Written by Clay Smith
The 2020 AHA adult basic and advanced life support guidelines have been updated. Here is the Spoon Feed.
Why does this matter?
The last resuscitation guidelines were released in 2015. Since then, there have been some changes. Here is what you need to know. Keep in mind, COVID-19 has changed things as well. Be sure to see prior AHA guidance on keeping safe during the COVID-19 pandemic.
Annie is still not OK…new BLS and ACLS guidelines.
“On recognition of a cardiac arrest event, a layperson should simultaneously and promptly activate the emergency response system and initiate cardiopulmonary resuscitation (CPR).”
Comment: The focus is still on calling for help first in adult BLS but doing that while nearly simultaneously starting compressions. Cricoid pressure is specifically not recommended when opening the airway or ventilating.
“Performance of high-quality CPR includes adequate compression depth and rate while minimizing pauses in compressions.”
Comment: Nothing new about this. Two inch depth is recommended. The AHA now says bag mask ventilation or an advanced airway – supraglottic or endotracheal based on skill level – is acceptable. They suggest against using POCUS for prognostication during CPR.
“Early defibrillation with concurrent high-quality CPR is critical to survival when sudden cardiac arrest is caused by ventricular fibrillation or pulseless ventricular tachycardia.”
Comment: Dual sequential defibrillation is mentioned but given a 2b (weak) recommendation that there may be benefit.
“Administration of epinephrine with concurrent high-quality CPR improves survival, particularly in patients with nonshockable rhythms.”
Comment: This point is emphasized this year. Give epinephrine as soon as possible in non-shockable rhythm and after initial defibrillation attempt in shockable rhythm. Also, the IV route is favored over IO.
“Recognition that all cardiac arrest events are not identical is critical for optimal patient outcome, and specialized management is necessary for many conditions (eg, electrolyte abnormalities, pregnancy, after cardiac surgery).”
Comment: This is an explicit recognition that ACLS tends to be cookie cutter and show deference to experts who deviate from it for good reasons. They focus on perimortem C-section.
“The opioid epidemic has resulted in an increase in opioid-associated out-of-hospital cardiac arrest, with the mainstay of care remaining the activation of the emergency response systems and performance of high-quality CPR.”
Comment: Don’t forget about opioid overdose in patients with altered mental status and respiratory depression; give naloxone. If full arrest, just do CPR as normal.
“Post–cardiac arrest care is a critical component of the Chain of Survival and demands a comprehensive, structured, multidisciplinary system that requires consistent implementation for optimal patient outcomes.”
Comment: Of first importance is oxygenation but not too much. Keep SpO2 92-98% and EtCO2 35-45. Keep MAP >65. Get a 12 lead ECG as soon as possible. Get a head CT. Treat seizures, and monitor an EEG for seizure activity.
“Prompt initiation of targeted temperature management is necessary for all patients who do not follow commands after return of spontaneous circulation to ensure optimal functional and neurological outcome.”
Comment: If comatose (not following commands), start targeted temperature management, with a goal of 32C to 36C.
“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.”
Comment: Use multimodal prognostication at least 72 hours after rewarming and without sedative medication. This includes clinical, imaging, EEG, possibly biomarkers, and electrophysiology testing.
“Recovery expectations and survivorship plans that address treatment, surveillance, 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.”
Comment: Patients who survive may have cognitive deficits that slowly improve. Patients may also have mental health impact, such as PTSD. They need to know what to expect.
Part 3: Adult Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2020 Oct 20;142(16_suppl_2):S366-S468. doi: 10.1161/CIR.0000000000000916. Epub 2020 Oct 21.
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