AHA 2020 CPR AND ECC (Emergency Cardiovascular Care)
UPDATES - Importancedots
2020 AHA American Heart Association Guidelines (Full Text in English) CLICK HERE
ADULT BASIC AND ADVANCED CARDIAC LIFE SUPPORT
DECISION TO START EARLY CARDIOPULMONARY RESUITATION:
2020 (Updated): Even if the patient is not actually in arrest, we recommend initiating CPR for people suspected of arrest, as the risk of harm to the patient from chest compressions is low.
2010 (Old): A lay rescuer should not check for a pulse and should not accept a patient as arrest unless an adult faints suddenly or an unresponsive victim is not breathing normally. It should not take longer than 10 seconds for the paramedic to check the pulse, and if the rescuer does not feel any pulse during this time, he should start chest compressions.
Why: New evidence suggests that the risk of harm is low when chest compressions are administered to a victim without cardiac arrest. If lay rescuers are not able to accurately detect whether the victim has a pulse, the damage from not performing CPR will outweigh the harm that unnecessary chest compressions can do.
SIMULTANEOUS VISUAL FEEDBACK;
2020 (Unmodified / Reconfirmed): It may be reasonable to use audio-visual feedback devices during simultaneous CPR to optimize CPR performance.
(Smart watch, smart phone CPR feedback systems working principle)
PHYSIOLOGICAL MONITORING OF CPR EFFICIENCY
2020 (Updated): Improves the quality of CPR when it is possible to monitor and optimize physiological parameters such as arterial blood pressure or ETCO2.
2015 (Old): Although there are no clinical studies examining the adjustment of resuscitative effort in terms of physiological parameters during CPR to improve post-arrest outcome, physiological parameters (quantitative waveform capnography, arterial blood pressure) when applied to monitor and optimize CPR quality, guide vasopressor therapy, and detect ROSC. relaxation diastolic pressure, arterial pressure monitoring, and central venous oxygen saturation) may be reasonable.
Why: Data from the AHA's Get With The Guidelines®-Resuscitation registry show that spontaneous circulation is more likely to return when CPR quality is monitored using ETCO2 or diastolic blood pressure. • This monitoring is dependent on the presence of an endotracheal tube (ETT) or arterial tract, respectively. Compression can be done to target ETCO2 to at least 10 mm Hg and ideally 20 mm Hg or greater, but an ideal ETCO2 pressure value has not been determined.
DUAL DEFIBRILLATION;
2020 (New): Dual sequential defibrillation is not supported in refractory shockable rhythms.
Reason: Not recommended due to increased energy load and possible damage to defibrillators from each other.
ADULT BASIC AND ADVANCED LIFE SUPPORT
IV IS MORE PRIORITY THAN THE PATH IO
2020 (New): First, the iv route makes sense for drug administration in cardiac arrest.
2020 (Updated): IO path is considered if IV access attempts are unsuccessful or unavailable.
2010 (Old): If intravenous (IV) access is not immediately available, it makes sense to establish intraosseous (IO) access.
The reason: In retrospective studies, opening the iv route immediately and opening the io route if iv route attempts were unsuccessful were found to be more effective.
POST CARDIAC ARREST CARE AND NEUROLOGICAL HEALING
Treatment of hypotension, titration of oxygen to avoid both hypoxia and hyperoxia, detection and treatment of seizures, and targeted body temperature management were reassessed. To be reliable, neuroprognostication (assessment of neurological prognosis should be made no later than 72 hours after return to normothermia, and prognostic decisions should be based on more than one mode of patient assessment. The 2020 Guidelines evaluate 19 different modalities and specific findings and provide evidence for each.
SUPPORT IN THE HEALING PROCESS
2020 (New): We recommend that patients returning with arrest receive multimodal rehabilitation evaluation and treatment for physical, neurological, cardiopulmonary, and cognitive impairments prior to discharge from hospital.
2020 (New): We recommend that patients receive comprehensive, multidisciplinary discharge planning to return to their activity/work prospects.
