The Pre-brief
The American Heart Association (AHA) has released a guideline update of cardiopulmonary resuscitation (CPR) for 2020. The latest CPR guidelines address the management of opioid-related cardiac arrest, racial and gender disparities in rates of CPR, and the utilization of digital technology in facilitating cardiac arrest response.
Here is the summary of some of the changes:1
Laypersons should not delay initiating CPR for presumed cardiac arrest.
The latest evidence suggests that the risk of harm when chest compressions are performed on a victim who is not in cardiac arrest is low. The risk of withholding CPR from a pulseless victim far exceeds the harm from unneeded chest compressions.
The routine use of double sequential defibrillation is not recommended at this time.
Double sequential defibrillation is the practice of applying near-simultaneous shocks using two defibrillators. Existing studies supporting this practice are subject to multiple forms of bias. Many observational studies show no improvement in clinical outcomes. Based on the current evidence, it is not known whether double sequential defibrillation benefits cardiac arrest patients compared to standard defibrillation.
When caring for patients with opioid-related emergencies, both lay rescuers and trained responders should not delay activating emergency response systems while awaiting the patient’s response to naloxone or other interventions.
The AHA offers two new algorithms for managing patients who are experiencing opioid-related emergencies.2 For patients in cardiac arrest, in the absence of a proven benefit from using naloxone, conventional resuscitative measures should take high priority than naloxone administration with a strong emphasis on good quality chest compressions and positive ventilation. This acknowledges the critical nature of the opioid crisis facing healthcare today.
Infants and children who are receiving CPR and have an advanced airway in place or receiving rescue breathing and have a pulse should be ventilated at a higher respiratory rate (20-30 breaths/min).
Data from pediatric in-hospital cardiac arrest (IHCA) show improved rates of Return of Spontaneous Circulation (ROSC) with higher ventilation rates, at least 30/min in infants<1 year, and at least 25/min in children, previously 12-20 breaths per minute with an advanced airway. Although there are no data about the ideal ventilation rate during CPR without an advanced airway, or for apneic children with or without an advanced airway, for simplicity’s sake, the respiratory rate recommendation was standardized for both situations. Rates exceeding these recommendations may compromise hemodynamics
When caring for a pregnant patient in cardiac arrest, prioritize oxygenation, and airway management.
A new Cardiac Arrest in Pregnancy Algorithm has been added to address many of the special cases in this patient population. Rescuers should secure the airway early and ensure optimal oxygenation to pregnant patients in order to compensate for the decrease in functional reserve capacity caused by the gravid uterus and prevent fetal brain injury from hypoxemia. Monitoring the fetal heart during cardiac arrest is not necessary and may distract from important resuscitative measures. Targeted temperature management should be provided to the pregnant patient while closely monitoring the status of the fetus.
Finally, given the low rates of bystander CPR in communities of color and in those with low socioeconomic status, CPR training should be targeted to these communities.
Barriers to CPR training still exist in many communities of color. Additionally, black or hispanic patients and women are less likely to receive bystander CPR than white and male patients. Modifying education to address racial and gender disparities would enhance outcomes from cardiac arrest.
The Debrief
The AHA’s 2020 CPR guidelines provide a comprehensive guide to resuscitation. In addition to highlighting some of the issues related to patients with opioid overdose, they also address the existing racial and gender disparities in CPR education.
References
- Merchant Raina M., Topjian Alexis A., Panchal Ashish R., et al. Part 1: Executive Summary: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2020;142(16_suppl_2):S337-S357. doi:10.1161/CIR.0000000000000918
- Panchal Ashish R., Bartos Jason A., Cabañas José G., et al. Part 3: Adult Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2020;142(16_suppl_2):S366-S468. doi:10.1161/CIR.0000000000000916
