Recommendations for Initial Recognition of Cardiac Arrest/Initiation of Resuscitation

Recognition

• If a Victim is Unconscious/Unresponsive, with Absent/Abnormal Breathing (i.e. Only Gasping), the Lay Rescuer Should Assume the Victim is in Cardiac Arrest (Class of Recommendation: 1, Level of Evidence: C-LD)
• If a Victim is Unconscious/Unresponsive, with Absent/Abnormal Breathing (i.e. Only Gasping), the Healthcare Provider Should Check for a Pulse for ≤10 sec and, if No Definite Pulse is Felt, Should Assume the Victim is in Cardiac Arrest (Class of Recommendation: 1, Level of Evidence: C-LD)

Initiation of Resuscitation

• Untrained/Trained Lay Rescuer
  • All Lay Rescuers Should Provide Chest Compressions for Victims of Cardiac Arrest (Class of Recommendation: 1, Level of Evidence: B-NR)
  • After Identifying a Cardiac Arrest, a Lone Responder Should Activate the Emergency Response System First and Immediately Begin Cardiopulmonary Resuscitation (CPR) (Class of Recommendation: 1, Level of Evidence: C-LD)
  • Laypersons Should Initiate Cardiopulmonary Resuscitation (CPR) for Presumed Cardiac Arrest, Because the Risk of Harm to the Patient is Low if the Patient is Not in Cardiac Arrest (Class of Recommendation: 1, Level of Evidence: C-LD)
  • For Lay Rescuers Trained in Cardiopulmonary Resuscitation (CPR) Using Chest Compressions and Ventilation (Rescue Breaths), it is Reasonable to Provide Ventilation (Rescue Breaths) in Addition to Chest Compressions for the Adult in Out-of-Hospital Cardiac Arrest (OHCA) (Class of Recommendation: 2a, Level of Evidence: C-LD)
• Healthcare Provider
  • A Lone Healthcare Provider Should Start with Chest Compressions Rather than Start with Ventilation (Class of Recommendation: 1, Level of Evidence: C-LD)
  • Healthcare Providers Should Perform Chest Compressions and Ventilation for All Adult Patients in Cardiac Arrest from Either a Cardiac or Non-Cardiac Etiology (Class of Recommendation: 2a, Level of Evidence: C-LD)

Recommendations for Opening the Airway

Absence of Head/Neck Trauma

• When No Cervical Spine Injury is Suspected, a Healthcare Provider Should Use the Head Tilt–Chin Lift Maneuver to Open the Airway of a Patient (Class of Recommendation: 1, Level of Evidence: C-EO)
• When No Cervical Spine Injury is Suspected, a Trained Lay Rescuer Who Feels Confident in Performing Both Compressions and Ventilation Should Open the Airway Using a Head Tilt–Chin Lift Maneuver (Class of Recommendation: 1, Level of Evidence: C-EO)
• The Use of an Airway Adjunct (Oropharyngeal/Nasopharyngeal Airway) May Be Reasonable in the Unconscious (Unresponsive) Patient with No Cough/Gag Reflex to Facilitate Delivery of Ventilation with a Bag-Valve-Mask (BVM) Device (Class of Recommendation: 2b, Level of Evidence: C-EO)
• In the Presence of Known/Suspected Basal Skull Fracture or Severe Coagulopathy, an Oral Airway is Preferred, as Compared to a Nasopharyngeal Airway (Class of Recommendation: 2a, Level of Evidence: C-EO)
• The Routine Use of Cricoid pressure in Adult Cardiac Arrest is Not recommended (Class of Recommendation: 3 = No Benefit, Level of Evidence: C-LD)

Presence of Head/Neck Trauma

• In Cases of Suspected Cervical Spine Injury, Healthcare Providers Should Open the Airway by Using a Jaw Thrust without Head Extension (Class of Recommendation: 1, Level of Evidence: C-EO)
• In the Setting of Head/Neck Trauma, a Head Tilt–Chin Lift Maneuver Should Be Performed if the Airway Cannot Be Opened with a Jaw Thrust and Airway Adjunct Insertion (Class of Recommendation: 1, Level of Evidence: C-EO)
• In the Setting of Head/Neck Trauma, Lay Rescuers Should Not Use Immobilization Devices Because Their Use by Untrained Rescuers May Be Harmful (Class of Recommendation: 3 = Harm, Level of Evidence: C-LD)

Recommendations for Cardiopulmonary Resuscitation (CPR) Technique

Positioning and Location for Cardiopulmonary Resuscitation (CPR)

• When Providing Chest Compressions, the Rescuer Should Place the Heel of One Hand on the Center (Middle) of the Patient’s Chest (the Lower Half of the Sternum) and the Heel of the Other Hand on Top of the First So that the Hands are Overlapped (Class of Recommendation: 1, Level of Evidence: C-LD)
• Resuscitation Should Generally Be Conducted Where the Victim is Found, as Long as High-Quality Cardiopulmonary Resuscitation (CPR) Can Be Administered Safely and Effectively in that Location (Class of Recommendation: 1, Level of Evidence: C-EO)
• It is Preferred to Perform Cardiopulmonary Resuscitation (CPR) on a Firm Surface and with the Victim in the Supine Position, when Feasible (Class of Recommendation: 2a, Level of Evidence: C-LD)
• When the Victim Cannot Be Placed in the Supine Position, it May BeReasonable for Rescuers to Provide Cardiopulmonary Resuscitation (CPR) with the Victim in the Prone Position, Particularly in Hospitalized Patients with an Advanced Airway in Place (Class of Recommendation: 1, Level of Evidence: C-LD)

Compression Fraction and Pauses

• In Adult Cardiac Arrest, total preshock and postshock pauses in chest compressions should be as short as possible (Class of Recommendation: 1, Level of Evidence: C-LD)
• The healthcare provider should minimize the time taken to check for a pulse (no more than 10 s) during a rhythm check, and if the rescuer does not definitely feel a pulse, chest compressions should be resumed (Class of Recommendation: 1, Level of Evidence: C-LD)
• 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 (Class of Recommendation: 2a, Level of Evidence: B-R)
• It is reasonable to immediately resume chest compressions after shock delivery for adults in Cardiac Arrest in any setting (Class of Recommendation: 2a, Level of Evidence: B-R)
• For adults in Cardiac Arrest receiving Cardiopulmonary Resuscitation (CPR) without an advanced airway, it is reasonable to pause compressions to deliver 2 breaths, each given over 1 s Class of Recommendation: 2a, Level of Evidence: C-LD)
• In Adult Cardiac Arrest, it May Be Reasonable to Perform Cardiopulmonary Resuscitation (CPR) with a Chest Compression Fraction of ≥60% (Class of Recommendation: 2b, Level of Evidence: C-LD)

Compression Depth and Rate

• During Manual Cardiopulmonary Resuscitation (CPR), Rescuers Should Perform Chest Compressions to a Depth of ≥2 inches (≥5 cm), for an Average Adult While Avoiding Excessive Chest Compression Depths (>2.4 inches, >6 cm) (Class of Recommendation: 1, Level of Evidence: B-NR)
• In Adult Victims of Cardiac Arrest, it is Reasonable for Rescuers to Perform Chest Compressions at a Rate of 100-120/min (Class of Recommendation: 2a, Level of Evidence: B-NR)
• It Can Be Beneficial for Rescuers to Avoid Leaning on the Chest Between Compressions to Allow Complete chest Wall Recoil for Adults in Cardiac Arrest (Class of Recommendation: 2a, Level of Evidence: C-LD)
• It May Be Reasonable to Perform Chest Compressions so that Chest Compression and Recoil/Relaxation Times are Approximately Equal (Class of Recommendation: 2b, Level of Evidence: C-EO)

