แนวทางปฏิบัติการช่วยฟื้นคืนชีพ ปี 2020 (AHA Guidelines BSL & ACLS 2020)

Topics Adult Pediatric Neonatal Life Resuscitation Systems of Basic and Basic and Support Education Care Advanced Advanced Science Life Support Life Support 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 guide- lines 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. © 2020 American Heart Association 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 intervention, targeted temperature management, and In 2015, approximately 350 000 adults in the United States multimodal neuroprognostication. experienced nontraumatic out-of-hospital cardiac arrest (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 has plateaued since 2012. • After a resuscitation, debriefing for lay rescuers, EMS 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 changes to algorithms and other performance aids include • The importance of early initiation of CPR by lay rescuers the following: has been re-emphasized. • A sixth link, Recovery, was added to the IHCA and OHCA • Previous recommendations about epinephrine Chains of Survival (Figure 3). administration have been reaffirmed, with emphasis on early epinephrine administration. • The universal Adult Cardiac Arrest Algorithm was modified to emphasize the role of early epinephrine administration for • Use of real-time audiovisual feedback is suggested as a patients with nonshockable rhythms (Figure 4). means to maintain CPR quality. • Two new Opioid-Associated Emergency Algorithms have • Continuously measuring arterial blood pressure and end- been added for lay rescuers and trained rescuers tidal carbon dioxide (ETCO2) during ACLS resuscitation (Figures 5 and 6). may be useful to improve CPR quality. • The Post–Cardiac Arrest Care Algorithm was updated to • On the basis of the most recent evidence, routine use of emphasize the need to prevent hyperoxia, hypoxemia, and double sequential defibrillation is not recommended. hypotension (Figure 7). • Intravenous (IV) access is the preferred route of medication • A new diagram has been added to guide and inform administration during ACLS resuscitation. Intraosseous (IO) neuroprognostication (Figure 8). access is acceptable if IV access is not available. • A new Cardiac Arrest in Pregnancy Algorithm has been • Care of the patient after return of spontaneous circulation added to address these special cases (Figure 9). (ROSC) requires close attention to oxygenation, blood 4 American Heart Association

Adult Basic and Advanced Life Support 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. 6 American Heart Association

Adult Basic and Advanced Life Support Figure 5. Opioid-Associated Emergency for Lay Responders Algorithm. eccguidelines.heart.org 7

Figure 6. Opioid-Associated Emergency for Healthcare Providers Algorithm. 8 American Heart Association

Adult Basic and Advanced Life Support 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. 10 American Heart Association

Adult Basic and Advanced Life Support 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, and detect ROSC. Early Initiation of CPR by Lay Rescuers Of 16 observational studies on timing in the recent systematic review, Why: Although the use of physiologic 2020 (Updated): We recommend that all found an association between monitoring such as arterial blood laypersons initiate CPR for presumed earlier epinephrine and ROSC for pressure and ETCO2 to monitor CPR cardiac arrest because the risk of harm patients with nonshockable rhythms, quality is an established concept, to the patient is low if the patient is not although improvements in survival new data support its inclusion in the in cardiac arrest. were not universally seen. For patients guidelines. Data from the AHA’s Get 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. The healthcare provider should take Any drug that increases the rate This monitoring depends on the no more than 10 seconds to check for of ROSC and survival but is given presence of an endotracheal tube (ETT) a pulse and, if the rescuer does not after several minutes of downtime or arterial line, respectively. Targeting definitely feel a pulse within that time will likely increase both favorable and compressions to an ETCO2 value of at period, the rescuer should start chest unfavorable neurologic outcome. least 10 mm Hg, and ideally 20 mm Hg compressions. Therefore, the most beneficial or greater, may be useful as a marker approach seems to be continuing of CPR quality. An ideal target has not Why: New evidence shows that the risk to use a drug that has been shown been identified. of harm to a victim who receives chest to increase survival while focusing compressions when not in cardiac broader efforts on shortening time Double Sequential Defibrillation arrest is low. Lay rescuers are not able to drug for all patients; by doing so, Not Supported to determine with accuracy whether more survivors will have a favorable a victim has a pulse, and the risk of neurologic outcome. 2020 (New): The usefulness of double withholding CPR from a pulseless victim sequential defibrillation for refractory exceeds the harm from unneeded chest Real-Time Audiovisual Feedback shockable rhythm has not been compressions. established. 2020 (Unchanged/Reaffirmed): It may be Early Administration of Epinephrine reasonable to use audiovisual feedback Why: Double sequential defibrillation devices during CPR for real-time is the practice of applying near- 2020 (Unchanged/Reaffirmed): With optimization of CPR performance. simultaneous shocks using 2 respect to timing, for cardiac arrest defibrillators. Although some case with a nonshockable rhythm, it is Why: A recent RCT reported a 25% reports have shown good outcomes, reasonable to administer epinephrine increase in survival to hospital dis- a 2020 ILCOR systematic review found as soon as feasible. charge from IHCA with audio feedback no evidence to support double sequen- on compression depth and recoil. tial defibrillation and recommended 2020 (Unchanged/Reaffirmed): With against its routine use. Existing studies respect to timing, for cardiac arrest with Physiologic Monitoring of CPR Quality are subject to multiple forms of bias, a shockable rhythm, it may be reason- and observational studies do not show able to administer epinephrine after 2020 (Updated): It may be reasonable to improvements in outcome. initial defibrillation attempts have failed. use physiologic parameters such as arterial blood pressure or ETCO2 when A recent pilot RCT suggests that Why: The suggestion to administer feasible to monitor and optimize changing the direction of defibrillation epinephrine early was strengthened CPR quality. current by repositioning the pads may to a recommendation on the basis of a be as effective as double sequential systematic review and meta-analysis, 2015 (Old): 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) 12 American Heart Association

