardiac ultrasound during cardiac arrest improve outcomes? The goal of ECPR is to support end organ perfusion while potentially reversible conditions are addressed. Although the administration of IV magnesium has not been found to be beneficial for VF/VT in the absence of prolonged QT, consideration of its use for cardiac arrest in patients with prolonged QT is advised. A recent consensus statement on this topic has been published by the Society of Thoracic Surgeons.9, This topic last received formal evidence review in 2010.35These recommendations were supplemented by a 2017 review published by the Society of Thoracic Surgeons.9. 2. Early activation of the emergency response system is critical for patients with suspected opioid overdose. Clinicians must determine if the tachycardia is narrow-complex or wide-complex tachycardia and if it has a regular or irregular rhythm. Unfortunately, despite improvements in the design and funding support for resuscitation research, the overall certainty of the evidence base for resuscitation science is low. You are working in an OB/GYN office when your patient, Mrs. Tribble, suddenly goes into cardiac arrest. Synchronized cardioversion or drugs or both may be used to control unstable or symptomatic regular narrow-complex tachycardia. In hemodynamically stable patients, IV adenosine may be considered for treatment and aiding rhythm diagnosis when the cause of the regular, monomorphic rhythm cannot be determined. When an arrest occurs in the hospital, a strong multidisciplinary approach includes teams of medical professionals who respond, provide CPR, promptly defibrillate, begin ALS measures, and continue post-ROSC care. When evaluated with other prognostic tests, the prognostic value of seizures in patients who remain comatose after cardiac arrest is uncertain. 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.