3. INTRODUCTION
● Approximately every five years the International Liaison Committee on
Resuscitation (ILCOR), updates the guidelines for CPR and ECC
(Emergency Cardiac Care)
● One of the biggest changes was D-R-A-B-C to D-R-C-A-B in the 2010
update
● A total of 213 OHCA cases occurred under Kuala Lumpur MECC in 2011
Source: Nurumal MS, Karim SSA. 2015. Out of hospital cardiac arrest in Kuala Lumpur: incidence;
adherence to protocol; and issues: a mixed method study. Malaysian J Public Health Med , 15(3), 94–103
Performed CPR Applied AED and
analyzed the rhythm
Inserted advanced
airway
126
(59.2%)
102
(47.9%)
94
(44.1%)
Secured IV line and at
least 1mg adrenaline
was administered
Survival rate
38
(17.8%)
48
(22.5%)
Ambulance
dispatched within
3 minutes
181
(85%)
7. 02. Early Initiation of CPR by Lay
Rescuers
• Lay rescuer CPR improves survival from cardiac arrest by 2-3 fold1
• The benefit of providing CPR to a patient in cardiac arrest outweighs any
potential risk of providing chest compressions to someone who is unconscious
but not in cardiac arrest. It has been shown that the risk of injury from CPR is low
in these patients2
• Bystanders should not be afraid to start CPR even if they are not sure whether
the victim is breathing or in cardiac arrest
1. Sasson C, Rogers MA, Dahl J, Kellermann AL. 2010. Predictors of survival from out-of-hospital cardiac arrest: a systematic review and meta-analysis. Circ
Cardiovasc Qual Outcomes, 3:63–81
2. Olasveengen TM, Mancini ME, Perkins GD, Avis S, Brooks S, Castrén M, Chung SP, Considine J, Couper K, Escalante R, et al; on behalf of the Adult Basic Life Support
Collaborators. 2020. Adult basic life support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With
Treatment Recommendations. Circulation, 142(suppl 1):S41–S91
8. “If I say my staff adhere 100% to
OHCA protocol, but the society
never take their roles as a
bystander, it is still not
meaningful.”
Source: Nurumal MS, Karim SSA. 2015. Out of hospital cardiac
arrest in Kuala Lumpur: incidence; adherence to protocol; and
issues: a mixed method study. Malaysian J Public Health Med ,
15(3), 94–103
—Prof SFJ,
Former National Head of Trauma & Emergency
9. 03. The Use of Adrenaline in Cardiac
Arrest
• The AHA Guidelines 2015 made a weak recommendation that resuscitation teams
consider giving adrenaline as soon as feasible when the patient presents with a non-
shockable rhythm1
• The AHA Guidelines 2015 made no recommendation on when resuscitation teams
should administer adrenaline to patients with shockable rhythms1
• The 2019 AHA Focused Update recommended adrenaline for the treatment of cardiac
arrest in adult patients2.
• The AHA Guidelines 2020 strongly reaffirm that position. With respect to timing, for
cardiac arrest with a non-shockable rhythm, it is reasonable to administer adrenaline
as soon as feasible. And for cardiac arrest with a shockable rhythm, it may be
reasonable to administer adrenaline after initial defibrillation attempts have failed.
1. Link MS, Berkow LC, Kudenchuk PJ, Halperin HR, et al. 2015. Part 7: Adult advanced cardiovascular life support: 2015 American Heart Association guidelines update for
cardiopulmonary resuscitation and emergency cardiovascular care. Circulation, 132(18 Suppl 2), S444-S464
2. Panchal AR, Berg KM, Hirsch KG, Kudenchuk PJ, et al. 2019. 2019 American Heart Association focused update on advanced cardiovascular life support: Use of advanced
airways, vasopressors, and extracorporeal cardiopulmonary resuscitation during cardiac arrest: An update to the American Heart Association guidelines for
cardiopulmonary resuscitation and emergency cardiovascular care. Circulation, 140(24), e881-e894
10.
11. 04. Real-Time Audiovisual Feedback
• It may be reasonable to use audiovisual feedback devices during CPR for real-
time optimization of CPR performance.
