Resuscitation Patient Management Tool Cardiopulmonary Arrest (CPA) EVENT January 2021 NOT FOR USE WITHOUT PERMISSION. ©2021 American Heart Association OPTIONAL: Local Event ID: Did patient receive chest compressions and/or  No/ Not Documented (Does  Yes defibrillation during this event? NOT meet inclusion criteria) Date/Time the need for chest compressions (or ___/___/______:__ defibrillation when initial rhythm was VF or Pulseless  Time Not Documented (MM/DD/YYYY HH:MM) VT) was FIRST recognized: CPA 2.1 PRE-EVENT Pre-Event Tab OPTIONAL Was patient discharged from an Intensive Care Unit (ICU)  Yes  No within 24 hours prior to this CPA event? ____/_____/______:__ If yes, date admitted to non-ICU unit (after ICU discharge): MM/DD/YYYY HH:MM __ Was patient discharged from a Post Anesthesia Care Unit  Yes  No (PACU) within 24 hours prior to this CPA event? Was patient in the ED within 24 hours prior to this CPA  Yes  No event? Did patient receive conscious/procedural sedation or general  Yes  No anesthesia within 24 hours prior to this CPA event? Enter vital signs taken in the 4 hours prior to the CPA event  Pre-Event VS Unknown/Not Documented (up to 4 sets)

Systolic / Date / Time Heart Rate Respiratory Rate SpO2 Temp Units Diastolic BP ____/_____/______ C

____:____ ❑ Not Documented ❑ Not Documented ❑ Not Documented ❑ Not Documented ❑ Not Documented  F ____/_____/______ C

____:____ ❑ Not Documented ❑ Not Documented ❑ Not Documented ❑ Not Documented ❑ Not Documented  F ____/_____/______ C

____:____ ❑ Not Documented ❑ Not Documented ❑ Not Documented ❑ Not Documented ❑ Not Documented  F ____/_____/______ C

____:____ ❑ Not Documented ❑ Not Documented ❑ Not Documented ❑ Not Documented ❑ Not Documented  F

CPA 2.2 PRE-EXISTING CONDITIONS Pre-Event Tab Did patient have an out-of-hospital arrest leading to this  Yes  No/Not Documented admission? Pre-existing Conditions at Time of Event (check all that apply):  None (review options below carefully)  Myocardial ischemia/infarction (prior to admit)  Acute CNS non-stroke event  Pneumonia  Acute Stroke  Recently delivered or currently pregnant (if  Baseline depression in CNS function selected, maternal in-hospital cardiac arrest  Cardiac malformation/abnormality – acyanotic section is required) (pediatric and newborn/neonate only)  Renal Insufficiency  Cardiac malformation/abnormality – cyanotic (pediatric  Respiratory Insufficiency and newborn/neonate only)  Sepsis  Congenital malformation/abnormality (Non-Cardiac)  Active or suspected bacterial or viral infection (pediatric and newborn/neonate only) at admission or during hospitalization:  Congestive heart failure (this admission) ❑ None  Congestive heart failure (prior to this admission) ❑ Bacterial Infection  Diabetes mellitus ❑ Emerging Infectious Disease  Hepatic insufficiency  SARS-COV-1  History of vaping or e-cigarette use in the past 12  SARS-COV-2 (COVID-19) months?  MERS Page 1 of 8

