Highlights of the 2020 American Heart Association's Guidelines for CPR

Home , Basic life support, Chain of survival, Defibrillation, Life support

Topics

Adult Pediatric Resuscitation Basic and Basic and Neonatal Life Systems of Education Advanced Advanced Support Care Life Support Life Support Science

Introduction

These Highlights summarize the key issues and changes in the 2020 American Heart Association (AHA) Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC). The 2020 Guidelines are a comprehensive revision of the AHA’s guidelines for adult, pediatric, neonatal, resuscitation education science, and systems of care topics. They have been developed for resuscitation providers and AHA instructors to focus on the resuscitation science and guidelines recommendations that are most significant or controversial, or those that will result in changes in resuscitation training and practice, and to provide the rationale for the recommendations. Because this publication is a summary, it does not reference the supporting published studies and does not list Classes of Recommendation (COR) or Levels of Evidence (LOE). For more detailed information and references, please read the 2020 AHA Guidelines for CPR and ECC, including the Executive Summary,1 published in Circulation in October 2020, and the detailed summary of resuscitation science in the 2020 International Consensus on CPR and ECC Science With Treatment Recommendations, developed by the International Liaison Committee on Resuscitation (ILCOR) and published simultaneously in Circulation2 and Resuscitation3 in October 2020. The methods used by ILCOR to perform evidence evaluations4 and by the AHA to translate these evidence evaluations into resuscitation guidelines5 have been published in detail. The 2020 Guidelines use the most recent version of the AHA definitions for the COR and LOE (Figure 1). Overall, 491 specific recommendations are made for adult, pediatric, and neonatal life support; resuscitation education science; and systems of care. Of these recommendations, 161 are class 1 and 293 are class 2 recommendations (Figure 2). Additionally, 37 recommendations are class 3, including 19 for evidence of no benefit and 18 for evidence of harm.

The American Heart Association thanks the following people for their contributions to the development of this publication: Eric J. Lavonas, MD, MS; David J. Magid, MD, MPH; Khalid Aziz, MBBS, BA, MA, MEd(IT); Katherine M. Berg, MD; Adam Cheng, MD; Amber V. Hoover, RN, MSN; Melissa Mahgoub, PhD; Ashish R. Panchal, MD, PhD; Amber J. Rodriguez, PhD; Alexis A. Topjian, MD, MSCE; Comilla Sasson, MD, PhD; and the AHA Guidelines Highlights Project Team.

eccguidelines.heart.org 1 Figure 1. Applying Class of Recommendation and Level of Evidence to Clinical Strategies, Interventions, Treatments, or Diagnostic Testing in Patient Care (Updated May 2019)*

2 American Heart Association Figure 2. Distribution of COR and LOE as percent of 491 total recommendations in the 2020 AHA Guidelines for CPR and ECC.*

*Results are percent of 491 recommendations in Adult Basic and Advanced Life Support, Pediatric Basic and Advanced Life Support, Neonatal Life Support, Resuscitation Education Science, and Systems of Care. Abbreviations: COR, Classes of Recommendation; EO, expert opinion; LD, limited data; LOE, Level of Evidence; NR, nonrandomized; R, Randomized.

About the Recommendations

The fact that only 6 of these 491 recommendations (1.2%) are based on Level A evidence (at least 1 high-quality randomized clinical trial [RCT], corroborated by a second high-quality trial or registry study) testifies to the ongoing challenges in perform- ing high-quality resuscitation research. A concerted national and international effort is needed to fund and otherwise support resuscitation research. Both the ILCOR evidence-evaluation process and the AHA guidelines-development process are governed by strict AHA disclosure policies designed to make relationships with industry and other conflicts of interest fully transparent and to protect these processes from undue influence. The AHA staff processed conflict-of-interest disclosures from all participants. All guidelines writing group chairs and at least 50% of guidelines writing group members are required to be free of all conflicts of interest, and all relevant relationships are disclosed in the respective Consensus on Science With Treatment Recommendations and Guidelines publications.

eccguidelines.heart.org 3 Adult Basic and Advanced Life Support

Summary of Key Issues and Major Changes pressure control, evaluation for percutaneous coronary In 2015, approximately 350 000 adults in the United States intervention, targeted temperature management, and experienced nontraumatic out-of-hospital cardiac arrest multimodal neuroprognostication. (OHCA) attended by emergency medical services (EMS) • Because recovery from cardiac arrest continues long personnel. Despite recent gains, less than 40% of adults after the initial hospitalization, patients should have formal receive layperson-initiated CPR, and fewer than 12% have assessment and support for their physical, cognitive, and an automated external defibrillator (AED) applied before EMS psychosocial needs. arrival. After significant improvements, survival from OHCA • After a resuscitation, debriefing for lay rescuers, EMS has plateaued since 2012. providers, and hospital-based healthcare workers may be In addition, approximately 1.2% of adults admitted to US beneficial to support their mental health and well-being. hospitals suffer in-hospital cardiac arrest (IHCA). Outcomes from IHCA are significantly better than outcomes from OHCA, • Management of cardiac arrest in pregnancy focuses on and IHCA outcomes continue to improve. maternal resuscitation, with preparation for early perimortem cesarean delivery if necessary to save the infant and Recommendations for adult basic life support (BLS) and improve the chances of successful resuscitation of advanced cardiovascular life support (ACLS) are combined the mother. in the 2020 Guidelines. Major new changes include the following: Algorithms and Visual Aids • Enhanced algorithms and visual aids provide easy-to- The writing group reviewed all algorithms and made focused remember guidance for BLS and ACLS resuscitation improvements to visual training aids to ensure their utility as scenarios. point-of-care tools and reflect the latest science. The major • The importance of early initiation of CPR by lay rescuers changes to algorithms and other performance aids include has been re-emphasized. the following: • Previous recommendations about epinephrine • A sixth link, Recovery, was added to the IHCA and OHCA administration have been reaffirmed, with emphasis on Chains of Survival (Figure 3). early epinephrine administration. • The universal Adult Cardiac Arrest Algorithm was modified • Use of real-time audiovisual feedback is suggested as a to emphasize the role of early epinephrine administration for means to maintain CPR quality. patients with nonshockable rhythms (Figure 4). • Continuously measuring arterial blood pressure and end- • Two new Opioid-Associated Emergency Algorithms have been added for lay rescuers and trained rescuers tidal carbon dioxide (ETCO2) during ACLS resuscitation may be useful to improve CPR quality. (Figures 5 and 6). • On the basis of the most recent evidence, routine use of • The Post–Cardiac Arrest Care Algorithm was updated to double sequential defibrillation is not recommended. emphasize the need to prevent hyperoxia, hypoxemia, and hypotension (Figure 7). • Intravenous (IV) access is the preferred route of medication administration during ACLS resuscitation. Intraosseous (IO) • A new diagram has been added to guide and inform access is acceptable if IV access is not available. neuroprognostication (Figure 8). • Care of the patient after return of spontaneous circulation • A new Cardiac Arrest in Pregnancy Algorithm has been (ROSC) requires close attention to oxygenation, blood added to address these special cases (Figure 9).

