Dry goods! Key points of updating 2020AHA cardiopulmonary resuscitation guidelines
Recently, AHA has just released the 2020 Cardiopulmonary Resuscitation (CPR)-Cardiovascular First Aid (ECC) Guide. The guide is divided into five parts, namely, basic and advanced life support for adults, basic and advanced life support for children, life support for newborns, resuscitation education science and rescue system.
Adult basic and advanced life support
Despite the progress in recent years, less than 40% of adults received CPR initiated by non-professionals, while less than 12% received AED first aid before EMS arrived. AHA adult IHCA and OHCA survival chain
(Click to enlarge, the same below)
Emergency procedures for adult cardiac arrest
Opioid-related emergency procedures for non-professional emergency personnel
Opioid-related emergency procedures for medical staff
Flow chart of treatment after recovery of spontaneous circulation in adult cardiac arrest
Suggested methods for multimodal neural prediction of adult patients after cardiac arrest and recovery of autonomic circulation
ACLS flow chart of pregnant women with cardiac arrest in hospital
Main new and updated suggestions in 2020
Non-professional rescuers should start as soon as possible.
CPR2020 (updated)：We recommend that non-professionals perform CPR on patients with possible cardiac arrest, because if the patient is not in a state of cardiac arrest, the risk of injury to the patient is low.
2010 (old): If the adult suddenly falls down or the unresponsive patient’s breathing is abnormal, the non-professional rescuer should not check the pulse, but assume that there is cardiac arrest. The medical staff should check the pulse within no more than 10 seconds. If the pulse is not clearly touched within this time, the rescuer should start chest compressions.
Reason: New evidence shows that patients who receive chest compressions when they are not in cardiac arrest have a lower risk of injury. Non-professional rescuers cannot accurately determine whether the patient has a pulse, and the risk of not performing CPR on patients without a pulse exceeds the harm caused by unnecessary chest compressions.
Physiological monitoring of CPR quality
2020 (updated): It may be reasonable to use physiological parameters such as arterial blood pressure or ETCO2 to monitor and optimize CPR quality when feasible.
2015 (old): Although there is no clinical study to investigate whether adjusting resuscitation operation according to physiological parameters during CPR can improve the prognosis, it may be reasonable to use physiological parameters (quantitative carbon dioxide waveform, arterial diastolic pressure, arterial pressure monitoring and central venous blood oxygen saturation) to monitor and optimize CPR quality, guide vasopressor drug treatment and detect ROSC when feasible.
Reason: Although it is an established concept to monitor the quality of CPR by physiological monitoring methods such as arterial blood pressure and ETCO2, new data support its inclusion in the guidelines. According to the data of AHA’s "Follow the Guide-Resuscitation" registration study, the possibility of ROSC is increased when using ETCO2 or diastolic blood pressure to monitor CPR quality.
The monitoring depends on the existence of endotracheal intubation (ETT) or arterial catheterization. Adjusting the compression target so that the ETCO2 value is at least 10 mm Hg, ideally 20 mm Hg or higher, may be useful as a CPR quality marker. The ideal goal has not yet been determined.
Dual continuous defibrillation is not supported.
2020 (new):The usefulness of dual continuous defibrillation for refractory shockable rhythm has not been determined.
Reason: Double continuous defibrillation refers to the practice of using two defibrillators to perform electric shock almost simultaneously. Although some case reports show a good prognosis, the ILCOR system review in 2020 found no evidence to support dual continuous defibrillation, so routine use is not recommended. There are many forms of bias in existing studies, and observational studies have not shown improvement in prognosis. A recent experimental RCT shows that changing the direction of defibrillation current by repositioning electrode pads may be equivalent to the effect of dual continuous defibrillation, while avoiding the risk of injury caused by energy increase and defibrillator damage. According to the current evidence, it is not clear whether dual continuous defibrillation is beneficial.
Venous access takes precedence over intraosseous access.
2020 (new):It is reasonable for practitioners to try to establish venous access for drug administration in patients with cardiac arrest first.
2020 (updated):If venous access is not successful or feasible, we can consider using intraosseous access instead.
2010 (old):If there is no ready-made venous (IV) access, it is reasonable for practitioners to establish intraosseous (IO) access.