2020 (New): We recommend seeking support for cardiac arrest patients and their families for anxiety, depression, post-traumatic stress and fatigue. Reason: Recovery is a long process and support is needed for physical, emotional and cognitive recovery to be complete.
INFORMATION FOR RESCUES
2020 (New): For non-medical rescuers, other emotional health care workers, and hospital workers after an arrest event Information and direction for support can be helpful. Cause: Rescuers do not provide or provide basic life support or post-traumatic may experience stress. Team briefings allow review of team performance (education, quality improvement) and recognition of the inherent stressors associated with caring for a near-death patient. An AHA scientific statement devoted to this topic is expected in early 2021.
CARDIAC ARREST IN PREGNANCY
2020 (New): Oxygenation and airway management should be given priority during resuscitation due to cardiac arrest during pregnancy, as pregnant patients are more prone to hypoxia.
2020 (New): Due to potential interference with maternal resuscitation, fetal monitoring should not be performed during cardiac arrest in pregnancy.
2020 (New): We recommend targeted temperature management for pregnant women who remain in a coma after resuscitation.
2020 (New): During the targeted temperature management of the pregnant patient, continuous monitoring of the fetus for bradycardia as a potential complication and obstetric and neonatal consultation are recommended.
Why: Recommendations for managing cardiac arrest in pregnancy were reviewed in the 2015 Guidelines Update and the 2015 AHA scientific statement. Airway, ventilation and oxygenation; It is particularly important in pregnancy because of increased maternal metabolism, decreased functional reserve capacity due to the gravid uterus, and the risk of fetal brain damage from hypoxemia.
Evaluation of the fetal heart is not helpful during maternal cardiac arrest and may be distracting. Unless otherwise indicated, pregnant women returning from arrest should receive targeted temperature management, as with other arrestees, taking into account the condition of the fetus.
PEDIATRIC BASIC AND ADVANCED CARDIAC LIFE SUPPORT
MAJOR NEW AND UPDATED RECOMMENDATIONS
CHANGES IN VENTILATION RATE - Rescue breath
2020 (Updated): (Pediatric BLS) For infants and children with a pulse but no or insufficient respiratory effort, 1 breath should be given every 2-3 seconds (20-30 breaths/minute).
2010 (Old): (Pediatric BLS) If there is a palpable pulse of 60/min or higher but insufficient breathing, exhale at a rate of approximately 12 to 20/min (1 breath every 3-5 seconds) until spontaneous breathing.
CHANGES IN VENTILATION RATE
Breath rate when performing CPR with the Advanced Airway
2020 (Updated): (Pediatric ALS) When performing CPR in infants and children with advanced airway, it is reasonable to aim for a respiratory rate range of 1 breath every 2 to 3 seconds (20-30/min), taking into account age and clinical status. Frequent airway support in excess of these recommendations may compromise hemodynamics. 2010 (Old): (PALS) If the infant or child is intubated, interrupt their chest compressions at 10 / 6 seconds without interruption. min) ventilate at a rate of about 1 breath.
Why: New data suggest that higher ventilation rates (at least 30/min in infants [less than 1 year old] and at least 25/min in children) are associated with improved perfusion rates and survival.
CARDIAC ARREST IN PREGNANCY
2020 (New): Oxygenation and airway management should be given priority during resuscitation due to cardiac arrest during pregnancy, as pregnant patients are more prone to hypoxia.
2020 (New): Due to potential interference with maternal resuscitation, fetal monitoring should not be performed during cardiac arrest in pregnancy.
2020 (New): We recommend targeted temperature management for pregnant women who remain in a coma after resuscitation.
2020 (New): During the targeted temperature management of the pregnant patient, continuous monitoring of the fetus for bradycardia as a potential complication and obstetric and neonatal consultation are recommended.
Why: Recommendations for managing cardiac arrest in pregnancy were reviewed in the 2015 Guidelines Update and the 2015 AHA scientific statement. Airway, ventilation and oxygenation; It is particularly important in pregnancy because of increased maternal metabolism, decreased functional reserve capacity due to the gravid uterus, and the risk of fetal brain damage from hypoxemia.