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Despite recent gains, less than 40% of adults receive layperson-initiated CPR, and fewer than 12% have an AED applied before EMS arrival.

Figure 3. AHA Chains of Survival for adult IHCA and OHCA.

eccguidelines.heart.org 5 Figure 4. Adult Cardiac Arrest Algorithm.

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Figure 5. Opioid-Associated Emergency for Lay Responders Algorithm.

eccguidelines.heart.org 7 Figure 6. Opioid-Associated Emergency for Healthcare Providers Algorithm.

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Figure 7. Adult Post–Cardiac Arrest Care Algorithm.

eccguidelines.heart.org 9 Figure 8. Recommended approach to multimodal neuroprognostication in adult patients after cardiac arrest.

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Figure 9. Cardiac Arrest in Pregnancy In-Hospital ACLS Algorithm.

eccguidelines.heart.org 11 Major New and Updated and unfavorable neurologic outcome in when feasible to monitor and optimize Recommendations the epinephrine group. CPR quality, guide vasopressor therapy, Of 16 observational studies on and detect ROSC. Early Initiation of CPR by Lay Rescuers Why: timing in the recent systematic review, Although the use of physiologic all found an association between 2020 (Updated): monitoring such as arterial blood We recommend that earlier epinephrine and ROSC for pressure and ETCO2 to monitor CPR laypersons initiate CPR for presumed patients with nonshockable rhythms, quality is an established concept, cardiac arrest because the risk of harm although improvements in survival new data support its inclusion in the to the patient is low if the patient is not were not universally seen. For patients guidelines. Data from the AHA’s Get in cardiac arrest. with shockable rhythm, the literature With The Guidelines®-Resuscitation 2010 (Old): The lay rescuer should not supports prioritizing defibrillation and registry show higher likelihood of check for a pulse and should assume CPR initially and giving epinephrine ROSC when CPR quality is monitored that cardiac arrest is present if an adult if initial attempts with CPR and using either ETCO2 or diastolic blood suddenly collapses or an unrespon- defibrillation are not successful. pressure. sive victim is not breathing normally. Any drug that increases the rate This monitoring depends on the The healthcare provider should take of ROSC and survival but is given presence of an endotracheal tube (ETT) no more than 10 seconds to check for after several minutes of downtime or arterial line, respectively. Targeting a pulse and, if the rescuer does not will likely increase both favorable and compressions to an ETCO2 value of at definitely feel a pulse within that time unfavorable neurologic outcome. least 10 mm Hg, and ideally 20 mm Hg period, the rescuer should start chest Therefore, the most beneficial or greater, may be useful as a marker compressions. approach seems to be continuing of CPR quality. An ideal target has not Why: been identified. New evidence shows that the risk to use a drug that has been shown of harm to a victim who receives chest to increase survival while focusing Double Sequential Defibrillation broader efforts on shortening time compressions when not in cardiac Not Supported arrest is low. Lay rescuers are not able to drug for all patients; by doing so, more survivors will have a favorable to determine with accuracy whether 2020 (New): a victim has a pulse, and the risk of neurologic outcome. The usefulness of double sequential defibrillation for refractory withholding CPR from a pulseless victim Real-Time Audiovisual Feedback exceeds the harm from unneeded chest shockable rhythm has not been established. compressions. 2020 (Unchanged/Reaffirmed): It may be Why: Double sequential defibrillation Early Administration of Epinephrine reasonable to use audiovisual feedback is the practice of applying near- devices during CPR for real-time simultaneous shocks using 2 2020 (Unchanged/Reaffirmed): optimization of CPR performance. With defibrillators. Although some case Why: respect to timing, for cardiac arrest A recent RCT reported a 25% reports have shown good outcomes, with a nonshockable rhythm, it is increase in survival to hospital dis- a 2020 ILCOR systematic review found reasonable to administer epinephrine charge from IHCA with audio feedback no evidence to support double sequen- as soon as feasible. on compression depth and recoil. tial defibrillation and recommended 2020 (Unchanged/Reaffirmed): against its routine use. Existing studies With Physiologic Monitoring of CPR Quality respect to timing, for cardiac arrest with are subject to multiple forms of bias, and observational studies do not show a shockable rhythm, it may be reason- 2020 (Updated): able to administer epinephrine after It may be reasonable to improvements in outcome. initial defibrillation attempts have failed. use physiologic parameters such as A recent pilot RCT suggests that Why: arterial blood pressure or ETCO2 when changing the direction of defibrillation The suggestion to administer feasible to monitor and optimize epinephrine early was strengthened current by repositioning the pads may CPR quality. be as effective as double sequential to a recommendation on the basis of a 2015 (Old): systematic review and meta-analysis, Although no clinical study has defibrillation while avoiding the risks which included results of 2 randomized examined whether titrating resuscita- of harm from increased energy and trials of epinephrine enrolling more than tive efforts to physiologic parameters damage to defibrillators. On the basis 8500 patients with OHCA, showing during CPR improves outcome, it may of current evidence, it is not known that epinephrine increased ROSC and be reasonable to use physiologic whether double sequential defibrillation survival. At 3 months, the time point felt parameters (quantitative waveform cap- is beneficial. to be most meaningful for neurologic nography, arterial relaxation diastolic recovery, there was a nonsignificant in- pressure, arterial pressure monitoring, crease in survivors with both favorable and central venous oxygen saturation)

