“

”
Moderator : Dr. Ajeet Kumar Presenter: Dr. Sushant Satya Priya
1.Double- sequential Defibrillation –
Not supported
-It is practice of applying near simultaneous
shocks using 2 defibrillators.
In 2020 (New)
The usefulness of double sequential
defibrillation for refractory shockable rhythm
has not been established .
 Not showed decreased in mortality.
 A recent pilot RCT suggested that changing the direction of
defibrillation current by repositioning the pads may be as effective as
double sequential defibrillation while avoiding the risks of harm from
increased energy and damage to defibrillators.

 On the basis of current evidence , it is not known whether double

sequential defibrillation is beneficial.
2.Early Initiation of CPR by Lay Rescuers

2020 (Updated):-

Recommended that laypersons initiate CPR for presumed cardiac arrest because
the risk of harm to the patient is low if the patient is not in cardiac arrest.

2010 (Old):

The lay rescuer should not check for a pulse and should assume that cardiac
arrest is present if an adult suddenly collapses or an unresponsive victim is not
breathing normally.

The healthcare provider should take no more than 10 sec. to check for a pulse
and ,if the rescuer does not definitely feel a pulse within that time period,
rescuer should start chest compressions.
• New evidence shows that the risk of harm to a victim who receives chest
compressions when not in cardiac arrest is low.
Lay rescuers are not able to determine with accuracy whether a victim has a
pulse, and the risk of withholding CPR from a pulseless victim exceeds the harm
from unneeded chest compressions.

 A) 75 yr old elderly man , DM(On B)

Insulin), taken in early morning ---went
to airport – there was rush, traffic
Elderly male, k/c/o Chronic stable
jam ,not able to eat—when he arrived angina--- Pt had sudden palpitation,
at airport – he was hypoglycemic – he developed Ventricular fibrillation---
collaped. collapsed on floor.
 For us Doctor- It is under stable that  Police personnel came started
we have to start sugar, or need to take CPR+
I.V excess.
 Recovery ++,
 For police personnel –presumed cardiac
arrest ( look for chest movement,  Here CPR - Required.
carotid pulsation)
 Start CRP +, Even early CRP/By
standard CRP will able to save life.
3. Early administration of Epinephrine
Administration of Epinephrine
2020 (Unchanged /Reaffirmed)
 With respect to timing , for cardiac
arrest with a non shockable
rhythm, it is reasonable to
administer epinephrine ASAP.
2020 (Unchanged /Reaffirmed)
 With respect to timing for cardiac
arrest with a shockable rhythm, It
may be reasonable to administer
epinephrine after initial
defibrillation attempts have failed.
Which enhances the coronary
perfusion and reduced the
Ischemia.
In Pediatric resuscitation –
Epinephrine <5 min of CPR Initiation.
In Adult - ASAP
4.Post- Cardiac Arrest Care and Neuroprognostication

2020 Guidelines contain significant new clinical data about optimal care in the
days after cardiac arrest .

Recommendations from 2015 AHA Guidelines Update for CPR and ECC about
treatment of hypotension, titrating oxygen to avoid both hypoxia and hyperoxia,
detection and treatment of seizures and targeted temperature management
were reaffirmed with new supporting evidence.

2020 Guidelines evaluate 19 different modalities and specific findings and

present the evidence for each.
 Evaluate and treat rapidly reversible etiologies.
5 H’S 5 T’S
Hypovolemia Tension pneumothorax
Hypoxia Tamponade, cardiac
Hydrogen ion(acidosis) Toxins
Hypokalemia /hyperkalemia Thrombosis, pulmonary
Hypothermia Thrombosis , coronary
 5.Care and Support During Recovery

2020 (New) :

Recommended that cardiac arrest survivors have multimodal rehabilitation assessment and
treatment for physical , neurologic, cardiopulmonary , and cognitive impairments before
discharge from the hospital.

2020 (New) :

Recommended that cardiac arrest survivors and their caregivers receive comprehensive,
multidisciplinary discharge planning , to include medical and rehabilitative treatment
recommendations and return to activity /work expectations.