Adult Basic and Advanced Life Support 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. neuroprognostication. 2020 (Updated): IO access may be 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 2020 (New): We recommend that cardiac are more prone to hypoxia, oxygenation 2010 (Old): It is reasonable for providers arrest survivors have multimodal reha- and airway management should be to establish intraosseous (IO) access bilitation assessment and treatment for prioritized during resuscitation from if intravenous (IV) access is not readily physical, neurologic, cardiopulmonary, cardiac arrest in pregnancy. available. and cognitive impairments before discharge from the hospital. 2020 (New): Because of potential Why: A 2020 ILCOR systematic review interference with maternal resusci- comparing IV versus IO (principally 2020 (New): We recommend that cardiac tation, fetal monitoring should not be pretibial placement) drug administra- arrest survivors and their caregivers undertaken during cardiac arrest in tion during cardiac arrest found that receive comprehensive, multidisci- pregnancy. the IV route was associated with better plinary discharge planning, to include clinical outcomes in 5 retrospective medical and rehabilitative treatment 2020 (New): We recommend targeted studies; subgroup analyses of RCTs recommendations and return to temperature management for pregnant that focused on other clinical questions activity/work expectations. women who remain comatose after found comparable outcomes when IV resuscitation from cardiac arrest. or IO were used for drug administration. 2020 (New): We recommend structured Although IV access is preferred, for assessment for anxiety, depression, 2020 (New): During targeted tempera- situations in which IV access is difficult, posttraumatic stress, and fatigue for ture management of the pregnant IO access is a reasonable option. cardiac arrest survivors and their patient, it is recommended that the caregivers. fetus be continuously monitored for Post–Cardiac Arrest Care and bradycardia as a potential complication, Neuroprognostication Why: The process of recovering from and obstetric and neonatal consultation cardiac arrest extends long after the should be sought. The 2020 Guidelines contain signifi- initial hospitalization. Support is needed cant new clinical data about optimal during recovery to ensure optimal Why: Recommendations for manag- care in the days after cardiac arrest. physical, cognitive, and emotional ing cardiac arrest in pregnancy were Recommendations from the 2015 well-being and return to social/role reviewed in the 2015 Guidelines Update AHA Guidelines Update for CPR and functioning. This process should be and a 2015 AHA scientific statement.7 ECC about treatment of hypotension, initiated during the initial hospitalization Airway, ventilation, and oxygenation titrating oxygen to avoid both hypoxia and continue as long as needed. These are particularly important in the setting and hyperoxia, detection and treatment themes are explored in greater detail in of pregnancy because of an increase of seizures, and targeted temperature a 2020 AHA scientific statement.6 in maternal metabolism, a decrease in management were reaffirmed with new functional reserve capacity due to the supporting evidence. Debriefings for Rescuers gravid uterus, and the risk of fetal brain injury from hypoxemia. In some cases, the LOE was 2020 (New): Debriefings and referral for upgraded to reflect the availability of follow up for emotional support for Evaluation of the fetal heart is not new data from RCTs and high-quality lay rescuers, EMS providers, and helpful during maternal cardiac arrest, observational studies, and the post– hospital-based healthcare workers and it may distract from necessary cardiac arrest care algorithm has after a cardiac arrest event may be resuscitation elements. In the absence been updated to emphasize these beneficial. of data to the contrary, pregnant important components of care. To be women who survive cardiac arrest reliable, neuroprognostication should Why: Rescuers may experience anxiety should receive targeted temperature be performed no sooner than 72 or posttraumatic stress about providing management just as any other survivors hours after return to normothermia, or not providing BLS. Hospital-based would, with consideration for the status and prognostic decisions should be care providers may also experience of the fetus that may remain in utero. based on multiple modes of patient emotional or psychological effects of assessment. caring for a patient with cardiac arrest. 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, is appropriate in resuscitation from septic shock. More than 20 000 infants and children have a cardiac arrest 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 for pediatric basic life support (PBLS) and CPR in infants, • Opioid overdose management includes CPR and the timely children, and adolescents have been combined with rec- administration of naloxone by either lay rescuers or trained ommendations for pediatric advanced life support (PALS) rescuers. in a single document in the 2020 Guidelines. The causes of cardiac arrest in infants and children differ from cardiac • Children with acute myocarditis who have arrhythmias, heart arrest in adults, and a growing body of pediatric-specif- block, ST-segment changes, or low cardiac output are at ic evidence supports these recommendations. Key issues, high risk of cardiac arrest. Early transfer to an intensive care major changes, and enhancements in the 2020 Guidelines unit is important, and some patients may require mechanical include the following: circulatory support or extracorporeal life support (ECLS). • Algorithms and visual aids were revised to incorporate • Infants and children with congenital heart disease and the best science and improve clarity for PBLS and PALS single ventricle physiology who are in the process of staged resuscitation providers. reconstruction require special considerations in PALS