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IV Access Preferred Over IO The 2020 Guidelines evaluate 19 improvement) as well as recognition of different modalities and specific the natural stressors associated with 2020 (New): It is reasonable for providers findings and present the evidence caring for a patient near death. An AHA to first attempt establishing IV access for each. A new diagram presents scientific statement devoted to this for drug administration in cardiac arrest. this multimodal approach to topic is expected in early 2021. 2020 (Updated): IO access may be neuroprognostication. Cardiac Arrest in Pregnancy considered if attempts at IV access are Care and Support During Recovery unsuccessful or not feasible. 2020 (New): Because pregnant patients 2010 (Old): 2020 (New): It is reasonable for providers We recommend that cardiac are more prone to hypoxia, oxygenation to establish intraosseous (IO) access arrest survivors have multimodal reha- and airway management should be if intravenous (IV) access is not readily bilitation assessment and treatment for prioritized during resuscitation from available. physical, neurologic, cardiopulmonary, cardiac arrest in pregnancy. Why: 2020 (New): A 2020 ILCOR systematic review and cognitive impairments before Because of potential comparing IV versus IO (principally discharge from the hospital. interference with maternal resusci- 2020 (New): pretibial placement) drug administra- We recommend that cardiac tation, fetal monitoring should not be tion during cardiac arrest found that arrest survivors and their caregivers undertaken during cardiac arrest in the IV route was associated with better receive comprehensive, multidisci- pregnancy. clinical outcomes in 5 retrospective 2020 (New): plinary discharge planning, to include We recommend targeted studies; subgroup analyses of RCTs medical and rehabilitative treatment temperature management for pregnant that focused on other clinical questions recommendations and return to women who remain comatose after found comparable outcomes when IV activity/work expectations. resuscitation from cardiac arrest. or IO were used for drug administration. 2020 (New): 2020 (New): Although IV access is preferred, for We recommend structured During targeted tempera- situations in which IV access is difficult, assessment for anxiety, depression, ture management of the pregnant IO access is a reasonable option. posttraumatic stress, and fatigue for patient, it is recommended that the cardiac arrest survivors and their fetus be continuously monitored for Post–Cardiac Arrest Care and caregivers. bradycardia as a potential complication, Why: Neuroprognostication The process of recovering from and obstetric and neonatal consultation cardiac arrest extends long after the should be sought. Why: The 2020 Guidelines contain signifi- initial hospitalization. Support is needed Recommendations for manag- cant new clinical data about optimal during recovery to ensure optimal ing cardiac arrest in pregnancy were care in the days after cardiac arrest. physical, cognitive, and emotional reviewed in the 2015 Guidelines Update Recommendations from the 2015 well-being and return to social/role and a 2015 AHA scientific statement.7 AHA Guidelines Update for CPR and functioning. This process should be Airway, ventilation, and oxygenation ECC about treatment of hypotension, initiated during the initial hospitalization are particularly important in the setting titrating oxygen to avoid both hypoxia and continue as long as needed. These of pregnancy because of an increase themes are explored in greater detail in and hyperoxia, detection and treatment 6 in maternal metabolism, a decrease in of seizures, and targeted temperature a 2020 AHA scientific statement. functional reserve capacity due to the management were reaffirmed with new Debriefings for Rescuers gravid uterus, and the risk of fetal brain supporting evidence. injury from hypoxemia. 2020 (New): Evaluation of the fetal heart is not In some cases, the LOE was Debriefings and referral for helpful during maternal cardiac arrest, upgraded to reflect the availability of follow up for emotional support for new data from RCTs and high-quality lay rescuers, EMS providers, and and it may distract from necessary observational studies, and the post– hospital-based healthcare workers resuscitation elements. In the absence cardiac arrest care algorithm has after a cardiac arrest event may be of data to the contrary, pregnant been updated to emphasize these beneficial. women who survive cardiac arrest important components of care. To be Why: should receive targeted temperature reliable, neuroprognostication should Rescuers may experience anxiety management just as any other survivors be performed no sooner than 72 or posttraumatic stress about providing would, with consideration for the status or not providing BLS. Hospital-based hours after return to normothermia, of the fetus that may remain in utero. care providers may also experience and prognostic decisions should be emotional or psychological effects of based on multiple modes of patient caring for a patient with cardiac arrest. assessment. Team debriefings may allow a review of team performance (education, quality

eccguidelines.heart.org 13 Pediatric Basic and Advanced Life Support

Summary of Key Issues and Major Changes or norepinephrine infusions if vasopressors are needed, More than 20 000 infants and children have a cardiac arrest is appropriate in resuscitation from septic shock. each year in the United States. Despite increases in survival • On the basis largely of extrapolation from adult data, and comparatively good rates of good neurologic outcome balanced blood component resuscitation is reasonable after pediatric IHCA, survival rates from pediatric OHCA for infants and children with hemorrhagic shock. remain poor, particularly in infants. Recommendations • Opioid overdose management includes CPR and the timely for pediatric basic life support (PBLS) and CPR in infants, administration of naloxone by either lay rescuers or trained children, and adolescents have been combined with rec- rescuers. ommendations for pediatric advanced life support (PALS) in a single document in the 2020 Guidelines. The causes • Children with acute myocarditis who have arrhythmias, heart of cardiac arrest in infants and children differ from cardiac block, ST-segment changes, or low cardiac output are at arrest in adults, and a growing body of pediatric-specif- high risk of cardiac arrest. Early transfer to an intensive care ic evidence supports these recommendations. Key issues, unit is important, and some patients may require mechanical major changes, and enhancements in the 2020 Guidelines circulatory support or extracorporeal life support (ECLS). include the following: • Infants and children with congenital heart disease and • Algorithms and visual aids were revised to incorporate single ventricle physiology who are in the process of staged the best science and improve clarity for PBLS and PALS reconstruction require special considerations in PALS resuscitation providers. management. • Based on newly available data from pediatric resuscitations, • Management of pulmonary hypertension may include the the recommended assisted ventilation rate has been use of inhaled nitric oxide, prostacyclin, analgesia, sedation, increased to 1 breath every 2 to 3 seconds (20-30 breaths neuromuscular blockade, the induction of alkalosis, or per minute) for all pediatric resuscitation scenarios. rescue therapy with ECLS. • Cuffed ETTs are suggested to reduce air leak and the need Algorithms and Visual Aids for tube exchanges for patients of any age who require The writing group updated all algorithms to reflect the latest intubation. science and made several major changes to improve the • The routine use of cricoid pressure during intubation is no visual training and performance aids: longer recommended. • A new pediatric Chain of Survival was created for IHCA in • To maximize the chance of good resuscitation outcomes, infants, children, and adolescents (Figure 10). epinephrine should be administered as early as possible, • A sixth link, Recovery, was added to the pediatric OHCA ideally within 5 minutes of the start of cardiac arrest from Chain of Survival and is included in the new pediatric IHCA a nonshockable rhythm (asystole and pulseless Chain of Survival (Figure 10). electrical activity). • The Pediatric Cardiac Arrest Algorithm and the Pediatric • For patients with arterial lines in place, using feedback from Bradycardia With a Pulse Algorithm have been updated to continuous measurement of arterial blood pressure may reflect the latest science (Figures 11 and 12). improve CPR quality. • The single Pediatric Tachycardia With a Pulse Algorithm • After ROSC, patients should be evaluated for seizures; status now covers both narrow- and wide-complex tachycardias in epilepticus and any convulsive seizures should be treated. pediatric patients (Figure 13). • Because recovery from cardiac arrest continues long • Two new Opioid-Associated Emergency Algorithms have after the initial hospitalization, patients should have formal been added for lay rescuers and trained rescuers (Figures 5 assessment and support for their physical, cognitive, and and 6). psychosocial needs. • A new checklist is provided for pediatric post–cardiac arrest • A titrated approach to fluid management, with epinephrine care (Figure 14).

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The causes of cardiac arrest in infants and children differ from cardiac arrest in adults, and a growing body of pediatric-specific evidence supports these recommendations.

Figure 10. AHA Chains of Survival for pediatric IHCA and OHCA.

eccguidelines.heart.org 15 Figure 11. Pediatric Cardiac Arrest Algorithm.

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Figure 12. Pediatric Bradycardia With a Pulse Algorithm.

eccguidelines.heart.org 17 Figure 13. Pediatric Tachycardia With a Pulse Algorithm.