Cardiopulmonary Resuscitation (CPR) Feedback and Monitoring

• It May Be Reasonable to Use Audiovisual Feedback Devices During Cardiopulmonary Resuscitation (CPR) for Real-Time Optimization of Cardiopulmonary Resuscitation (CPR) Performance (Class of Recommendation: 2b, Level of Evidence: B-R)
• It May Be Reasonable to Use Physiological Parameters Such as Arterial Blood Pressure (BP) or End-Tidal Carbon Dioxide (ETCO2) When Feasible to Monitor and Optimize Cardiopulmonary Resuscitation (CPR) Quality (Class of Recommendation: 2b, Level of Evidence: C-LD)
  • End-Tidal Carbon Dioxide (ETCO2) (see End-Tidal Carbon Dioxide)
    • For Every 1 cm Increase in Chest Compression Depth, ETCO2 Increases 1.4 mm Hg (Resuscitation, 2015) [MEDLINE]
    • In a 2018 Systematic Review of End-Tidal Carbon Dioxide (ETCO2) as a Prognostic Indicator for Return of Spontaneous Circulation (ROSC) Found Variability in Cutoff Values, But <10 mm Hg was Generally Associated with Poor Outcome and >20 mm Hg had a Stronger Association with Return of Spontaneous Circulation (ROSC) than a Value of >10 mm Hg (Resuscitation, 2018) [MEDLINE]
    • Targeting Compressions to >10 mm Hg, and Ideally ≥20 mm Hg is Recommended
      • The Validity and Reliability of ETCO2 in Non-Intubated Patients is Not Well Established
  • Diastolic Blood Pressure (DBP)
    • The Use of Diastolic blood Pressure Monitoring During Cardiac Arrest is Associated with Higher Probability of Return of Spontaneous Circulation (ROSC), But There are Inadequate Human Data to Suggest Any Specific Diastolic Blood Pressure

Mechanical Cardiopulmonary Resuscitation (CPR) Devices

• The Use of Mechanical Cardiopulmonary Resuscitation (CPR) Devices May Be Considered in Specific Settings Where the Delivery of High-Quality Manual Compressions May Be Challenging or Dangerous for the Provider, as Long as Rescuers Strictly Limit Interruptions in Cardiopulmonary Resuscitation (CPR) During Deployment and Removal of the Device (Class of Recommendation: 2b, Level of Evidence: C-LD)
• The Routine Use of Mechanical Cardiopulmonary Resuscitation (CPR) is Not Recommended (Class of Recommendation: 3 = No Benefit, Level of Evidence: B-R)

Active Compression-Decompression Cardiopulmonary Resuscitation (CPR) and Impedance Threshold Devices

• The effectiveness of active compression-Decompression Cardiopulmonary Resuscitation (CPR) is Uncertain (Class of Recommendation: 2b, Level of Evidence: B-NR)
  • Active Compression-decompression Cardiopulmonary Resuscitation (CPR) might Be considered for use when providers are Adequately trained and monitored (Class of Recommendation: 2b, Level of Evidence: B-NR)
• The combination of active compression-Decompression Cardiopulmonary Resuscitation (CPR) and impedance Threshold device may be reasonable in Settings with available equipment and Properly trained personnel (Class of Recommendation: 2b, Level of Evidence: C-LD)
• The Routine Use of the Impedance Threshold Device as an Adjunct During Conventional Cardiopulmonary Resuscitation (CPR) is Not Recommended (Class of Recommendation: 3 = No Benefit, Level of Evidence: A)

Alternative Cardiopulmonary Resuscitation (CPR) Techniques

• Interposed Abdominal Compression Cardiopulmonary Resuscitation (CPR) May Be Considered During In-Hospital Resuscitation When Sufficient Personnel Trained in its Use are Available (Class of Recommendation: 2b, Level of Evidence: B-NR)

Recommendations for Ventilation

General

• For Adults in Cardiac Arrest Receiving Ventilation, Tidal Volumes of Approximately 500-600 mL (or Enough to Produce Visible Chest Rise) are Reasonable (Class of Recommendation: 2a, Level of Evidence: C-LD)
• In Patients without an Advanced Airway, is Reasonable to Deliver Breaths Either by Mouth or by Using Bag-Valve-Mask (BVM) Ventilation (Class of Recommendation: 2a, Level of Evidence: C-EO)
• When Providing Rescue Breaths, it May Be Reasonable to Give 1 Breath Over 1 sec, Take a “Regular” (Not Deep) Breath, and Give a Second Rescue Breath Over 1 sec (Class of Recommendation: 2b, Level of Evidence: C-EO)
• Rescuers Should Avoid Excessive Ventilation (Too Many Breaths or Too Large of a Tidal Volume) During Cardiopulmonary resuscitation (CPR) (Class of Recommendation: 3 = Harm, Level of Evidence: C-LD)

Special Situations

• It is Reasonable for a Rescuer to Use mouth-to-nose ventilation if ventilation through the victim’s mouth is impossible or impractical (Class of Recommendation: 2a, Level of Evidence: C-LD)
• For a victim with a tracheal stoma who Requires rescue breathing, either mouth-to-stoma or face mask (pediatric preferred)–to–stoma Ventilation May Be Reasonable (Class of Recommendation: 2b, Level of Evidence: C-EO)

Spontaneous Circulation (Respiratory Arrest)

• If an Adult Victim with Spontaneous Circulation (i.e. Strong and Easily Palpable Pulses) Requires Ventilatory Support, it May Be Reasonable for the Healthcare Provider to Give Rescue Breaths at a Rate of About 1 Breath q6 sec (About 10 Breaths/min) (Class of Recommendation: 2b, Level of Evidence: C-LD)

Compression-to-Ventilation Ratio (Advanced Cardiac Life Support/ACLS)

• Before Placement of an Advanced Airway (Supraglottic Airway/Endotracheal Tube), it is Reasonable for Healthcare Providers to Perform Cardiopulmonary Resuscitation (CPR) with Cycles of 30 Compressions: 2 Breaths (Class of Recommendation: 2a, Level of Evidence: B-R)
• It May Be Reasonable for EMS Providers to Use a Rate of 10 Breaths/min (1 Breath q6 sec) to Provide Asynchronous Ventilation During Continuous Chest Compressions Before Placement of an Advanced Airway (Supraglottic Airway/Endotracheal Tube) (Class of Recommendation: 2b, Level of Evidence: B-R)
• If an Advanced Airway (Supraglottic Airway/Endotracheal Tube) is in Place, it May Be Reasonable for the Provider to Deliver 1 Breath q6 sec (10 Breaths/min) While Continuous Chest Compressions are Being Performed (Class of Recommendation: 2b, Level of Evidence: C-LD)
• It May Be Reasonable to Initially Use Minimally Interrupted Chest Compressions (i.e. Delayed Ventilation) for Witnessed Shockable Out-of-Hospital Cardiac Arrest as Part of a Bundle of Care (Class of Recommendation: 2b, Level of Evidence: C-LD)

Recommendations for Defibrillation

Indication, Type, and Energy

• Defibrillators (Using Biphasic or Monophasic Waveforms) are Recommended to Treat Tachyarrhythmias Requiring a Shock (Class of Recommendation: 1, Level of Evidence: B-NR)
• Based on Their Greater Success in Arrhythmia Termination, Defibrillators Using Biphasic Waveforms are Preferred Over Monophasic Defibrillators for Treatment of Tachyarrhythmias (Class of Recommendation: 2a, Level of Evidence: B-NR)
• A Single Shock Strategy is Reasonable in Preference to Stacked Shocks for Defibrillation in the Setting of Unmonitored Cardiac Arrest (Class of Recommendation: 2a, Level of Evidence: B-NR)
• It is Reasonable that Selection of Fixed vs Escalating Energy Levels for Subsequent Shocks for Presumed Shock-Refractory Arrhythmias Be Based on the Specific Manufacturer’s Instructions for that Waveform (Class of Recommendation: 2a, Level of Evidence: C-LD)
  • If This is Not Known, Defibrillation at the Maximal Dose May Be Considered (Class of Recommendation: 2a, Level of Evidence: C-LD)
• If Using a Defibrillator Capable of Escalating Energies, Higher Energy for Second and Subsequent Shocks May Be Considered for Presumed Shock-Refractory Arrhythmias (Class of Recommendation: 2b, Level of Evidence: B-NR)
• In the Absence of Conclusive Evidence that One Biphasic Waveform is Superior to Another in Termination of Ventricular Fibrillation, it is Reasonable to Use the Manufacturer’s Recommended Energy Dose for the First Shock (Class of Recommendation: 2b, Level of Evidence: C-LD)
  • If this is not known, defibrillation at the maximal dose may be considered (Class of Recommendation: 2b, Level of Evidence: C-LD)

Pads for Defibrillation

• It is reasonable to place defibrillation paddles or pads on the exposed chest in an anterolateral or anteroposterior position, and to use a paddle or pad electrode diameter more than 8 cm in adults (Class of Recommendation: 2a, Level of Evidence: C-LD)

