the functional capacity and safety of hospitals and the health-care system at large. Notably, when the QRS complex is of uniform morphology, shock synchronized to the QRS is encouraged because this minimizes the risk of provoking VF by a mistimed shock during the vulnerable period of the cardiac cycle (T wave). How does this affect compressions and ventilations? What is the ideal sequencing of modalities (traditional vasopressors, calcium, glucagon, high-dose During a resuscitation, the team leader assigns team roles and tasks to each member. Can artifact-filtering algorithms for analysis of ECG rhythms during CPR in a real-time clinical setting Existing evidence suggests that the potential harm from CPR in a patient who has been incorrectly identified as having cardiac arrest is low.1 Overall, the benefits of initiation of CPR in cardiac arrest outweigh the relatively low risk of injury for patients not in cardiac arrest. It is a multi-layered system involving individuals and teams from tribal, local, state, and federal agencies, as well as industry and other organizations. 2. In some instances, prognostication and withdrawal of life support may appropriately occur earlier because of nonneurologic disease, brain herniation, patients goals and wishes, or clearly nonsurvivable situations. We do not recommend routine use of magnesium for the treatment of polymorphic VT with a normal QT interval. 2. As with all AHA guidelines, each 2020 recommendation is assigned a Class of Recommendation (COR) based on the strength and consistency of the evidence, alternative treatment options, and the impact on patients and society (Table 1(link opens in new window)). 4. The head tiltchin lift has been shown to be effective in establishing an airway in noncardiac arrest and radiological studies. 2. Your adult patient is in respiratory arrest due to an opioid overdose. The BLS care of adolescents follows adult guidelines. Cocaine toxicity can cause adverse effects on the cardiovascular system, including dysrhythmia, hypertension, tachycardia and coronary artery vasospasm, and cardiac conduction delays. At minimum, one drill per year must be completed for each type of emergency response: evacuation, shelter in place, and hide/run/fight. Emergency Response Services (ERS) are provided through an electronic monitoring system used by functionally impaired adults who live alone or who are functionally isolated in the community. 2. A comprehensive, structured, multidisciplinary system of care should be implemented in a consistent manner for the treatment of postcardiac arrest patients. The ITD is a pressure-sensitive valve attached to an advanced airway or face mask that limits air entry into the lungs during the decompression phase of CPR, enhancing the negative intrathoracic pressure generated during chest wall recoil and improving venous return and cardiac output during CPR. SSEPs are obtained by stimulating the median nerve and evaluating for the presence of a cortical N20 wave. Applying Class of Recommendation and Level of Evidence to Clinical Strategies, Interventions, Treatments, or Diagnostic Testing in Patient Care (Updated May 2019)*, Table 3. Obtaining EEG in status myoclonus is important to rule out underlying ictal activity. A study in critically ill patients who required ventilatory support found that bag-mask ventilation at a rate of 10 breaths per minute decreased hypoxic events before intubation. 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). Airway, ventilation, and oxygenation are particularly important in the setting of pregnancy because of increased maternal metabolism and decreased functional reserve capacity due to the gravid uterus, making pregnant patients more prone to hypoxia. Effective ventilation of the patient with a tracheal stoma may require ventilation through the stoma, either by using mouth-to-stoma rescue breaths or by use of a bag-mask technique that creates a tight seal over the stoma with a round, pediatric face mask. 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. 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. A. Identifying and treating early clinical deterioration B. (a) zero order; The block-and-tackle system is released from rest with all cables taut. Table 1. 1. Provide 30 chest compressions. 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. 3. 3. Which is the next appropriate action? 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. This is a rare opportunity to gain experience working at one of the most sophisticated Security Alarm monitoring and security command centers in North America and be part of a high-performing team . 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. A description of the situation (e.g. More uniform definitions for status epilepticus, malignant EEG patterns, and other EEG patterns are When spinal injury is suspected or cannot be ruled out, rescuers should maintain manual spinal motion restriction and not use immobilization devices. 1. You are alone performing high-quality CPR when a second provider arrives to take over compressions. 2. CPR should be initiated if defibrillation is not successful within 1 min. Therefore, the management of bradycardia will depend on both the underlying cause and severity of the clinical presentation. The benefit of any specific target range of glucose management is uncertain in adults with ROSC after cardiac arrest. Furthermore, fetal hypoxia has known detrimental effects. When performed with other prognostic tests, it may be reasonable to consider extensive areas of restricted diffusion on brain MRI at 2 to 7 days after cardiac arrest to support the prognosis of poor neurological outcome in patients who remain comatose. Advanced monitoring such as ETCO2 monitoring is being increasingly used. 3. For each recommendation, the writing group discussed and approved specific recommendation wording and the COR and LOE assignments. Which technique should you use to open the patient's airway? Signs and symptoms include a rapid, weak pulse; a skin rash; and nausea and vomiting. WEAs are no more than 360 characters and include the type and time of the alert, any action you should take and the agency issuing the alert. Mouth-to-mouth ventilation in the water may be helpful when administered by a trained rescuer if it does not compromise safety. Evidence for the effectiveness of -adrenergic blockers in terminating SVT is limited. Send the second person to retrieve an AED, if one is available. During an emergency call on a personal emergency response system: A. ACLS indicates advanced cardiovascular life support; BLS, basic life support; CPR, cardiopulmonary resuscitation; ET, endotracheal; IV, intravenous; and ROSC, 1. Possible contributors to this goal include optimization of cerebral perfusion pressure, management of oxygen and carbon dioxide levels, control of core body temperature, and detection and treatment of seizures (Figure 9). In a trained provider-witnessed arrest of a postcardiac surgery patient, immediate defibrillation for VF/VT should be performed. After calling 911, follow the dispatcher's instructions. 