+ Htmo signs of return of, spontaneous circulation (ROSC}, goto 100° 11 + IFROSC, go to Post-Cérdiac ArestCare + Consider appropriateness ‘of continued resuscitation (© 2020AmericanHeartAsscition + Pushhard atleast emi and fast(t00-120"rn) and tow ‘complete chestrecol. + Minimize interruptions *+ Endotrachealintubation or a proplotte advanced arway + Puseandbioodpressure * Abrupt sustainedincreasein Perco,typealy 240mg) + Spontaneous arteral pressurePee Atropine IV dose: First dose: 1 mg bolus. Repeat every 3-5 minutes. Maximum: 3 mg. Dopamine IV infusion: Usualintusion rate 5-20 meg/kg per minute, Titrate to patient response; taper slowly. Epinephrine IV infusion: 2-10 meg per minute infusion. Titrate to patient response. Causes: + Myocardialischeria/ infarction '* Drugs/toxicologic (eg, calcium-channel blockers, beta blockers, digoxin) + Hypoxia * Electrolyte abnormality (eg. hyperkalemia) (© 2020 AmericanHeart Association‘Synchronized cardioversion: Refer to your specific device's recommended energy level to ‘maximize first shock success. ‘Adenosine 1V dose: First dose: 6 mg rapid IV push: follow with NS flush. ‘Second dose: 12mgif required. Antiarrhythmic Infusions for Stable Wide-QRS Tachycardia Procainamide IV dose: 20-50 mg/min unti arrhythmia suppressed, hypotension ensues. {QRS duration increases >50%, oF maximum dose 17 mg/kg given. ‘Maintenance infusion: 1-4 mg/min. Avoidif prolonged QT or CHF. ‘Amiodarone IV dose: First dose: 150 mg over 10 minutos. Repeat as needed if VT recurs. Follow by maintenance infusion of 1 mg/min for frst 6 hours. Sotalol lV dose: 100 mg (1.5 mg/kg) over § minutes. Avoid if prolonged QT. (©2020 American Heart AssociationInitial Stabilization Phase Continued Management and Additional Emergent Activities: ©2020 American Heart Association (Bead the long description of Adult Post-Cardiac Arrest Gare Algorithm) ora Resuscitation is ongoing during the post-ROSC phase, and many of these activities can occur concurrently. However. if prioritization is necessary, follow these steps: + Airway management: ‘Waveform capnography or ‘capnometry to confirm and monitor ‘endotracheal tube placement + Manage respiratory parameters: Titrate FiO, for SpO, 92%-98%: start ‘at 10 breaths/min; titrate to Paco, of 35-45mmHg + Manage hemodynamic parameters: ‘Administer crystalloid and/or ‘vasopressor or inatrope for goal ‘systolic blood pressure >90mm Hg ‘ormean arterial pressure >65 mmHg eran Additional Emergent Activities These evaluations should be done concurrently so that decisions on targeted temperature management (TTM) receive high priority as, cardiacinterventions. + Emergent cardiac intervention: Early evaluation of 12-lead ‘electrocardiogram (ECG); consider hemodynamics for decision on cardiac intervention ‘TIMI patientis not following ‘commands, start TTMas soon as possible: begin at 32-36°C for 24 hours by using a cooling device with feedbackloop Other critical care management Continuously monitor core temperature (esophageal, rectal, bladder) = Maintain normoxia, normocapnia, euglycemia ~ Provide continuous or intermittent ‘electroencephalogram (EEG) monitoring ~ Provide lung-protective ventilation Hypovolemia Hypoxia Hydrogen ion (acidosis) Hypokalemia/hyperkalemia Hypothermia ‘Tension pneumothorax ‘Tamponade, cardiac Toxins ‘Thrombosis, pulmonary ‘Thrombosis, coronary(Read the long description of Acute Coronary Syndromes Algorithm) ‘Symptoms suggestive of ischemia or infarction ' EMS assessment and care and hospital preparation + Assess ABCs. Be prepared to provide CPR and defibrilation ‘Administer aspicn and consider oxygen. nitroglycerin, and morphine if needed * Obtain 12-lead ECG; if ST elevation: = Notify recelving hospital with transmission or interpretation, note time of onset and frst medical contact Provide prehospital notification: on arrival, transport to EDicath ab per protocol 'Notifed hospital should mobilize resources to respond to STEM! + lf considering prehospital fibrinolysis, use fibrinolytic checklist Concurrent ED/cath ab assessment Immediate ED/eath ab goneral treatment {<10 minutes) + If, sat <20% start oxygen at 4L/min titrate + Actwate STEMIteamuponEMSnotieation | + Aspirin 1620 325mg natglven by EMS) + Assess ABCs; give oxygenifnecded + Nitroglyeerin subingualo transingul + EstablohIV access + MorphineIV if ciscomfort not reeved by + Perform brief targetedhistory.pysicatexam | nitroglycerin + Revienfcomplete lrinolytic checklist: + Consider administration of P2¥, Inhibitors ‘check contraindleations + Obtain nta cardiac marker levels, complete ‘blood counts, and coagulation studies + Obtain portable chestx-ray (<30 minutes \donotdelaytransportto the ath J ‘STelevation or new or 'Non-ST-elevation ACS (NSTE-ACS) presumably new BBE, ‘Determine sk sing vabdated strongly suopiciousfornury ‘core e, Thor