Automatic vs Manual-Mode Defibrillation

• It may be reasonable to use a defibrillator in manual mode as compared with automatic mode depending on the skill set of the operator (Class of Recommendation: 2b, Level of Evidence: C-LD)

Cardiopulmonary Resuscitation (CPR) Before Defibrillation

• Cardiopulmonary Resuscitation (CPR) is recommended until a defibrillator or AED is applied (Class of Recommendation: 1, Level of Evidence: C-LD)
• In unmonitored cardiac arrest, it is reasonable to provide a brief prescribed period of Cardiopulmonary Resuscitation (CPR) while a defibrillator is being obtained and readied for use Before initial rhythm analysis and possible Defibrillation (Class of Recommendation: 2a, Level of Evidence: B-R)
• Immediate defibrillation is reasonable for Provider-witnessed or monitored VF/pVT of short duration when a defibrillator is Already applied or immediately available (Class of Recommendation: 2a, Level of Evidence: C-LD)

Postshock Rhythm Check

• It may be reasonable to immediately Resume chest compressions after shock Administration rather than pause CPR to perform a postshock rhythm check cardiac arrest patients (Class of Recommendation: 2b, Level of Evidence: C-LD)

Anticipatory Defibrillator Charging

• It may be reasonable to charge a manual Defibrillator during chest compressions Either before or after a scheduled rhythm Analysis (Class of Recommendation: 2b, Level of Evidence: C-LD)

Ancillary Defibrillator Technologies

• The Value of Artifact-Filtering Algorithms for Analysis of Electrocardiogram (EKG) Rhythms During Chest Compressions Has Not Been Established (Class of Recommendation: 2b, Level of Evidence: C-LD)
• The Value of Ventricular Fibrillation Waveform Analysis to Guide the Acute Management of Adults with Cardiac Arrest Has Not Been Established (Class of Recommendation: 2b, Level of Evidence: C-LD)

Double Sequential Defibrillation

• The Usefulness of Double Sequential Defibrillation for Refractory Shockable Rhythm Has Not Been Established (Class of Recommendation: 2b, Level of Evidence: C-LD)

Recommendation for Other Electric/Pseudo-Electric Therapies

Electric Pacing

• Electric Pacing is Not Recommended for Routine Use in Established Cardiac Arrest (Class of Recommendation: 3 = No Benefit, Level of Evidence: B-R)

Precordial Thump

• Precordial Thump May Be Considered at the Onset of a Rescuer-Witnessed, Monitored, Unstable Ventricular Tachyarrhythmia When a Defibrillator is Not Immediately Ready for Use and is Performed without Delaying Cardiopulmonary Resuscitation (CPR) or Shock Delivery (Class of Recommendation: 2b, Level of Evidence: B-R)
• Precordial Thump Should Not Be Used Routinely for Established Cardiac Arrest (Class of Recommendation: 3 = No Benefit, Level of Evidence: C-LD)

Fist/Percussion Pacing

• Fist (Percussion) Pacing May Be Considered as a Temporizing Measure in Exceptional Circumstances Such as Witnessed, Monitored in-Hospital Cardiac Arrest (Such as in the Cardiac Catheterization Laboratory) for Bradyasystole Before a Loss of Consciousness and if Performed without Delaying Definitive Therapy (Class of Recommendation: 2b, Level of Evidence: C-LD)

Cough Cardiopulmonary Resuscitation (CPR)

• “Cough” Cardiopulmonary Resuscitation (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 (Class of Recommendation: 2b, Level of Evidence: C-LD)

Recommendations for Vascular Access

• It is Reasonable for Providers to First Attempt Establishing Intravenous (IV) Access for Drug Administration in Cardiac Arrest (Class of Recommendation: 2a, Level of Evidence: B-NR)
• Intraosseous (IO) Access May Be Considered if Attempts at Intravenous Access are Unsuccessful or Not Feasible (Class of Recommendation: 2b, Level of Evidence: B-NR) (see Intraosseous Vascular Access)
• Central Venous Catheter (CVC) Access May Be Considered if Attempts to Establish Intravenous/Intraosseous Access are Unsuccessful or Not Feasible (Class of Recommendation: 2b, Level of Evidence: C-LD) (see Central Venous Catheter)
• Endotracheal Drug Administration May Be Considered When Other Access Routes are Not Available (Class of Recommendation: 2b, Level of Evidence: C-LD)

Recommendations for Medication Management

Vasopressors

• We Recommend that Epinephrine be Administered for Patients in Cardiac Arrest (Class of Recommendation: 1, Level of Evidence: B-R)
• Based on the Protocols Used in Clinical Trials, it is Reasonable to Administer Epinephrine 1 mg q3-5 min for Cardiac Arrest (Class of Recommendation: 2a, Level of Evidence: B-R)
• With Respect to Timing, for Cardiac Arrest with a Non-Shockable rhythm, it is Reasonable to Administer Epinephrine as Soon as Feasible (Class of Recommendation: 2a, Level of Evidence: C-LD)
• With Respect to Timing, for Cardiac Arrest with a Shockable Rhythm, it may be Reasonable to Administer Epinephrine After initial defibrillation attempts have Failed (Class of Recommendation: 2b, Level of Evidence: C-LD)
• Vasopressin Alone or Vasopressin in Combination with Epinephrine May Be Considered in Cardiac Arrest But Offers No Advantage as a Substitute for Epinephrine in Cardiac Arrest (Class of Recommendation: 2b, Level of Evidence: C-LD)
• High-Dose Epinephrine is Not Recommended for Routine Use in Cardiac Arrest (Class of Recommendation: 3 = No Benefit, Level of Evidence: B-R)

Non-Vasopressors

• Amiodarone or Lidocaine May Be Considered for Ventricular Fibrillation (VF)/Pulseless Ventricular Tachycardia (VT) Which is Unresponsive to Defibrillation (Class of Recommendation: 2b, Level of Evidence: B-R)
• For Patients with Out-of-Hospital Cardiac Arrest (OHCA), Use of Steroids During Cardiopulmonary Resuscitation (CPR) is of Uncertain Benefit (Class of Recommendation: 2b, Level of Evidence: C-LD)
• Routine Administration of Calcium for Treatment of Cardiac Arrest is not Recommended (Class of Recommendation: 3 = No Benefit, Level of Evidence: B-NR)
• Routine Use of Sodium Bicarbonate is Not Recommended for Patients in Cardiac Arrest (Class of Recommendation: 3 = No Benefit, Level of Evidence: B-R)
• Routine Use of Magnesium for Cardiac Arrest is Not Recommended (Class of Recommendation: 3 = No Benefit, Level of Evidence: B-R)

Recommendations for Adjuncts to Cardiopulmonary Resuscitation (CPR)

Echocardiogram (see Echocardiogram)

• If an Experienced sonographer is Present and Use of Echocardiogram Does Not Interfere with the Standard Cardiac Arrest Treatment Protocol, then Echocardiogram May Be Considered as an Adjunct to Standard Patient Evaluation, Although its Usefulness Has Not Been Well Established (Class of Recommendation: 2b, Level of Evidence: C-LD)

Oxygen (see Oxygen)

• When Supplemental Oxygen is Available, it May Be Reasonable to Use the Maximal Feasible Inspired Oxygen Concentration During Cardiopulmonary Resuscitation (CPR) (Class of Recommendation: 2b, Level of Evidence: C-LD)

End-Tidal Carbon Dioxide (ETCO2) (see End-Tidal Carbon Dioxide)

• An Abrupt Increase in End-Tidal Carbon Dioxide (ETCO2) May Be Used to Detect Return of Spontaneous Circulation (ROSC) During Compressions or When a Rhythm Check Reveals an Organized Rhythm (Class of Recommendation: 2b, Level of Evidence: C-LD)

Arterial Blood Gas (ABG) (see Arterial Blood Gas)

• Routine Measurement of Arterial Blood Gases During Cardiopulmonary Resuscitation (CPR) has uncertain value (Class of Recommendation: 2b, Level of Evidence: C-EO)

Arterial Line (see Arterial Line)

• Arterial pressure monitoring by arterial Line may be used to Detect Return of Spontaneous Circulation (ROSC) During Chest Compressions or when a rhythm Check reveals an organized rhythm (Class of Recommendation: 2b, Level of Evidence: C-EO)

