Practice EssentialsCardiopulmonary resuscitation (CPR) consists of the use of chest compressions and artificial ventilation to maintain circulatory flow and oxygenation during cardiac arrest (see the images below). Although survival rates and neurologic outcomes are poor for patients with cardiac arrest, early appropriate resuscitation—including early defibrillation when needed—and appropriate implementation of post–cardiac arrest care lead to improved survival and neurologic outcomes. Show
Indications and contraindicationsCPR should be performed immediately on any person who has become unconscious and is found to be pulseless. Assessment of cardiac electrical activity via rapid rhythm strip recording can provide a more detailed analysis of the type of cardiac arrest, as well as indicate additional treatment options. Loss of effective cardiac activity is generally due to the spontaneous initiation of a nonperfusing arrhythmia, sometimes referred to as a malignant arrhythmia. The most common nonperfusing arrhythmias include the following:
Although prompt defibrillation has been shown to improve survival for VF and pulseless VT rhythms, [1] CPR should be started before the rhythm is identified and should be continued while the defibrillator is being applied and charged. Additionally, CPR should be resumed immediately after a defibrillatory shock until a pulsatile state is established. This is supported by studies showing that preshock pauses in CPR result in lower rates of defibrillation success and patient recovery. [2] In a study involving out-of-hospital cardiac arrests in Seattle, 84% of patients regained a pulse when defibrillated during VF. [3] Defibrillation is generally most effective the faster it is deployed. The American College of Surgeons, the American College of Emergency Physicians, the National Association of EMS Physicians, and the American Academy of Pediatrics have issued guidelines on the withholding or termination of resuscitation in pediatric out-of-hospital traumatic cardiopulmonary arrest. [4] Recommendations include the following:
ContraindicationsThe only absolute contraindication to CPR is a do-not-resuscitate (DNR) order or other advanced directive indicating a person’s desire to not be resuscitated in the event of cardiac arrest. A relative contraindication to performing CPR is if a physician justifiably believes that the intervention would be medically futile. This is an area of active research. [5, 6] EquipmentCPR, in its most basic form, can be performed anywhere without the need for specialized equipment. Universal precautions (ie, gloves, mask, gown) should be taken. However, CPR is delivered without such protections in the vast majority of patients who are resuscitated in the out-of-hospital setting. Some hospitals and EMS systems employ devices to provide mechanical chest compressions. A cardiac defibrillator provides an electrical shock to the heart via 2 electrodes placed on the patient’s torso and may restore the heart into a normal perfusing rhythm. TechniqueIn its full, standard form, CPR comprises the following 3 steps, performed in order:
For lay rescuers, compression-only CPR (COCPR) is recommended. Positioning for CPR is as follows:
For an unconscious adult, CPR is initiated as follows:
Chest compression The provider should do the following:
Ventilation If the patient is not breathing, 2 ventilations are given via the provider’s mouth or a bag-valve-mask (BVM). If available, a barrier device (pocket mask or face shield) should be used. To perform the BVM or invasive airway technique, the provider does the following:
To perform the mouth-to-mouth technique, the provider does the following:
ComplicationsComplications of CPR include the following:
ACLSIn the in-hospital setting or when a paramedic or other advanced provider is present, ACLS guidelines call for a more robust approach to treatment of cardiac arrest, including the following:
Emergency cardiac treatments no longer recommended include the following:
BackgroundFor patients with cardiac arrest, survival rates and neurologic outcomes are poor, though early appropriate resuscitation, involving cardiopulmonary resuscitation (CPR), early defibrillation, and appropriate implementation of post–cardiac arrest care, leads to improved survival and neurologic outcomes. Targeted education and training regarding treatment of cardiac arrest directed at emergency medical services (EMS) professionals as well as the public has significantly increased cardiac arrest survival rates. [7] CPR consists of the use of chest compressions and artificial ventilation to maintain circulatory flow and oxygenation during cardiac arrest. A variation of CPR known as “hands-only” or “compression-only” CPR (COCPR) consists solely of chest compressions. This variant therapy is receiving growing attention as an option for lay providers (that is, nonmedical witnesses to cardiac arrest events). The relative merits of standard CPR and COCPR continue to be widely debated. An observational study involving more than 40,000 patients concluded that standard CPR was associated with increased survival and more favorable neurologic outcomes than COCPR was. [8] However, other studies have shown opposite results, and it is currently accepted that COCPR is superior to standard CPR in out-of-hospital cardiac arrest. Several large randomized controlled and prospective cohort trials, as well as one meta-analysis, demonstrated that bystander-performed COCPR leads to improved survival in adults with out-of-hospital cardiac arrest, in comparison with standard CPR. [9, 10, 11] Differences between these results may be attributable to a subgroup of younger patients arresting from noncardiac causes, who clearly demonstrate better outcomes with conventional CPR. [8] The 2010 revisions to the American Heart Association (AHA) CPR guidelines state that untrained bystanders should perform COCPR in place of standard CPR or no CPR (see American Heart