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Figure 14. Pediatric Post–Cardiac Arrest Care Checklist.

eccguidelines.heart.org 19 Major New and Updated Cuffed ETTs Emphasis on Early Recommendations Epinephrine Administration 2020 (Updated): It is reasonable to 2020 (Updated): Changes to the Assisted Ventilation choose cuffed ETTs over uncuffed For pediatric patients in Rate: Rescue Breathing ETTs for intubating infants and children. any setting, it is reasonable to admin- When a cuffed ETT is used, attention ister the initial dose of epinephrine 2020 (Updated): should be paid to ETT size, position, within 5 minutes from the start of chest (PBLS) For infants and and cuff inflation pressure (usually children with a pulse but absent or compressions. <20-25 cm H2O). 2015 (Old): inadequate respiratory effort, it is rea- 2010 (Old): It is reasonable to administer sonable to give 1 breath every Both cuffed and uncuffed epinephrine in pediatric cardiac arrest. 2 to 3 seconds (20-30 breaths/min). ETTs are acceptable for intubating Why: 2010 (Old): infants and children. In certain circum- A study of children with IHCA (PBLS) If there is a palpa- stances (eg, poor lung compliance, high who received epinephrine for an initial ble pulse 60/min or greater but there airway resistance, or a large glottic air nonshockable rhythm (asystole and is inadequate breathing, give rescue leak) a cuffed ETT may be preferable to pulseless electrical activity) demon- breaths at a rate of about 12 to 20/min an uncuffed tube, provided that atten- strated that, for every minute of delay (1 breath every 3-5 seconds) until tion is paid to [ensuring appropriate] in administration of epinephrine, there spontaneous breathing resumes. ETT size, position, and cuff inflation was a significant decrease in ROSC, Changes to the Assisted Ventilation pressure. survival at 24 hours, survival to dis- Why: charge, and survival with favorable Rate: Ventilation Rate During CPR Several studies and systematic neurological outcome. reviews support the safety of cuffed With an Advanced Airway Patients who received epinephrine ETTs and demonstrate decreased need within 5 minutes of CPR initiation for tube changes and reintubation. 2020 (Updated): compared with those who received (PALS) When perform- Cuffed tubes may decrease the risk of ing CPR in infants and children with an aspiration. Subglottic stenosis is rare epinephrine more than 5 minutes advanced airway, it may be reasonable when cuffed ETTs are used in children after CPR initiation were more likely to target a respiratory rate range of and careful technique is followed. to survive to discharge. Studies of 1 breath every 2 to 3 seconds pediatric OHCA demonstrated that (20-30/min), accounting for age and Cricoid Pressure During Intubation earlier epinephrine administration clinical condition. Rates exceeding increases rates of ROSC, survival to 2020 (Updated): these recommendations may Routine use of cricoid intensive care unit admission, survival compromise hemodynamics. pressure is not recommended during to discharge, and 30-day survival. 2010 (Old): (PALS) If the infant or child is endotracheal intubation of pediatric In the 2018 version of the Pediatric intubated, ventilate at a rate of about patients. Cardiac Arrest Algorithm, patients 2010 (Old): 1 breath every 6 seconds (10/min) There is insufficient evidence with nonshockable rhythms received without interrupting chest to recommend routine application of epinephrine every 3 to 5 minutes, but compressions. cricoid pressure to prevent aspiration early administration of epinephrine Why: was not emphasized. Although New data show that higher during endotracheal intubation in the sequence of resuscitation has ventilation rates (at least 30/min in children. not changed, the algorithm and infants [younger than 1 year] and at Why: New studies have shown that recommendation language have been least 25/min in children) are associated routine use of cricoid pressure reduces with improved rates of ROSC and updated to emphasize the importance intubation success rates and does not of giving epinephrine as early as survival in pediatric IHCA. Although reduce the rate of regurgitation. The possible, particularly when the rhythm there are no data about the ideal writing group has reaffirmed previous is nonshockable. ventilation rate during CPR without recommendations to discontinue an advanced airway, or for children in cricoid pressure if it interferes with Invasive Blood Pressure Monitoring to respiratory arrest with or without an ad- ventilation or the speed or ease of Assess CPR Quality vanced airway, for simplicity of training, intubation. the respiratory arrest recommendation 2020 (Updated): was standardized for both situations. For patients with continuous invasive arterial blood pressure monitoring in place at the time of cardiac arrest, it is reasonable for providers to use diastolic blood pressure to assess CPR quality.

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2015 (Old): For patients with invasive treatment of status epilepticus is Corticosteroid Administration hemodynamic monitoring in place at beneficial in pediatric patients in 2020 (New): the time of cardiac arrest, it may be general. For infants and children with reasonable for rescuers to use blood septic shock unresponsive to fluids and pressure to guide CPR quality. Evaluation and Support for requiring vasoactive support, it may be Why: Cardiac Arrest Survivors reasonable to consider stress-dose Providing high-quality chest corticosteroids. compressions is critical to successful 2020 (New): Why: resuscitation. A new study shows that, It is recommended that Although fluids remain the main- among pediatric patients receiving pediatric cardiac arrest survivors be stay of initial therapy for infants and CPR with an arterial line in place, evaluated for rehabilitation services. children in shock, especially in hypovo- 2020 (New): rates of survival with favorable neu- It is reasonable to refer lemic and septic shock, fluid overload rologic outcome were improved if the pediatric cardiac arrest survivors for can lead to increased morbidity. In diastolic blood pressure was at least ongoing neurologic evaluation for at recent trials of patients with septic 25 mm Hg in infants and at least shock, those who received higher fluid 8 least the first year after cardiac arrest. 30 mm Hg in children. Why: volumes or faster fluid resuscitation There is growing recognition that were more likely to develop clinically Detecting and Treating recovery from cardiac arrest continues significant fluid overload and require Seizures After ROSC long after the initial hospitalization. mechanical ventilation. The writing Survivors may require ongoing integrat- group reaffirmed previous recommen- 2020 (Updated): ed medical, rehabilitative, caregiver, and When resources are dations to reassess patients after each community support in the months to available, continuous electroencepha- fluid bolus and to use either crystalloid years after their cardiac arrest. A recent lography monitoring is recommended or colloid fluids for septic shock resus- AHA scientific statement highlights the for the detection of seizures following citation. importance of supporting patients and cardiac arrest in patients with Previous versions of the Guidelines families during this time to achieve the persistent encephalopathy. 6 did not provide recommendations best possible long-term outcome. 2020 (Updated): about choice of vasopressor or the It is recommended to Septic Shock use of corticosteroids in septic shock. treat clinical seizures following Two RCTs suggest that epinephrine cardiac arrest. Fluid Boluses 2020 (Updated): is superior to dopamine as the initial It is reasonable to treat vasopressor in pediatric septic shock, 2020 (Updated): nonconvulsive status epilepticus In patients with septic and norepinephrine is also appropriate. following cardiac arrest in consultation shock, it is reasonable to administer Recent clinical trials suggest a benefit with experts. fluid in 10 mL/kg or 20 mL/kg aliquots from corticosteroid administration in 2015 (Old): An electroencephalography with frequent reassessment. some pediatric patients with refractory 2015 (Old): septic shock. for the diagnosis of seizure should be Administration of an initial promptly performed and interpreted fluid bolus of 20 mL/kg to infants and Hemorrhagic Shock and then should be monitored frequent- children with shock is reasonable, ly or continuously in comatose patients 2020 (New): including those with conditions such Among infants and children after ROSC. as severe sepsis, severe malaria, and 2015 (Old): with hypotensive hemorrhagic shock The same anticonvulsant dengue. following trauma, it is reasonable to regimens for the treatment of status Choice of Vasopressor administer blood products, when avail- epilepticus caused by other etiologies able, instead of crystalloid for ongoing may be considered after cardiac arrest. 2020 (New): volume resuscitation. Why: In infants and children with For the first time, the Guidelines Why: fluid-refractory septic shock, it is rea- Previous versions of the provide pediatric-specific recommen- sonable to use either epinephrine or Guidelines did not differentiate the dations for managing seizures after norepinephrine as an initial vasoactive treatment of hemorrhagic shock from cardiac arrest. Nonconvulsive sei- infusion. other causes of hypovolemic shock. A zures, including nonconvulsive status 2020 (New): growing body of evidence (largely from In infants and children epilepticus, are common and cannot adults but with some pediatric data) with fluid-refractory septic shock, if be detected without electroenceph- suggests a benefit to early, balanced epinephrine or norepinephrine are un- alography. Although outcome data resuscitation using packed red blood available, dopamine may be considered. from the post–cardiac arrest popula- cells, fresh frozen plasma, and platelets. tion are lacking, both convulsive and Balanced resuscitation is supported by nonconvulsive status epilepticus are recommendations from the several US associated with poor outcome, and and international trauma societies.