Recommendations for Termination of Resuscitation

• If Termination of Resuscitation (TOR) is Being considered, BLS EMS providers Should use the BLS termination of Resuscitation Rule where ALS is not Available or may be significantly delayed (Class of Recommendation: 1, Level of Evidence: B-NR)
• It is reasonable for prehospital ALS providers to use the Adult ALS Termination of Resuscitation rule to terminate resuscitation efforts in the Field for adult victims of OHCA (Class of Recommendation: 2a, Level of Evidence: B-NR)
• In a tiered ALS- and BLS-provider system, the use of the BLS Termination of Resuscitation rule can avoid Confusion at the Scene of a cardiac Arrest without compromising diagnostic Accuracy (Class of Recommendation: 2a, Level of Evidence: B-NR)
• In intubated patients, failure to achieve an end-tidal CO2 of greater than 10 mm Hg by waveform capnography After 20 min of ALS resuscitation may Be considered as a component of a Multimodal Approach to decide when to End resuscitative efforts, but it should not Be used in isolation (Class of Recommendation: 2b, Level of Evidence: C-LD)
• We suggest against the use of point-of-care ultrasound for prognostication During CPR (Class of Recommendation: 3 = No Benefit, Level of Evidence: C-LD)
• In Nonintubated Patients, a Specific End-Tidal Carbon Dioxide (ETCO2) Cutoff Value at Any Time During CPR Should Not Be Used as an Indication to End Resuscitative Efforts (Class of Recommendation: 3 = Harm, Level of Evidence: C-EO)

Recommendation for Airway Interventions

Advanced Airway Interventions

• Either Bag-Valve-Mask (BVM) Ventilation or an Advanced Airway Strategy May Be Considered During Cardiopulmonary Resuscitation (CPR) for Adult Cardiac Arrest in Any Setting Depending on the Situation and Skill Set of the Provider (Class of Recommendation: 2b, Level of Evidence: B-R)

Choice of Advanced Airway Device: Endotracheal Intubation Versus Supraglottic Airway

• If an advanced airway is used, a Supraglottic airway can be used for adults with OHCA in settings with low tracheal Intubation success rates or minimal Training opportunities for endotracheal Tube placement (Class of Recommendation: 2a, Level of Evidence: B-R)
• If an advanced airway is used, either a supraglottic airway or endotracheal Intubation can be Used for adults with OHCA in settings with high tracheal Intubation success rates or optimal Training opportunities for endotracheal Tube placement (Class of Recommendation: 2a, Level of Evidence: B-R)
• If an advanced airway is used in the in-hospital setting by expert providers Trained in these Procedures, either a Supraglottic airway or an endotracheal Tube Placement Can Be Used (Class of Recommendation: 2a, Level of Evidence: B-R)

Advanced Airway Placement Considerations

• Frequent experience or frequent Retraining is recommended for providers Who perform endotracheal intubation (Class of Recommendation: 1, Level of Evidence: B-NR)
• If advanced airway placement will Interrupt chest compressions, providers May consider deferring insertion of the Airway until the patient fails to respond to initial CPR and defibrillation attempts or obtains ROSC (Class of Recommendation: 1, Level of Evidence: C-LD)
• Continuous waveform capnography is recommended in addition to clinical Assessment as the most reliable method of confirming and monitoring correct Placement of an endotracheal tube (Class of Recommendation: 1, Level of Evidence: C-LD)
• EMS systems that perform prehospital Intubation should provide a program of ongoing quality Improvement to Minimize complications and track overall Supraglottic airway and endotracheal Tube Placement Success Rates (Class of Recommendation: 1, Level of Evidence: C-LD)

Recommendation for Extracorporeal Cardiopulmonary Resuscitation (CPR)

• There is insufficient evidence to Recommend the routine use of Extracorporeal CPR (ECPR) for patients with cardiac arrest. ECPR may be Considered for select cardiac arrest Patients for whom the Suspected cause of the cardiac arrest is potentially Reversible during a limited period of Extracorporeal CPR Mechanical cardiorespiratory support. (Class of Recommendation: 2b, Level of Evidence: C-LD)

Recommendations for Pharmacological Management of Hemodynamically Stable Wide-Complex Tachycardia

• In Hemodynamically Stable Patients, Intravenous Adenosine Maye Be Considered for Treatment and Aiding Rhythm Diagnosis When the Etiology of the Regular, Monomorphic Rhythm Cannot Be Determined (Class of Recommendation: 2b, Level of Evidence: B-NR)
• Administration of IV amiodarone, Procainamide, or sotalol may be Considered for the treatment of Wide-Complex Tachycardia (Class of Recommendation: 2b, Level of Evidence: B-R)
• Verapamil should not be administered for any wide-complex tachycardia unless Known to be of supraventricular origin and not being conducted by an accessory Pathway (Class of Recommendation: 3 = Harm, Level of Evidence: B-NR)
• Adenosine should Not Be Administered for Hemodynamically Unstable, Irregularly Irregular, or Polymorphic Wide-Complex Tachycardias (Class of Recommendation: 3 = Harm, Level of Evidence: C-LD)

Recommendation for Electric Management of Hemodynamically Stable Wide-Complex Tachycardia

• If Pharmacological Therapy is Unsuccessful for the Treatment of a Hemodynamically Stable Wide-Complex Tachycardia, cardioversion or Seeking Urgent Expert Consultation is Reasonable (Class of Recommendation: 2a, Level of Evidence: C-LD)

Recommendation for Electric Treatment of Polymorphic Ventricular Tachycardia (VT)

• Immediate Defibrillation is Recommended for Sustained, Hemodynamically Unstable Polymorphic Ventricular Tachycardia (VT) (Class of Recommendation: 1, Level of Evidence: B-NR)

Recommendation for Pharmacological Treatment of Polymorphic Ventricular Tachycardia (VT) Associated With a Long QT Interval (Torsades De Pointes)

• Magnesium may be considered for Treatment of polymorphic VT associated with a long QT interval (Torsades de Pointes) (Class of Recommendation: 2b, Level of Evidence: C-LD)

Recommendations for Pharmacological Treatment of Polymorphic Ventricular Tachycardia (VT) Not Associated With a Long QT Interval

• Intravenous Lidocaine, amiodarone, and measures to treat myocardial ischemia may be Considered to treat polymorphic Ventricular Tachycardia (VT) in the Absence of a prolonged QT interval (Class of Recommendation: 2b, Level of Evidence: C-LD)
• We do not recommend routine use of magnesium for the treatment of Polymorphic Ventricular Tachycardia (VT) with a normal QT interval (Class of Recommendation: 3 = No Benefit, Level of Evidence: C-LD)

Recommendations for Electric Therapies for Regular Narrow-Complex Tachycardia

• Synchronized Cardioversion is Recommended for Acute Treatment in Patients with Hemodynamically Unstable Supraventricular Tachycardia (SVT) (Class of Recommendation:1, Level of Evidence: B-NR)
• Synchronized Cardioversion is Recommended for Acute Treatment in Patients with Hemodynamically Stable Supraventricular Tachycardia (SVT) When Vagal Maneuvers and Pharmacological Therapy is Ineffective or Contraindicated (Class of Recommendation: 1, Level of Evidence: B-NR)

Recommendations for Pharmacological Therapies for Regular Narrow-Complex Tachycardia

• Vagal maneuvers are recommended for Acute Treatment in Patients with Supraventricular Tachycardia (SVT) at a Regular Rate (Class of Recommendation: 1, Level of Evidence: B-R)
• Adenosine is recommended for Acute Treatment in Patients with Supraventricular Tachycardia (SVT) at a Regular rate (Class of Recommendation: 1, Level of Evidence: B-R)
• Intravenous Diltiazem or verapamil can be effective for Acute Treatment in Patients with Hemodynamically Stable Supraventricular Tachycardia (SVT) at a regular Rate (Class of Recommendation: 2a, Level of Evidence: B-R)
• Intravenous β-Blockers are Reasonable for Acute Treatment in Patients with Hemodynamically Stable Supraventricular Tachycardia (SVT) at a Regular Rate (Class of Recommendation: 2a, Level of Evidence: C-LD)

Recommendations for Atrial Fibrillation/Flutter (see Atrial Fibrillation and Atrial Flutter)

