New AHA guidance on CPR, emergency CV care ‘a synthesis of important science’
The American Heart Association announced new guidance and updates to prior recommendations for the 2020 guidelines for CPR and emergency CV care, according to a publication in Circulation.
“The 2020 guidelines represent a synthesis of important science that guides how resuscitation is provided for critically ill patients,” Raina M. Merchant, MD, MSHP, assistant professor of emergency medicine at the University of Pennsylvania and chair of the AHA Emergency Cardiovascular Care Committee, said in a press release. “As the science evolves over time, it’s important that we review it and make recommendations about how providers can deliver high-quality care that reflects the most updated and state-of-the-art information.”
New recommendations for 2020
New for 2020, the AHA has included a sixth chain link to the association’s Chains of Survival series of critical actions to take to treat cardiac arrest. The sixth link represents recovery, which extends long after an individual’s initial hospitalization.
Previously, these links represented the five steps of optimal survival for in-hospital cardiac arrest (IHCA) and out-of-hospital cardiac arrest (OHCA), but ended with post-cardiac arrest care, with little emphasis on the longer-term recovery period.
“Analogous Chains of Survival have also been developed for pediatric OHCA and for both adult and pediatric IHCA,” the committee wrote. “Similarly, successful neonatal resuscitation depends on a continuum of integrated lifesaving steps that begins with careful assessment and preparation in advance of birth as well as resuscitation and stabilization at the time of birth and through the first 28 days after birth.”
Another addition to the 2020 guidance discouraged the routine use of double sequential defibrillation for patients with a refractory shockable rhythm.
“Double sequential defibrillation is the practice of applying near simultaneous shocks using two defibrillators,” the committee wrote. “Although some case reports have shown good outcomes, a 2020 International Liaison Committee on Resuscitation systematic review found no evidence to support double sequential defibrillation and recommended against its routine use.”
The AHA also included detailed updates for the care of pregnant patients who are experiencing cardiac arrest:
- Pregnant patients are prone to hypoxia. Therefore, oxygenation and airway management should be prioritized.
- Due to potential interference with resuscitation of the mother, fetal monitoring should not be undertaken during resuscitation.
- Targeted temperature management should be maintained among pregnant women who remain comatose after resuscitation from cardiac arrest.
- During targeted temperature management, the fetus should be continuously monitored for bradycardia and obstetric and neonatal consultation should be sought.
- A new Cardiac Arrest in Pregnancy Algorithm has been added to address these special cases.
New guidance for lay rescuer training for response to opioid overdose has also been included in the 2020 updates.
Targeted training for people who use opioids, their families and friends for the administration of naloxone to overdosed individuals may reduce the overall mortality associated with witnessed overdoses.
According to the guidance, racial, ethnic and socioeconomic disparities in layperson CPR training is reduced in low socioeconomic status communities and those with predominantly Black and Hispanic populations.
“It is recommended to target low-socioeconomic status populations and neighborhoods for layperson CPR training and awareness efforts,” the committee wrote. “Targeting training efforts should consider barriers such as language, financial considerations and poor access to information.”
Bolstering layperson educational training and public awareness for women experiencing cardiac arrest is a new aspect of the AHA’s 2020 guidance. Targeted training may improve outcomes in these cases.
“Women are also less likely to receive bystander CPR, which may be because bystanders fear injuring female victims or being accused of inappropriate touching. Modifying education to address gender differences could eliminate disparities in CPR training and bystander CPR, potentially enhancing outcomes from cardiac arrest.”
Included in the updated guidelines is information on neonatal life support and the importance of skin-to-skin contact.
“Most newly born infants do not require immediate cord clamping or resuscitation and can be evaluated and monitored during skin-to-skin contact with their mothers after birth,” the committee wrote. “Placing healthy newborn infants who do not require resuscitation skin-to-skin after birth can be effective in improving breastfeeding, temperature control and blood glucose stability.”
The guidance added that skin-to-skin care following initial resuscitation reduced mortality, improved breastfeeding, shortened length of stay and improved weight gain among low birth weight babies.
Mobile phone technology is another potential avenue to improve OHCA outcomes by increasing bystander awareness and participation in CPR.
“A recent International Liaison Committee on Resuscitation systematic review found that notification of lay rescuers via a smartphone app or text message alert is associated with shorter bystander response times, higher bystander CPR rates, shorter time to defibrillation and higher rates of survival to hospital discharge for people who experience OHCA,” the committee wrote. “The differences in clinical outcomes were seen only in the observational data.”
The final new recommendation addressed the motivations for organizations to collect process-of-care and outcomes data of patients with cardiac arrest.
“It is reasonable for organizations that treat cardiac arrest patients to collect processes-of-care data and outcomes,” the committee wrote. “Clinical registries collect information on the processes of care (CPR performance, defibrillation times) and outcomes of care (return of spontaneous circulation, survival) associated with real-world management of cardiac arrest. Registries provide information that can be used to identify opportunities to improve the quality of care.”
Updated recommendations for 2020
In addition to issuing new recommendations, the AHA updated several older recommendations.
The association streamlined its prior recommendations for layperson initiation of CPR.
“Laypersons should initiate CPR for presumed cardiac arrest because the risk of harm to the patient is low if the patient is not in cardiac arrest,” the committee wrote.
The committee cited that prior research determined withholding chest compressions from a pulseless individual may cause more harm than the unneeded compressions.
Another updated guidance, involving suspected cardiac arrest among people with known opioid use, now states that rescuers should focus on providing traditional CPR techniques and avoid the administration of naloxone without established benefit.
In such cases that naloxone is administered, the updated guidance specifies that rescuers should continue by activating emergency response systems while awaiting the individual’s reaction to naloxone or other interventions.
For infants or children receiving CPR with an advanced airway in place or rescue breathing and have a pulse, the association increased its rescue breaths per minute recommendation of from between 12 and 20 to between 20 and 30.
“New data show that 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 return of spontaneous circulation (ROSC) and survival in pediatric IHCA,” the committee wrote.
The final updated guidance states that among pediatric patients with cardiac arrest, the administration of epinephrine should be within 5 minutes of initiating chest compressions. The previous recommendation in 2015 did not state a specific time frame within which to administer epinephrine.
Reaffirmed measures for 2020
The AHA’s previous suggestion for the early administration of epinephrine was unchanged for 2020 and strengthened to a recommendation.
“Of 16 observational studies on timing in the recent systematic review, all found an association between earlier epinephrine and ROSC for patients with nonshockable rhythms, although improvements in survival were not universally seen,” the committee wrote. “For patients with shockable rhythm, the literature supports prioritizing defibrillation and CPR initially and giving epinephrine if initial attempts with CPR and defibrillation are not successful.
“Any drug that increases the rate of ROSC and survival but is given after several minutes of downtime will likely increase both favorable and unfavorable neurologic outcome,” the committee wrote. “Therefore, the most beneficial approach seems to be continuing to use a drug that has been shown to increase survival while focusing broader efforts on shortening time to drug for all patients; by doing so, more survivors will have a favorable neurologic outcome.”