Evaluation of the fetal heart is not helpful during maternal cardiac arrest and may be distracting. Unless otherwise indicated, pregnant women returning from arrest should receive targeted temperature management, as with other arrestees, taking into account the condition of the fetus.
ENDOTRACHEAL Cuffed TUBE
2020 (Updated): It makes sense to prefer cuffed ETTs over uncuffed ETTs to intubate infants and children. When using a cuffed ETT, consideration should be given to ETT size, position, and cuff inflation pressure (usually <20-25 cm H2O).
2010 (Old): Both cuffed and uncuffed ETTs are acceptable for intubating infants and children. In certain situations (for example, poor lung compliance, high airway resistance, or a large glottic air leak), the cuffed tube may be preferred over the uncuffed tube, provided size and pressure are considered.
Why: Several studies and reviews support the safety of cuffed ETTs and show a reduced need for tube replacement and reintubation. Cuffed tubes can reduce the risk of aspiration. Subglottic stenosis is rare when a cuffed ETT is used and carefully monitored in children.
CRICOID PRESSURE DURING INTUBATION
2020 (Updated): Routine cricoid compression is not recommended during endotracheal intubation of pediatric patients.
2010 (Old): There is insufficient evidence to recommend routine cricoid compression to prevent aspiration during endotracheal intubation in pediatric patients.
Why: Recent studies have shown that routine use of cricoid pressure reduces intubation success rates and not regurgitation rates.
EARLY ADRENALINE START
2020 (Updated): For pediatric patients in any setting, it makes sense to administer the first dose of adrenaline within 5 minutes of the start of chest compressions.
2015 (Old): It is reasonable to administer adrenaline in pediatric arrests.
Why: A study in children showed that for each minute of delay in adrenaline administration, there was a significant decrease in the return of spontaneous circulation, survivability and survival at 24 hours. In the 2018 version of the Pediatric Cardiac Arrest Algorithm, patients with non-shockable rhythms were given adrenaline every 3 to 5 minutes, but did not emphasize early epinephrine administration. While the resuscitation sequence has not changed, the algorithm and recommendation language have been updated to highlight the importance of adrenaline administration.
INVASIVE BLOOD PRESSURE MONITORING FOR EVALUATION OF CPR EFFICIENCY
2020 (Updated): For patients with continuous invasive arterial blood pressure monitoring during cardiac arrest, it makes sense to use diastolic blood pressure to evaluate CPR effectiveness.
2015 (Old): It may be reasonable to use CPR for patients undergoing invasive hemodynamic monitoring during arrest.
Reason: Providing effective chest compressions is essential for successful resuscitation. A recent study shows that among pediatric patients undergoing CPR with an open arterial line, survival rates with favorable neurological outcomes are increased if diastolic blood pressure is at least 25 mm Hg in infants and at least 30 mm Hg in children.
DETECTING AND TREATING SEIZURES AFTER RETURN OF Spontaneous Circulation
2020 (Updated): Continuous EEG monitoring is recommended to detect seizures following cardiac arrest in patients with persistent encephalopathy, if available.
2020 (Updated): It is recommended to treat clinical seizures following arrest.
2020 (Updated): It is reasonable to treat non-convulsive epilepsy after cardiac arrest in consultation with a neurologist.
2015 (Old): EEG should be performed and interpreted promptly for the diagnosis of seizures, followed by frequent or continuous monitoring in coma patients.
2015 (Old): The same anticonvulsant regimens can be considered after cardiac arrest for the treatment of status epilepticus caused by other etiologies.
Why: For the first time, the AHA guidelines offer pediatrics-specific recommendations for managing seizures after cardiac arrest. Non-convulsive seizures, including non-convulsive status epilepticus, are common and cannot be detected without an EEG. Although outcome data from the post-cardiac arrest population are lacking, both convulsive and nonconvulsive status epilepticus are associated with poor prognosis, and treatment of status epilepticus is beneficial in pediatric patients in general.