eccguidelines.heart.org 21 Opioid Overdose for managing children with respiratory Single Ventricle: Recommendations arrest or cardiac arrest from opioid for the Treatment of Preoperative 2020 (Updated): For patients in overdose. and Postoperative Stage I Palliation respiratory arrest, rescue breathing These recommendations are (Norwood/Blalock-Tausig Shunt) Patients or bag-mask ventilation should be identical for adults and children, except maintained until spontaneous breathing that compression-ventilation CPR is 2020 (New): Direct (superior vena cava returns, and standard PBLS or PALS recommended for all pediatric victims catheter) and/or indirect (near infrared measures should continue if return of of suspected cardiac arrest. Naloxone spectroscopy) oxygen saturation spontaneous breathing does not occur. can be administered by trained 2020 (Updated): monitoring can be beneficial to trend For a patient with providers, laypersons with focused and direct management in the critically suspected opioid overdose who has a training, and untrained laypersons. ill neonate after stage I Norwood definite pulse but no normal breathing Separate treatment algorithms palliation or shunt placement. or only gasping (ie, a respiratory arrest), are provided for managing opioid- 2020 (New): in addition to providing standard PBLS associated resuscitation emergencies In the patient with an appro- or PALS, it is reasonable for responders by laypersons, who cannot reliably priately restrictive shunt, manipulation to administer intramuscular or intrana- check for a pulse (Figure 5), and by of pulmonary vascular resistance sal naloxone. trained rescuers (Figure 6). Opioid- may have little effect, whereas low- 2020 (Updated): ering systemic vascular resistance For patients known or associated OHCA is the subject of a 10 with the use of systemic vasodilators 2020 AHA scientific statement. suspected to be in cardiac arrest, in the (alpha-adrenergic antagonists and/or absence of a proven benefit from the Myocarditis phosphodiesterase type III inhibitors), use of naloxone, standard resuscitative with or without the use of oxygen, can measures should take priority over 2020 (New): be useful to increase systemic delivery naloxone administration, with a focus Given the high risk of cardiac arrest in children with acute myocarditis of oxygen (DO2.) on high-quality CPR (compressions plus 2020 (New): ventilation). who demonstrate arrhythmias, heart ECLS after stage I Norwood 2015 (Old): block, ST-segment changes, and/or low palliation can be useful to treat low Empiric administration of cardiac output, early consideration of systemic DO2. intramuscular or intranasal naloxone transfer to ICU monitoring and therapy 2020 (New): In the situation of known to all unresponsive opioid-associated is recommended. life-threatening emergency patients 2020 (New): or suspected shunt obstruction, it may be reasonable as an adjunct to For children with myocarditis is reasonable to administer oxygen, standard first aid and non–healthcare or cardiomyopathy and refractory low vasoactive agents to increase shunt provider BLS protocols. cardiac output, prearrest use of ECLS perfusion pressure, and heparin 2015 (Old): or mechanical circulatory support can (50-100 units/kg bolus) while preparing ACLS providers should be beneficial to provide end-organ for catheter-based or surgical support ventilation and administer support and prevent cardiac arrest. intervention. naloxone to patients with a perfusing 2020 (New): 2020 (Updated): cardiac rhythm and opioid-associated Given the challenges to For neonates prior to respiratory arrest or severe respiratory successful resuscitation of children stage I repair with pulmonary over- depression. Bag-mask ventilation with myocarditis and cardiomyopathy, circulation and symptomatic low should be maintained until spontaneous once cardiac arrest occurs, early systemic cardiac output and DO2, it is breathing returns, and standard ACLS consideration of extracorporeal reasonable to target a Paco2 of 50 to measures should continue if return of CPR may be beneficial. 60 mm Hg. This can be achieved during Why: spontaneous breathing does not occur. Although myocarditis accounts mechanical ventilation by reducing 2015 (Old): for about 2% of sudden cardiovascular minute ventilation or by administering We can make no 11 analgesia/sedation with or without neu- recommendation regarding the deaths in infants, 5% of sudden cardiovascular deaths in children,11 and 6% romuscular blockade. administration of naloxone in confirmed 2010 (Old): to 20% of sudden cardiac death in ath- Neonates in a prearrest opioid-associated cardiac arrest. 12,13 Why: letes, previous PALS guidelines did state due to elevated pulmonary- The opioid epidemic has not not contain specific recommendations to-systemic flow ratio prior to Stage I spared children. In the United States for management. These recommenda- repair might benefit from a Paco2 of in 2018, opioid overdose caused 65 tions are consistent with the 2018 AHA 50 to 60 mm Hg, which can be achieved deaths in children younger than 15 scientific statement on CPR in infants during mechanical ventilation by reduc- 14 years and 3618 deaths in people 15 to and children with cardiac disease. ing minute ventilation, increasing the 24 years old,9 and many more children inspired fraction of CO2, or administer- required resuscitation. The 2020 Guide- ing opioids with or without chemical lines contain new recommendations paralysis.

