AHA ACLS PALS NRP updates and cardiac arrest management - Nave.pdf

Received: 8 October 2021 | Accepted: 22 December 2021 DOI: 10.1002/jhm.2778 PROGRESS NOTES: CLINICAL PRACTICE UPDATE OR METHODOLOGICAL UPDATE Clinical progress note: AHA ACLS/PALS/NRP updates and cardiac arrest management in the time of COVID‐19 Jessica Nave MD, FHM1 | Cassi Smola MD2 1 Dep...

Received: 8 October 2021 | Accepted: 22 December 2021 DOI: 10.1002/jhm.2778 PROGRESS NOTES: CLINICAL PRACTICE UPDATE OR METHODOLOGICAL UPDATE Clinical progress note: AHA ACLS/PALS/NRP updates and cardiac arrest management in the time of COVID‐19 Jessica Nave MD, FHM1 | Cassi Smola MD2 1 Department of Medicine, Emory University, Atlanta, Georgia, USA 2 Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama, USA Correspondence Jessica Nave, MD, FHM, Department of Medicine, Emory University, 1364 Clifton Rd NE, Atlanta, GA 30322, USA. Email: [email protected]; Twitter: @allen_nave I NTR O D U C TI O N 20 2 0 A C L S U P D A T E S SU M M A R Y Despite advances in technology and research, cardiac arrest re- In the AHA ACLS 2020 updates, there were minor changes to the mains a leading cause of death around the world. It is estimated Cardiac Arrest algorithms. In the Adult Bradycardia algorithm, that 292,000 adults, 15,200 children, and 1% of newborns ad- the Atropine dose was increased from 0.5 to 1 mg, maintaining the same mitted to U.S. hospitals suffer an in‐hospital cardiac arrest (IHCA), frequency of every 3–5 min with a maximum dose of 3 mg. Other no- and hospitalists are often at the forefront of management. The table mentions in the 2020 updates include the reaffirmation of early most basic principles of cardiac arrest management are still the epinephrine in nonshockable rhythms, the lack of evidence for double prevailing determinants of survival: high‐quality chest compres- sequential defibrillation (using two defibrillators at once), preference of 1 sions and rapid defibrillation. The American Heart Association intravenous (IV) before intraosseous route for delivery of medications, (AHA) and the International Liaison Committee on Resuscitation utilization of end‐tidal CO2 (ETCO2) for monitoring CPR quality, and have moved from updating basic life support (BLS), advanced guidance for timing of neuroprognostication after cardiac arrest. Two cardiac life support (ACLS), pediatric advanced life support new algorithms addressing opioid overdose and pregnancy were also (PALS), and neonatal resuscitation program (NRP) guidelines from included (Table 1), as well as a new postcardiac arrest care algorithm. In every five years to a continuously updated review, with the most addition, postcardiac arrest care has been added to the AHA chain of recent updates released in October of 2020. Given the un- survival for both IHCA and OHCA. predictable nature of cardiac arrests, there is a paucity of clinical trials and strong evidence to support current recommendations. Specifically noted within the 2020 guidelines is that 51% of re- 2020 PALS UPDA TES S UMMARY commendations are based on limited data and 17% are based on expert opinion.1 The most important update to PALS is an increase in the In addition, the AHA released a Scientific Statement in April 2020 delivery rate of breaths during cardiac arrest with an advanced airway providing initial guidance on BLS and ACLS for patients with suspected or from 1 breath every 6 s (10/min), as in the adult algorithms, to 1 breath confirmed COVID‐19, updated in October 2021 to account for the in- every 2–3 s (20–30/min) for all scenarios.1,5 Another new re- creased understanding of viral transmissibility and to mitigate some of the commendation is the use of electroencephalography monitoring after early pandemic data that showed decreased cardiac arrest survival for cardiac arrest to detect and monitor nonconvulsive seizures for patients both IHCA and out‐of‐hospital cardiac arrest (OHCA) since the onset of that remain encephalopathic. Early delivery of epinephrine (within 5 min the pandemic. But with the emergence of more transmissible strains, of starting chest compressions) is still encouraged and may be shown to further interim guidance was provided in January 2022 to focus on the increase survival to discharge rates. Cuffed ET tubes are recommended. 2–4 protection of healthcare workers. The highlights of these updated Routine use of cricoid pressure during intubation is discouraged. The guidelines and COVID‐19 recommendations that are most relevant to relative risks and benefits of fluid resuscitation remain uncertain, although hospitalist practice are summarized below. avoiding fluid overload is recommended (Table 2). 