management. • Based on newly available data from pediatric resuscitations, the recommended assisted ventilation rate has been • Management of pulmonary hypertension may include the increased to 1 breath every 2 to 3 seconds (20-30 breaths use of inhaled nitric oxide, prostacyclin, analgesia, sedation, per minute) for all pediatric resuscitation scenarios. neuromuscular blockade, the induction of alkalosis, or rescue therapy with ECLS. • Cuffed ETTs are suggested to reduce air leak and the need for tube exchanges for patients of any age who require Algorithms and Visual Aids intubation. The writing group updated all algorithms to reflect the latest • The routine use of cricoid pressure during intubation is no science and made several major changes to improve the longer recommended. visual training and performance aids: • To maximize the chance of good resuscitation outcomes, • A new pediatric Chain of Survival was created for IHCA in epinephrine should be administered as early as possible, infants, children, and adolescents (Figure 10). ideally within 5 minutes of the start of cardiac arrest from a nonshockable rhythm (asystole and pulseless • A sixth link, Recovery, was added to the pediatric OHCA electrical activity). Chain of Survival and is included in the new pediatric IHCA Chain of Survival (Figure 10). • For patients with arterial lines in place, using feedback from continuous measurement of arterial blood pressure may • The Pediatric Cardiac Arrest Algorithm and the Pediatric improve CPR quality. Bradycardia With a Pulse Algorithm have been updated to reflect the latest science (Figures 11 and 12). • After ROSC, patients should be evaluated for seizures; status epilepticus and any convulsive seizures should be treated. • The single Pediatric Tachycardia With a Pulse Algorithm now covers both narrow- and wide-complex tachycardias in • Because recovery from cardiac arrest continues long pediatric patients (Figure 13). after the initial hospitalization, patients should have formal assessment and support for their physical, cognitive, and • Two new Opioid-Associated Emergency Algorithms have psychosocial needs. been added for lay rescuers and trained rescuers (Figures 5 and 6). • A titrated approach to fluid management, with epinephrine • A new checklist is provided for pediatric post–cardiac arrest care (Figure 14). 14 American Heart Association

Pediatric Basic and Advanced Life Support 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. 16 American Heart Association

Pediatric Basic and Advanced Life Support Figure 12.  Pediatric Bradycardia With a Pulse Algorithm. eccguidelines.heart.org 17

Figure 13.  Pediatric Tachycardia With a Pulse Algorithm. 18 American Heart Association

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

Pediatric Basic and Advanced Life Support 2015 (Old): For patients with invasive treatment of status epilepticus is Corticosteroid Administration hemodynamic monitoring in place at beneficial in pediatric patients in the time of cardiac arrest, it may be general. 2020 (New): 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 Cardiac Arrest Survivors reasonable to consider stress-dose Why: Providing high-quality chest corticosteroids. compressions is critical to successful 2020 (New): It is recommended that resuscitation. A new study shows that, pediatric cardiac arrest survivors be Why: Although fluids remain the main- among pediatric patients receiving evaluated for rehabilitation services. stay of initial therapy for infants and CPR with an arterial line in place, children in shock, especially in hypovo- rates of survival with favorable neu- 2020 (New): 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 least the first year after cardiac arrest. shock, those who received higher fluid 30 mm Hg in children.8 volumes or faster fluid resuscitation Why: 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): When resources are ed medical, rehabilitative, caregiver, and dations to reassess patients after each available, continuous electroencepha- community support in the months to fluid bolus and to use either crystalloid lography monitoring is recommended years after their cardiac arrest. A recent or colloid fluids for septic shock resus- for the detection of seizures following AHA scientific statement highlights the citation. cardiac arrest in patients with importance of supporting patients and persistent encephalopathy. families during this time to achieve the Previous versions of the Guidelines best possible long-term outcome.6 did not provide recommendations 2020 (Updated): It is recommended to about choice of vasopressor or the treat clinical seizures following Septic Shock use of corticosteroids in septic shock. cardiac arrest. Two RCTs suggest that epinephrine Fluid Boluses is superior to dopamine as the initial 2020 (Updated): It is reasonable to treat vasopressor in pediatric septic shock, nonconvulsive status epilepticus 2020 (Updated): 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 with frequent reassessment. some pediatric patients with refractory 2015 (Old): An electroencephalography septic shock. for the diagnosis of seizure should be 2015 (Old): 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 including those with conditions such 2020 (New): Among infants and children after ROSC. as severe sepsis, severe malaria, and with hypotensive hemorrhagic shock dengue. following trauma, it is reasonable to 2015 (Old): The same anticonvulsant administer blood products, when avail- regimens for the treatment of status Choice of Vasopressor able, instead of crystalloid for ongoing epilepticus caused by other etiologies volume resuscitation. may be considered after cardiac arrest. 