22 American Heart Association Neonatal Life Support

Single Ventricle: Recommendations for PALS care. Previous PALS guidelines administration can be useful while the Treatment of Postoperative Stage II did not contain recommendations for pulmonary-specific vasodilators are (Bidirectional Glenn/Hemi-Fontan) and this specialized patient population. administered. These recommendations are con- 2020 (New): Stage III (Fontan) Palliation Patients For children who develop sistent with the 2018 AHA scientific refractory pulmonary hypertension, statement on CPR in infants and 2020 (New): 14 including signs of low cardiac output For patients in a prearrest children with cardiac disease. state with superior cavopulmonary or profound respiratory failure despite anastomosis physiology and severe Pulmonary Hypertension optimal medical therapy, ECLS may hypoxemia due to inadequate pul- be considered. 2020 (Updated): 2010 (Old): monary blood flow (Qp), ventilatory Inhaled nitric oxide or Consider administering strategies that target a mild respiratory prostacyclin should be used as the inhaled nitric oxide or aerosolized acidosis and a minimum mean airway initial therapy to treat pulmonary hyper- prostacyclin or analogue to reduce pressure without atelectasis can be tensive crises or acute right-sided heart pulmonary vascular resistance. useful to increase cerebral and system- failure secondary to increased pulmo- Why: Pulmonary hypertension, a rare ic arterial oxygenation. nary vascular resistance. disease in infants and children, is 2020 (New): 2020 (New): ECLS in patients with su- Provide careful respiratory associated with significant morbidity perior cavopulmonary anastomosis or management and monitoring to avoid and mortality and requires specialized Fontan circulation may be considered hypoxia and acidosis in the postoper- management. Previous PALS guidelines to treat low DO2 from reversible causes ative care of the child with pulmonary did not provide recommendations for or as a bridge to a ventricular assist hypertension. managing pulmonary hypertension in device or surgical revision. 2020 (New): infants and children. These recommen- For pediatric patients Why: dations are consistent with guidelines Approximately 1 in 600 infants and who are at high risk for pulmonary on pediatric pulmonary hypertension children are born with critical con- hypertensive crises, provide adequate published by the AHA and the genital heart disease. Staged surgery analgesics, sedatives, and neuromus- 16 American Thoracic Society in 2015, for children born with single ventricle cular blocking agents. and with recommendations contained physiology, such as hypoplastic left 2020 (New): heart syndrome, spans the first several For the initial treatment of in a 2020 AHA scientific statement on 15 pulmonary hypertensive crises, oxygen CPR in infants and children with years of life. Resuscitation of these 14 infants and children is complex and administration and induction of alka- cardiac disease. differs in important ways from standard losis through hyperventilation or alkali Neonatal Life Support

There are over 4 million births every The process of facilitating Summary of Key Issues year in the United States and Canada. transition is described in the Neonatal and Major Changes Up to 1 of every 10 of these newborns Resuscitation Algorithm that starts will need help to transition from the with the needs of every newborn • Newborn resuscitation requires fluid-filled environment of the womb and proceeds to steps that address anticipation and preparation by to the air-filled room. It is essential the needs of at-risk newborns. In providers who train individually and that every newborn have a caregiver the 2020 Guidelines, we provide as teams. dedicated to facilitating that transition recommendations on how to follow • Most newly born infants do not and for that caregiver to be trained and the algorithm, including anticipation require immediate cord clamping or equipped for the role. Also, a signifi- and preparation, umbilical cord resuscitation and can be evaluated cant proportion of newborns who need management at delivery, initial actions, and monitored during skin-to-skin facilitated transition are at risk for com- heart rate monitoring, respiratory contact with their mothers after birth. plications that require additional trained support, chest compressions, personnel. All perinatal settings should intravascular access and therapies, • Prevention of hypothermia is be ready for this scenario. withholding and discontinuing an important focus for neonatal resuscitation, postresuscitation care, resuscitation. The importance of and human factors and performance. skin-to-skin care in healthy babies is Here, we highlight new and updated reinforced as a means of promoting recommendations that we believe will parental bonding, breastfeeding, and have a significant impact on outcomes normothermia. from cardiac arrest.

eccguidelines.heart.org 23 • Inflation and ventilation of the lungs Major New and Updated Clearing the Airway When are the priority in newly born infants Recommendations Meconium Is Present who need support after birth. Anticipation of Resuscitation Need 2020 (Updated): • A rise in heart rate is the most For nonvigorous newborns (presenting with apnea or important indicator of effective 2020 (New): ventilation and response to Every birth should be at- ineffective breathing effort) delivered resuscitative interventions. tended by at least 1 person who can through MSAF, routine laryngoscopy perform the initial steps of newborn with or without tracheal suctioning is • Pulse oximetry is used to guide resuscitation and initiate PPV and not recommended. oxygen therapy and meet oxygen whose only responsibility is the care of 2020 (Updated): saturation goals. For nonvigorous new- the newborn. borns delivered through MSAF who Why: • Routine endotracheal suctioning for To support a smooth and safe have evidence of airway obstruction both vigorous and nonvigorous infants newborn transition from being in the during PPV, intubation and tracheal born with meconium-stained amniotic womb to breathing air, every birth suction can be beneficial. fluid (MSAF) is not recommended. 2015 (Old): should be attended by at least 1 person When meconium is present, Endotracheal suctioning is indicated whose primary responsibility is to the routine intubation for tracheal suction only if airway obstruction is suspected newly born and who is trained and in this setting is not suggested because after providing positive-pressure equipped to begin PPV without delay. there is insufficient evidence to ventilation (PPV). Observational and quality-improvement continue recommending this practice. • Chest compressions are provided if studies indicate that this approach Why: In newly born infants with MSAF there is a poor heart rate response enables identification of at-risk newborns, promotes use of checklists who are not vigorous at birth, initial to ventilation after appropriate to prepare equipment, and facilitates steps and PPV may be provided. Endo- ventilation-corrective steps, which team briefing. A systematic review of tracheal suctioning is indicated only if preferably include endotracheal neonatal resuscitation training in low- airway obstruction is suspected after intubation. resourced settings showed a reduction providing PPV. Evidence from RCTs • The heart rate response to in both stillbirth and 7-day mortality. suggests that nonvigorous newborns chest compressions and delivered through MSAF have the same Temperature Management for medications should be monitored outcomes (survival, need for respiratory electrocardiographically. Newly Born Infants support) whether they are suctioned before or after the initiation of PPV. • When vascular access is required 2020 (New): Direct laryngoscopy and endotracheal Placing healthy newborn in newly born infants, the umbilical suctioning are not routinely required for infants who do not require resuscitation venous route is preferred. When IV newborns delivered through MSAF, but skin-to-skin after birth can be effective access is not feasible, the IO route they can be beneficial in newborns who in improving breastfeeding, tempera- may be considered. have evidence of airway obstruction ture control, and blood glucose stability. • If the response to chest Why: while receiving PPV. compressions is poor, it may be Evidence from a Cochrane systematic review showed that Vascular Access reasonable to provide epinephrine, early skin-to-skin contact promotes preferably via the intravascular route. 2020 (New): normothermia in healthy newborns. In For babies requiring vascular • Newborns who fail to respond to addition, 2 meta-analyses of RCTs and access at the time of delivery, the um- epinephrine and have a history or an observational studies of extended skin- bilical vein is the recommended route. exam consistent with blood loss may to-skin care after initial resuscitation If IV access is not feasible, it may be require volume expansion. and/or stabilization showed reduced reasonable to use the IO route. mortality, improved breastfeeding, Why: • If all these steps of resuscitation Newborns who have failed to respond shortened length of stay, and improved are effectively completed and there to PPV and chest compressions require weight gain in preterm and low-birth- vascular access to infuse epinephrine and/ is no heart rate response by 20 weight babies. minutes, redirection of care should be or volume expanders. Umbilical venous discussed with the team and family. catheterization is the preferred technique in the delivery room. IO access is an alternative if umbilical venous access is not feasible or care is being provided outside of the delivery room. Several case reports have described local complications associated with IO needle placement.