364 | © 2022 Society of Hospital Medicine wileyonlinelibrary.com/journal/jhm J. Hosp. Med. 2022;17:364–367. NAVE AND | SMOLA TABLE 1 365 AHA ACLS 2020 updates summary table ACLS Update 2020 Update Adult bradycardia algorithm • Atropine dose increased to 1 mg (from 0.5 to 1 mg) every 3–5 min with a max dose of 3 mg on the algorithm Vasopressors • Nonshockable rhythms: Give 1 mg epi as soon as feasible (Class 2a, C‐LD) • Shockable rhythms: Give 1 mg epi after initial defibrillation attempts have failed (Class 2b, C‐LD). Per the published ACLS algorithm, epi is given after the second defibrillation attempt Route of medication delivery • Intravenous (IV) delivery of medications is preferable to intraosseous (IO) due to efficacy concerns. IO may be used if IV is not readily available (Class 2a, LOE B‐NR) Improving neuroprognostication • Perform multimodal neuroprognostication at a minimum of 72 h after return to normothermia (Class 2a, LOE B‐NR) Double sequential defibrillation in refractory VF • Recommends against the routine use (Class 2b, LOE C‐LD) Physiologic monitoring of CPR quality • Reasonable to use physiologic parameters such as arterial blood pressure or ETCO2 (targets of at least 10mmHg, ideally >20mmHg) to optimize quality (2b, C‐LD) Opioid overdose • Do not delay activating emergency response systems while awaiting a response to naloxone • In cardiac arrest, resuscitative measures take priority over naloxone administration Cardiac arrest in pregnancy • Priorities include the provision of high‐quality CPR and relief of aortocaval compression through left lateral uterine displacement (the uterus is cupped or pushed upward and leftward off maternal vessels while the patient is supine)4 (Class 1, LOE C‐LD) • If no ROSC within 5 min, consider immediate perimortem cesarean delivery Abbreviations: AHA, American Heart Association; ACLS, advanced cardiac life support. COVID ‐19 UPDATES FOR ACLS, P ALS, AND NRP 2 0 2 0 N R P UP D A T E S S U M M A R Y There were four updates for NRP.1,6 There is no longer a need to intubate and suction nonvigorous newborns delivered through meconium In January 2022, the AHA released updated interim guidance for BLS and unless there is a concern for airway obstruction after positive pressure ACLS in adults, children, and neonates with suspected or confirmed ventilation. The umbilical vein is the preferred vascular access for the COVID‐19.4 The initial guidance released early in the pandemic in April delivery of IV medications. Every birth should be attended by at least 2020 recommended donning appropriate personal protective equipment one person who can perform newborn resuscitation and is only re- (PPE) prior to any resuscitative attempt in suspected or confirmed cases.2 sponsible for the neonate. Finally, for newborns who have not responded However, the October 2021 guidance recommended not delaying chest to resuscitation efforts after 20 min, termination of resuscitation can be compressions or defibrillation to don provider PPE, but did recommend considered (Table 2). appropriate PPE as soon as feasible, and especially prior to any ventilation strategies. Given the emergence of new, more transmissible strains, the AHA returned to the initial guidance of ensuring adequate PPE is worn A C L S G U I D E L I N E S F O R I N ‐H O S P I TA L T E R M I N A T I O N OF RE S U S C I T A T I O N prior to any resuscitative attempts. In addition, the AHA aligns with the World Health Organization and the Center for Disease Control and Prevention in that it now considers all components of resuscitation (chest Knowing when to terminate a resuscitation attempt remains a challenge. compressions, ventilation, and defibrillation) to be aerosol‐generating Several clinical decision rules have been developed to assist in this de- (Table 3). cision, most notably the UN10 rule which uses three intra‐arrest variables (unwitnessed arrest, nonshockable rhythm, and 10 min of CPR without ROSC) to predict survival. The 2020 guidelines made a strong re- IN SUMMARY commendation against the use of the UN10 rule as the sole strategy for stopping resuscitation. They recommend using the clinicians' experience, The goals of these updates were to incorporate recently published the clinical exam, and the patient's prearrest condition and wishes to studies and provide graded recommendations based on the strength 1 inform their