2020 (New): In infants and children with fluid-refractory septic shock, it is rea- Why: Previous versions of the Why: For the first time, the Guidelines sonable to use either epinephrine or Guidelines did not differentiate the provide pediatric-specific recommen- norepinephrine as an initial vasoactive treatment of hemorrhagic shock from dations for managing seizures after infusion. other causes of hypovolemic shock. A cardiac arrest. Nonconvulsive sei- growing body of evidence (largely from zures, including nonconvulsive status 2020 (New): In infants and children adults but with some pediatric data) epilepticus, are common and cannot with fluid-refractory septic shock, if suggests a benefit to early, balanced be detected without electroenceph- epinephrine or norepinephrine are un- resuscitation using packed red blood alography. Although outcome data available, dopamine may be considered. cells, fresh frozen plasma, and platelets. from the post–cardiac arrest popula- Balanced resuscitation is supported by tion are lacking, both convulsive and recommendations from the several US nonconvulsive status epilepticus are and international trauma societies. associated with poor outcome, and 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 (Norwood/Blalock-Tausig Shunt) Patients or bag-mask ventilation should be These recommendations are maintained until spontaneous breathing identical for adults and children, except 2020 (New): Direct (superior vena cava returns, and standard PBLS or PALS that compression-ventilation CPR is catheter) and/or indirect (near infrared measures should continue if return of recommended for all pediatric victims spectroscopy) oxygen saturation spontaneous breathing does not occur. of suspected cardiac arrest. Naloxone monitoring can be beneficial to trend can be administered by trained and direct management in the critically 2020 (Updated): For a patient with providers, laypersons with focused ill neonate after stage I Norwood suspected opioid overdose who has a training, and untrained laypersons. palliation or shunt placement. definite pulse but no normal breathing Separate treatment algorithms or only gasping (ie, a respiratory arrest), are provided for managing opioid- 2020 (New): In the patient with an appro- in addition to providing standard PBLS associated resuscitation emergencies priately restrictive shunt, manipulation or PALS, it is reasonable for responders by laypersons, who cannot reliably of pulmonary vascular resistance to administer intramuscular or intrana- check for a pulse (Figure 5), and by may have little effect, whereas low- sal naloxone. trained rescuers (Figure 6). Opioid- ering systemic vascular resistance associated OHCA is the subject of a with the use of systemic vasodilators 2020 (Updated): For patients known or 2020 AHA scientific statement.10 (alpha-adrenergic antagonists and/or suspected to be in cardiac arrest, in the phosphodiesterase type III inhibitors), absence of a proven benefit from the Myocarditis with or without the use of oxygen, can use of naloxone, standard resuscitative be useful to increase systemic delivery measures should take priority over 2020 (New): Given the high risk of cardiac of oxygen (DO2.) naloxone administration, with a focus arrest in children with acute myocarditis on high-quality CPR (compressions plus who demonstrate arrhythmias, heart 2020 (New): ECLS after stage I Norwood ventilation). block, ST-segment changes, and/or low palliation can be useful to treat low cardiac output, early consideration of systemic DO2. 2015 (Old): Empiric administration of transfer to ICU monitoring and therapy intramuscular or intranasal naloxone is recommended. 2020 (New): In the situation of known to all unresponsive opioid-associated or suspected shunt obstruction, it life-threatening emergency patients 2020 (New): For children with myocarditis is reasonable to administer oxygen, may be reasonable as an adjunct to or cardiomyopathy and refractory low vasoactive agents to increase shunt standard first aid and non–healthcare cardiac output, prearrest use of ECLS perfusion pressure, and heparin provider BLS protocols. or mechanical circulatory support can (50-100 units/kg bolus) while preparing be beneficial to provide end-organ for catheter-based or surgical 2015 (Old): ACLS providers should support and prevent cardiac arrest. intervention. support ventilation and administer naloxone to patients with a perfusing 2020 (New): Given the challenges to 2020 (Updated): For neonates prior to cardiac rhythm and opioid-associated successful resuscitation of children stage I repair with pulmonary over- respiratory arrest or severe respiratory with myocarditis and cardiomyopathy, circulation and symptomatic low depression. Bag-mask ventilation once cardiac arrest occurs, early systemic cardiac output and DO2, it is should be maintained until spontaneous consideration of extracorporeal reasonable to target a Paco2 of 50 to breathing returns, and standard ACLS CPR may be beneficial. 60 mm Hg. This can be achieved during measures should continue if return of mechanical ventilation by reducing spontaneous breathing does not occur. Why: Although myocarditis accounts minute ventilation or by administering for about 2% of sudden cardiovascular analgesia/sedation with or without neu- 2015 (Old): We can make no deaths in infants,11 5% of sudden car- romuscular blockade. recommendation regarding the diovascular deaths in children,11 and 6% administration of naloxone in confirmed to 20% of sudden cardiac death in ath- 2010 (Old): Neonates in a prearrest opioid-associated cardiac arrest. letes, previous12,13 PALS guidelines did state due to elevated pulmonary- not contain specific recommendations to-systemic flow ratio prior to Stage I Why: The opioid epidemic has not for management. These recommenda- repair might benefit from a Paco2 of spared children. In the United States tions are consistent with the 2018 AHA 50 to 60 mm Hg, which can be achieved in 2018, opioid overdose caused 65 scientific statement on CPR in infants during mechanical ventilation by reduc- deaths in children younger than 15 and children with cardiac disease.14 ing minute ventilation, increasing the years and 3618 deaths in people 15 to inspired fraction of CO2, or administer- 24 years old,9 and many more children ing opioids with or without chemical required resuscitation. The 2020 Guide- paralysis. lines contain new recommendations 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. Stage III (Fontan) Palliation Patients These recommendations are con- sistent with the 2018 AHA scientific 2020 (New): For children who develop 2020 (New): For patients in a prearrest statement on CPR in infants and refractory pulmonary hypertension, state with superior cavopulmonary children with cardiac disease.14 including signs of low cardiac output anastomosis physiology and severe or profound respiratory failure despite hypoxemia due to inadequate pul- Pulmonary Hypertension optimal medical therapy, ECLS may monary blood flow (Qp), ventilatory be considered. strategies that target a mild respiratory 2020 (Updated): Inhaled nitric oxide or acidosis and a minimum mean airway prostacyclin should be used as the 2010 (Old): Consider administering pressure without atelectasis can be initial therapy to treat pulmonary hyper- inhaled nitric oxide or aerosolized useful to increase cerebral and system- tensive crises or acute right-sided heart prostacyclin or analogue to reduce ic arterial oxygenation. failure secondary to increased pulmo- pulmonary vascular resistance. nary vascular resistance. 