key: cord-1038877-lr0nsyi1 authors: Nave, Jessica; Smola, Cassi title: Clinical progress note: AHA ACLS/PALS/NRP updates and cardiac arrest management in the time of COVID‐19 date: 2022-02-26 journal: J Hosp Med DOI: 10.1002/jhm.2778 sha: 8348c935d8a479f4bd646f9c37e4b82406335031 doc_id: 1038877 cord_uid: lr0nsyi1 nan Specifically noted within the 2020 guidelines is that 51% of recommendations are based on limited data and 17% are based on expert opinion. 1 In addition, the AHA released a Scientific Statement in April 2020 providing initial guidance on BLS and ACLS for patients with suspected or confirmed COVID-19, updated in October 2021 to account for the increased understanding of viral transmissibility and to mitigate some of the early pandemic data that showed decreased cardiac arrest survival for both IHCA and out-of-hospital cardiac arrest (OHCA) since the onset of the pandemic. But with the emergence of more transmissible strains, further interim guidance was provided in January 2022 to focus on the protection of healthcare workers. [2] [3] [4] The highlights of these updated guidelines and COVID-19 recommendations that are most relevant to hospitalist practice are summarized below. In the AHA ACLS 2020 updates, there were minor changes to the Cardiac Arrest algorithms. In the Adult Bradycardia algorithm, the Atropine dose was increased from 0.5 to 1 mg, maintaining the same frequency of every 3-5 min with a maximum dose of 3 mg. Other notable mentions in the 2020 updates include the reaffirmation of early epinephrine in nonshockable rhythms, the lack of evidence for double sequential defibrillation (using two defibrillators at once), preference of intravenous (IV) before intraosseous route for delivery of medications, utilization of end-tidal CO 2 (ETCO 2 ) for monitoring CPR quality, and guidance for timing of neuroprognostication after cardiac arrest. Two new algorithms addressing opioid overdose and pregnancy were also included ( Table 1) , as well as a new postcardiac arrest care algorithm. In addition, postcardiac arrest care has been added to the AHA chain of survival for both IHCA and OHCA. The most important update to PALS is an increase in the delivery rate of breaths during cardiac arrest with an advanced airway from 1 breath every 6 s (10/min), as in the adult algorithms, to 1 breath every 2-3 s (20-30/min) for all scenarios. 1, 5 Another new recommendation is the use of electroencephalography monitoring after cardiac arrest to detect and monitor nonconvulsive seizures for patients that remain encephalopathic. Early delivery of epinephrine (within 5 min of starting chest compressions) is still encouraged and may be shown to increase survival to discharge rates. Cuffed ET tubes are recommended. Routine use of cricoid pressure during intubation is discouraged. The relative risks and benefits of fluid resuscitation remain uncertain, although avoiding fluid overload is recommended ( There were four updates for NRP. 1, 6 There is no longer a need to intubate and suction nonvigorous newborns delivered through meconium unless there is a concern for airway obstruction after positive pressure ventilation. The umbilical vein is the preferred vascular access for the delivery of IV medications. Every birth should be attended by at least one person who can perform newborn resuscitation and is only responsible for the neonate. Finally, for newborns who have not responded to resuscitation efforts after 20 min, termination of resuscitation can be considered ( Table 2) . Knowing when to terminate a resuscitation attempt remains a challenge. 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 ETCO 2 (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 The authors have reported no conflicts of interest. https://orcid.org/0000-0003-3580-2049 TWITTER Jessica Nave @allen_nave Executive Summary: 2020 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care 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 Interim guidance to health care providers for basic and advanced cardiac life support in adults, children, and neonates with suspected or confirmed COVID-19 Interim guidance to healthcare providers for basic and advanced cardiac 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 in collaboration with the American Academy of Pediatrics, American Association for Respiratory Care, The Society of Critical Care Anesthesiologists, and American Society of Anesthesiologists Pediatric basic and advanced life support: 2020 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care Neonatal resuscitation: 2020 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care Reverse CPR: a pilot study of CPR in the prone position Clinical progress note: AHA ACLS/PALS/NRP updates and cardiac arrest management in the time of COVID-19