Resuscitation Patient Management Tool Cardiopulmonary Arrest (CPA) EVENT January 2021 NOT FOR USE WITHOUT PERMISSION. ©2021 American Heart Association  Hypotension/Hypoperfusion  Other Emerging Infectious Disease  Major trauma ❑ Influenza  Metastatic or hematologic malignancy ❑ Seasonal cold  Metabolic/electrolyte abnormality ❑ Other Viral Infection  Myocardial ischemia/infarction (this admission) Additional Personal Protective Equipment (PPE) Donned by the responders? ❑ Yes ❑ No/ND CPA 2.2 INTERVENTIONS ALREADY IN PLACE Pre-Event Tab Interventions ALREADY IN PLACE when need for chest compressions and/or defibrillation was first recognized (check all that apply): Part A:  None ❑ Non-invasive assisted ventilation ❑ Invasive assisted ventilation, via an:  Bag-Valve-Mask  Endotracheal Tube (ET)  Mask and/or Nasal CPAP  Tracheostomy Tube  Mouth-to-Barrier Device ❑ Intra-arterial catheter  Mouth-to-Mouth ❑ Conscious/procedural sedation  Laryngeal Mask Airway (LMA) ❑ End Tidal CO2 (ETCO2) Monitoring  Other Non-Invasive Ventilation: (specify) ❑ Supplemental oxygen (cannula, mask, hood, or tent) ______Monitoring  Apnea  Apnea/Bradycardia  ECG  Pulse Oximetry Vascular Access  Yes  No/ Not Documented Any Vasoactive Agent in Place?  Yes  No/Not Documented OPTIONAL Part B:  None  IV/IO continuous infusion of antiarrhythmic(s)  Implantable cardiac defibrillator (ICD)  Dialysis/extracorporeal filtration therapy  Extracorporeal membrane oxygenation (ECMO) (ongoing) CPA 3.1 EVENT Event Tab Date/Time of Birth: _____/_____/______:____ (MM/DD/YYYY HH:MM) Age at Event (in yrs., months,  Years  Days ❑ Estimated weeks, days, hrs., or minutes): ______ Months  Hours ❑ Age Unknown/Not  Weeks  Minutes Documented  Ambulatory/Outpatient  Rehab Facility Inpatient  Emergency Department  Skilled Nursing Facility Inpatient Subject Type  Hospital Inpatient – (rehab, skilled  Mental Health Facility Inpatient nursing, mental health wards)  Visitor or Employee  Medical-Cardiac  Medical-Noncardiac  Surgical-Cardiac  Surgical-Noncardiac Illness Category  Obstetric  Trauma  Other (Visitor/Employee)  Ambulatory/Outpatient Area  Operating Room (OR)  Adult Coronary Care Unit (CCU)  Pediatric ICU (PICU)  Adult ICU  Pediatric Cardiac Intensive Care  Cardiac Catheterization Lab  Post-Anesthesia Recovery Room  Delivery Suite (PACU) Event Location (Area)  Diagnostic/Intervention Area  Rehab, Skilled Nursing, or Mental (excludes Cath Lab) Health Unit/Facility  Emergency Department (ED)  Same-Day Surgical Area  General Inpatient Area  Telemetry Unit or Step-Down Unit  Neonatal ICU (NICU)  Other  Newborn Nursery  Unknown/Not Documented

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Resuscitation Patient Management Tool Cardiopulmonary Arrest (CPA) EVENT January 2021 NOT FOR USE WITHOUT PERMISSION. ©2021 American Heart Association Event Location (Name) ______Event Witnessed?  Yes  No/Not Documented Was a hospital-wide resuscitation  Yes  No/Not Documented response activated? CPA 4.1 INITIAL CONDITION Initial Condition/Defibrillation/Ventilation Tab  Patient was PULSELESS when need for chest compressions and/or need for defibrillation of initial rhythm VF/Pulseless VT was first identified Condition that best describes this  Patient had a pulse (poor perfusion) requiring chest compressions PRIOR event: to becoming pulseless  Patient had a pulse (poor perfusion) requiring chest compressions, but did NOT become pulseless at any time during this event Did patient receive chest  Yes compressions (includes open  No/Not Documented cardiac massage)?  No, Per Advance Directive  Standard Manual Compression  Open chest CPR (direct [internal] cardiac compression) Compression Method(s) used (check  IAC-CPR (interposed abdominal compression cardiopulmonary all that apply): resuscitation)  Automatic Compressor  Unknown/Not documented Date/Time compression started ____/____/______:___  Time Not Documented (MM/DD/YYYY HH:MM)  Accelerated idioventricular rhythm If compressions provided while  Supraventricular Tachyarrhythmia (AIVR) pulse present: (SVTarrhy)  Bradycardia Rhythm when patient with pulse  Ventricular Tachycardia (VT) with a  Pacemaker FIRST received chest compressions pulse  Sinus (including Sinus during event:  Unknown/Not Documented Tachycardia) If pulseless at ANY time during ___/___/______:__ event: Date/Time pulselessness  Time Not Documented (MM/DD/YYYY HH:MM) first identified:  Asystole  Ventricular Fibrillation First documented pulseless rhythm:  Pulseless Electrical Activity (PEA)  Unknown/Not Documented  Pulseless Ventricular Tachycardia CPA 4.2 AED AND VF/PULSELESS VT Initial Condition/Defibrillation/Ventilation Tab Was automated external defibrillator (AED) applied or  No/Not  Not Applicable (not  Yes manual defibrillator in AED/Shock Advisory mode applied? Documented used by facility) Date/Time AED or manual defibrillator in AED/Shock ___/___/______:__  Time Not Advisory mode applied? (MM/DD/YYYY HH:MM) Documented Did the patient have Ventricular Fibrillation (VF) OR Pulseless Ventricular Tachycardia ANY time during this  Yes  No/Not Documented event? Date/Time of Ventricular Fibrillation (VF) OR Pulseless ___/___/______:__  Time Not Ventricular Tachycardia? (MM/DD/YYYY HH:MM) Documented Was Defibrillation shock provided for Ventricular Fibrillation  No/Not  No, Per Advance  Yes (VF) OR Pulseless Ventricular Tachycardia? Documented Directive Total # of Shocks ______ Unknown/Not Documented ___/___/______:__ Date/Time  Not Documented (MM/DD/YYYY HH:MM) Energy (Joules) ______ Not Documented Details of Each Shock (maximum of 4):