2020 (New):

Recommended structured assessment of anxiety, depression, posttraumatic stress, and

fatigue for cardiac arrest survivors and their caregivers.
6.Recommended approach to multimodal neuroprognostication in adult
patients after cardiac arrest
Therapeutic hypothermia –
first 24 hrs
Low the temperature –
metabolism of Neurons will
decrease
Energy requirement of cell
decreases – cell survival
chance increases.
7.AHA Chains of survival for adult IHCA and OHCA

A sixth link , Recovery, was added to the IHCA and OHCA Chains of Survival
8. AHA Chains of Survival for pediatrics IHCA and OHCA
9.Pediatric Basic and Advanced Life Support

 Major changes
3. Choose of Cuffed ETTS
2020 (Updated )
It is reasonable to choose cuffed ETTS over uncuffed ETTS for intubating
infants and children.
 When a cuffed ETT is used , attention should be paid to ETT size, position and
cuff inflation pressure (<20-25 cm H20).
 Currently we are using high volume , less pressure cuffed so, chances of
subglottic stenosis is less.
2010 (old)
Both cuffed and uncuffed ETTS are acceptable for intubating infants and
children.
10.Cricoid pressure during Intubation

2020 (Updated)-
 Routine use of cricoid pressure is not recommended during endotracheal
intubation of pediatric patients.

Reason- If we are using cuffed ETT reduced chance of aspiration .

 Routine use of Cricoid pressure reduces intubation success rates and does not
reduce the rate of regurgitation .

2010 (Old)

 There is insufficient evidence to recommended routine application of cricoid

pressure to prevent aspiration during endotracheal intubation in children.
 11.Changes to the Assisted Ventilation Rate: Rescue Breathing

2020 (Updated ) (PBLS)

 For infants and children with a pulse but absent or inadequate respiratory effort.

 it is reasonable to give 1 breath every 2 to 3 seconds (20-30 breaths/min).

2010 (old) (PBLS)

 If there is a palpable pulse 60/min or greater but there is inadequate breathing.

 Give rescue breaths @ 12-20 /min (1 breath every 3-5 seconds) until spontaneous
breathing resumes.
12.Changes to the Assisted Ventilation Rate: Ventilation Rate
During CPR With an Advanced Airway
Ventilation Rate during CPR with an advanced Airway.
2020 (Updated): (PALS)
1 breath every 2 to3 seconds :- 20-30 breath /min.
2010 (Old): (PALS)
1 breath /5-6 seconds :- 10-12 breath /min.

Reason – New data show that higher ventilation rates ( at least 30/min in infants [ <1
year] and at least 25/min in children) are associated with improved rate of ROSC and
survival in pediatric IHCA.

 There is no data about the ideal ventilation rate during CRP without an advanced
airway or, for children in respiratory arrest with or without an advanced airway.
13. Septic shock
Fluid Boluses
2020 (Updated):
In patients with septic shock, it is reasonable to administer fluid in 10 ml/kg or 20 ml/kg
aliquots with frequent reassessment.
2015(Old):
Administration of an initial fluid bolus of 20 ml /kg to infants and children with shock is
reasonable , including those with conditions such as severe malaria , and dengue.
Choice of Vasopressor
2020 (New):
In infants and children with fluid –refractory septic shock, it is reasonable to use either
epinephrine or norepinephrine as an initial vasoactive infusion.
2020 (New):
In Infants and children with fluid- refractory septic shock, if Epinephrine or
norepinephrine are unavailable, dopamine may be considered.
14. Corticosteroid Administration

2020 (New)
 For Infants and children with septic shock unresponsive to fluid and requiring
vasoactive support.
 It may be reasonable to consider stress- dose corticosteroids.
Reason
 Fluid remain the main stay of initial therapy for infants and children in shock,
especially in hypovolemic and septic shock.
 Fluid overload can lead to increased morbidity.
 In recent trails of patients with septic shock, those who received higher volumes or
faster fluid resuscitation were more likely to develop clinically significant fluid
overload and require mechanical ventilation.
 Earlier the Guidelines did not provide recommendations about choice of vasopressor
or the use of corticosteroids in septic shock.
15.Hemorrhagic shock
2020 (New):

 Among infants and children with hypotensive hemorrhagic shock following

trauma, it is reasonable to administer blood products (PRBC, FFP and
Platelets) when available , instead of crystalloid for ongoing volume
resuscitation.