2020 (New): ECLS in patients with su- Why: Pulmonary hypertension, a rare perior cavopulmonary anastomosis or 2020 (New): Provide careful respiratory disease in infants and children, is Fontan circulation may be considered management and monitoring to avoid associated with significant morbidity to treat low DO2 from reversible causes hypoxia and acidosis in the postoper- and mortality and requires specialized or as a bridge to a ventricular assist ative care of the child with pulmonary management. Previous PALS guidelines device or surgical revision. hypertension. did not provide recommendations for managing pulmonary hypertension in Why: Approximately 1 in 600 infants and 2020 (New): For pediatric patients infants and children. These recommen- children are born with critical con- who are at high risk for pulmonary dations are consistent with guidelines genital heart disease. Staged surgery hypertensive crises, provide adequate on pediatric pulmonary hypertension for children born with single ventricle analgesics, sedatives, and neuromus- published by the AHA and the physiology, such as hypoplastic left cular blocking agents. American Thoracic Society in 2015,16 heart syndrome, spans the first several and with recommendations contained years of life.15 Resuscitation of these 2020 (New): For the initial treatment of in a 2020 AHA scientific statement on infants and children is complex and pulmonary hypertensive crises, oxygen CPR in infants and children with differs in important ways from standard administration and induction of alka- cardiac disease.14 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 and for that caregiver to be trained and the algorithm, including anticipation • Most newly born infants do not equipped for the role. Also, a signifi- and preparation, umbilical cord require immediate cord clamping or cant proportion of newborns who need management at delivery, initial actions, resuscitation and can be evaluated facilitated transition are at risk for com- heart rate monitoring, respiratory and monitored during skin-to-skin plications that require additional trained support, chest compressions, contact with their mothers after birth. personnel. All perinatal settings should intravascular access and therapies, be ready for this scenario. withholding and discontinuing • Prevention of hypothermia is resuscitation, postresuscitation care, an important focus for neonatal and human factors and performance. resuscitation. The importance of Here, we highlight new and updated skin-to-skin care in healthy babies is recommendations that we believe will reinforced as a means of promoting have a significant impact on outcomes parental bonding, breastfeeding, and from cardiac arrest. normothermia. 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): For nonvigorous new- • A rise in heart rate is the most borns (presenting with apnea or important indicator of effective 2020 (New): Every birth should be at- ineffective breathing effort) delivered ventilation and response to tended by at least 1 person who can through MSAF, routine laryngoscopy resuscitative interventions. perform the initial steps of newborn with or without tracheal suctioning is resuscitation and initiate PPV and not recommended. • Pulse oximetry is used to guide whose only responsibility is the care of oxygen therapy and meet oxygen the newborn. 2020 (Updated): For nonvigorous new- saturation goals. borns delivered through MSAF who Why: To support a smooth and safe have evidence of airway obstruction • Routine endotracheal suctioning for newborn transition from being in the during PPV, intubation and tracheal both vigorous and nonvigorous infants womb to breathing air, every birth suction can be beneficial. born with meconium-stained amniotic should be attended by at least 1 person fluid (MSAF) is not recommended. whose primary responsibility is to the 2015 (Old): When meconium is present, Endotracheal suctioning is indicated newly born and who is trained and routine intubation for tracheal suction only if airway obstruction is suspected equipped to begin PPV without delay. in this setting is not suggested because after providing positive-pressure Observational and quality-improvement there is insufficient evidence to ventilation (PPV). studies indicate that this approach continue recommending this practice. enables identification of at-risk • Chest compressions are provided if newborns, promotes use of checklists Why: In newly born infants with MSAF there is a poor heart rate response to prepare equipment, and facilitates who are not vigorous at birth, initial to ventilation after appropriate team briefing. A systematic review of steps and PPV may be provided. Endo- ventilation-corrective steps, which neonatal resuscitation training in low- tracheal suctioning is indicated only if preferably include endotracheal resourced settings showed a reduction airway obstruction is suspected after intubation. in both stillbirth and 7-day mortality. providing PPV. Evidence from RCTs suggests that nonvigorous newborns • The heart rate response to Temperature Management for delivered through MSAF have the same chest compressions and Newly Born Infants outcomes (survival, need for respiratory medications should be monitored support) whether they are suctioned electrocardiographically. 