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Resuscitation Patient Management Tool Cardiopulmonary Arrest (CPA) EVENT January 2021 NOT FOR USE WITHOUT PERMISSION. ©2021 American Heart Association Date/Time Energy (joules) ____/____/______:____ ❑ Not Documented ______❑ Not Documented ____/____/______:____ ❑ Not Documented ______❑ Not Documented ____/____/______:____ ❑ Not Documented ______❑ Not Documented ____/____/______:____ ❑ Not Documented ______❑ Not Documented

Documented reason (s) (patient, medical, hospital related or other) for not providing defibrillation shock for Ventricular Fibrillation (VF) or Pulseless Ventricular Tachycardia  Yes  No (VT) in first two minutes? Patient Reason(s):  Initial Refusal (e.g. family refused)  ICD in place which shocked patient within first 2 minutes of identification of VF or Pulseless VT  LVAD or BIVAD in place Medical Reason(s)  Rhythm change to non-shockable rhythm within 2 minutes of identification of VF or Pulseless VT  Spontaneous Return of Circulation within first 2 minutes of identification of VF or Pulseless VT  Equipment related delay (e.g., defibrillator not available, pad not attached) Hospital Related or Other  In-hospital time delay (e.g. code team delays, personnel not familiar with Reason(s) protocol or equipment, unable to locate hospital defibrillator)  Other → (Please Specify) ______CPA 4.3 VENTILATION Initial Condition/Defibrillation/Ventilation Tab Types of Ventilation/Airways  None  Unknown/Not Documented used  Laryngeal Mask Airway (LMA)  Bag-Valve-Mask  Endotracheal Tube (ET)  Mask and/or Nasal Ventilation/Airways Used (Select  Supraglottic Airway CPAP/BiPAP all that apply)  Tracheostomy Tube  Mouth-to-Barrier Device  Other Non-Invasive Ventilation,  Mouth-to-Mouth Specify______Was Bag-Valve-Mask ventilation initiated during  Yes  No  Not Documented the event? ____/____/______:___ Date/Time  Time Not Documented (MM/DD/YYYY HH:MM) Was any Endotracheal Tube (ET) or Tracheostomy Tube inserted/re-inserted during  Yes  No event? Date/Time Endotracheal Tube (ET) or ____/____/______:___ Tracheostomy Tube inserted if not already in  Time Not Documented (MM/DD/YYYY HH:MM) place and/or re-inserted during event: Method(s) of confirmation used  Waveform capnography (waveform ETCO2)  Revisualization with direct to ensure Endotracheal Tube  Capnometry (numeric ETCO2) laryngoscopy (ET) or Tracheostomy Tube  Exhaled CO2 colorimetric monitor (ETCO2  None of the above placement in trachea (check all by color change)  Not Documented that apply):  Esophageal detection devices CPA 5.1 EPINEPHRINE Other Interventions Tab Was IV/IO Epinephrine BOLUS  Yes  No  Not Documented administered? _____/_____/______:____ Date/Time  Time Not Documented (MM/DD/YYYY HH:MM) Total Number of Doses ______ Unknown/Not Documented