Association CPR Guidelines). [12] Of the more than 300,000 cardiac arrests that occur annually in the United States, survival rates are typically lower than 10% for out-of-hospital events and lower than 20% for in-hospital events. [13, 14, 15, 16, 17] A study by Akahane et al suggested that survival rates may be higher in men but that neurologic outcomes may be better in women of younger age, though the reasons for such sex differences are unclear. [18] Additionally, studies have shown that survival falls by 10-15% for each minute of cardiac arrest without CPR delivery. [19, 20] Bystander CPR initiated within minutes of the onset of arrest has been shown to improve survival rates 2- to 3-fold, as well as improve neurologic outcomes at 1 month. [21, 22] It has also been demonstrated that out-of hospital cardiac arrests occurring in public areas are more likely to be associated with initial ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT) and have better survival rates than arrests occurring at home. [23] This article focuses on CPR, which is just one aspect of resuscitation care. Other interventions, such as the administration of pharmacologic agents, cardiac defibrillation, invasive airway procedures, post–cardiac arrest therapeutic hypothermia, [24, 25, 26, 27, 28] the use of echocardiography in resuscitation, [29] and various diagnostic maneuvers, [30, 31] are beyond the scope of this article. For more information, see the Resuscitation Resource Center; for specific information on the resuscitation of neonates, see Neonatal Resuscitation. See the guidelines sections detailed later in the article. Indications & ContraindicationsIndicationsCPR should be performed immediately on any person who has become unconscious and is found to be pulseless. Assessment of cardiac electrical activity via rapid rhythm strip recording can provide a more detailed analysis of the type of cardiac arrest, as well as indicate additional treatment options. Loss of effective cardiac activity is generally due to the spontaneous initiation of a nonperfusing arrhythmia, sometimes referred to as a malignant arrhythmia. The most common nonperfusing arrhythmias include the following:
Although prompt defibrillation has been shown to improve survival for VF and pulseless VT rhythms, [1] CPR should be started before the rhythm is identified and should be continued while the defibrillator is being applied and charged. Additionally, CPR should be resumed immediately after a defibrillatory shock until a pulsatile state is established. This is supported by studies showing that preshock pauses in CPR result in lower rates of defibrillation success and patient recovery. [2] In a study involving out-of-hospital cardiac arrests in Seattle, 84% of patients regained a pulse when defibrillated during VF. [3] Defibrillation is generally most effective the faster it is deployed. The American College of Surgeons, the American College of Emergency Physicians, the National Association of EMS Physicians, and the American Academy of Pediatrics have issued guidelines on the withholding or termination of resuscitation in pediatric out-of-hospital traumatic cardiopulmonary arrest. [4] Recommendations include the following:
ContraindicationsThe only absolute contraindication to CPR is a do-not-resuscitate (DNR) order or other advanced directive indicating a person’s desire to not be resuscitated in the event of cardiac arrest. A relative contraindication to performing CPR is if a physician justifiably believes that the intervention would be medically futile. This is an area of active research. [5, 6] PreparationAnesthesiaBecause a person in cardiac arrest is almost invariably unconscious, anesthetic agents are not typically required for cardiopulmonary resuscitation (CPR). EquipmentCPR, in its most basic form, can be performed anywhere without the need for specialized equipment. Regardless of the equipment available, proper technique (see Technique) is essential. Universal precautions (ie, gloves, mask, gown) should be taken. However, in the vast majority of patients who are resuscitated in the out-of-hospital setting, CPR is delivered without such protections. Some hospitals and emergency medical services (EMS) systems employ devices to provide mechanical chest compressions, although until relatively recently, such devices had not been shown to be more effective than high-quality manual compressions. [32] One study has shown increased survival with better neurologic outcome in patients receiving active compression-decompression CPR with augmentation of negative intrathoracic pressure (achieved with an impedance threshold device), compared with patients receiving standard CPR. [33] In a meta-analysis of 12 studies, mechanical chest compression devices proved superior to manual chest compressions in the ability to achieve return of spontaneous circulation. In the meta-analysis, Westfall and colleagues found that devices that use a distributing band to deliver chest compression (load-distributing band CPR) was significantly superior to manual CPR (odds ratio, 1.62), while the difference between piston-driven CPR devices and manual resuscitation did not reach significance (odds ratio, 1.25) [34] This finding was supported by a study conducted by Pinto et al. [35] Additionally, other health systems have begun to implement devices to monitor CPR electronically and provide audiovisual CPR feedback to providers, thereby helping them improve the quality of compressions during CPR. [2, 36, 37, 38] An Advanced Cardiac Life Support (ACLS) provider (ie, physician, nurse, paramedic) may also elect to insert an endotracheal tube directly into the trachea of the patient (intubation), which provides the most efficient and effective ventilations. However, 2 retrospective cohort studies have called into question the value of prehospital endotracheal intubation. [39, 40] Further study in this area is warranted. An additional device employed in the treatment