EVALUATION FOR PATIENTS RETURNING FROM ARREST
2020 (New): Rehabilitation is recommended for those who have had a pediatric heart attack.
2020 (New): Pediatric patients returning from arrest should be followed up neurologically for at least two years.
Reason: It is accepted that my recovery process continues after the hospital. A recent AHA scientific statement highlights the importance of supporting patients and families during this time to achieve the best long-term outcome possible.
SEPTIC SHOCK
BOLUS FLUID THERAPY
2020 (Updated): In patients with septic shock, it makes sense to administer the fluid as 10 mL/kg or 20 mL/kg with frequent reassessment.
2015 (Old): Initial fluid bolus of 20 mL/kg to infants and children in shock is reasonable, including in severe sepsis, severe malaria, and dengue fever.
VASOPRESSOR AGENT SELECTION
2020 (New): In infants and children with fluid-resistant septic shock, it is reasonable to use adrenaline or noradrenaline as an initial vasopressor infusion.
2020 (New): In infants and children with fluid-resistant septic shock, dopamine may be considered if adrenaline or noradrenaline is unavailable.
Administering CorticosteroidsI
2020 (New): For infants and children with septic shock who are not responsive to fluids and need vasopressors, it may be reasonable to administer stress-dose corticosteroids.
The reason: Although fluids are the mainstay of initial therapy, fluid overload can lead to increased morbidity. The guideline reaffirmed previous recommendations to reevaluate patients after each fluid bolus and to use crystalloid or colloid fluids for septic shock resuscitation.
Previous versions of the guideline did not provide recommendations on vasopressor selection or corticosteroid use in septic shock. It is thought that adrenaline is superior to dopamine as the first vasopressor in pediatric septic shock, and noradrenaline is also suitable. Recent clinical studies show that corticosteroid administration is beneficial in some pediatric patients with refractory septic shock.
HEMORAGIC SHOCK
2020 (New): Among infants and children with post-traumatic hypotensive hemorrhagic shock, blood products should be administered instead of crystalloid for maintenance replacement whenever possible.
Why: Previous versions of the guideline did not separate the treatment of hemorrhagic shock from other causes of hypovolemic shock. Evidence (largely from adults, but with some pediatric data) suggests that the use of blood products is beneficial for early, balanced resuscitation. Balanced resuscitation is supported by recommendations from various US and international trauma societies.
OPIOID OVERDOSE
2020 (Updated): For patients with respiratory arrest, rescue breathing or ambu ventilation should be continued until spontaneous breathing returns, and standard pediatric BLS and ALS should be performed if spontaneous breathing does not return.
2020 (Updated): Intramuscular or intranasal naloxone can be administered to patients responding to life support, in addition to standard BLS and ALS, for a patient with a pulse but no normal breathing or only normal breathing, gasping, or suspected opioid overdose.
2020 (Updated): For patients with known or suspected cardiac arrest, standard resuscitative measures should take precedence over naloxone with a focus on effective CPR if there is no proven benefit from using naloxone.
2015 (Old): Empirical administration of intramuscular or intranasal naloxone to all unresponsive opioid-related life-threatening emergencies may be reasonable in addition to standard first aid BLS protocols.
2015 (Old): Rescuers should support ventilation and administer naloxone to patients with cardiac arrest, respiratory arrest, or severe respiratory depression. Ambu mask ventilation should be continued until spontaneous breathing returns, and standard ALS precautions should be continued if spontaneous breathing does not return.
2015 (Old): No recommendations were made regarding the administration of naloxone in confirmed opioid-related cardiac arrest.
The reason: Unfortunately, opioid use is also becoming common in children. In the United States in 2018, opioid overdose caused 65 deaths in children younger than 15 years and 3618 deaths in people aged 15 to 24 years. The 2020 Guidelines contain new recommendations for the management of children with respiratory arrest or cardiac arrest due to opioid overdose. These recommendations are the same for adults and children, but CPR is recommended for all patients with suspected pediatric cardiac arrest. Naloxone can be administered by trained rescuers, non-healthcare workers with or without focused training. Management treatment algorithms for opioid-related resuscitation emergencies are provided for non-HCWs and trained rescuers who cannot reliably control the pulse.