Electrical Therapies

• Hemodynamically Unstable Patients with Atrial Fibrillation or Atrial Flutter with Rapid Ventricular Response Should Receive Electric Cardioversion (Class of Recommendation: 1, Level of Evidence: C-LD)
• Urgent Direct-Current Cardioversion of New-Onset Atrial Fibrillation in the Setting of Acute Coronary Syndrome is Recommended for Patients with Hemodynamic Compromise, Ongoing Ischemia, or Inadequate Rate Control (Class of Recommendation: 1, Level of Evidence: C-LD)
• For Synchronized Cardioversion of Atrial Fibrillation Using Biphasic Energy, an Initial Energy of 120-200 J is Reasonable, Depending on the Specific Biphasic Defibrillator Being Used (Class of Recommendation: 2a, Level of Evidence: C-LD)
• For synchronized Cardioversion of Atrial Flutter Using Biphasic Energy, an Initial Energy of 50-100 J is Reasonable, Depending on the Specific Biphasic Defibrillator Being Used (Class of Recommendation: 2b, Level of Evidence: C-LD)

Medical Therapies

• Intravenous Administration of a β-Blocker or Non-Dihydropyridine Calcium Channel Blocker is Recommended to Slow the Ventricular Heart Rate in the Acute Setting in Patients with Atrial Fibrillation/Flutter with Rapid Ventricular Response without Preexcitation (Class of Recommendation: 1, Level of Evidence: B-NR)
• Intravenous Amiodarone Can Be Useful for Rate Control in Critically Ill Patients with Atrial Fibrillation with Rapid Ventricular Response without Preexcitation (Class of Recommendation: 2a, Level of Evidence: B-NR)
• In Patients with Atrial Fibrillation/Flutter in the Setting of Preexcitation, Digoxin, Non-Dihydropyridine Calcium Channel Blockers, β-Blockers, and Intravenous Amiodarone Should Not Be Administered Because They May Increase the Ventricular Response and Result in Ventricular Fibrillation (Class of Recommendation: 3 = Harm, Level of Evidence: C-LD)
• Non-Dihydropyridine Calcium Channel Blockers and Intravenous β-Blockers Should Not Be Used in Patients with Left Ventricular Systolic Dysfunction and Decompensated Heart Failure Because These May Lead to Further Hemodynamic Compromise (Class of Recommendation: 3 = Harm, Level of Evidence: C-LD)

Recommendations for Bradycardia (see Sinus Bradycardia)

• In Patients Presenting with Acute Symptomatic Bradycardia, Evaluation and Treatment of Reversible Etiologies is Recommended (Class of Recommendation: 1, Level of Evidence: C-EO)
• In Patients with Acute Bradycardia Associated with Hemodynamic Compromise, Administration of Atropine is Reasonable to Increase the Heart Rate (Class of Recommendation: 2a, Level of Evidence: B-NR)
• If Bradycardia is Unresponsive to Atropine, Intravenous Adrenergic Agonists with Rate-Accelerating Effects (Epinephrine, etc) or Transcutaneous Pacing May Be Effective While the Patient is Prepared for Emergent Transvenous Temporary Pacing (if Required) (Class of Recommendation: 2b, Level of Evidence: C-LD)
• Immediate Pacing May Be Considered in Unstable Patients with High-Degree Atrioventricular (AV) Block When Intravenous/Intraosseus Access is Not Available (Class of Recommendation: 2b, Level of Evidence: C-EO)
• In Patients with Persistent Hemodynamically Unstable Bradycardia Refractory to Medical Therapy, Temporary Transvenous Pacing is Reasonable to Increase Heart Rate and Improve Symptoms (Class of Recommendation: 2a, Level of Evidence: C-LD)

Recommendations for the Post-Resuscitation Period

Multidisciplinary System of Care

• A comprehensive, structured, Multidisciplinary System of Care should Be implemented in a consistent manner for the treatment of post–cardiac arrest Patients (Class of Recommendation: 1, Level of Evidence: B-NR)

Electrocardiogram (EKG (see Electrocardiogram)

• A 12-lead ECG should be obtained as Soon as feasible after Return of Spontaneous Circulation (ROSC) to determine Whether acute ST-segment elevation is Present (Class of Recommendation: 1, Level of Evidence: B-NR)

Hemodynamic Management

• It is Preferable to Avoid Hypotension by Maintaining a Systolic Blood Pressure ≥90 mm Hg and a Mean Arterial Pressure ≥65 mm Hg in the Post-Resuscitation Period (Class of Recommendation: 2a, Level of Evidence: B-NR)

Respiratory Management

• To avoid hypoxia in adults with Return of Spontaneous Circulation (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 (Class of Recommendation: 2a, Level of Evidence: C-EO)
• We Recommend Avoiding hypoxemia in All Patients who remain comatose after Return of Spontaneous Circulation (ROSC) (Class of Recommendation: 1, Level of Evidence: B-NR)
• Once reliable measurement of peripheral Blood oxygen saturation is available, Avoiding Hyperoxemia by titrating the Fraction of inspired oxygen to target an Oxygen saturation of 92% to 98% may Be reasonable in patients who remain Comatose after Return of Spontaneous Circulation (ROSC) (Class of Recommendation: 2b, Level of Evidence: B-R)
• Maintaining the arterial partial pressure of carbon dioxide (Paco2) within a normal Physiological range (generally 35–45 mm Hg) may be reasonable in patients Who remain comatose after Return of Spontaneous Circulation (ROSC) (Class of Recommendation: 2b, Level of Evidence: B-R)

Neurologic Management

• We Recommend Treatment of Clinically Apparent seizures in adult post–cardiac Arrest survivors (Class of Recommendation: 1, Level of Evidence: C-LD)
• We recommend promptly performing and Interpreting an electroencephalogram (EEG) for the diagnosis of seizures in all comatose patients after Return of Spontaneous Circulation (ROSC) (Class of Recommendation: 1, Level of Evidence: C-LD)
• The Treatment of Nonconvulsive Seizures (Diagnosed by EEG only) May Be Considered (Class of Recommendation: 2b, Level of Evidence: C-LD)
• The Same Anticonvulsant Regimens Used for the Treatment of Seizures Caused by Other Etiologies May Be Considered for Seizures Detected After Cardiac Arrest (Class of Recommendation: 2b, Level of Evidence: C-LD)
• Seizure Prophylaxis in Adult Post–Cardiac Arrest Survivors is Not Recommended (Class of Recommendation: 3 = No Benefit, Level of Evidence: B-R)

Other Management

• The Benefit of Any Specific Target Range of Glucose Management is Uncertain in Adults with Return of Spontaneous Circulation (ROSC) After Cardiac Arrest (Class of Recommendation: 2b, Level of Evidence: B-R)
• The Routine Use of Prophylactic Antibiotics in Postarrest Patients is of Uncertain Benefit (Class of Recommendation: 2b, Level of Evidence: B-R)
• The Effectiveness of Agents to Mitigate Neurological Injury in Patients Who Remain Comatose After Return of Spontaneous Circulation (ROSC) is Uncertain (Class of Recommendation: 2b, Level of Evidence: B-R)
• The Routine Use of Steroids for Patients with Shock After Return of Spontaneous Circulation (ROSC) is of Uncertain Value (Class of Recommendation: 2b, Level of Evidence: B-R)

Targeted Temperature Management (TTM) (see Hypothermia)

• We Recommend Targeted Temperature Management (TTM) for Adults Who Do Not Follow Commands After ROSC from Out-of-Hospital Cardiac Arrest (OHCA) with Any Initial Rhythm (Class of Recommendation: 1, Level of Evidence: B-R)
• We Recommend Targeted Temperature Management (TTM) for Adults Who Do Not Follow Commands After ROSC from In-Hospital Cardiac Arrest (IHCA) with Initial Non-Shockable Rhythm (Class of Recommendation: 1, Level of Evidence: B-R)
• We Recommend Targeted Temperature Management (TTM) for Adults Who Do Not Follow Commands After ROSC from In-Hospital Cardiac Arrest (IHCA) with Initial Shockable Rhythm (Class of Recommendation: 1, Level of Evidence: B-R)
• We recommend selecting and Maintaining a constant temperature Between 32°C and 36°C during Targeted Temperature Management (TTM) (Class of Recommendation: 1, Level of Evidence: B-R)
• It is reasonable that TTM be maintained for at least 24 h after achieving target Temperature (Class of Recommendation: 2a, Level of Evidence: B-NR)
• It may be reasonable to actively prevent Fever in comatose patients after Targeted Temperature Management (TTM) (Class of Recommendation: 2b, Level of Evidence: C-LD)
• We do not recommend the routine use of rapid infusion of cold IV fluids for Prehospital cooling of patients after Return of Spontaneous Circulation (ROSC) (Class of Recommendation: 3 = No Benefit, Level of Evidence: A)