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Resuscitation Patient Management Tool Cardiopulmonary Arrest (CPA) EVENT January 2021 NOT FOR USE WITHOUT PERMISSION. ©2021 American Heart Association If IV/IO Epinephrine was not administered within the first five minutes of the event, was there a documented patient, medical, hospital related or other reason for not providing  Yes  No Epinephrine bolus? Patient Reason(s) ❑ Initial Refusal (e.g. family refused) ❑ Patient already receiving vasopressor (e.g. Epinephrine) as a continuous IV infusion prior to and during arrest ❑ Spontaneous Return of Circulation within first 5 minutes of the date/time Medical Reason(s) pulselessness was first identified (or the need for chest compressions was first recognized (pediatric only)) ❑ Medication allergy ❑ In-hospital time delay (e.g., delay in locating medication) Hospital Related or Other ❑ No route to deliver medication (e.g. no IV/IO access) Reason(s) ❑ Other → (Please Specify) ______CPA 5.2 OTHER DRUG INTERVENTIONS Other Interventions Tab Select all either initiated, or if already in place immediately prior to, continued during event. ❑ None (select only after ❑ Atropine careful review of options ❑ Vasopressor(s) other than ❑ Calcium Chloride/Calcium Gluconate below) epinephrine bolus: ❑ Dextrose Bolus ❑ Antiarrhythmic  Dobutamine ❑ Magnesium Sulfate medication(s):  Dopamine > 3mcg/kg/min ❑ Reversal agent (e.g.,  Adenosine/Adenocard  Epinephrine, IV/IO continuous naloxone/Narcan,  Amiodarone/Cordarone infusion flumazenil/Romazicon,  Lidocaine  Norepinephrine neostigmine/Prostigim)  Procainamide  Phenylephrine ❑ Sodium Bicarbonate  Other antiarrhythmics:  Other Vasopressors: ______❑ Other Drug Interventions: ______CPA 5.3 NON-DRUG INTERVENTIONS Other Interventions Tab Select each intervention that was employed during the resuscitation event. ❑ None (review options below carefully) ❑ Pacemaker, transcutaneous ❑ Cardiopulmonary bypass / extracorporeal CPR ❑ Pacemaker, transvenous or epicardial (ECPR) ❑ Pericardiocentesis ❑ Chest tube(s) inserted ❑ Other non-drug interventions ______❑ Needle thoracostomy CPA 6.1 EVENT OUTCOME Event Outcome Tab Was ANY documented return of adequate circulation [ROC] (in the absence of  Yes ongoing chest compressions return of adequate pulse/heart rate by palpation,

auscultation, Doppler, arterial blood pressure waveform, or documented blood  No/Not Documented pressure) achieved during the event? Date/Time of FIRST adequate return ___/___/______:___  Time Not Documented of circulation (ROC): (MM/DD/YYYY HH:MM) Reason resuscitation ended  Survived – ROC  Died – Efforts terminated, no sustained ROC Date and time sustained ROC began ___/___/______:___ lasting > 20 min OR resuscitation  Time Not Documented (MM/DD/YYYY HH:MM) efforts were terminated (End of event) CPA 6.2 POST-ROC CARE Event Outcome Tab Highest patient temperatures  Temperature Not during first 24 hrs. after ROC:  ______C  ______F Documented Temperature  Surface (skin,  Axillary  Blood  Oral  Unknown Site temporal)  Bladder  Brain  Rectal  Tympanic  Other

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Resuscitation Patient Management Tool Cardiopulmonary Arrest (CPA) EVENT January 2021 NOT FOR USE WITHOUT PERMISSION. ©2021 American Heart Association ____/____/______:___ Date/Time Recorded:  Time Not Documented (MM/DD/YYYY HH:MM) CPA 7.1 CPR QUALITY CPR Quality Tab  None  Waveform Capnography/End Tidal CO2  CPR Quality Coach Was performance of CPR (ETCO2)  Metronome monitored or guided using any of  Arterial Wave Form/Diastolic Pressure  Other, Specify: the following? (Check all that apply)  CPR mechanics device (e.g. accelerometer, ______force transducer, TFI device) If CPR mechanics device (e.g. accelerometer, force transducer, TFI device) used: Average Compression Rate ______(Per Minute)  Not Documented  ______ ______ ______Average Compression Depth  Not Documented mm cm inches Compression Fraction ______(Enter number between 0 and 1)  Not Documented Percent of chest compressions with complete release ______(%)  Not Documented Average Ventilation Rate ______(Per Minute)  Not Documented Longest Pre-shock pause ______(Seconds)  Not Documented Was a team debriefing on the quality of CPR provided  Yes  No  Not Documented completed after the event? CPA 7.2 RESUSCITATION-RELATED EVENTS AND ISSUES CPR Quality Tab OPTIONAL: □ No/Not Documented Universal Precautions  Not followed by all team members (specify in comments section)  Signature of code team leader not  Medication route(s) not documented on code sheet Documentation  Incomplete documentation  Missing other signatures  Other (specify in comments section)  Initial ECG rhythm not documented Alerting Hospital-Wide  Delay  Other (specify in comments section) Resuscitation Response  Pager Issues  Aspiration related to provision of airway  Multiple intubation attempts →  Delay Number of Attempts ______Airway  Delayed recognition of airway  Unknown/ Not Documented misplacement/displacement  Other (specify in comments section)  Intubation attempted, not achieved  Delay  Infiltration/Disconnection Vascular Access  Inadvertent arterial cannulation  Other (specify in comments section) Chest Compression  Delay  No back board  Other (specify in comments section)  Energy level lower/higher than  Initial delay, issue with paddle recommended placement  Initial delay, personnel not available  Equipment Malfunction Defibrillations to operate defibrillator  Given, not indicated  Initial delay, issues with defibrillator  Indicated, not given access to patient  Other (specify in comments section)  Delay  Selection Medications  Route  Other (specify in comments section)  Dose  Delay in identifying leader  Team oversight  Knowledge of equipment Leadership  Too many team members  Knowledge of medications/protocols  Other (specify in comments section)  Knowledge of roles