of cardiac arrest is a cardiac defibrillator. This device provides an electrical shock to the heart via 2 electrodes placed on the patient’s chest and can restore the heart into a normal perfusing rhythm. PositioningCPR is most easily and effectively performed by laying the patient supine on a relatively hard surface, which allows effective compression of the sternum. Delivery of CPR on a mattress or other soft material is generally less effective. The health care provider giving compressions should be positioned high enough above the patient to achieve sufficient leverage, so that he or she can use body weight to adequately compress the chest (see the video below). CPR positioning. Video courtesy of Daniel Herzberg, 2008. In the hospital setting, where patients are in gurneys or beds, appropriate positioning is often achieved by lowering the bed, having the CPR provider stand on a step-stool, or both. In the out-of-hospital setting, the patient is often positioned on the floor, with the CPR provider kneeling over him or her. TechniqueOverviewIn its full, standard form, cardiopulmonary resuscitation (CPR) comprises 3 steps: chest compressions, airway, and breathing (CAB), to be performed in that order in accordance with American Heart Association (AHA) guidelines. Note that artificial respirations are no longer recommended for bystander rescuers; thus, lay rescuers should perform compression-only CPR (COCPR). Healthcare providers, however, should perform all 3 components of CPR (chest compressions, airway, and breathing). For an unconscious adult, CPR is initiated using 30 chest compressions. Perform the head-tilt chin-lift maneuver to open the airway and determine if the patient is breathing. Before beginning ventilations, rule out airway obstruction by looking in the patient’s mouth for a foreign body blocking the patient’s airway. CPR in the presence of an airway obstruction results in ineffective ventilation/oxygenation and may lead to worsening hypoxemia. The techniques described here refer specifically to CPR as prescribed by the Basic Cardiac Life Support (BCLS) guidelines. In the in-hospital setting, or when a paramedic or other advanced provider is present in the out-of-hospital setting, Advanced Cardiac Life Support (ACLS) guidelines call for a more robust approach to treatment of cardiac arrest, including drug interventions, electrocardiographic (ECG) monitoring, defibrillation, and invasive airway procedures. Attempting to perform CPR is better than doing nothing at all, even if the provider is unsure if he or she is doing it correctly. This especially applies to many people’s aversion to providing mouth-to-mouth ventilations. If one does not feel comfortable giving ventilations, chest compressions alone are still better than doing nothing. Chest compressionThe heel of one hand is placed on the patient’s sternum, and the other hand is placed on top of the first, fingers interlaced. The elbows are extended and the provider leans directly over the patient (see the image below). The provider presses down, compressing the chest at least 2 in. The chest is released and allowed to recoil completely (see the video below). Delivery of chest compressions. Note the overlapping hands placed on the center of the sternum, with the rescuer's arms extended. Although it may be difficult to tell from the illustration, the rescuer's elbows should be locked out. Chest compressions are to be delivered at a rate of 100 to 120 per minute. The rescuer should push as hard as needed to attain a depth of each compression of 2 inches, and should allow complete chest recoil between each compression ('2 inches down, all the way up'). The rescuer should minimize any interruptions in compressions.CPR compressions. Video courtesy of Daniel Herzberg, 2008. With the hands kept in place, the compressions are repeated 30 times at a rate of 100/min. The key thing to keep in mind when doing chest compressions during CPR is to push fast and hard. Care should be taken to not lean on the patient between compressions, as this prevents chest recoil and worsens blood flow. After 30 compressions, 2 breaths are given (see Ventilation). Of note, an intubated patient should receive continuous compressions while ventilations are given 8-10 times per minute. This entire process is repeated until a pulse returns or the patient is transferred to definitive care. When done properly, CPR can be quite fatiguing for the provider. If possible, in order to give consistent, high-quality CPR and prevent provider fatigue or injury, new providers should intervene every 2-3 minutes (ie, providers should swap out, giving the chest compressor a rest while another rescuer continues CPR). For COCPR (ie, CPR without rescue breaths), the provider delivers only the chest compression portion of care at a rate of 100/min to a depth of 38-51 mm (1-1.5 in.) without pause. This delivery of compressions continues until the arrival of medical professionals or until another rescuer is available to continue compressions. [9] The use of mechanical CPR devices was reviewed in three large trials. Outcomes were similar between mechanical devices and manual compressions. The studies did not recommend routinely replacing manual compressions with mechanical CPR devices, but they did not rule out a role for the mechanical devices if high-quality manual chest compression is not available. [41] VentilationIf the patient is not breathing, 2 ventilations are given via the provider’s mouth (see the image below) or a bag-valve-mask (BVM). Delivery of mouth-to-mouth ventilations. Avoid excessive ventilation. If no advanced airway, 30:2 compression-ventilation ratio. That is, perform 30 compressions and then 2 breaths.The mouth-to-mouth technique is performed as follows (see the video below):