• A 2019 RCT reported a 25% increase in survival to hospital discharge from
IHCA with audio feedback on compression depth and recoil1
1. Goharani R, Vahedian-Azimi A, Farzanegan B, Bashar FR, Hajiesmaeili M, Shojaei S,
Madani SJ, Gohari-Moghaddam K, Hatamian S, Mosavinasab SMM, Khoshfetrat M,
Khabiri Khatir MA, Miller AC; MORZAK Collaborative. 2019. Real-time compression
feedback for patients with in-hospital cardiac arrest: a multi-center randomized
controlled clinical trial. J Intensive Care, 7:5
12. 05. Physiologic Monitoring of CPR Quality
• It may be reasonable to use physiologic parameters such as IABP or EtCO2 to monitor
and optimize CPR quality
• A 2018 systematic review1 found EtCO2 less than 10 mmHg was generally associated with
poor outcome and greater than 20 mmHg had a stronger association with ROSC than a
value of greater than 10 mmHg.
1. Paiva EF, Paxton JH, O’Neil BJ. 2018. The use of end-tidal carbon dioxide (ETCO2) measurement to guide management of cardiac arrest: A systematic review. Resuscitation, 123:1–7
13. 06. Double Sequential Defibrillation Not
Supported
• Double sequential defibrillation is the practice of applying near
simultaneous shocks using 2 defibrillators
• The usefulness of double sequential defibrillation for refractory
shockable rhythm has not been established
• A 2020 ILCOR systematic review1 found no evidence to support
double sequential defibrillation and recommended against its
routine use
1. Berg KM, Soar J, Andersen LW, Böttiger BW, Cacciola S, Callaway CW, Couper K, Cronberg T, D’Arrigo S, Deakin CD, et al; on behalf of the
Adult Advanced Life Support Collaborators. 2020. Adult advanced life support: 2020 International Consensus on Cardiopulmonary
Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation, 142(suppl 1):S92–S139
14. 07. IV Access Preferred Over IO
• The AHA Guidelines 2010 recommended providers to establish IO access if IV access is
not readily available
• The AHA Guidelines 2020 recommends to first attempt establishing IV access for drug
administration in cardiac arrest and consider IO if attempts at IV access are
unsuccessful or not feasible
15. 08. Two New Opioid-Associated Emergency
Algorithms
19. 10. Debriefing for Rescuers
• 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
• Rescuers may experience anxiety or posttraumatic stress about providing or not
providing BLS. Hospital-based care providers may also experience emotional or
psychological effects of caring for a patient with cardiac arrest.
• Team debriefings may allow a review of team performance (education, quality,
improvement) as well as recognition of the natural stressors associated with caring for a
patient near death
20. 11. Cardiac Arrest in Pregnancy
• Because pregnant patients are more prone to hypoxia, oxygenation and airway
management should be prioritized during resuscitation from cardiac arrest in pregnancy
• Priorities for the pregnant woman in cardiac arrest should include provision of high-quality
CPR, left lateral uterine displacement, and removal of fetal monitoring devices
• perimortem cesarean delivery should be considered as soon as cardiac arrest in a woman
in the second half of pregnancy is recognized
• Recommendation of targeted temperature management with fetal monitoring for
pregnant women who remain comatose after resuscitation from cardiac arrest
24. 02. Changes to Assisted Ventilation Rate
• Rescue breaths: 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)
• Ventilation rate with advanced airway: When performing CPR in infants and children with an
advanced airway, it may be reasonable to target a respiratory rate range of 1 breath every 2 to
3 seconds (20-30/min)
• Higher ventilation rates (at least 30/min in infants [younger than 1 year] and at least 25/min in
children) are associated with improved rates of ROSC and survival in pediatric IHCA1
1. Sutton RM, Reeder RW, Landis WP, Meert KL, Yates AR, Morgan RW, Berger JT, Newth CJ, Carcillo JA, McQuillen PS, Harrison RE, Moler FW, Pollack MM, Carpenter TC, Notterman DA, Holubkov
R, Dean JM, Nadkarni VM, Berg RA; Eunice Kennedy Shriver National Institute of Child Health and Human Development Collaborative Pediatric Critical Care Research Network (CPCCRN). 2019.
Ventilation Rates and Pediatric In-Hospital Cardiac Arrest Survival Outcomes. Crit Care Med, 47:1627–1636
25.
26. 03. Cuffed ETTs
• The AHA Guidelines 2010 accepts the use of both cuffed and uncuffed ETTs for intubating
infants and children.