 Previous versions of the Guidelines did not differentiate the treatment of

hemorrhagic shock from other causes of hypovolemic shock.
16. Opioid Overdose
2020 (Updated):

For patients in respiratory arrest, rescue breathing or bag-mask ventilation

should be maintained until spontaneous breathing returns, and standard PBLS or
PALS measures should continue if return of spontaneous breathing does not
occur.

2020(Updated):

For a patient with suspected opioids overdose who has a definite pulse but no
normal breathing or only gasping (i.e a respiratory arrest ), in addition to
providing standard PBLS or PALS, it reasonable for responders to administer
intramuscular or intranasal naloxone.
2020 (Updated): Opioid Overdose

 For patients known or suspected to be cardiac arrest, in the absence of a proven

benefit from the use of naloxone, standard resuscitative measures should take priority
over naloxone administration, with a focus on high-quality CPR(compressions plus
ventilation).

 These recommendations are identical for adult and children, except that compression-
ventilation CPR is recommended for all pediatric victims of suspected cardiac arrest.

 Naloxone can be administered by trained providers, laypersons with focused training ,

and untrained laypersons (who cannot reliably check pulse).
17.Pediatric Cardiac Arrest Algorithm
18.Pediatric Bradycardia with a Pulse Algorithm
19.Pediatric Tachycardia With a Pulse Algorithm
20.Cardiac Arrest in Pregnancy
2020 (New):
Because pregnant patients are more prone to hypoxia , oxygenation and airway
management should be prioritized during resuscitation from cardiac arrest in pregnancy.
2020 (New):
Because of potential interference with maternal resuscitation, fetal monitoring should
not be undertaken during cardiac arrest in pregnancy.
2020(New):
Recommended targeted temperature management of pregnant women who remain
comatose after resuscitation from cardiac arrest.
2020 (New):

During targeted temperature management of the pregnant patient, it is recommended

that the fetus be continuously monitored for bradycardia as a potential complication, and
obstetric and neonatal consultation should be sought.
Cardiac Arrest in Pregnancy
Etiology: Potential Etiology of Maternal Cardiac Arrest.
A : Anesthetic complications:- Anesthetic Drugs
B: Bleeding :- PPH
C: CVS- Pre-existing valvular lesion
D:Drugs : Lignocaine : Used in Episiotomy
E: Embolism
F: Fever
G:General non-obstetrics causes of cardiac arrest(H’S and T’S)
H: Hypertension
Maternal Intervention

 1. Airway management
 2. 100 % Oxygen administration
 3. Secure I.V line above the diaphragm
 4. If receiving I.V magnesium –stopped and give calcium chloride or gluconate.

Obstetric Intervention for fetus

 Provide continuous lateral uterine displacement- to relief of aorto-caval
compression.
 Prepare for perimortem caesarean section.
 Goal is to improve maternal and fetal outcome.
 Ideally perform perimortem c-delivery in 5 min if No ROSC.
21.Cardiac Arrest in Pregnancy In- Hospital ACLS Algorithm
22. Real Time Audiovisual Feedback
 For training purpose
2020 (Unchanged /Reaffirmed ):

It may be reasonable to use audio-visual feedback devices during CPR for real –
time optimization of CPR performance.

23. Physiological monitoring of CPR Quality

2020 (Updated):

CPR Quality is monitored by using either ETCo2, diastolic blood pressure,

CvO2( Central Venous oxygen saturation).
 Monitoring depends on the presence of ETT or arterial line, respectively.
 Targeting compressions to an ETCo2 value- at least 10 mm of Hg, Ideally 20 mm
of Hg.
23. I.V Access Preferred Over I.O
2020 (New):

It is reasonable for providers to first attempt establishing intravenous(IV)

access for drug administration in cardiac arrest.