Effective mouth-to-mouth ventilation is determined by observation of chest rise during each exhalation. Failure to observe chest rise indicates an inadequate mouth seal or airway occlusion. As noted (see above), 2 such exhalations should be given in sequence after 30 compressions (the 30:2 cycle of CPR). When breaths are completed, compressions are restarted. If available, a barrier device (pocket mask or face shield) should be used. More commonly, health care providers use a BVM, which forces air into the lungs when the bag is squeezed. Several adjunct devices may be used with a BVM, including oropharyngeal and nasopharyngeal airways. The BVM or invasive airway technique is performed as follows:
Next, the provider checks for a carotid or femoral pulse. If the patient has no pulse, chest compressions are begun. Post ProcedureComplicationsPerforming chest compressions may result in the fracturing of ribs or the sternum, although the incidence of increased mortality from such fractures is widely considered to be low. [42] Artificial respiration using noninvasive ventilation methods (eg, mouth-to-mouth, bag-valve-mask [BVM]) can often result in gastric insufflation. This can lead to vomiting, which can further lead to airway compromise or aspiration. The problem is eliminated by inserting an invasive airway, which prevents air from entering the esophagus. CPR and ECC Guidelines SummaryUpdated cardiopulmonary resuscitation (CPR) and/or emergency cardiovascular care (ECC) guidelines were issued in 2020 by the American Heart Association (AHA) and International Liaison Committee on Resuscitation (ILCOR), and in 2020-2021 by the European Resuscitation Council (ERC). American Heart AssociationThe AHA's CPR guidelines are updated every 5 years and have transitioned to a new online format for continuous evidence evaluation since 2015. The 2020 guidelines include recommendations in the following areas [43] :
European Resuscitation CouncilThe ERC guidelines provide detailed algorithms and recommendations in 10 areas, which are updated and published approximately every 5 years in separate papers. The 2021 guidelines cover the following areas [44] :
The International Liaison Committee on ResuscitationInitially formed in 1993, the ILCOR includes representatives from the AHA, the ERC, the Heart and Stroke Foundation of Canada, the Australian and New Zealand Committee on Resuscitation, the Resuscitation Council of Southern Africa, the InterAmerican Heart Foundation, and the Resuscitation Council of Asia. The ILCOR defines emergency cardiac care as “all responses necessary to treat sudden life-threatening events affecting the cardiovascular and respiratory systems, with a particular focus on sudden cardiac arrest.” [45] Like the AHA and ERC guidelines, the ILCOR guidelines are updated on a 5-year cycle and include consensus treatment recommendations in the following areas [46] :
Chain of Survival GuidelinesThe 2020 update added a 'Recovery' link to the chain of survival for both in-hospital cardiac arrests (IHCAs) and out-of-hospital cardiac arrests (OHCAs). [43] Table 1. Adult Chain of Survival (Open Table in a new window)
ILCOR and ERC do not separate in-hospital from out-of-hospital cardiac arrest in their definition of chain of survival, and, therefore, they do not have the IHCA’s link 1 of surveillance and prevention. Otherwise they have similar chains of survival. [47, 45] Postresuscitation care recommendations were added back in the 2015 update as a new section in collaboration with the European Society of Intensive Care Medicine. These postresuscitation care guidelines acknowledge the importance of high-quality postresuscitation care as a vital link in the chain of survival. [48] Adult BLS and AED GuidelinesThe AHA adult basic life support (BLS) algorithm reflects the widespread use of mobile telephones that can be used for assistance without leaving the patient. The algorithm is detailed in Table 2, below. [49] Table 2. Adult BLS Algorithm (Open Table in a new window)
The AHA 2010 guidelines revised the initial CPR sequence of steps from ABC (airway, breathing, chest compressions) to CAB (chest compressions, airway, breathing) [50] ; this was reaffirmed in subsequent updates, which also offered the following revised recommendations for performance of CPR [49] :
Class I recommendations specifically for lay responders include the following [51] :
Recommendations specifically for dispatchers include the following [51] :
Although the guideline recommends that dispatchers ask only about responsiveness and breathing, cardiac arrest is defined physiologically by the lack of a detectable pulse. For example, a person who is post-ictal may be unresponsive and have abnormal breathing, yet have a completely normal heart and normal pulse. Therefore, one should consider simultaneous detection of pulse if possible. The guidelines recommend a simultaneous, choreographed approach to the performance of chest compressions, airway management, rescue breathing, rhythm detection, and shocks (if indicated) by an integrated team of highly trained rescuers in applicable settings. [51] Additional recommendations specifically for EMS and other healthcare providers include the following [51] :
To open the airway in victims with suspected spinal injury, lay rescuers should initially use manual spinal motion restriction (eg, placing their hands on the sides of the patient’s head to hold it still) rather than immobilization devices, because use of immobilization devices by lay rescuers may be harmful (class III). For healthcare providers and others trained in two-person CPR, if there is evidence of trauma that suggests spinal injury, a jaw thrust without head tilt should be used to open the airway (class IIb) There are no significant differences in the recommendations from ERC or ILCOR. [47, 52] Adult ACLS GuidelinesAlthough management of cardiac arrest begins with BLS and progresses sequentially through the links of the chain of survival, there is some overlap as each stage of care progresses to the next. Generally, in the three guidelines, advanced cardiovascular life support (ACLS) comprises the level of care between basic life support (BLS) and post–cardiac arrest care. Recommendations for adult BLS and ACLS are combined in the 2020 guidelines. [43] The following summarizes the 2020 AHA adult cardiac arrest algorithm [43] :