Percutaneous Coronary Intervention (PCI)

• Coronary angiography should be Performed emergently for all cardiac Arrest patients with suspected cardiac Sause of arrest and ST-segment elevation on ECG (Class of Recommendation: 1, Level of Evidence: B-NR)
• 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. (Class of Recommendation: 2a, Level of Evidence: B-NR)
• Independent of a patient’s mental status, Coronary angiography is reasonable in All post–cardiac Arrest patients for whom Coronary angiography is otherwise Indicated (Class of Recommendation: 2a, Level of Evidence: C-LD)

Recommendations for Neuroprognostication

• General
  • In patients who remain comatose After cardiac arrest, we recommend that neuroprognostication involve a Multimodal approach and not be based on any single finding (Class of Recommendation: 1, Level of Evidence: B-NR)
  • In patients who remain comatose After cardiac arrest, we recommend that neuroprognostication be Delayed Until adequate time has passed to Ensure avoidance of confounding by Medication effect or a transiently poor Examination in the early postinjury Period (Class of Recommendation: 1, Level of Evidence: B-NR)
  • We recommend that teams caring for comatose cardiac arrest survivors Have regular and Transparent Multidisciplinary discussions with Surrogates about the anticipated time Course for and uncertainties around Neuroprognostication (Class of Recommendation: 1, Level of Evidence: C-EO)
  • In patients who remain comatose After cardiac arrest, it is Reasonable to perform multimodal Neuroprognostication at a minimum of 72 h after normothermia, though Individual prognostic tests may Be Obtained earlier than this. (Class of Recommendation: 2a, Level of Evidence: B-NR)
• Clinical Examination
  • When performed with other prognostic Tests, it may be reasonable to Consider Bilaterally absent Pupillary light reflex at 72 h or more after cardiac arrest to support the prognosis of poor Neurological outcome in patients who Remain comatose (Class of Recommendation: 2b, Level of Evidence: B-NR)
  • When performed with other prognostic Tests, it may be reasonable to consider Quantitative Pupillometry at 72 hrs or More after cardiac arrest to support the Prognosis of poor neurological outcome in patients who remain comatose (Class of Recommendation: 2b, Level of Evidence: B-NR)
  • When performed with other prognostic Tests, it may be reasonable to consider Bilaterally absent corneal reflexes at 72 hrs or more after cardiac arrest to support the prognosis of poor neurological Outcome in patients who remain Comatose (Class of Recommendation: 2b, Level of Evidence: B-NR)
  • When performed with other prognostic Tests, it may be reasonable to consider Status myoclonus that occurs within 72 hrs after cardiac arrest to support the Prognosis of poor neurological outcome (Class of Recommendation: 2b, Level of Evidence: B-NR)
  • We suggest recording EEG in the Presence of myoclonus to determine if There is an associated cerebral correlate (Class of Recommendation: 2b, Level of Evidence: B-NR)
  • The presence of undifferentiated Myoclonic movements after cardiac arrest Should not be used to support a poor Neurological prognosis (Class of Recommendation: 3 = Harm, Level of Evidence: B-NR)
  • We recommend that the findings of a best motor response in the upper Extremities being either Absent or Extensor movements not be used alone for predicting a poor neurological Outcome in patients who remain Comatose after cardiac arrest (Class of Recommendation: 3 = Harm, Level of Evidence: B-NR)
• Serum Biomarkers
  • When performed in combination with other prognostic tests, it may be Reasonable to consider high serum Values of neuron-specific enolase (NSE) within 72 h after cardiac arrest to support the prognosis of poor Neurological outcome in patients who Remain comatose (Class of Recommendation: 2b, Level of Evidence: B-NR)
  • The usefulness of S100 calcium-binding Protein (S100B), Tau, neurofilament light Chain, and glial fibrillary acidic protein in Neuroprognostication is uncertain (Class of Recommendation: 2b, Level of Evidence: C-LD)
• Electrophysiology
  • When evaluated with other prognostic Tests, the prognostic value of seizures in patients who remain comatose after Cardiac arrest is uncertain (Class of Recommendation: 2b, Level of Evidence: B-NR)
  • 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 (Class of Recommendation: 2b, Level of Evidence: B-NR)
  • 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 (Class of Recommendation: 2b, Level of Evidence: B-NR)
  • 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 (Class of Recommendation: 2b, Level of Evidence: B-NR)
  • When evaluated with other prognostic Tests after arrest, the usefulness of Rhythmic periodic discharges to support the prognosis of poor neurological Outcome is uncertain. (Class of Recommendation: 2b, Level of Evidence: B-NR)
  • We recommend that the absence of EEG reactivity within 72 h after arrest Not be used alone to support a poor Neurological prognosis (Class of Recommendation: 3 = No Benefit, Level of Evidence: B-NR)
• Neuroimaging
  • When performed with other prognostic Tests, it may be reasonable to consider Reduced gray-white ratio (GWR) on brain Computed tomography (CT) after cardiac Arrest to support the prognosis of poor neurological outcome in patients who Remain comatose (Class of Recommendation: 2b, Level of Evidence: B-NR)
  • When performed with other prognostic Tests, it may be reasonable to consider Extensive areas of restricted diffusion on brain MRI (MRI) at 2 to 7 days after Cardiac arrest to support the prognosis of poor neurological outcome in patients Who remain comatose (Class of Recommendation: 2b, Level of Evidence: B-NR)
  • When performed with other prognostic Tests, it may be reasonable to consider Extensive areas of reduced apparent Diffusion coefficient (ADC) on brain MRI at 2 to 7 days after cardiac arrest to support the prognosis of poor Neurological outcome in patients who Remain comatose (Class of Recommendation: 2b, Level of Evidence: B-NR)

Recommendations for Recovery and Survivorship After Cardiac Arrest

• We recommend structured assessment for anxiety, depression, posttraumatic Stress, and fatigue for cardiac arrest Survivors and their caregivers (Class of Recommendation: 1, Level of Evidence: B-NR)
• We recommend that cardiac arrest Survivors have multimodal rehabilitation Assessment and treatment for physical, Neurological, cardiopulmonary, and Cognitive impairments before discharge from the hospital (Class of Recommendation: 1, Level of Evidence: C-LD)
• We recommend that cardiac arrest Survivors and their caregivers receive Comprehensive, multidisciplinary Discharge planning, to include Medical and rehabilitative treatment recommendations and return to activity/Work expectations (Class of Recommendation: 1, Level of Evidence: C-LD)
• 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 (Class of Recommendation: 2b, Level of Evidence: C-LD)

Recommendations for Accidental Hypothermia (see Hypothermia)

• Full resuscitative measures, including Extracorporeal rewarming when Available, are recommended for all Victims of accidental hypothermia without characteristics that deem them Unlikely to survive and without any Obviously lethal traumatic injury (Class of Recommendation: 1, Level of Evidence: C-LD)
• Victims of accidental hypothermia Should not be considered dead before Rewarming has been provided unless There are signs of obvious death (Class of Recommendation: 1, Level of Evidence: C-EO)
• It may be reasonable to perform Defibrillation attempts according to the Standard BLS algorithm concurrent with Rewarming strategies (Class of Recommendation: 2b, Level of Evidence: C-LD)
• It may be reasonable to consider Administration of epinephrine during Cardiac arrest according to the standard ACLS algorithm concurrent with Rewarming strategies (Class of Recommendation: 2b, Level of Evidence: C-LD)

Recommendations for Anaphylaxis (see Anaphylaxis)

Anaphylaxis without Cardiac Arrest (see Anaphylaxis)