1. Because of their longer duration of action, antiarrhythmic agents may also be useful to prevent recurrences of wide-complex tachycardia. ACLS indicates advanced cardiovascular life support; and CPR, cardiopulmonary resuscitation. 7. You are providing high-quality CPR on a 6-year-old patient who weighs 44 pounds. In some observational studies, improved outcomes have been noted in victims of cardiac arrest who received conventional CPR (compressions and ventilation) compared with those who received chest compressions only. Team planning for cardiac arrest in pregnancy should be done in collaboration with the obstetric, neonatal, emergency, anesthesiology, intensive care, and cardiac arrest services. The peripheral IV route has been the traditional approach to vascular access for emergency drug and fluid administration during resuscitation. Alert the team leader immediately and identify for them what task has been overlooked. In addition, it may be helpful for providers to master an advanced airway strategy as well as a second (backup) strategy for use if they are unable to establish the first-choice airway adjunct. and 2. In addition, 15 recommendations are designated Class 3: No Benefit, and 11 recommendations are Class 3: Harm. Chest compression depth begins to decrease after 90 to 120 seconds of CPR, although compression rates do not decrease significantly over that time window. 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. Serum biomarkers are blood-based tests that measure the concentration of proteins normally found in the central nervous system (CNS). What is the minimum safe observation period after reversal of respiratory depression from opioid 2. Saturday: 9 a.m. - 5 p.m. CT How is a child defined in terms of CPR/AED care? A 12-lead ECG should be obtained as soon as feasible after ROSC to determine whether acute ST-segment elevation is present. Cough CPR may be considered as a temporizing measure for the witnessed, monitored onset of a hemodynamically significant tachyarrhythmia or bradyarrhythmia before a loss of consciousness without delaying definitive therapy. EEG patterns that were evaluated in the 2020 ILCOR systematic review include unreactive EEG, epileptiform discharges, seizures, status epilepticus, burst suppression, and highly malignant EEG. 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. 1. Routine administration of calcium for treatment of cardiac arrest is not recommended. Thus, the confidence in the prognostication of the diagnostic tests studied is also low. Early defibrillation with concurrent high-quality CPR is critical to survival when sudden cardiac arrest is caused by ventricular fibrillation or pulseless ventricular tachycardia. 3. Electroencephalography is widely used in clinical practice to evaluate cortical brain activity and diagnose seizures. You recognize that a task has been overlooked. 3. What is the correct course of action? 4. The evidence for these recommendations was last reviewed thoroughly in 2010. Animal studies, case reports, and case series have reported increased heart rate and improved hemodynamics after high-dose insulin administration for -adrenergic blocker toxicity. A two-person technique is the preferred methodology for BVM ventilations as it provides better seal and ventilation volume, A well-organized team response when performing high-quality CPR includes ensuring that providers switch off performing compressions every _____ minutes. Standing or kneeling at the side of the infant with your hips at a slight angle, provide chest compressions using the encircling thumbs technique and deliver ventilations with a pocket mask or face shield. Agonal breathing is characterized by slow, irregular gasping respirations that are ineffective for ventilation. 4. If a jaw thrust and/or insertion of an airway adjunct are ineffective in opening the airway and allowing ventilation to occur, a head tiltchin lift may be the only way to open the airway. 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. Administration of epinephrine may be lifesaving. 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. Each of these features can also be useful in making a presumptive rhythm diagnosis. Anticoagulation alone is inadequate for patients with fulminant PE. In adult cardiac arrest, total preshock and postshock pauses in chest compressions should be as short as possible. Emergency Response Plan Revised 8/21/2017 Page 2 of 42 TABLE OF CONTENTS 1. 4. 4. State the number of significant digits in each of the following measurements. What is the best approach to rewarming postarrest patients after treatment with targeted temperature 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. Prompt initiation of targeted temperature management is necessary for all patients who do not follow commands after return of spontaneous circulation to ensure optimal functional and neurological outcome. Hydroxocobalamin and 100% oxygen, with or without sodium thiosulfate, can be beneficial for cyanide poisoning. Cyanide reversibly binds to the ferric ion cytochrome oxidase in the mitochondria and stops cellular respiration and adenosine triphosphate production. Both of these considerations support earlier advanced airway management for the pregnant patient. The 2020 ILCOR systematic review evaluated studies that obtained serum biomarkers within the first 7 days after arrest and correlated serum biomarker concentrations with neurological outcome. 1. 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). In the rare situation when a lone rescuer must leave the victim to dial EMS, the priority should be on prompt EMS activation followed by immediate return to the victim to initiate CPR. The routine use of cricoid pressure in adult cardiac arrest is not recommended. While providing ventilations, you notice that Mr. Sauer moves and appears to be breathing. 1. Rowan Hall room #225, etc.) Much of the evidence examining the effectiveness of airway strategies comes from radiographic and cadaver studies. carotid or femoral artery you are alone performing high-quality CPR when a second provider arrives to take over compressions. No large RCT evaluating different treatment strategies for patients suffering from acute cocaine toxicity exists. 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. 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. 4. 1. 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. Cyanide poisoning may result from smoke inhalation, industrial exposures, self-poisoning, terrorism, or the administration of sodium nitroprusside. 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.