24 American Heart Association Resuscitation Education Science

Termination of Resuscitation reason, a time frame for decisions advantages in psychomotor perfor- about discontinuing resuscitation mance and knowledge and confidence 2020 (Updated): In newly born babies efforts is suggested, emphasizing when focused training occurred every receiving resuscitation, if there is no engagement of parents and the resus- 6 months or more frequently. It is heart rate and all the steps of resusci- citation team before redirecting care. therefore suggested that neonatal tation have been performed, cessation resuscitation task training occur more of resuscitation efforts should be Human and System Performance frequently than the current 2-year discussed with the healthcare team and interval. 2020 (Updated): the family. A reasonable time frame for For participants who Why: Educational studies suggest that this change in goals of care is around have been trained in neonatal resus- cardiopulmonary resuscitation knowl- 20 minutes after birth. citation, individual or team booster edge and skills decay within 3 to 12 2010 (Old): training should occur more frequently In a newly born baby with no months after training. Short, frequent than every 2 years at a frequency that detectable heart rate, it is appropriate booster training has been shown to supports retention of knowledge, skills, to consider stopping resuscitation if the improve performance in simulation and behaviors. heart rate remains undetectable for studies and reduce neonatal mortality 2015 (Old): 10 minutes. Studies that explored how in low-resource settings. To anticipate Why: frequently healthcare providers or and prepare effectively, providers and Newborns who have failed to healthcare students should train teams may improve their performance respond to resuscitative efforts by showed no differences in patient with frequent practice. approximately 20 minutes of age have outcomes but were able to show some a low likelihood of survival. For this Resuscitation Education Science

Effective education is a key variable support training, and incorporating • Virtual reality, which is the use of in improving survival outcomes from repetition with feedback and minimum a computer interface to create cardiac arrest. Without effective passing standards, can improve skill an immersive environment, and education, lay rescuers and acquisition. gamified learning, which is play and healthcare providers would struggle • Booster training (ie, brief retraining competition with other students, can to consistently apply the science sessions) should be added to massed be incorporated into resuscitation supporting the evidence-based learning (ie, traditional course based) training for laypersons and healthcare treatment of cardiac arrest. Evidence- to assist with retention of CPR skills. providers. based instructional design is critical to Provided that individual students can • Laypersons should receive training in improving provider performance and attend all sessions, separating training how to respond to victims of opioid patient-related outcomes from cardiac into multiple sessions (ie, spaced overdose, including the administration arrest. Instructional design features are learning) is preferable to massed of naloxone. the active ingredients, the key elements learning. of resuscitation training programs that • Bystander CPR training should target determine how and when content is • For laypersons, self-directed training, specific socioeconomic, racial, delivered to students. either alone or in combination and ethnic populations who have In the 2020 Guidelines, we provide with instructor-led training, is historically exhibited lower rates of recommendations about various recommended to improve willingness bystander CPR. CPR training should instructional design features in and ability to perform CPR. Greater address gender-related barriers to resuscitation training and describe use of self-directed training may improve rates of bystander CPR how specific provider considerations remove an obstacle to more performed on women. influence resuscitation education. widespread training of laypersons in • EMS systems should monitor how Here, we highlight new and updated CPR. much exposure their providers recommendations in education that we • Middle school– and high school–age receive in treating cardiac arrest believe will have a significant impact on children should be trained to provide victims. Variability in exposure among outcomes from cardiac arrest. high-quality CPR. providers in a given EMS system Summary of Key Issues • In situ training (ie, resuscitation may be supported by implementing and Major Changes education in actual clinical spaces) targeted strategies of supplementary can be used to enhance learning training and/or staffing adjustments. • The use of deliberate practice outcomes and improve resuscitation • All healthcare providers should complete and mastery learning during life performance. an adult ACLS course or its equivalent.

eccguidelines.heart.org 25 • Use of CPR training, mass training, The frequency of booster sessions In Situ Education CPR awareness campaigns, and should be balanced against student 2020 (New): hands-only CPR promotion should availability and the provision of It is reasonable to conduct continue on a widespread basis to resources that support implementation in situ simulation-based resuscitation improve willingness to provide CPR of booster training. Studies show that training in addition to traditional train- to cardiac arrest victims, increase the spaced-learning courses, or training ing. 2020 (New): prevalence of bystander CPR, and that is separated into multiple sessions, It may be reasonable to improve outcomes from OHCA. are of equal or greater effectiveness conduct in situ simulation-based resus- Major New and Updated when compared with courses delivered citation training in place of traditional as a single training event. Student Recommendations training. attendance across all sessions is Why: required to ensure course completion In situ simulation refers to training activities that are conducted in Deliberate Practice and because new content is presented at actual patient care areas, which has the Mastery Learning each session. advantage of providing a more realistic 2020 (New): Lay Rescuer Training training environment. New evidence Incorporating a deliberate shows that training in the in situ envi- practice and mastery learning model 2020 (Updated): ronment, either alone or in combination A combination of into basic or advanced life support with traditional training, can have a self-instruction and instructor-led courses may be considered for improv- positive impact on learning outcomes teaching with hands-on training is ing skill acquisition and performance. (eg, faster time to perform critical tasks recommended as an alternative to Why: and team performance) and patient Deliberate practice is a training instructor-led courses for lay rescuers. outcomes (eg, improved survival, neu- approach where students are given a If instructor-led training is not available, rological outcomes). discrete goal to achieve, immediate self-directed training is recommended feedback on their performance, and for lay rescuers. When conducting in situ simulation, ample time for repetition to improve 2020 (New): instructors should be wary of potential performance. Mastery learning is It is recommended to train risks, such as mixing training supplies defined as the use of deliberate middle school– and high school–age with real medical supplies. practice training and testing that children in how to perform high-quality includes a set of criteria to define CPR. Gamified Learning and Virtual Reality a specific passing standard, which 2015 (Old): A combination of self- 2020 (New): implies mastery of the tasks being instruction and instructor-led The use of gamified learning learned. teaching with hands-on training can and virtual reality may be considered for Evidence suggests that incorporating be considered as an alternative to basic or advanced life support train- a deliberate practice and mastery traditional instructor-led courses for lay ing for lay rescuers and/or healthcare learning model into basic or advanced providers. If instructor-led training is not providers. Why: life support courses improves multiple available, self-directed training may be Gamified learning incorporates learning outcomes. considered for lay providers learning competition or play around the topic of AED skills. Booster Training and resuscitation, and virtual reality uses a Why: computer interface that allows the user Spaced Learning Studies have found that self- instruction or video-based instruction to interact within a virtual environment. Some studies have demonstrated 2020 (New): is as effective as instructor-led training It is recommended to imple- for lay rescuer CPR training. A shift positive benefits on learning outcomes ment booster sessions when utilizing a to more self-directed training may (eg, improved knowledge acquisition, massed-learning approach for resusci- lead to a higher proportion of trained knowledge retention, and CPR skills) tation training. lay rescuers, thus increasing the with these modalities. Programs 2020 (New): looking to implement gamified learning It is reasonable to use a chances that a trained lay rescuer or virtual reality should consider spaced-learning approach in place of a will be available to provide CPR when high start-up costs associated with massed-learning approach for resusci- needed. Training school-age children purchasing equipment and software. tation training. to perform CPR instills confidence and Why: a positive attitude toward providing The addition of booster training CPR. Targeting this population with CPR sessions, which are brief, frequent training helps build the future cadre of sessions focused on repetition of prior community-based, trained lay rescuers. content, to resuscitation courses improves the retention of CPR skills.