2020 (New): Placing healthy newborn before or after the initiation of PPV. infants who do not require resuscitation Direct laryngoscopy and endotracheal • When vascular access is required skin-to-skin after birth can be effective suctioning are not routinely required for in newly born infants, the umbilical in improving breastfeeding, tempera- newborns delivered through MSAF, but venous route is preferred. When IV ture control, and blood glucose stability. they can be beneficial in newborns who access is not feasible, the IO route have evidence of airway obstruction may be considered. Why: Evidence from a Cochrane while receiving PPV. systematic review showed that • If the response to chest early skin-to-skin contact promotes Vascular Access compressions is poor, it may be normothermia in healthy newborns. In reasonable to provide epinephrine, addition, 2 meta-analyses of RCTs and 2020 (New): For babies requiring vascular preferably via the intravascular route. observational studies of extended skin- access at the time of delivery, the um- to-skin care after initial resuscitation bilical vein is the recommended route. • Newborns who fail to respond to and/or stabilization showed reduced If IV access is not feasible, it may be epinephrine and have a history or an mortality, improved breastfeeding, reasonable to use the IO route. exam consistent with blood loss may shortened length of stay, and improved require volume expansion. weight gain in preterm and low-birth- Why: Newborns who have failed to respond weight babies. to PPV and chest compressions require • If all these steps of resuscitation vascular access to infuse epinephrine and/ are effectively completed and there or volume expanders. Umbilical venous is no heart rate response by 20 catheterization is the preferred technique in minutes, redirection of care should be the delivery room. IO access is an alter- discussed with the team and family. native if umbilical venous access is not feasible or care is being provided outside of the delivery room. Several case reports have described local complications associ- ated 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. the family. A reasonable time frame for 2020 (Updated): For participants who this change in goals of care is around have been trained in neonatal resus- Why: Educational studies suggest that 20 minutes after birth. citation, individual or team booster cardiopulmonary resuscitation knowl- training should occur more frequently edge and skills decay within 3 to 12 2010 (Old): In a newly born baby with no than every 2 years at a frequency that months after training. Short, frequent detectable heart rate, it is appropriate supports retention of knowledge, skills, booster training has been shown to to consider stopping resuscitation if the and behaviors. improve performance in simulation heart rate remains undetectable for studies and reduce neonatal mortality 10 minutes. 2015 (Old): Studies that explored how in low-resource settings. To anticipate frequently healthcare providers or and prepare effectively, providers and Why: 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 competition with other students, can to consistently apply the science • Booster training (ie, brief retraining be incorporated into resuscitation supporting the evidence-based sessions) should be added to massed training for laypersons and healthcare treatment of cardiac arrest. Evidence- learning (ie, traditional course based) providers. based instructional design is critical to to assist with retention of CPR skills. improving provider performance and Provided that individual students can • Laypersons should receive training in patient-related outcomes from cardiac attend all sessions, separating training how to respond to victims of opioid arrest. Instructional design features are into multiple sessions (ie, spaced overdose, including the administration the active ingredients, the key elements learning) is preferable to massed of naloxone. of resuscitation training programs that learning. determine how and when content is • Bystander CPR training should target delivered to students. • For laypersons, self-directed training, specific socioeconomic, racial, 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 Here, we highlight new and updated CPR. • EMS systems should monitor how recommendations in education that we much exposure their providers believe will have a significant impact on • Middle school– and high school–age receive in treating cardiac arrest outcomes from cardiac arrest. children should be trained to provide victims. Variability in exposure among high-quality CPR. providers in a given EMS system Summary of Key Issues may be supported by implementing and Major Changes • In situ training (ie, resuscitation targeted strategies of supplementary education in actual clinical spaces) training and/or staffing adjustments. • The use of deliberate practice can be used to enhance learning and mastery learning during life outcomes and improve resuscitation • All healthcare providers should complete 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 hands-only CPR promotion should availability and the provision of 2020 (New): 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. prevalence of bystander CPR, and that is separated into multiple sessions, improve outcomes from OHCA. are of equal or greater effectiveness 2020 (New): It may be reasonable to when compared with courses delivered conduct in situ simulation-based resus- Major New and Updated as a single training event. Student citation training in place of traditional Recommendations attendance across all sessions is training. required to ensure course completion Deliberate Practice and because new content is presented at Why: In situ simulation refers to train- Mastery Learning each session. ing activities that are conducted in actual patient care areas, which has the 2020 (New): Incorporating a deliberate Lay Rescuer Training advantage of providing a more realistic practice and mastery learning model training environment. New evidence into basic or advanced life support 2020 (Updated): A combination of shows that training in the in situ envi- courses may be considered for improv- self-instruction and instructor-led ronment, either alone or in combination ing skill acquisition and performance. teaching with hands-on training is with traditional training, can have a recommended as an alternative to positive impact on learning outcomes Why: Deliberate practice is a training instructor-led courses for lay rescuers. (eg, faster time to perform critical tasks approach where students are given a If instructor-led training is not available, and team performance) and patient discrete goal to achieve, immediate self-directed training is recommended outcomes (eg, improved survival, neu- feedback on their performance, and for lay rescuers. rological outcomes). ample time for repetition to improve performance. Mastery learning is 2020 (New): It is recommended to train When conducting in situ simulation, defined as the use of deliberate middle school– and high school–age instructors should be wary of potential practice training and testing that children in how to perform high-quality risks, such as mixing training supplies includes a