Reason: In 2020, ILCOR systematically reviewed and compared intravenous and intraosseous administration during cardiac arrest, and found that venous pathway was related to better clinical prognosis in five retrospective studies. RCT subgroup analysis focusing on other clinical problems also found similar results when intravenous or intraosseous routes were used for drug delivery. Although venous access is the first choice, intraosseous access is also a reasonable choice for the situation that it is difficult to establish venous access.
Treatment and support during rehabilitation
2020 (new): We suggest that survivors of cardiac arrest undergo multimodal rehabilitation evaluation and treatment in terms of physical, neurological, cardiopulmonary and cognitive impairment before discharge.
2020 (new): We suggest that cardiac arrest survivors and their caregivers receive a comprehensive multidisciplinary discharge plan to incorporate medical and rehabilitation treatment suggestions and expected goals of activity/work recovery.
2020 (new): We suggest a structured assessment of anxiety, depression, post-traumatic stress response and fatigue for survivors of cardiac arrest and their caregivers.
Reason: Patients with cardiac arrest need to go through a long rehabilitation period after initial hospitalization. Support is needed during rehabilitation to ensure the best physical, cognitive and emotional health and restore social/role functions. This process should start from the initial hospitalization period and continue as needed. These topics are discussed in more detail in the 2020 AHA scientific statement.
Analysis and summary of rescuers
2020 (new): After cardiac arrest, it may be beneficial to organize non-professional rescuers, EMS implementers and hospital medical staff to analyze and summarize and provide follow-up for them in the follow-up for emotional support.
Reason: The rescuer may feel anxious or have post-traumatic stress reaction because of providing or not providing BLS. Hospital medical staff may also encounter emotional or psychological influence when treating patients with cardiac arrest. Team analysis and summary can review team performance (education and quality improvement) and identify natural stress factors related to the treatment of dying patients. It is expected that an AHA scientific statement dedicated to this topic will be released in early 2021.
Cardiac arrest in pregnant women
2020 (new): Because pregnant women are more prone to hypoxia, oxygenation and airway management should be given priority during the resuscitation of pregnant women’s cardiac arrest.
2020 (new): Because it may interfere with the recovery of pregnant women, fetal monitoring should not be carried out during the cardiac arrest of pregnant women.
2020 (new): We suggest that pregnant women who are still unconscious after cardiac arrest and resuscitation should be managed by target temperature.
2020 (new): During the management of target body temperature for pregnant patients, it is suggested to continuously monitor the fetus for the possibility of bradycardia, and consult obstetrics and neonatology.
Reason: Reviewed the recommendations on the management of cardiac arrest in pregnant women in the guideline update in 2015 and AHA scientific statement in 2015. Due to the increase of maternal metabolism, the decrease of functional residual capacity caused by pregnant uterus and the risk of fetal brain damage caused by hypoxemia, airway, ventilation and oxygenation are particularly important in the context of pregnancy.
It is not helpful to evaluate the fetal heart during the period of maternal cardiac arrest, and it may also distract attention from the necessary resuscitation operation. In the absence of contrary data, pregnant women who survive after cardiac arrest should be managed by the target temperature like other survivors, and the condition of the fetus who may stay in the uterus should be considered.
Basic and advanced life support for children
The causes of cardiac arrest in infants and children are different from those in adults, and more and more pediatric specific evidence supports these suggestions.
AHA children’s IHCA and OHCA survival chain
Flow chart of cardiac arrest in children
Flow chart of bradycardia in children with pulse
Flow chart of pulse tachycardia in children
Checklist of treatment after spontaneous circulation recovery in children with cardiac arrest
Important Issues, Major Changes and Enhancements in the 2020 Guide
The flow chart and visual AIDS were modified to incorporate the best scientific knowledge and provide clearer information for PBLS and PALS resuscitation implementers.
According to the latest data of children’s resuscitation, it is suggested that the frequency of auxiliary ventilation should be increased to once every 2-3 seconds (20-30 times per minute) for all children’s resuscitation scenarios.
For patients of any age who need to be intubated, it is recommended to use a cuff ETT to reduce air leakage and the need to change tubes.
The routine use of cricoid cartilage compression during intubation is no longer recommended.
In order to maximize the chances of obtaining a good resuscitation prognosis, epinephrine should be given as soon as possible, and ideally it should be given within 5 minutes after cardiac arrest with non-shockable rhythm (cardiac arrest and pulseless electrical activity).