GRACE) ‘ST-elovation Ml (STEMI ’ ‘ST depression or dynamic T-wave Normal ECG or nondlagnostic + Startacjunctive therapies Inversion, transient ST elevation, changes InST segment or T wae, err soo esori ta u maditerith NSTE-ACS a ‘core ow-fimtermediate- cee IMigh-risk NSTE-ACS | ar mae high-risk pationt Consider admission ours or Sr to Time fromonsetof symetore S13 hoe, Consider erly invasive strategy if ED chest painunitor to + Refractory cherie chest ciscorfort sepopitebeator + Recurtentpersistent ST deviation further monitorn sianours + Venticulartachyearala possibeineervention| + Hemodynamic stay x += Signs of heart failure Repertusion goats: east itive ‘Therapy defined by patent and (eg ritoatycern heparin as indicated corte cet nation ‘See AHAMCCNSTE-ACS Culdelnes (Pe goslof=20 minutes + Door-to-needle(fibrinelysis) ‘goal of 20 minutes (©2020 American Heart Association(Read the long description of Emergency Medical Services Acute © Perform physical tram and valdated prenosntn' stoke ‘contiemton © Obisin FOC blood jucose ————— Stroke Suspected? — NO See eras etd patient presentation YES Stroke Routing Algorithm) EMERGENCY MEDICAL SERVICES ACUTE STROKE ROUTING Law<24 rs >No —— © Transport to nearest TEC foneis located Yes win 30 mins @ ttrocsc or tse meets algortim Transporttime to time parameters, EVI-capable stoke 5 iy tranapertonearest center val not dsauaity certiied stroke center for twrombotyte per regional stroke systoms ofeae a protocol vis © Provide prenosoital notitestion Total transport ime — from sane to nearest CScie <30mntotal NO an within maximum time permitted by EMS ne) O tersporte the nearest CSC Yes © Provide prehospital netiteaton —_—_—__(Read the long description of Adult Suspected Stroke Algorithm) Identify signs and symptoms of possible stroke Activate emergency response a Critical EMS assessments and actions ‘+ Assess ABCs; give oxygen if needed + Initiate stroke protocol + Perform physical + Perform validated prehospital stroke screen and stroke severity tool Establish time of symptom onset last known normal) + Triage to most appropriate stroke center ‘= Check glucose; reatif indicated + Provide prehospital notification; on arrival, transport to brainimaging suite Note: Refer to the expanded EMS stroke algorithm. y ED or brain imaging suite* Immediate general and neurologic assessment by hospital or stroke team * Activate stroke team upon EMS notification * Prepare for emergent CT scan or MRI of brain upon arrival * Stroke team meets EMS on arrival + Assess ABCs; give oxygenifneeded * Obtain IV access and perform|aboratory assessments * Check glucose; treatifindicated + Review patient history, medications, and procedures * Establish time of symptom onset of last known normal + Perform physical exam and neurologic examination, including NIH Stroke Scale ‘or Canadian Neurological Scale: *Best practice is tobypass the ED and go straight to the brain imaging suite, Initiate intracranial hemorrhage protocol Yos Administer alteplase Consider EVT L___, « pertormora + Perform CTP as indicated a Rapidly transport to cath lab or transfer to EVT-capable center 4 s >» Admit to stroke unit or neurological ICU, ‘Admit to neurological ICU or transfer to higher level of care (© 2020 American Heart Association(© 2020 AmericanHeart Association (Bend the long description of Cardiac Arrest in Pregnancy In-Hospital ACLS Algorithm) Neonatal teamtoreceiveneonate ) ‘+ Team planning should be done in collaboration with the obstetric, ‘neonatal, emergency, inesthesiology, intensive care, and cardiac arrest services. * Priorities for pregnant women in cardiac arrest should include provision of high-quality CPRand relief of aortocaval compression with lateral uterine displacement. ‘+ The goal of perimortem cesarean delivery is to improve maternal and fetal outcomes. * Ideally, perform perimortem cesarean olivery in 5 minutes, depending on provider resources and skill sets. * Inpregnancy,a difficult airway iscommon. Use the most ‘experienced provider. + Provide endotracheal intubation or supraglottic advanced airway. ‘+ Perform waveform capnography or ‘capnometry to confirm and monitor ET tube placement. + Once advanced airwayisin place, give 1 breathevery 6 seconds (MO breaths/min) with continuous. chest compressions. eee ete Cree ‘A Anesthetic complications B Bleeding © Cardiovascular D Drugs E Embolic F Fever General nonobstetric causes of cardiac arrest (H's and T's) H HypertensionCal eee ee ee *The PETCO, cutoff of >20 mm Hg should be used only when an ET tube or tracheostomy is used to ventilate the patient. Use of a supragiottic (eg, King) airway results ina falsely elevated PETCO, value. (©2020 American Heart Association(©2020 American Heart AssociationCinieat Management Imaging Clinical Examination Serum Biomarkers OSC 2ahous 48hous 72 hours Time after ROSC