set of criteria to define CPR. with real medical supplies. a specific passing standard, which implies mastery of the tasks being 2015 (Old): A combination of self- Gamified Learning and Virtual Reality learned. instruction and instructor-led teaching with hands-on training can 2020 (New): The use of gamified learning Evidence suggests that incorporating be considered as an alternative to and virtual reality may be considered for a deliberate practice and mastery traditional instructor-led courses for lay basic or advanced life support train- learning model into basic or advanced providers. If instructor-led training is not ing for lay rescuers and/or healthcare life support courses improves multiple available, self-directed training may be providers. learning outcomes. considered for lay providers learning AED skills. Why: Gamified learning incorporates Booster Training and competition or play around the topic of Spaced Learning Why: Studies have found that self- resuscitation, and virtual reality uses a instruction or video-based instruction computer interface that allows the user 2020 (New): It is recommended to imple- is as effective as instructor-led training to interact within a virtual environment. ment booster sessions when utilizing a for lay rescuer CPR training. A shift Some studies have demonstrated massed-learning approach for resusci- to more self-directed training may positive benefits on learning outcomes tation training. lead to a higher proportion of trained (eg, improved knowledge acquisition, lay rescuers, thus increasing the knowledge retention, and CPR skills) 2020 (New): It is reasonable to use a chances that a trained lay rescuer with these modalities. Programs spaced-learning approach in place of a will be available to provide CPR when looking to implement gamified learning massed-learning approach for resusci- needed. Training school-age children or virtual reality should consider tation training. to perform CPR instills confidence and high start-up costs associated with a positive attitude toward providing purchasing equipment and software. Why: 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 im- proves 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): It is reasonable for lay rescu- ers fear injuring female victims or being ers to receive training in responding to accused of inappropriate touching. ACLS Course Participation opioid overdose, including provision of naloxone. Targeting specific racial, ethnic, 2020 (New): It is reasonable for health- and low-socioeconomic populations care professionals to take an adult Why: Deaths from opioid overdose in the for CPR education and modifying ACLS course or equivalent training. United States have more than doubled education to address gender in the past decade. Multiple studies differences could eliminate disparities Why: 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. higher rates of naloxone administration Studies show that resuscitation teams in witnessed overdoses. EMS Practitioner Experience 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): It is recommended to target 2020 (New): It is reasonable for EMS and tailor layperson CPR training to systems to monitor clinical personnel’s 2020 (New): It is reasonable to increase specific racial and ethnic populations exposure to resuscitation to ensure bystander willingness to perform and neighborhoods in the United treating teams have members com- CPR through CPR training, mass CPR States. petent in managing cardiac arrest training, CPR awareness initiatives, and cases. Competence of teams may be promotion of Hands-Only CPR. 2020 (New): It is reasonable to address supported through staffing or training barriers to bystander CPR for female strategies. Why: Prompt delivery of bystander CPR victims through educational training doubles a victim’s chances of survival and public awareness efforts. Why: A recent systematic review found from cardiac arrest. CPR training, mass that EMS provider exposure to cardiac CPR training, CPR awareness initiatives, Why: Communities with low socio- arrest cases is associated with im- and promotion of Hands-Only CPR are economic status and those with proved patient outcomes, including all associated with increased rates of predominantly Black and Hispanic rates of ROSC and survival. Because bystander CPR. populations have lower rates of by- 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 all contribute to successful resuscita- in clinical outcomes were seen only tion from OHCA. Within hospitals, the • Cognitive aids may improve in the observational data. The use of work of physicians, nurses, respirato- resuscitation performance by mobile phone technology has yet to be ry therapists, pharmacists, and other untrained laypersons, but in simulation studied in a North American setting, but professionals supports resuscitation settings, their use delays the start of the suggestion of benefit in other coun- outcomes. CPR. More development and study are tries makes this a high priority for future 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 diverse patient, community, and geo- of equipment manufacturers, • Surprisingly little is known about 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 from family and professional caregivers, • Although specialized cardiac New (2020): It is reasonable for organiza- including experts in cognitive, physical, arrest centers offer protocols and tions that treat cardiac arrest patients and psychological rehabilitation and technology not available at all to collect processes-of-care data and recovery. A systems-wide commitment hospitals, the available literature outcomes. to quality improvement at every about their impact on resuscitation level of care is essential to achieving outcomes is mixed. Why: Many industries, including health- successful outcomes. care, collect and assess performance • Team feedback matters. Structured data to measure quality and identify Summary of Key Issues debriefing protocols improve the opportunities for improvement. This and Major Changes performance of resuscitation teams in can be done at the local, regional, or subsequent resuscitation. national level through participation in • Recovery continues long after the data registries that collect informa- initial hospitalization and is a critical • System-wide feedback matters. tion on processes of care (eg, CPR component of the resuscitation Implementing structured data performance data, defibrillation