Go to '3c' above. If no shockable rhythm (and no pulse):
Go to '9b' below. If no shockable rhythm (PEA, asystole):
If shockable rhythm (VF, pVT), Go to '4' above. If no shockable rhythm (and no pulse):
Go to '9b' above. If signs of return of spontaneous circulation (ROSC), Go to Post–Cardiac Arrest Care. Note that for defibrillation, it is important to make sure the pads are correctly placed. Reversible causes of adult cardiac arrest include the following:
AHA recommendations regarding termination of resuscitation in OHCAAccording to the AHA, if termination of resuscitation (TOR) is being considered, BLS providers should use the BLS TOR rule where ALS is not available or will be delayed, and it is reasonable for ALS providers to use the adult ALS TOR rule in the field. The BLS TOR rule recommends TOR when all of the following three criteria apply before moving to the ambulance for transport:
The 2020 AHA guidelines note that in a recent meta-analysis of seven published studies (33,795 patients), only 0.13% (95% confidence interval [CI], 0.03-0.58%) of patients who fulfilled the BLS termination criteria survived to hospital discharge. [43] The ALS TOR rule recommends TOR when all of the following criteria apply before moving to the ambulance for transport:
The 2020 AHA guidelines note that in a recent meta-analysis of two 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. [43] DefibrillationAHA recommendations for defibrillation include the following [49] :
Adjuncts for airway control and ventilationThe AHA guidelines provide the following recommendations for airway control and ventilation [49] :
The recommendations from ERC or ILCOR do not differ significantly from those of the AHA. [53, 54] Medication managementAHA guidelines offer the following recommendations for the administration of drugs during cardiac arrest [49] :
Post–Cardiac Arrest Care GuidelinesThe 2020 AHA guidelines reaffirmed recommendations from the 2015 AHA Guidelines Update for CPR and ECC about treatment of hypotension, titrating oxygen to avoid both hypoxia and hyperoxia, detection and treatment of seizures, and targeted temperature management. According to the AHA guidelines, although the best hospital care for patients with ROSC after cardiac arrest is not completely known, a comprehensive, structured, multidisciplinary system of care should be implemented in a consistent manner for the treatment of post–cardiac arrest patients (class I). Components of structured interventions include the following [49] :
The key issues and major changes in the 2015 AHA guidelines update for post–cardiac-arrest care include the following [49] :
The following summarizes the AHA algorithm for adult immediate post‒cardiac arrest care after ROSC [49] :
Targeted temperature managementThe 2010 AHA guidelines strongly advised induced hypothermia (32-34˚C) for patients with out-of-hospital VF/pVT cardiac arrest and post-ROSC coma (the absence of purposeful movements) and encouraged consideration of induced hypothermia for most other comatose patients after cardiac arrest. However, the precise duration and optimal temperature targets were unknown. Because a range of temperatures is used, the term “targeted temperature management” (TTM) has been adopted. This term encompasses both induced hypothermia and active control of temperature at any target. [49] The reaffirmed (from 2015) 2020 recommendations for TTM included the following [49] :
Management of seizuresThe detection and treatment of nonconvulsive status epilepticus remains a priority. NeuroprognosticationThe 2020 AHA guidelines note that the timing for prognostication is typically greater than 72 hours after ROSC for patients treated with TTM. However, the guidelines acknowledge that withdrawal of life support may occur before 72 hours because of underlying terminal disease, brain herniation, or other clearly nonsurvivable situations. [49] Additional recommendations for the timing of prognostication include the following [49] :
The ERC guidelines indicate that poor outcome is very likely in patients who are unconscious for 72 hours or more after ROSC and have one or both of the following [48] :
If neither of those are present, the ERC recommends waiting at least 24 hours. At that point, poor outcome is very likely in patients with two or more of the following:
Organ donationAll three guidelines recommend that all patients who are resuscitated from cardiac arrest but subsequently progress to death or brain death be evaluated for organ donation. [49, 48, 54] In addition, the AHA guidelines recommend considering kidney or liver donation in patients who do not have ROSC after resuscitation efforts and would otherwise have termination of efforts. [49] Pediatric BLS and ACLS GuidelinesAHA guidelines on initiating CPRAs with the adult BLS recommendations, the AHA 2010 guidelines revised the initial CPR sequence of steps from ABC (airway, breathing, chest compressions) to CAB (chest compressions, airway, breathing). [50] This change was reaffirmed in the 2020 update, which states "It may be reasonable to initiate CPR with compressions-airway-breathing over airway breathing-compressions." [43] The AHA 2020 guidelines also recommend that (1) lay rescuers should begin CPR for any victim who is unresponsive, not breathing normally, and does not have signs of life; do not check for a pulse and (2) in infants and children with no signs of life, it is reasonable for healthcare providers to check for a pulse for up to 10 seconds and begin compressions unless a definite pulse is felt. [43] AHA guidelines algorithm for pediatric BLSFor lay rescuers Step 1. Make sure the scene is safe. Check to see if the person is awake and breathing normally. Step 2. If not, shout for help.