MYOCARDITIS
2020 (New): Considering the high risk of cardiac arrest in children with acute myocarditis with arrhythmia, block, ST-segment changes, and/or low cardiac output, early referral to the ICU should be considered.
2020 (New): For children with myocarditis or cardiomyopathy and refractory low EF, early use of ECLS or mechanical circulatory support may be beneficial to prevent arrest.
2020 (New): Given the challenges of successful resuscitation of children with myocarditis and cardiomyopathy, early evaluation of extracorporeal CPR may be beneficial when cardiac arrest occurs.
Reason: Although myocarditis accounts for approximately 2% of sudden cardiovascular deaths in infants, 5% of sudden cardiovascular deaths in children, and 6% to 20% of sudden cardiac deaths in athletes, previous PALS (pediatric advanced life support) guidelines did not include specific recommendations. These recommendations are in line with the 2018 AHA scientific statement on CPR in infants and children with heart disease.
NEWBORN RESUITATION
MAJOR NEW AND UPDATED RECOMMENDATIONS
STARTING RESUSITATION
2020 (New): At least 1 person who can perform the first steps of neonatal resuscitation and whose sole responsibility is the care of the newborn should attend each birth.
Why: Studies show that this approach enables the identification of newborns at risk, encourages the use of checklists to prepare equipment, and facilitates team training. Neonatal resuscitation training in low-resource settings has shown a reduction in both stillbirth and 7-day mortality.
NEWBORN BODY TEMPERATURE MANAGEMENT
2020 (New): Skin-to-skin contact of healthy newborn babies who do not need resuscitation after birth; Breastfeeding can be effective in improving temperature control and blood sugar stability.
Why: Evidence from a Cochrane systematic review has shown that early skin contact promotes normothermia in healthy neonates. In addition, observational studies of extended skin care after initial resuscitation and/or stabilization have shown reduced mortality, improved breastfeeding, shorter length of stay, and better weight gain in preterm and low birth weight infants.
AIRWAY CLEANING IN MECONIUM ASPIRATION
2020 (Updated): Routine laryngoscopy with or without tracheal aspiration is not recommended for neonates born after the introduction of meconium water (presenting with apnea or ineffective respiratory effort).
2020 (Updated): Intubation and tracheal aspiration may be beneficial in non-severe neonates with meconium water with evidence of airway obstruction during positive pressure ventilation.
2015 (Old): Routine intubation for tracheal aspiration is not recommended in this situation when meconium is available because there is insufficient evidence to continue recommending this practice.
Reason: Positive pressure ventilation can be applied in the first intervention in newborn babies with non-vigorous meconium water inflow at birth. Endotracheal aspiration is only indicated if airway obstruction is suspected after PPV has been achieved. Evidence suggests that neonates with not severe meconium contamination have the same outcomes (survival, need for respiratory support) before or after the onset of PPV. Direct laryngoscopy and endotracheal aspiration are not routinely required, but may be helpful in neonates with evidence of airway obstruction while receiving PPV.
VASCULAR PATH
2020 (New): The recommended route for infants requiring vascular access during delivery is the umbilical vein. If iv access is not possible, it may be reasonable to use the io route.
Why: Neonates that are unresponsive to PPV and chest compressions require vascular access to infuse adrenaline and/or volume expanders. Umbilical venous catheterization is the preferred technique in the delivery room. Intraosseous access is an alternative if umbilical venous access is not available or care is provided outside the delivery room. Several case reports have described complications associated with io needle insertion.
TERMINATION OF RESUSITATION
2020 (Updated): If resuscitation newborns do not have a heart rate and all steps of resuscitation have been performed, discontinuation of resuscitation should be discussed with the healthcare team and family. The reasonable time frame for this is around 20 minutes after birth.
2010 (Old): In a newborn without detectable heart rate, it is appropriate to consider stopping resuscitation if the heart rate is still undetectable after 10 minutes.