decision to terminate resuscitative attempts. In intubated of the evidence. Addressing the COVID‐19 pandemic, the AHA re- patients, failure to achieve an ETCO2 of >10 mmHg after 20 min of CPR commends strategies to keep healthcare workers safe, including may be used to inform a multimodal decision to terminate resuscitation donning appropriate PPE prior to any resuscitation attempt and en- efforts.7 couraging vaccination with a booster. Significant gaps in knowledge 366 | TABLE 2 CARDIAC ARREST MANAGEMENT UPDATES AHA PALS and NRP 2020 updates summary table 2020 Updates PALS update Respiratory rate (RR) in PALS • With an advanced airway, it may be reasonable to target a RR of 1 breath every 2–3 s (20–30 breaths per minute) (Class 2b, LOE C‐LD) Epinephrine in PALS • Use of epinephrine within 5 min from the start of chest compressions is reasonable (Class 2a, LOE C‐LD) Electroencephalography (EEG) use in postcardiac arrest care • When resources are available, continuous EEG monitoring is recommended for the detection of seizures in patients that remain encephalopathic after cardiac arrest (Class 1, LOE C‐LD) NRP update Vascular access • Umbilical vein is the recommended route at the time of delivery for babies requiring vascular access. Intraosseous access is an alternative if umbilical vein or other IV access is not feasible (Class 1, LOE C‐EO) Intubation for meconium • For nonvigourous newborns delivered through meconium‐stained amniotic fluid, routine laryngoscopy with or without tracheal suctioning is not recommended. Endotracheal suctioning is only indicated if airway obstruction is suspected after positive pressure ventilation (Class 3: No benefit, LOE C‐LD) Skilled provider present • Every birth should be attended by at least 1 person who can perform the initial steps of newborn resuscitation and whose only responsibility is to the newborn Termination of resuscitation • For newborns who have not responded to resuscitation efforts after 20 min, termination of resuscitation can be considered. (Class 1: LOE C‐LD) Abbreviations: AHA, American Heart Association; NRP, neonatal resuscitation program; PALS, pediatric advanced life support. TABLE 3 COVID‐19 ACLS guidance summary4,8 Recommendation/scenario Strategy Reduce provider exposure to COVID‐19 • Don appropriate PPE prior to performing any resuscitative attempts, including chest compressions, defibrillation, bag‐mask ventilation, intubation and positive pressure ventilation • Consider using mechanical compression devices if available and personnel are already trained • Relieve initial resuscitation personnel with providers Prioritize oxygenation and ventilation strategies with lower aerosolization risk • • • • • Intubated patients at the time of cardiac arrest • Leave on mechanical ventilation with appropriate adjusted settings with a HEPA filter Prone patient at the time of arrest • Without an advanced airway: attempt to place in supine position first • With an advanced airway: if unable to be safely turned, place pads in AP position and perform compressions over T7/T10 vertebral bodies Attach a HEPA filter to any manual or mechanical ventilation device Intubate early and connect to a ventilator with HEPA filter Use the most skilled and experienced provider to intubate Consider the use of video laryngoscopy if available and if the operator is experienced Avoid endotracheal administration of meds Abbreviations: ACLS, advanced cardiac life support; PPE, personal protective equipment. surrounding cardiac resuscitation remain. Ongoing research and innova- ORC I D tion are vital to achieve the goals of improved survival and quality of life. Cassi Smola CO NFL I CTS OF I NTEREST TW I TT ER The authors have reported no conflicts of interest. Jessica Nave https://orcid.org/0000-0003-3580-2049 @allen_nave NAVE AND | SMOLA REFERENCES 1. 2. 3. 4. 5. 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(16_suppl_2):S337‐S357. Edelson DP, Sasson C, Chan PS, et al. Interim guidance for basic and advanced life support in adults, children, and neonates with suspected or confirmed COVID‐19: from the emergency cardiovascular care committee and get with the guidelines‐resuscitation adult and pediatric task forces of the American Heart Association. Circulation. 2020;141(25):e933‐e943. 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How to cite this article: Nave J, Smola C. Clinical progress note: AHA ACLS/PALS/NRP updates and cardiac arrest management in the time of COVID‐19. J Hosp Med. 2022;17: 364‐367. doi:10.1002/jhm.2778