• The AHA Guidelines 2020 recommends choosing cuffed ETTs over uncuffed ETTs for
intubating infants and children.
27. 04. Cricoid Pressure
• In the AHA Guidelines 2010 there was insufficient evidence to recommend routine
application of cricoid pressure to prevent aspiration during endotracheal intubation in
children
• The AHA Guidelines 2020 recommended against the use of cricoid pressure due to studies
showing that routine use of cricoid pressure reduces intubation success rates and does not
reduce the rate of regurgitation1,2
1. Kojima T, Laverriere EK, Owen EB, Harwayne-Gidansky I, Shenoi AN, Napolitano N, Rehder KJ, Adu-Darko MA, Nett ST, Spear D, et al; and the National Emergency Airway Registry for Children
(NEAR4KIDS) Collaborators and Pediatric Acute Lung Injury and Sepsis Investigators (PALISI). 2018. Clinical impact of external laryngeal manipulation during laryngoscopy on tracheal
intubation success in critically ill children. Pediatr Crit Care Med, 19:106–114
2. Kojima T, Harwayne-Gidansky I, Shenoi AN, Owen EB, Napolitano N, Rehder KJ, Adu-Darko MA, Nett ST, Spear D, Meyer K, Giuliano JS Jr, Tarquinio KM, Sanders RC Jr, Lee JH, Simon DW,
Vanderford PA, Lee AY, Brown CA III, Skippen PW, Breuer RK, Toedt-Pingel I, Parsons SJ, Gradidge EA, Glater LB, Culver K, Nadkarni VM, Nishisaki A; National Emergency Airway Registry for
Children (NEAR4KIDS) and Pediatric Acute Lung Injury and Sepsis Investigators (PALISI). 2018. Cricoid Pressure During Induction for Tracheal Intubation in Critically Ill Children: A Report From
National Emergency Airway Registry for Children. Pediatr Crit Care Med, 19:528–537
28. 05. Adrenaline Within 5 Minutes
• The AHA Guidelines 2015 recommends the administration of adrenaline in pediatric cardiac
arrest
• The AHA Guidelines 2020 further reaffirms by recommending administration of the initial
dose of adrenaline within 5 minutes from the start of chest compressions
• Patients who received adrenaline within 5 minutes of CPR compared to those who received
adrenaline more than 5 minutes after CPR initiation were more likely to survive to discharge1
1. Andersen LW, Berg KM, Saindon BZ, Massaro JM, Raymond TT, Berg RA, Nadkarni VM, Donnino MW; American Heart Association Get With the Guidelines–Resuscitation Investigators.
Time to Epinephrine and Survival After Pediatric In-Hospital Cardiac Arrest. JAMA. 2015;314:802–810
29.
30. 06. Shock Resuscitation
• Fluid boluses: In patients with septic shock, it is reasonable to administer fluid in 10 mL/kg
or 20 mL/kg with frequent reassessment
• Vasopressors: In infants and children with fluid-refractory septic shock, it is reasonable to
use either adrenaline or noradrenaline as an initial vasoactive infusion. If neither is available,
dopamine may be considered
• Corticosteroids: For infants and children with septic shock unresponsive to fluids and
requiring vasoactive support, it may be reasonable to consider stress-dose corticosteroids
• Blood products: Among infants and children with hypotensive hemorrhagic shock
following trauma, it is reasonable to administer blood products, when available, instead of
crystalloid for ongoing volume resuscitation
Malaysia's MECC also practices telephone CPR, but only recently during the year the data was collected, thus this study could not capture how many of the bystanders performed CPR among the 213 cases.