2020(Updated):

Intraosseous(IO) access may be considered if attempts at IV access are

unsuccessful or not feasible.

2010(Old):

It is reasonable for providers to establish IO access if IV access is not readily

available.
24.Debriefings for Rescuers

2020 (New):

Debriefings and referral for follow up for emotional support for lay rescuers, EMS
providers, and hospital –based healthcare workers after a cardiac arrest event may
be beneficial.

25.Myocarditis

2020(New)
 Children with acute myocarditis who have arrythmias, heart block, ST-segment
changes, or low cardiac output are at high risk of cardiac arrest.

 Early transfer to an intensive care unit is important , and some patients may
require mechanical circulatory support or extracorporeal life support( ECLS)
26. Pulmonary Hypertension

2020 (Updated):

 Management of pulmonary hypertension may include the use of inhaled nitric

oxide, prostacyclin, analgesia, sedation, neuromuscular blockade, the
induction of alkalosis, or recue therapy with ECLS( extracorporeal life support).
27. Single Ventricle
2020(New):

 Infants and children with congenital heart disease and single ventricle
physiology who are in the process of staged reconstruction require special
considerations in PALS management.
Highlights of Key changes In 2020 CPR Guidelines
BLS
 1. A sixth link , Recovery added to all 4 chains of survival
 2. Emphasis on early Epinephrine administration ( within 5 min of cardiac
arrest ), repeat doses every 4 minutes to coincide with alternate pulse
check
 3. Separate algorithm for pregnant women ( for perimortem C/S if no ROSC
in 4 min changed to 5 min) and Opioid related arrests.
 4. EEG, neurological imaging introduced as part of post resuscitation care
 5.Rate of breaths in pediatric age group increased to 1 breath every 2 to3
seconds( 20-30 bpm). 30 in children <1 year, 25 for >1 year.
 Advise to consider a cuffed ETT in pediatric age group
 New algorithm for pediatric tachycardia with pulse ( QRS duration 0.09 sec)
 Umbilical vein catheterization to be considered.
 2 thumb encircling compression in infants is better than 2 fingers compression
 FAS (facial drop, arm drift, speech difficulties) changed to FAST ( time to call
emergency number) for stroke
 Aspirin intake advised for all non traumatic chest pain before arrival of EMS
unless contraindicated
 Fetal monitoring not advised during maternal resuscitation. Post ROSC, yes.
Rolling over on left post ROSC
 Ventilation rate in adults 1 breath every 6 seconds rather than 5-6 seconds
 Use of waveform capnography recommended during bag mask ventilation too
 Use of mobile technology reasonable.
ACLS
 Amiodarone and lidocaine are now considered equivalent as antiarrhythmic
in cardiac arrest scenarios.
 For adult symptomatic bradycardia atropine dose changed to 1 mg from 0.5
mg. Dopamine dose for this changed from 2-20 mcg/kg/min to 5-20
mcg/kg/minute
 Emphasis on prevention of hyperoxia , hypoxemia and hypotension
 Initial stabilization split in to manage airway , manage hemodynamic
parameters
 For adult tachycardia IV access and ECG moved earlier in the algorithm
 Updated ACS algorithm contact to balloon inflation goal less than or equal to
90 minutes
 Target SpO2 >94 % for stroke and general care ; 92-98% for post cardiac
arrest care
 During CPR, 15 seconds before pausing compressions, high performance team
should check for pulse , pre charge defibrillator, and prepare to deliver shock
in 10 seconds or less to increase CCF> 80 % as 10% rise in CCF leads to 11 %
rise in survival
 Real Time Audiovisual Feedback
 IV preferred over IO
 New diagram to guide neuro prognostication
Reference-
2020 American Heart Association Guidelines for CPR and ECC