For patients with arterial catheterization, the feedback from continuous measurement of arterial blood pressure can improve the quality of CPR.
After Rosc, the patient’s seizure should be evaluated; Status epilepticus and any convulsive seizures should be treated.
Patients with cardiac arrest need to go through a long rehabilitation period after their initial hospitalization, so their physiological, cognitive and psychosocial needs should be formally evaluated and given corresponding support.
When epinephrine or norepinephrine is infused when vasopressor drugs are needed, it is appropriate to adopt titration liquid management method for resuscitation of septic shock.
According to adult data, it is generally inferred that the balanced blood component resuscitation scheme is reasonable for infants and children with hemorrhagic shock.
Opioid overdose management, including seizures by non-professional rescuers or trained rescuers, should be treated.
Patients with cardiac arrest need to go through a long rehabilitation period after their initial hospitalization, so their physiological, cognitive and psychosocial needs should be formally evaluated and given corresponding support.
When epinephrine or norepinephrine is infused when vasopressor drugs are needed, it is appropriate to adopt titration liquid management method for resuscitation of septic shock.
According to adult data, it is generally inferred that the balanced blood component resuscitation scheme is reasonable for infants and children with hemorrhagic shock.
Opioid overdose management includes CPR by non-professional rescuers or trained rescuers and timely administration of naloxone.
Children with acute myocarditis with arrhythmia, cardiac block, ST segment changes or low cardiac output are at higher risk of cardiac arrest. It is important to be transferred to the intensive care unit as soon as possible. Some patients may need mechanical circulatory support or extracorporeal life support (ECLS).
Babies and children with congenital heart disease and single ventricular physiological function need special consideration in the management of PALS if they are in the process of staged reconstruction.
The management of pulmonary hypertension may include the use of inhaled nitric oxide, prostacyclin, analgesic drugs, sedative drugs, neuromuscular blocking drugs, induced alkalosis or ECLS rescue treatment.
Neonatal life support
Newborn resuscitation needs to be predicted and prepared by the implementers who have received individual and team training.
Most newborns do not need umbilical cord ligation or resuscitation immediately, but can be evaluated and monitored during the skin contact between mother and baby after birth.
Preventing hypothermia is an important concern of neonatal resuscitation. As a way to close the parent-child relationship, promote breastfeeding and maintain normal body temperature, the importance of skin contact nursing for healthy infants is strengthened.
For newborns who need support after birth, lung dilatation and ventilation are the primary tasks.
The increase of heart rate is the most important index of effective ventilation and response to resuscitation intervention.
Pulse oxygen saturation is used to guide oxygen supply and achieve oxygen saturation target.
Routine endotracheal suction is not recommended for active or inactive infants born in meconium-contaminated amniotic fluid (MSAF). Endotracheal aspiration is only applicable when airway obstruction is suspected after providing positive pressure ventilation (PPV).
If proper ventilation correction steps are taken (preferably including tracheal intubation), but the heart rate does not respond well to ventilation, chest compressions can be performed.
Electrocardiogram should be used to monitor the response of heart rate to chest compressions and drugs.
When newborns need vascular access, umbilical vein pathway should be the first choice. When venous access is not feasible, the intraosseous approach can be considered.
If the response to chest compressions is not good, it may be reasonable to provide epinephrine, preferably through the intravascular route.
If there is no response to adrenaline and there is a history or examination consistent with blood loss, the newborn may need to expand.
If all these resuscitation steps have been effectively completed, but there is still no heart rate reaction after 20 minutes, we should discuss with the team and the family members of the child to adjust the treatment direction.
Survival after cardiac arrest depends on the establishment of an organic system covering personnel, training, equipment and organization. Willing bystanders, owners equipped with AED, emergency service telecommunication personnel and BLS and ALS implementers working in EMS system can all contribute to the successful recovery of OHCA.
Within the hospital, the work of doctors, nurses, respiratory therapists, pharmacists and other professionals also provides support for the prognosis of resuscitation. Successful recovery also depends on the efforts of equipment manufacturers, pharmaceutical companies, recovery teachers, guide compilers and many others. Long-term survival depends on the support of family members and professional nurses, including experts in cognitive, physical and psychological rehabilitation and recovery. All links in the whole system are striving to improve the quality of treatment in an all-round way, which is very important for achieving a successful prognosis.