• 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) (Class of Recommendation: 1, Level of Evidence: C-LD)
  • Injection of Epinephrine into the Lateral Aspect of the Thigh Produces Rapid Peak Plasma Epinephrine Concentrations
• The Recommended Epinephrine Dose in Anaphylaxis is 0.2-0.5 mg (1:1,000) Intramuscularly, to Be Repeated q5-15 min as Required (Class of Recommendation: 1, Level of Evidence: C-LD)
• In Patients with Anaphylactic Shock, Close Hemodynamic Monitoring is Recommended (Class of Recommendation: 1, Level of Evidence: C-LD
• Given the Potential for the Rapid Development of Oropharyngeal/Laryngeal Edema, Immediate Referral to a Health Professional with Expertise in Advanced Airway Placement (Including Surgical Airway Management) is Recommended (Class of Recommendation: 1, Level of Evidence: C-LD)
  • When Anaphylaxis Produces Obstructive Airway Edema, Rapid Advanced Airway management is Critical
    • In Some Cases, Emergency Cricothyrotomy/Tracheostomy May Be Required
• If an Intravenous (IV) Line is in Place, it is Reasonable to Consider the Intravenous (IV) Route for Epinephrine in Anaphylactic Shock, at a Dose of 0.05-0.1 mg (0.1 mg/mL, aka 1:10 000) (Class of Recommendation: 2a, Level of Evidence: C-LD)
• Intravenous (IV) Infusion of Epinephrine is a Reasonable Alternative to Intravenous (IV) Boluses for the Treatment of Anaphylaxis in Patients Not in Cardiac Arrest (Class of Recommendation: 2a, Level of Evidence: C-LD)
• Intravenous (IV) Infusion of Epinephrine May Be Considered for Postarrest Shock in Patients with Anaphylaxis (Class of Recommendation: 2b, Level of Evidence: C-LD)

Anaphylaxis with Cardiac Arrest (see Anaphylaxis)

• General Comments
  • There are No Randomized Controlled Trials (RCT’s) Evaluating Alternative Treatment Algorithms for Cardiac Arrest Due to Anaphylaxis
    • Evidence is Limited to Case Reports and Extrapolations from Non-Fatal Anaphylaxis Cases, Interpretation of Pathophysiology, and Consensus Opinion
  • Because of Limited Evidence, the Cornerstone of Management of Anaphylaxis-Associated Cardiac Arrest is Standard Basic Life Support/Advanced Cardiac Life Support, Including Airway Management and Early Epinephrine
    • There is No Proven Benefit from the Use of Antihistamines, Inhaled β2-Agonists, and Intravenous Corticosteroids During Anaphylaxis-Induced Cardiac Arrest
• In Cardiac Arrest Secondary to Anaphylaxis, Standard Resuscitative Measures and Immediate Administration of Epinephrine Should Take Priority (Class of Recommendation: 1, Level of Evidence: C-LD)

Recommendations for Asthma (see Asthma)

• For Asthmatic Patients with Cardiac Arrest, Sudden Increase in Peak Inspiratory Pressures (PIP) or Difficulty ventilating Should Prompt Evaluation for Tension Pneumothorax (Class of Recommendation: 1, Level of Evidence: C-LD)
• Due to the Potential Effects of Intrinsic Positive End-Expiratory Pressure (Auto-PEEP) and Risk of Barotrauma in an Asthmatic Patient with Cardiac Arrest, a Ventilation Strategy of Low Respiratory Rate and Low Tidal Volume is Reasonable (Class of Recommendation: 2a, Level of Evidence: C-LD)
• If Increased Auto-PEEP or Sudden Decrease in Blood Pressure is Noted in Asthmatics Receiving Bag-Valve-Mask (BVM) Ventilation/Mechanical Ventilation in a Periarrest State, a Brief Disconnection from the Bag-Valve-Mask (BVM) or Ventilator with Compression of the Chest Wall to Relieve Air Trapping Can Be Effective (Class of Recommendation: 2a, Level of Evidence: C-LD)

Recommendations for Cardiac Arrest After Cardiac Surgery

• External chest compressions should be Performed if emergency resternotomy is Not immediately available (Class of Recommendation: 1, Level of Evidence: B-NR)
• In a trained provider-witnessed arrest of a post–cardiac surgery patient, Immediate Defibrillation for VF/VT should Be performed. CPR should be initiated if Defibrillation is not successful within 1 min (Class of Recommendation: 1, Level of Evidence: C-LD)
• In a trained provider-witnessed arrest of a post–cardiac surgery patient where Pacer wires are Already in Place, we Recommend immediate pacing in an Asystolic or bradycardic arrest. CPR Should be initiated if pacing is not Successful within 1 min (Class of Recommendation: 1, Level of Evidence: C-LD)
• For patients with cardiac arrest after Cardiac surgery, it is reasonable to Perform resternotomy early in an Appropriately staffed and equipped ICU (Class of Recommendation: 2a, Level of Evidence: B-NR)
• Open-chest CPR can be useful if cardiac Arrest develops during surgery when the Chest or abdomen is already open, or in the early postoperative period after Cardiothoracic surgery (Class of Recommendation: 2a, Level of Evidence: C-LD)
• In post–cardiac surgery patients who are refractory to standard resuscitation Procedures, mechanical circulatory Support may be effective in improving Outcome (Class of Recommendation: 2b, Level of Evidence: C-LD)

Recommendations for Drowning (see Near Drowning)

• Rescuers should provide CPR, including Rescue breathing, as soon as an Unresponsive submersion victim is Removed from the water (Class of Recommendation: 1, Level of Evidence: C-LD)
• 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 (Class of Recommendation: 1, Level of Evidence: C-LD)
• Mouth-to-mouth ventilation in the water May be helpful when administered by a Trained rescuer if it does not compromise Safety (Class of Recommendation: 2b, Level of Evidence: C-LD)
• Routine Stabilization of the Cervical Spine in the Absence of Circumstances Which Might Suggest a Spinal Injury is Not Recommended (Class of Recommendation: 3 = No Benefit, Level of Evidence: B-NR)

Recommendations for Electrolyte Abnormalities in Cardiac Arrest

Hyperkalemia (see Hyperkalemia)

• For Cardiac Arrest with Known/Suspected Hyperkalemia, in Addition to Standard Advanced Cardiac Life Support (ACLS) Care, Intravenous Calcium Should Be Administered (Class of Recommendation: 1, Level of Evidence: C-LD)

Hypomagnesemia (see Hypomagnesemia)

• For Cardiotoxicity and Cardiac Arrest from Severe Hypomagnesemia, in Addition to Standard Advanced Cardiac Life Support (ACLS) Care, Intravenous Magnesium is Recommended (Class of Recommendation: 1, Level of Evidence: C-LD)

Hypermagnesemia (see Hypermagnesemia)

• For Cardiac Arrest with Known/Suspected hypermagnesemia, in Addition to Standard Advanced Cardiac Life Support (ACLS) Care, it May Be Reasonable to Administer Empirical Intravenous Calcium (Class of Recommendation: 2b, Level of Evidence: C-EO)

Hypokalemia (see Hypokalemia)

• In Suspected Hypokalemia, Intravenous Bolus Administration of Potassium for Cardiac Arrest is Not Recommended (Class of Recommendation: 3 = Harm, Level of Evidence: C-LD)

Recommendations for Pregnancy (see Pregnancy)

Planning and Preparation for Cardiac Arrest in Pregnancy (see Pregnancy)

• Team planning for cardiac arrest in pregnancy should be done in Collaboration with the obstetric, Neonatal, emergency, anesthesiology, Intensive care, and cardiac arrest services (Class of Recommendation: 1, Level of Evidence: C-LD)
• Because immediate ROSC cannot Always be achieved, local resources for a Perimortem cesarean delivery should be Summoned as soon as cardiac arrest in a Woman in the second half of pregnancy is recognized (Class of Recommendation: 1, Level of Evidence: C-LD)
• Protocols for management of OHCA in pregnancy should be developed to Facilitate timely transport to a Center with capacity to immediately perform Perimortem cesarean delivery while Providing ongoing resuscitation (Class of Recommendation: 1, Level of Evidence: C-LD)

Resuscitation of Cardiac Arrest in Pregnancy (see Pregnancy)

• Priorities for the pregnant woman in Cardiac arrest should include provision of High-quality CPR and relief of aortocaval Compression Through Left Lateral Uterine Displacement (Class of Recommendation: 1, Level of Evidence: C-LD)
• Because pregnant patients are more Prone to hypoxia, oxygenation and Airway management should be prioritized During resuscitation from cardiac arrest in Pregnancy (Class of Recommendation: 1, Level of Evidence: C-LD)
• Because of potential interference with Maternal resuscitation, fetal monitoring Should not be undertaken during cardiac Arrest in pregnancy (Class of Recommendation: 1, Level of Evidence: C-EO)
• We recommend targeted temperature Management for pregnant women who Remain comatose after resuscitation from Cardiac Arrest (Class of Recommendation: 1, Level of Evidence: C-EO)
• 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 (Class of Recommendation: 1, Level of Evidence: C-EO)