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Resuscitation Patient Management Tool Cardiopulmonary Arrest (CPA) EVENT January 2021 NOT FOR USE WITHOUT PERMISSION. ©2021 American Heart Association Protocol Derivation  ACLS/PALS  NRP  Other (specify in comments section) Equipment  Availability  Function  Other (specify in comments section) Comments Was this cardiac arrest event the  Yes  No patient's index (first) event? Comments & Optional Fields: Do not enter any Personal Health Information/Protected Health Information into this section.

Field 1 Field 2 Field 3 Field 4

Field 5 Field 6 Field 7 Field 8 Field 9 Field 10 Field 11 Field 12 Field 13 ____/____/______:____ Field 14 ____/____/______:____

MATERNAL IN-HOSPITAL CARDIAC ARREST Research Tab If Recently delivered or currently pregnant was selected ____/____/______:____ under Pre-existing conditions, please select one of the  Not Documented (MM/DD/YYYY HH:MM) following:  Patient recently delivered If patient recently delivered a fetus, select delivery date:  Not Documented fetus ____/____/______:____ (MM/DD/YYYY HH:MM) If patient is currently pregnant, enter  Not  Patient is currently pregnant EDC/Due Date: ____/____/______Documente Gestational Age ___ (MM/DD/YYYY) d Select Number of Fetuses (Single  Single  Unknown Select)  Multiple  Not Documented  Not Documented  Maternal Group B Strep (Positive)  None  Maternal Infection  Alcohol Use  Methamphetamine/ICE use  Chorioamnionitis  Narcotic given to mother within 4  Cocaine/Crack use hours of delivery The patient had the following  Gestational Diabetes  Narcotics addiction and/or on delivery or pregnancy  Diabetes methadone maintenance complications  Eclampsia  Obstetrical hemorrhage  GHTN (Pregnancy  Pre-eclampsia induced/gestational hypertension)  Prior Cesarean  Hypertensive Disease  Urinary Tract Infection (UTI)  Magnesium Exposure  Other (specify) ______ Major Trauma Total # of pregnancies (gravida) ______(Integer Field)  Unknown/Not Documented Total # of deliveries (parity) ______(Integer Field)  Unknown/Not Documented  Vaginal/Spontaneou  VBAC  C-Section/Emergent Delivery Mode (Single Select): s  C-  Unknown/Not Documented  Vaginal/Operative Section/Scheduled  Yes  Manual Uterine  Unknown/Not Select Method(s) Displacement Left Lateral Uterine Displacement: Documented (select all that apply)  Left Lateral Tilt Time recognized  Unknown/Not Documented ___:___

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Resuscitation Patient Management Tool Cardiopulmonary Arrest (CPA) EVENT January 2021 NOT FOR USE WITHOUT PERMISSION. ©2021 American Heart Association  Delivered (If delivered, enter Apgar Scores):  Undelivered  Enter 1 min. Apgar score (integer field range: 0-10)  IUFD (intrauterine Neonatal Outcome (Single ______fetal death) Select)  Enter 5 min Apgar score (integer field range: 0-10)  Viable ______ Unknown/Not  Unknown/Not Documented Documented Was a CPA event completed for  Unknown/ Not  Yes  No the newborn? Documented END OF FORM

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