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2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

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2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation Part 3: Adult Basic and Advanced Life Support 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care TOP 10 TAKE-HOME MESSAGES FOR ADULT Ashish R. Panchal, MD, CARDIOVASCULAR LIFE SUPPORT PhD, Chair 1. On recognition of a cardiac arrest event, a layperson should simultaneously Jason A. Bartos, MD, PhD and promptly activate the emergency response system and initiate cardiopul- José G. Cabañas, MD, monary resuscitation (CPR). MPH 2. Performance of high-quality CPR includes adequate compression depth and Michael W. Donnino, MD rate while minimizing pauses in compressions, Ian R. Drennan, ACP, 3. Early defibrillation with concurrent high-quality CPR is critical to survival PhD(C) Karen G. Hirsch, MD when sudden cardiac arrest is caused by ventricular fibrillation or pulseless Peter J. Kudenchuk, MD ventricular tachycardia. Michael C. Kurz, MD, MS 4. Administration of epinephrine with concurrent high-quality CPR improves Downloaded from http://ahajournals.org by on November 6, 2020 Eric J. Lavonas, MD, MS survival, particularly in patients with nonshockable rhythms. Peter T. Morley, MBBS 5. Recognition that all cardiac arrest events are not identical is critical for opti- Brian J. O’Neil, MD mal patient outcome, and specialized management is necessary for many Mary Ann Peberdy, MD conditions (eg, electrolyte abnormalities, pregnancy, after cardiac surgery). Jon C. Rittenberger, MD, 6. The opioid epidemic has resulted in an increase in opioid-associated out-of- MS hospital cardiac arrest, with the mainstay of care remaining the activation of Amber J. Rodriguez, PhD the emergency response systems and performance of high-quality CPR. Kelly N. Sawyer, MD, MS 7. Post–cardiac arrest care is a critical component of the Chain of Survival and Katherine M. Berg, MD, demands a comprehensive, structured, multidisciplinary system that requires Vice Chair consistent implementation for optimal patient outcomes. On behalf of the Adult 8. Prompt initiation of targeted temperature management is necessary for all Basic and Advanced Life patients who do not follow commands after return of spontaneous circula- Support Writing Group tion to ensure optimal functional and neurological outcome. 9. Accurate neurological prognostication in brain-injured cardiac arrest survivors is critically important to ensure that patients with significant potential for recovery are not destined for certain poor outcomes due to care withdrawal. 10. Recovery expectations and survivorship plans that address treatment, surveil- lance, and rehabilitation need to be provided to cardiac arrest survivors and their caregivers at hospital discharge to optimize transitions of care to home and to the outpatient setting. PREAMBLE Key Words: AHA Scientific Statements ◼ apnea ◼ cardiopulmonary In 2015, approximately 350 000 adults in the United States experienced non- resuscitation ◼ defibrillators ◼ delivery of health care ◼ electric countershock traumatic out-of-hospital cardiac arrest (OHCA) attended by emergency medical ◼ heart arrest ◼ life support care services (EMS) personnel.1 Approximately 10.4% of patients with OHCA survive their initial hospitalization, and 8.2% survive with good functional status. The key © 2020 American Heart Association, Inc. drivers of successful resuscitation from OHCA are lay rescuer cardiopulmonary https://www.ahajournals.org/journal/circ S366 October 20, 2020 Circulation. 2020;142(suppl 2):S366–S468. DOI: 10.1161/CIR.0000000000000916 Panchal et al Adult Basic and Advanced Life Support: 2020 AHA Guidelines for CPR and ECC resuscitation (CPR) and public use of an automated equipment. Other recommendations are relevant to external defibrillator (AED). Despite recent gains, only persons with more advanced resuscitation training, 39.2% of adults receive layperson-initiated CPR, and functioning either with or without access to resuscita- the general public applied an AED in only 11.9% of tion drugs and devices, working either within or outside cases.1 Survival rates from OHCA vary dramatically be- of a hospital. Some treatment recommendations in- tween US regions and EMS agencies.2,3 After significant volve medical care and decision-making after return of improvements, survival from OHCA has plateaued since spontaneous circulation (ROSC) or when resuscitation 2012. has been unsuccessful. Importantly, recommendations Approximately 1.2% of adults admitted to US hos- are provided related to team debriefing and systematic pitals suffer in-hospital cardiac arrest (IHCA).1 Of these feedback to increase future resuscitation success. patients, 25.8% were discharged from the hospital alive, and 82% of survivors have good functional