chances of survival could decrease 7-10% for every minute without CPR
A bystander practicing CPR is not a local problem and it is, indeed, a global problem which includes the developed nations
Japan has a rate of 45% bystander CPR and it is the highest in the world followed by Korea at 34%
In US in the year 2015 less than 40% of adults receive layperson-initiated CPR, and fewer than 12% have an automated external defibrillator (AED) applied before EMS arrival
The universal Adult Cardiac Arrest Algorithm was modified to emphasize the role of early epinephrine administration for patients with nonshockable rhythms
improved survival to hospital admission in patients receiving either amiodarone or lidocaine (compared with placebo) in the most recent ROC-ALPS (
Resuscitation Outcomes Consortium-Amiodarone, Lidocaine, Placebo Study) trial, as well as the improved survival to hospital discharge among patients with witnessed cardiac arrest who received amiodarone or lidocaine
A sixth link, Recovery, was added to the IHCA and OHCA Chains of Survival
highlights the enormous recovery and survivorship journey, from the end of acute treatment for critical illness through multimodal rehabilitation (both short- and long-term), for both survivors and families after cardiac arrest
This new link acknowledges the need for the system of care to support recovery, discuss expectations, and provide plans that address treatment, surveillance, and rehabilitation for cardiac arrest survivors and their caregivers as they transition care from the hospital to home and return to role and social function.
Cardiac arrest survivors should get multimodal rehabilitation assessment and treatment for physical, neurologic, cardiopulmonary, and cognitive impairments before discharge from the hospital
cardiac arrest survivors and their caregivers receive comprehensive, multidisciplinary discharge planning, to include medical and rehabilitative treatment recommendations and return to activity/work expectations
Which includes structured assessment for anxiety, depression, posttraumatic stress, and fatigue for cardiac arrest survivors and their caregivers
The importance of early initiation of CPR by lay rescuers has been re-emphasized
The suggestion to administer epinephrine early was strengthened to a recommendation on the basis of a systematic review and meta-analysis, which included results of 2 randomized trials of epinephrine enrolling more than 8500 patients with OHCA, showing that epinephrine increased ROSC and survival
The universal Adult Cardiac Arrest Algorithm was modified to emphasize the role of early epinephrine administration for patients with nonshockable rhythms
Changes to the algorithm now depict adrenaline administration as appropriate after the second defibrillation attempt for shock refractory rhythms
A recent systematic review of 11 RCTs (overall moderate to low certainty of evidence) found no evidence of improved survival with good neurological outcome with mechanical CPR compared with manual CPR in either OHCA or IHCA.1 Given the perceived logistic advantages related to limited personnel and safety during patient transport, mechanical CPR remains popular among some providers and systems.
Targeting compressions to an ETCO2 value of at least 10 mm Hg, and ideally 20 mm Hg or greater, may be useful as a marker of CPR quality
An observational study in adult patients (IHCA and OHCA) reported that for every 10 mm compression depth increase, ETCO2 increased 1.4 mm Hg
A ETCO2<10mmHg after 20min of CPR is associated with a 0.5% likelihood of ROSC
ROSC is recognized by the abrupt increase in the Petco2 (visible just after the fourth vertical line) to over 40 mm Hg, which is consistent with a substantial improvement in blood flow.
Refractory VF – VF that does not convert with 3 or more single defib attempts
Existing supporting studies are subject to multiple forms of bias, and observational studies do not show improvements in outcome
Risk – damage to one or both defibs
a rigorous review of the evidence questions the efficacy of the IO route when compared to the IV route
Two new Opioid-Associated Emergency Algorithms have been added for lay rescuers and trained rescuers
More refined
2015 guidelines only has 1 algorithm regarding opioid associated emergency
Enforcing the recommendation for a layperson to initiate CPR without checking pulse
The Post–Cardiac Arrest Care Algorithm was updated to emphasize the need to prevent hyperoxia, hypoxemia, and hypotension
Obtain 2 cooling blankets and cables (one machine) to “sandwich” the patient; each blanket should have a sheet covering it to protect the patient’s skin
Alternatively, place heat-exchange pads on the patient per the manufacturer’s recommendation
Pack the patient in ice (groin, chest, axillae, and sides of neck); use additional measures as needed to bring the patient to a temperature between 32°C and 36°C; avoid packing ice on top of the chest, which may impair chest wall motion
Monitor vital signs and oxygen saturation and place the patient on a continuous cardiac monitor, with particular attention to arrhythmia detection and hypotension, bradycardia
Once a temperature below the goal temperature is reached, remove ice bags and use the cooling blanket or heat-exchange device to maintain temperature between 32°C and 36°C
Rewarming can be begun 24 hours after the time of initiation of cooling, with avoidance of hyperthermia
Rewarm slowly at a rate of 0.3-0.5°C every hour
Rewarming will take approximately 8-12 hours
The gravid uterus can compress the inferior vena cava, impeding venous return, thereby reducing stroke volume and cardiac output. In the supine position, aortocaval compression can occur for singleton pregnancies starting at approximately 20 weeks of gestational age
Manual left lateral uterine displacement effectively relieves aortocaval pressure in patients with hypotension
2015 – consider PMCD after 4 mins of CA
PMCD provides the opportunity for separate resuscitation of the potentially viable fetus and the ultimate relief of aortocaval compression, which may improve maternal resuscitation outcomes
Because of potential interference with maternal resuscitation
A new Cardiac Arrest in Pregnancy Algorithm has been added to address these special cases
A new pediatric Chain of Survival was created for IHCA in infants, children, and adolescents (Figure 10).