Cardiac Arrest and Perimortem Cesarean Delivery (PMCD) (see Pregnancy)

• During cardiac arrest, if the pregnant Woman with a fundus height at or above the umbilicus has not achieved ROSC with usual resuscitation measures plus Manual left lateral uterine displacement, it is advisable to prepare to evacuate the Eterus while resuscitation continues (Class of Recommendation: 1, Level of Evidence: C-LD)
• In situations such as nonsurvivable Maternal trauma or prolonged Pulselessness, in which maternal Resuscitative efforts are considered futile, There is no reason to delay performing perimortem cesarean delivery in Appropriate patients (Class of Recommendation: 1, Level of Evidence: C-LD)
• 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 (Class of Recommendation: 2a, Level of Evidence: C-EO)

Recommendations for Acute Pulmonary Embolism (PE) (see Acute Pulmonary Embolism)

• In Patients with Confirmed Acute Pulmonary Embolism (PE) as the Precipitant of Cardiac Arrest, Thrombolysis, Surgical Embolectomy, and Mechanical Embolectomy are Reasonable Emergency Treatment Options (Class of Recommendation: 2a, Level of Evidence: C-LD)
• Thrombolysis May Be Considered when Cardiac Arrest is Suspected to Be Caused by Acute Pulmonary Embolism (PE) (Class of Recommendation: 2b, Level of Evidence: C-LD)

Recommendations for Intoxications

Opioid Intoxication (Acute Management) (see Opioids)

• For Patients in Respiratory Arrest, Rescue Breathing or Bag-Valve-Mask (BVM) Vnetilation Should Be Maintained Until Spontaneous Breathing Returns, and Standard Basic Life Support (BLS) and/or Advanced Cardiac Life Support (ACLS) Measures Should Continue if Return of Spontaneous Breathing Does Not Occur (Class of Recommendation: 1, Level of Evidence: C-LD)
• For patients known or suspected to Be in cardiac arrest, in the absence of a proven benefit from the use of naloxone, standard resuscitative Measures should take priority over Naloxone administration, with a focus on high-quality CPR (compressions plus Ventilation) (Class of Recommendation: 1, Level of Evidence: C-EO)
• Lay and trained responders should Not delay activating emergency Response systems while awaiting the Patient’s response to naloxone or other Interventions (Class of Recommendation: 1, Level of Evidence: C-EO)
• For a patient with suspected opioid Overdose who has a definite pulse but No normal breathing or only gasping (ie, a respiratory arrest), in addition to Providing standard BLS and/or ACLS Care, it is reasonable for responders to Administer naloxone (Class of Recommendation: 2a, Level of Evidence: B-NR)

Opioid Intoxication (Post-Resuscitation Management) (see Opioids)

• After return of spontaneous breathing, Patients should be observed in a Healthcare setting until the risk of Recurrent opioid toxicity is low and the Patient’s level of consciousness and vital signs have normalized (Class of Recommendation: 1, Level of Evidence: C-LD)
• If recurrent opioid toxicity develops, Repeated small doses or an infusion of Naloxone can be beneficial (Class of Recommendation: 2a, Level of Evidence: C-LD)

Benzodiazepine Intoxication (see Benzodiazepines)

• Administration of Flumazenil to Patients with Undifferentiated Coma Confers Risk and is Not Recommended (Class of Recommendation: 3 = Harm, Level of Evidence: B-R) (see Flumazenil)

β-Blocker Intoxication (see β-Adrenergic Receptor Antagonists)

• In Patients with β-Blocker Intoxication Who are in Refractory Shock, Administration of High-Dose Insulin with Glucose is Reasonable (Class of Recommendation: 2a, Level of Evidence: C-LD) (see Insulin)
• In Patients with β-Blocker Intoxication Who are in Refractory Shock, Administration of Intravenous Glucagon is Reasonable (Class of Recommendation: 2a, Level of Evidence: C-LD) (see Glucagon)
• In Patients with β-Blocker Intoxication Who are in Refractory Shock, Administration of Calcium May Be Considered (Class of Recommendation: 2b, Level of Evidence: C-LD)
• In Patients with β-Blocker Intoxication Who are in Refractory Shock, Extracorporeal Membrane Oxygenation (ECMO) Might Be Considered (Class of Recommendation: 2b, Level of Evidence: C-LD) (see Venoarterial Extracorporeal Membrane Oxygenation)

Calcium Channel Blocker Intoxication (see Calcium Channel Blockers)

• In Patients with Calcium Channel Blocker Overdose Who are in Refractory Shock, administration of Calcium is Reasonable (Class of Recommendation: 2a, Level of Evidence: C-LD)
• In Patients with Calcium Channel Blocker Overdose Who are in Refractory Shock, Administration of High-Dose Insulin with Glucose is Reasonable (Class of Recommendation: 2a, Level of Evidence: C-LD) (see Insulin)
• In Patients with Calcium Channel Blocker Overdose Who are in Refractory Shock, Administration of Intravenous Glucagon May Be Considered (Class of Recommendation: 2b, Level of Evidence: C-LD)
• In Patients with Calcium Channel Blocker Overdose Who are in Shock Refractory to Pharmacological Therapy, Extracorporeal Membrane Oxygenation (ECMO) Might Be Considered (Class of Recommendation: 2b, Level of Evidence: C-LD) (see Venoarterial Extracorporeal Membrane Oxygenation)

Cocaine Intoxication (see Cocaine)

• For patients with cocaine-induced Hypertension, tachycardia, agitation, or chest discomfort, Benzodiazepines, α-Blockers, Calcium Channel Blockers, Nitroglycerin, and/or Morphine Can Be Beneficial (Class of Recommendation: 2a, Level of Evidence: B-NR)
• Although Contradictory Evidence Exists, it May Be Reasonable to Avoid the Use of Pure β-Adrenergic Blocker Medications in the Setting of Cocaine Intoxication (Class of Recommendation: 2b, Level of Evidence: C-LD)

Local Anesthetic Overdose

• It May Be Reasonable to Administer Intravenous Lipid Emulsion, Concomitant with Standard Resuscitative Care, to Patients with Local Anesthetic Systemic Toxicity (LAST) (Class of Recommendation: 2b, Level of Evidence: C-LD)
  • Particularly to Patients who Have Premonitory Neurotoxicity or Cardiac Arrest Due to Bupivacaine Intoxication (Class of Recommendation: 2b, Level of Evidence: C-LD) (see Bupivacaine)

Sodium Channel Blockers (Including Tricyclic Antidepressant) Intoxication (see Tricyclic Antidepressants)

• Administration of Sodium Bicarbonate for Cardiac Arrest or Life-Threatening Cardiac Conduction Delays (i.e. QRS Prolongation >120 msec) Due to Sodium Channel Blocker/Tricyclic Antidepressant (TCA) Overdose Can Be Beneficial (Class of Recommendation: 2a, Level of Evidence: C-LD)
• The Use of Extracorporeal Membrane Oxygenation (ECMO) for Cardiac Arrest or Refractory Shock Due to Sodium Channel Blocker/Tricyclic Antidepressant Toxicity May Be Considered (Class of Recommendation: 2b, Level of Evidence: C-LD)

Digoxin Intoxication (see Digoxin)

• Anti-Digoxin Fab Antibodies Should Be Administered to Patients with Severe Cardiac Glycoside Intoxication (Class of Recommendation: 1, Level of Evidence: B-R) (see xxxx)

Carbon Monoxide Intoxication (see Carbon Monoxide)

• Hyperbaric oxygen therapy may be Helpful in the treatment of acute carbon Monoxide poisoning in Patients with Severe Toxicity (Class of Recommendation: 2b, Level of Evidence: B-R)

Cyanide Intoxication (see Cyanide)

• Hydroxocobalamin and 100% Oxygen, with/without Sodium Thiosulfate, Can Be Beneficial for Cyanide Toxicity (Class of Recommendation: 2a, Level of Evidence: C-LD)