times, Chains of Survival. collection and review improves adherence to guidelines) and outcomes resuscitation processes and survival of care (eg, ROSC, survival) associated • Efforts to support the ability and both inside and outside the hospital. with cardiac arrest. willingness of the members of the general public to perform CPR and Major New and Updated Three such initiatives are the AHA’s use an AED improve resuscitation Recommendations Get With The Guidelines-Resuscitation outcomes in communities. registry (for IHCA), the Cardiac Arrest Using Mobile Devices to Registry to Enhance Survival registry (for • Novel methods to use mobile phone Summon Rescuers OHCA), and the Resuscitation technology to alert trained lay Outcomes Consortium Cardiac Epistry rescuers of events that require New (2020): The use of mobile phone (for OHCA), and many regional CPR are promising and deserve technology by emergency dispatch databases exist. A 2020 ILCOR more study. systems to alert willing bystanders to systematic review found that most nearby events that may require CPR or studies assessing the impact of data • Emergency system telecommunica- AED use is reasonable. registries, with or without public tors can instruct bystanders to per- reporting, demonstrate improvement in form hands-only CPR for adults and Why: Despite the recognized role of lay cardiac arrest survival in organizations children. The No-No-Go framework is first responders in improving OHCA and communities that participated in effective. outcomes, most communities experi- cardiac arrest registries. ence low rates of bystander CPR and AED use. A recent ILCOR systematic review found that notification of lay 28 American Heart Association

References 1. Merchant RM, Topjian AA, Panchal AR, et al. Part 1: executive summary: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2020;142(suppl 2):In press. 2. International Liaison Committee on Resuscitation. 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation. 2020;142(suppl 1):In press. 3. International Liaison Committee on Resuscitation. 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation. 2020:In press. 4. Morley P, Atkins D, Finn JM, et al. 2: Evidence-evaluation process and management of potential conflicts of interest: 2020 International Consensus on Cardiopulmonary Resuscitation Science With Treatment Recommendations. Circulation. 2020;142(suppl 1):In press. 5. Magid DJ, Aziz K, Cheng A, et al. Part 2: evidence evaluation and guidelines development: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2020;142(suppl 2):In press. 6. Sawyer KN, Camp-Rogers TR, Kotini-Shah P, et al; for the American Heart Association Emergency Cardiovascular Care Committee; Council on Cardiovascular and Stroke Nursing; Council on Genomic and Precision Medicine; Council on Quality of Care and Outcomes Research; and Stroke Council. Sudden cardiac arrest survivorship: a scientific statement from the American Heart Association. Circulation. 2020;141:e654-e685. doi: 10.1161/CIR.0000000000000747 7. Jeejeebhoy FM, Zelop CM, Lipman S, et al; for the American Heart Association Emergency Cardiovascular Care Committee, Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation, Council on Cardiovascular Diseases in the Young, and Council on Clinical Cardiology. Cardiac arrest in pregnancy: a scientific statement from the American Heart Association. Circulation. 2015;132(18):1747-1773. doi: 10.1161/ CIR.0000000000000300 8. Berg RA, Sutton RM, Reeder RW, et al; for the Eunice Kennedy Shriver National Institute of Child Health and Human Development Collaborative Pediatric Intensive Care Quality of Cardio-Pulmonary Resuscitation Investigators. Association between diastolic blood pressure during pediatric in- hospital cardiopulmonary resuscitation and survival. Circulation. 2018;137(17):1784-1795. doi: 10.1161/CIRCULATIONAHA.117.032270 9. Wilson N, Kariisa M, Seth P, Smith H IV, Davis NL. Drug and opioid-involved overdose deaths—United States, 2017-2018. MMWR Morb Mortal Wkly Rep. 2020;69(11):290-297. doi: 10.15585/mmwr.mm6911a4 10. Dezfulian, et al. Opioid-associated out-of-hospital cardiac arrest: distinctive clinical features and implications for healthcare and public responses: a scientific statement from the American Heart Association. Circulation. 2020:In press. 11. Maron BJ, Udelson JE, Bonow RO, et al. Eligibility and disqualification recommendations for competitive athletes with cardiovascular abnormalities: task force 3: hypertrophic cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy and other cardiomyopathies, and myocarditis: a scientific statement from the American Heart Association and American College of Cardiology. Circulation. 2015;132(22):e273-e280. doi: 10.1161/ cir.0000000000000239 12. Maron BJ, Doerer JJ, Haas TS, Tierney DM, Mueller FO. Sudden deaths in young competitive athletes: analysis of 1866 deaths in the United States, 1980-2006. Circulation. 2009;119(8):1085-1092. doi: 10.1161/CIRCULATIONAHA.108.804617 13. Fung G, Luo H, Qiu Y, Yang D, McManus B. Myocarditis. Circ Res. 2016;118(3):496-514. doi: 10.1161/CIRCRESAHA.115.306573 14. Marino BS, Tabbutt S, MacLaren G, et al; for the American Heart Association Congenital Cardiac Defects Committee of the Council on Cardiovascular Disease in the Young; Council on Clinical Cardiology; Council on Cardiovascular and Stroke Nursing; Council on Cardiovascular Surgery and Anesthesia; and Emergency Cardiovascular Care Committee. Cardiopulmonary resuscitation in infants and children with cardiac disease: a scientific statement from the American Heart Association. Circulation. 2018;137(22):e691-e782. doi: 10.1161/CIR.0000000000000524 15. Oster ME, Lee KA, Honein MA, Riehle-Colarusso T, Shin M, Correa A. Temporal trends in survival among infants with critical congenital heart defects. Pediatrics. 2013;131(5):e1502-e1508. doi: 10.1542/peds.2012-3435 16. Abman SH, Hansmann G, Archer SL, et al; for the American Heart Association Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation; Council on Clinical Cardiology; Council on Cardiovascular Disease in the Young; Council on Cardiovascular Radiology and Intervention; Council on Cardiovascular Surgery and Anesthesia; and the American Thoracic Society. Pediatric pulmonary hypertension: guidelines from the American Heart Association and American Thoracic Society. Circulation. 2015;132(21):2037-2099. doi: 10.1161/CIR.0000000000000329 eccguidelines.heart.org 29

30 American Heart Association