A sixth link, Recovery, was added to the pediatric OHCA Chain of Survival and is included in the new pediatric IHCA Chain of Survival (Figure 10)
Many children who survive a cardiac arrest with a grossly “favorable outcome” have more subtle and sustained neuropsychological impairment.4 The full impact of brain injury on children’s development may not be fully appreciated until months to years after the cardiac arrest. Furthermore, because children are raised by caregivers, the impact of morbidity following cardiac arrest affects not only the child but also the family.
It is reasonable to refer pediatric cardiac arrest survivors for ongoing neurological evaluation for at least the first year after cardiac arrest
When performing CPR without an advanced airway, it is reasonable for single rescuers to provide a compression-to-ventilation ratio of 30:2 and for 2 rescuers to provide a compression-to-ventilation ratio of 15:2
For years, the AHA warned about the very real dangers of overventilation during cardiac arrest. Increasing assisted ventilation rates during CPR raises intrathoracic pressure, which reduces venous return to the heart. However, results from a large multi-center observational trial found in-hospital resuscitation teams often provide ventilation rates in excess of recommended rates [5]. More importantly, researchers found an association between faster ventilation rates and improved survival to hospital discharge for infants with endotracheal intubation.
2010 (Old): (PBLS) If there is a palpable pulse 60/min or greater but there is inadequate breathing, give rescue breaths at a rate of about 12 to 20/min (1 breath every 3-5 seconds) until spontaneous breathing resumes
2010 (Old): (PALS) If the infant or child is intubated, ventilate at a rate of about 1 breath every 6 seconds (10/min) without interrupting chest compressions.
Uncuffed ETTs were historically preferred for young children because the normal pediatric airway narrows below the vocal cords, creating an anatomic seal around the distal tube
Cuffed tubes improve capnography accuracy, reduce the need for ETT changes (resulting in high-risk reintubations or delayed compressions), and improve pressure and tidal volume delivery. However, high pressure in the cuff can cause airway mucosal damage. Although several studies have identified that cuffed tube use may actually decrease airway trauma by decreasing tube changes, attention must be made to selecting the correct tube size and cuff inflation pressure
Studies of pediatric OHCA demonstrated that earlier epinephrine administration increases rates of ROSC, survival to intensive care unit admission, survival to discharge, and 30-day survival
Previous versions of the Guidelines did not differentiate the treatment of hemorrhagic shock from other causes of hypovolemic shock. A growing body of evidence (largely from adults but with some pediatric data) suggests a benefit to early, balanced resuscitation using packed red blood cells, fresh frozen plasma, and platelets.
During sepsis, endotoxins induce nitric oxide synthase, which produces relaxation of vascular smooth muscle tone, with resultant hypotension and reduced contractility response to norepinephrine.10 Corticosteroids prevent induction of nitric oxide synthase and enhance the vaso-active response to catecholamines through the glucocorticoid receptors. In vascular endothelial cells, glucocorticoids also inhibit serum phospholipase A2, reducing the production of vasodilators, such as prostacyclin and prostaglandin E1.11,12
Steroids reduce inflammation. Sepsis is driven by a systemic inflammatory response, in which components of the outer-cell membrane of both gram-positive and gram-negative bacteria and endotoxins induce the production of inflammatory cytokines, such as tumor necrosis factor alpha (TNF-alpha) and interleukin-1 (IL-1).13 These cytokines have a direct toxic effect on various tissues. In addition, inflammatory cytokines suppress adrenal response to adrenocorticotropic hormone (ACTH), which results in decreased endogenous cortisol production, and compete with glucocorticoids for their receptors, inducing resistance to the action of steroids at the tissue level