sta- Organization of the Writing Group tus at the time of discharge. Despite steady improve- ment in the rate of survival from IHCA, much oppor- The Adult Cardiovascular Life Support Writing Group tunity remains. included a diverse group of experts with backgrounds The International Liaison Committee on Resusci- in emergency medicine, critical care, cardiology, toxicol- tation (ILCOR) Formula for Survival emphasizes 3 es- ogy, neurology, EMS, education, research, and public sential components for good resuscitation outcomes: health, along with content experts, AHA staff, and the guidelines based on sound resuscitation science, ef- AHA senior science editors. Each recommendation was fective education of the lay public and resuscitation developed and formally approved by the writing group. providers, and implementation of a well-functioning The AHA has rigorous conflict of interest policies Chain of Survival.4 and procedures to minimize the risk of bias or improp- These guidelines contain recommendations for ba- er influence during the development of guidelines. Be- sic life support (BLS) and advanced life support (ALS) fore appointment, writing group members disclosed for adult patients and are based on the best available all commercial relationships and other potential (in- resuscitation science. The Chain of Survival, introduced cluding intellectual) conflicts. These procedures are in Major Concepts, is now expanded to emphasize the described more fully in “Part 2: Evidence Evaluation and Guidelines Development.” Disclosure information Downloaded from http://ahajournals.org by on November 6, 2020 important component of survivorship during recovery from cardiac arrest, requires coordinated efforts from for writing group members is listed in Appendix 1. medical professionals in a variety of disciplines and, in the case of OHCA, from lay rescuers, emergency dis- Methodology and Evidence Review patchers, and first responders. In addition, specific rec- ommendations about the training of resuscitation pro- These guidelines are based on the extensive evidence viders are provided in “Part 6: Resuscitation Education evaluation performed in conjunction with the ILCOR and Science,” and recommendations about systems of care affiliated ILCOR member councils. Three different types are provided in “Part 7: Systems of Care.” of evidence reviews (systematic reviews, scoping reviews, and evidence updates) were used in the 2020 process. Each of these resulted in a description of the literature INTRODUCTION that facilitated guideline development. A more compre- hensive description of these methods is provided in “Part Scope of the Guidelines 2: Evidence Evaluation and Guidelines Development.” These guidelines are designed primarily for North Amer- ican healthcare providers who are looking for an up-to- Class of Recommendation and Level of date summary for BLS and ALS for adults as well as for those who are seeking more in-depth information on Evidence resuscitation science and gaps in current knowledge. As with all AHA guidelines, each 2020 recommendation The BLS care of adolescents follows adult guidelines. is assigned a Class of Recommendation (COR) based on This Part of the 2020 American Heart Association (AHA) the strength and consistency of the evidence, alterna- Guidelines for CPR and Emergency Cardiovascular Care tive treatment options, and the impact on patients and includes recommendations for clinical care of adults society (Table 1). The Level of Evidence (LOE) is based on with cardiac arrest, including those with life-threaten- the quality, quantity, relevance, and consistency of the ing conditions in whom cardiac arrest is imminent, and available evidence. For each recommendation, the writ- after successful resuscitation from cardiac arrest. ing group discussed and approved specific recommen- Some recommendations are directly relevant to lay dation wording and the COR and LOE assignments. In rescuers who may or may not have received CPR train- determining the COR, the writing group considered ing and who have little or no access to resuscitation the LOE and other factors, including systems issues, Circulation. 2020;142(suppl 2):S366–S468. DOI: 10.1161/CIR.0000000000000916 October 20, 2020 S367 Panchal et al Adult Basic and Advanced Life Support: 2020 AHA Guidelines for CPR and ECC This table defines the Classes of Recommendation (COR) and Levels of Evidence (LOE). COR indicates the strength the writing group assigns the recommendation, and the LOE is assigned based on the quality of the scientific evidence. The outcome or result of the intervention should be specified (an improved clinical outcome or increased diagnostic accuracy or incremental prognostic information). Classes of Recommendation COR designations include Class 1, a strong recommendation for which the potential
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