26 American Heart Association Resuscitation Education Science

Bystander CPR training should target specific socioeconomic, racial, and ethnic populations who have historically exhibited lower rates of bystander CPR. CPR training should address gender-related barriers to improve rates of bystander CPR performed on women.

Opioid Overdose Training for stander CPR and CPR training. Women ommend that EMS systems monitor Lay Rescuers are also less likely to receive bystander provider exposure and develop strate- CPR, which may be because bystand- gies to address low exposure. 2020 (New): ers fear injuring female victims or being It is reasonable for lay rescu- ACLS Course Participation ers to receive training in responding to accused of inappropriate touching. opioid overdose, including provision of Targeting specific racial, ethnic, 2020 (New): naloxone. and low-socioeconomic populations It is reasonable for health- Why: for CPR education and modifying care professionals to take an adult Deaths from opioid overdose in the education to address gender ACLS course or equivalent training. United States have more than doubled Why: in the past decade. Multiple studies differences could eliminate disparities For more than 3 decades, the have found that targeted resuscita- in CPR training and bystander CPR, ACLS course has been recognized as tion training for opioid users and their potentially enhancing outcomes from an essential component of resuscita- families and friends is associated with cardiac arrest in these populations. tion training for acute care providers. Studies show that resuscitation teams higher rates of naloxone administration EMS Practitioner Experience in witnessed overdoses. with 1 or more team members trained in and Exposure to Out-of-Hospital ACLS have better patient outcomes. Disparities in Education Cardiac Arrest Willingness to Perform Bystander CPR 2020 (New): 2020 (New): It is recommended to target It is reasonable for EMS 2020 (New): It is reasonable to increase and tailor layperson CPR training to systems to monitor clinical personnel’s bystander willingness to perform specific racial and ethnic populations exposure to resuscitation to ensure CPR through CPR training, mass CPR and neighborhoods in the United treating teams have members com- training, CPR awareness initiatives, and States. petent in managing cardiac arrest promotion of Hands-Only CPR. 2020 (New): cases. Competence of teams may be It is reasonable to address Why: barriers to bystander CPR for female supported through staffing or training Prompt delivery of bystander CPR victims through educational training strategies. doubles a victim’s chances of survival Why: from cardiac arrest. CPR training, mass and public awareness efforts. A recent systematic review found CPR training, CPR awareness initiatives, Why: that EMS provider exposure to cardiac Communities with low socio- and promotion of Hands-Only CPR are arrest cases is associated with im- economic status and those with all associated with increased rates of proved patient outcomes, including predominantly Black and Hispanic bystander CPR. populations have lower rates of by- rates of ROSC and survival. Because exposure can be variable, we rec-

eccguidelines.heart.org 27 Systems of Care

Survival after cardiac arrest requires an • Early warning scoring systems and rescuers via a smartphone app or integrated system of people, training, rapid response teams can prevent text message alert is associated with equipment, and organizations. Willing cardiac arrest in both pediatric and shorter bystander response times, bystanders, property owners who adult hospitals, but the literature higher bystander CPR rates, shorter maintain AEDs, emergency service is too varied to understand what time to defibrillation, and higher rates of telecommunicators, and BLS and ALS components of these systems are survival to hospital discharge for people providers working within EMS systems associated with benefit. who experience OHCA. The differences in clinical outcomes were seen only all contribute to successful resuscita- • Cognitive aids may improve tion from OHCA. Within hospitals, the in the observational data. The use of resuscitation performance by mobile phone technology has yet to be work of physicians, nurses, respirato- untrained laypersons, but in simulation ry therapists, pharmacists, and other studied in a North American setting, but settings, their use delays the start of the suggestion of benefit in other coun- professionals supports resuscitation CPR. More development and study are tries makes this a high priority for future outcomes. needed before these systems can be research, including the impact of these Successful resuscitation also fully endorsed. alerts on cardiac arrest outcomes in depends on the contributions • Surprisingly little is known about diverse patient, community, and geo- of equipment manufacturers, graphic contexts. pharmaceutical companies, the effect of cognitive aids on the resuscitation instructors, guidelines performance of EMS or hospital- Data Registries to Improve developers, and many others. Long- based resuscitation teams. System Performance term survivorship requires support • Although specialized cardiac New (2020): from family and professional caregivers, arrest centers offer protocols and It is reasonable for organiza- including experts in cognitive, physical, technology not available at all tions that treat cardiac arrest patients and psychological rehabilitation and hospitals, the available literature to collect processes-of-care data and recovery. A systems-wide commitment about their impact on resuscitation outcomes. to quality improvement at every outcomes is mixed. Why: level of care is essential to achieving Many industries, including health- • Team feedback matters. Structured successful outcomes. care, collect and assess performance debriefing protocols improve the data to measure quality and identify Summary of Key Issues performance of resuscitation teams in opportunities for improvement. This and Major Changes subsequent resuscitation. can be done at the local, regional, or • System-wide feedback matters. national level through participation in • Recovery continues long after the Implementing structured data data registries that collect informa- initial hospitalization and is a critical collection and review improves tion on processes of care (eg, CPR performance data, defibrillation times, component of the resuscitation resuscitation processes and survival adherence to guidelines) and outcomes Chains of Survival. both inside and outside the hospital. of care (eg, ROSC, survival) associated • Efforts to support the ability and Major New and Updated with cardiac arrest. willingness of the members of the Recommendations Three such initiatives are the AHA’s general public to perform CPR and Get With The Guidelines-Resuscitation use an AED improve resuscitation Using Mobile Devices to registry (for IHCA), the Cardiac Arrest outcomes in communities. Summon Rescuers Registry to Enhance Survival registry (for • Novel methods to use mobile phone OHCA), and the Resuscitation technology to alert trained lay New (2020): Outcomes Consortium Cardiac Epistry The use of mobile phone rescuers of events that require (for OHCA), and many regional technology by emergency dispatch CPR are promising and deserve databases exist. A 2020 ILCOR systems to alert willing bystanders to more study. systematic review found that most nearby events that may require CPR or • Emergency system telecommunica- AED use is reasonable. studies assessing the impact of data tors can instruct bystanders to per- Why: registries, with or without public form hands-only CPR for adults and Despite the recognized role of lay reporting, demonstrate improvement in first responders in improving OHCA children. The No-No-Go framework is cardiac arrest survival in organizations outcomes, most communities experi- effective. and communities that participated in ence low rates of bystander CPR and cardiac arrest registries. AED use. A recent ILCOR systematic review found that notification of lay

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eccguidelines.heart.org 29 30 American Heart Association