Step 3. Repeat cycles of CPR (30 compressions:2 breaths); use AED as soon as it arrives. For single healthcare providers on scene Step 1. Make sure the scene is safe. Check to see if the person is awake and breathing normally. Step 2. If not, shout for help. Activate 911. Step 3. Look for no breathing or only gasping and (simultaneously) check for a DEFINITE pulse WITHIN 10 SECONDS. 3b. If pulse and normal breathing, monitor until EMS arrives. 3c. If pulse but NO normal breathing:
3d. If no pulse or normal breathing AND a witnessed sudden collapse, call 911, then go get an AED, then use the AED and perform CPR (30 compressions:2 breaths). 3e. If no pulse and NOT witnessed sudden collapse:
Step 4. Use AED as soon as it is available. If shock is advised, give 1 shock. Resume CPR immediately for 2 minutes (until prompted by AED to allow rhythm check). Continue until ALS providers take over or the person starts to move. For two or more healthcare providers on scene Step 1. Make sure the scene is safe. Check to see if the person is awake and breathing normally. Step 2. If not, shout for help. Step 3. One person calls 911 and then gets an AED, while the other person looks for no breathing or only gasping and (simultaneously) checks for a DEFINITE pulse WITHIN 10 SECONDS. 3b. If pulse and normal breathing, monitor until EMS arrives. 3c. If pulse but NO normal breathing:
3d. If no pulse or normal breathing, start CPR. The first rescuer performs cycles of 30 compressions and 2 breaths. When the second rescuer returns, the two perform cycles of 15 compressions and 2 breaths. Use the AED as soon as it is available. Step 4. Use AED as soon as it is available. Use AED as soon as it is available. If shock is advised, give 1 shock. Resume CPR immediately for 2 minutes (until prompted by AED to allow rhythm check). Continue until ALS providers take over or the person starts to move. AHA guidelines algorithm for pediatric ALSStep 1: Begin CPR. Begin bag-mask ventilation and give oxygen. Attach monitor/defibrillator. Step 2a: If VF/pVT, deliver shock. Step 2b: If PEA/asystole, give epinephrine as soon as possible and go to step 8 (below). Step 3. Continue CPR for 2 min (5 rounds). Establish IV (preferred) or IO access. Step 4a. If VF/pVT, deliver shock. Step 4b: If PEA/asystole, give epinephrine as soon as possible and go to step 8 (below). Step 5. Continue CPR for 2 min (5 rounds). Give epinephrine every 3-5 minutes. Consider advanced airway placement. Step 6a. If VF/pVT, deliver shock. Step 6b: If PEA/asystole, give epinephrine as soon as possible and go to step 8 (below). Step 7. Continue CPR for 2 min (5 rounds). Continue epinephrine every 3-5 minutes. Give amiodarone (or lidocaine). Treat reversible causes. Go to step 4 (above). Step 8. Continue CPR for 2 min (5 rounds). Establish IV (preferred) or IO access. Continue epinephrine every 3-5 min. Consider advanced airway and capnography. Step 9a. If VF/pVT, go to step 6a (above) (deliver shock). Step 9b: If PEA/asystole, continue CPR for 2 min (5 rounds). Treat reversible causes. Step 10a. If VF/pVT, go to step 6a (above) (deliver shock). Step 10b: If PEA/asystole, go to step 8 (above). If signs of ROSC are noted, go to Post–Cardiac Arrest Care High-quality CPRThe following are considered essential elements of high-quality CPR:
Additional pediatric ALS guidelinesAs with BLS, algorithms are a key component of pediatric advanced life support (PALS) and are designed to simplify and expedite recognition and treatment of life-threatening conditions. Unlike BLS, PALS typically involves a coordinated team of trained responders who are able to initiate several processes simultaneously. VF or pVTThe following summarizes the AHA PALS algorithm for VF or pVT [49] :
Once the child is attached to the monitor or AED, the rhythm should be analyzed and determined to be shockable or nonshockable. Shockable rhythms include pulseless ventricular tachycardia or ventricular fibrillation. Nonshockable rhythms include pulseless electrical activity or asystole. If the rhythm indicates ventricular tachycardia or ventricular fibrillation, then it is a shockable rhythm and intervention proceeds as follows:
If the rechecked rhythm is determined to be shockable, intervention proceeds as follows:
If the rhythm is nonshockable, intervention proceeds as follows:
Once the patient is intubated, chest compressions and ventilations should work independently, with the compressions at a continuous rate of 100/min and the ventilations 10/min. In addition, identify and correct the following if necessary:
BradyarrhythmiasEmergency treatment of bradycardia is indicated when the rhythm results in hemodynamic compromise. The AHA algorithm for the recognition and management of bradyarrhythmias is summarized below. [49] When a pediatric patient is found to be bradycardiac, quickly check for a pulse. If no pulse is found, proceed to the pulseless arrest algorithm. If a pulse is found, assess for signs of cardiopulmonary compromise. These signs include the following:
If cardiopulmonary compromise is evident, the following immediate steps should be taken:
If the heart rate continues to be below 60 bpm and cardiopulmonary compromise is evident despite oxygenation and ventilation, then chest compressions should be initiated. While the algorithm is being applied, attempt to identify and treat any underlying causes. If bradycardia persists after 2 minutes of chest compressions, consider the following:
If the bradycardia resolves, continue to support the ABCs, monitor the child, and consider expert consultation. If the bradycardia evolves into pulseless arrest, proceed to the pulseless arrest algorithm. TachyarrhythmiaThe most common types of tachycardia in the pediatric population are sinus tachycardia, supraventricular tachycardia, and ventricular tachycardia. As with other elements of PALS, an algorithmic approach is used for tachyarrhythmia, as outlined below. If a pediatric patient is found to be unresponsive and not breathing in the context of tachycardia on the monitor, then proceed to the pulseless arrest algorithm. If a pulse is found, assess for signs of cardiopulmonary compromise. These signs include the following:
If cardiopulmonary compromise is evident, the following immediate steps should be taken:
If the QRS is wide on the initial ECG, ventricular tachycardia should be assumed. Supraventricular tachycardia with aberrant conduction is a less common possibility. If the patient shows signs of cardiopulmonary compromise, synchronized cardioversion is delivered at 0.5-1 J/kg, with an increase to 2 J/kg if initially unsuccessful. If the patient shows no signs of cardiopulmonary compromise, adenosine may be empirically given for the possibility of supraventricular tachycardia with aberrancy. Amiodarone and procainamide should not be routinely administered together, but they may be given in conjunction with expert consultation, as follows:
If the QRS is narrow, determine whether sinus tachycardia or supraventricular tachycardia is more probable. Evidence supporting sinus tachycardia includes the following:
Evidence supporting supraventricular tachycardia includes the following:
Sinus tachycardiaTreat the underlying cause(s). Common causes of sinus tachycardia include hypovolemia, sepsis, fever, pain, hypoxia, and anemia. The history and physical examination can provide important information for narrowing the differential diagnosis. Supraventricular tachycardia While preparations are being made for chemical or electrical cardioversion, vagal maneuvers may be attempted to break the dysrhythmia. Vagal maneuvers include the following:
If vagal maneuvers are unsuccessful and the patient has IV or IO access, then chemical cardioversion with adenosine is indicated. The regimen is as follows:
If chemical cardioversion is unsuccessful or not available, electrical cardioversion is indicated. The regimen is as follows:
If chemical and electrical cardioversion continue to be unsuccessful, consider expert consultation for additional antiarrhythmics and rate-controlling recommendations. Neonatal Resuscitation GuidelinesThe 2015 update of the AHA guidelines for neonatal resuscitation are the foundation for the seventh edition of the American Academy of Pediatrics’ Textbook of Neonatal Resuscitation. The textbook, in turn, forms the basis for the training provided by the Neonatal Resuscitation Program (NPR). The NRP should be completed by all clinicians—including physicians, nurses, and respiratory therapists—who may be involved in the stabilization and resuscitation of neonates in the delivery room. [29] In the 2015 AHA guidelines, a revised recommendation suggested that neonatal resuscitation training occur more frequently than at 2-year intervals. [49] The following is a summary of the AHA revised algorithm for neonatal resuscitation. [49] The neonatal resuscitation algorithm was reaffirmed unchanged in the 2020 guidelines. [43] Resuscitation equipment and anticipation of potential problemsPrior to delivery, risk factors should be identified, neonatal problems anticipated, equipment checked, qualified personal should be available, and a care plan formulated. A known perinatal risk factor, such as preterm birth, requires preparation of supplies specific to thermoregulation and respiratory support, and the delivery room should be equipped with all the tools necessary for successful resuscitation. A standardized checklist may be helpful to ensure that all necessary supplies and equipment are present and functioning. First minuteTime: 0-30 seconds The initial evaluation is the following questions:
If initial findings are normal, the infant stays with the mother and the following routine care is provided:
If initial findings are abnormal, care consists of the following:
Time: 30-60 seconds Secondary evaluation is the following:
If the heart rate is greater than 100 bpm and the baby is pink with nonlabored breathing, proceed with routine care. If the heart rate is greater than 100 bpm and the baby is cyanotic or has labored breathing, do the following:
If the heart rate is less than 100 bpm and the baby is gasping or has apnea, do the following:
After first minuteIf heart rate is less than 100 bpm, do the following:
If the heart rate is less than 60 bpm, do the following:
If the heart rate is greater than 60 bpm, stop compressions and continue ventilation. If the heart rate remains less than 60 bpm, do the following:
Oxygen saturationA comparison of the preductal oxygen saturation (SpO2) targets after birth are listed in Table 3, below. [49, 55] Table 3. Preductal Oxygen Saturation (SpO2) Targets (Open Table in a new window)
Umbilical cord managementThe following are the AHA recommendations for umbilical cord management [49] :
CompressionsThe AHA guidelines include the following specific recommendation for delivering compressions [49] :
Meconium-stained amniotic fluidThe 2015 AHA guidelines offer the following revised recommendations for infants born with meconium-stained amniotic fluid [49] :
Withholding or discontinuing resuscitationThe guidelines offer the following recommendations for withholding or discontinuance of resuscitation [49] :
Acute Coronary Syndromes GuidelinesLast updated in 2015, AHA, ERC, and ILCOR limited recommendations to prehospital and emergency department (ED) care for acute coronary syndromes (ACSs). For in-hospital care, clinicians are advised to consult either the AHA/American College of Cardiology or European Society of Cardiology guidelines for the management of STEMI and non-STEMI ACS. [49, 56, 57] The following summarizes the AHA algorithm for emergent treatment of ACS [49] :
Specific prehospital care is as follows:
ED assessment and immediate treatment is as follows:
Further therapy is based on ECG diagnosis, as follows:
For STEMI and high-risk non-STEMI ACS, adjunctive therapies should begin as indicated. For STEMI with symptom onset 12 or fewer hours ago, reperfusion should not be delayed. Selection of therapy is defined by patient and center criteria, with the following door-to-treatment goals:
In patients with suspected STEMI for whom primary PCI reperfusion is planned, unfractionated heparin can be administered either in the prehospital or the hospital setting (class IIb) For STEMI with onset of symptoms more than 12 hours or high-risk non-STEMI ACS, an early invasive strategy is indicated for patients with any of the following:
For low/intermediate-risk ACS, admit to the ED chest pain unit or appropriate bed for further monitoring and possible intervention. Further medical management of ACS should be conducted according to the other related guidelines. Diagnostic interventionsThe 2015 guidelines include the following class I recommendations for prehospital diagnostic intervention [49] :
Additional recommendations include the following [49] :
There are no significant variances in the ERC and ILCOR recommendations. [56, 57] Emergent reperfusion decisions in STEMIThe AHA guidelines advocate for a systems-of-care approach involving a reperfusion team that mobilizes hospital resources for an optimized approach. The guidelines argue that when such a system is active either in the ED or based on prehospital data, time-sensitive therapies can be offered more rapidly. [49] Specific recommendations for emergent reperfusion include the following:
ERC guidelines include one additional recommendation: When fibrinolysis is the treatment strategy, if transport times exceed 30 minutes, fibrinolysis using trained EMS staff is preferred. [56] Questions & AnswersWhen coordinating PPV with chest compressions How long does it take to complete a cycle of 3 compressions and 1 breath quizlet?One and Two and Three and Breathe. One cycle takes 2 seconds. There are 30 cycles in a minute so 30 times 1 breath is 30 breaths, and 30 times 3 compressions is 90 compressions.
How long is a cycle of PPV and chest compressions?A commonly used duration of CPR cycles in this type of research is 90 seconds or 2 minutes [9,10].
How do you coordinate chest compressions and ventilations NRP?Coordinate chest compressions with ventilations at a ratio of 3:1 and a rate of 120 events per minute to achieve approximately 90 compressions and 30 breaths per minute.
When chest compressions are in progress How often should the heart rate be assessed every 60 seconds?Every 30 seconds – 60 seconds, the patient should be reassessed (for a heart rate above 60 beats per minute).
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