Updated AHA Guidelines for CPR and Emergency Cardiovascular Care

The American Heart Association (AHA) issued Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC), which were published in Circulation.

The 2020 guidelines are based on an extensive evaluation of evidence that includes include systematic reviews, scoping reviews, and evidence updates, conducted in association with the International Liaison Committee on Resuscitation (ILCOR) and its member councils. The previous update was performed in 2015. The 2020 guidelines, include 491 recommendations for resuscitation and emergency cardiovascular care, 51% of which are based on limited data and 17% on expert opinion.

“This highlights the persistent knowledge gaps in resuscitation science that need to be addressed through expanded research initiatives and funding opportunities,” noted the guidelines authors.

Adult Basic and Advanced Life Support

The 2020 AHA guidelines include recommendations for the care of adult patients with out-of-hospital cardiac arrest (OHCA) and in-hospital cardiac arrest (IHCA). The guidelines reaffirm cardiopulmonary resuscitation (CPR) as the hallmark of cardiac arrest management and the importance of chest compression.

“We recommend that lay rescuers initiate CPR for presumed cardiac arrest because the risk [for] harm to patients is low if they are not in cardiac arrest (Class 1, Level of Evidence [LOE] C-LD),” noted the authors.

In addition to CPR, early defibrillation is important for patient survival when sudden cardiac arrest is caused by ventricular fibrillation or pulseless ventricular tachycardia. However, rescuers may encounter patients who are refractory to defibrillation attempts. Although double sequential defibrillation has emerged as a new approach to manage these patients, a systematic review found that usefulness of double sequential defibrillation for refractory shockable rhythm has not been established (Class 2b, LOE C-LD).

The peripheral intravenous (IV) route has been the traditional approach for administering emergency pharmacotherapy, although the intraosseous (IO) route has been increasingly implemented as a first-line approach for vascular access, although recent findings suggest some uncertainty regarding the efficacy of the IO route.

“Therefore, it is reasonable for providers to first attempt establishing IV access for drug administration in cardiac arrest (Class 2a, LOE B-NR),” noted the authors. “IO access may be considered if attempts at IV access are unsuccessful or not feasible (Class 2b, LOE B-NR).”

In light of the opioid epidemic, the 2020 guidelines include 2 new algorithms for managing patients with opioid-associated emergencies, with the recommendation that lay rescuers and trained responders should not delay activating emergency response systems while awaiting a patient’s response to naloxone or other interventions (Class 1, LOE E-O).

Regarding cardiac arrest in pregnancy, “The best outcomes for both mother and fetus are through successful maternal resuscitation,” noted the guidelines authors. “Team planning for cardiac arrest in pregnancy should be done in collaboration with the obstetric, neonatal, emergency, anesthesiology, intensive care, and cardiac arrest services (Class 1, LOE C-LD).”

The guidelines have also added an additional link in the Chain of Survival—recovery from cardiac arrest. “We recommend structured assessment for anxiety, depression, post-traumatic stress, and fatigue for cardiac arrest survivors and their caregivers (Class 1, LOE B-NR),” stated the AHA. “We recommend that cardiac arrest survivors have multimodal rehabilitation assessment and treatment for physical, neurological, cardiopulmonary, and cognitive impairments before discharge from the hospital (Class 1, LOE C-LD).”

Pediatric Basic and Advanced Life Support

New data support a higher respiratory rate for children with an advanced airway than was previously recommended, according to the updated guidelines.

“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 breaths/min), accounting for age and clinical condition,” stated the AHA. “Rates exceeding these recommendations may compromise hemodynamics (Class 2b, LOE C-LD). 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; Class 2a, LOE C-EO).”

The updated guidelines note that intubation with a cuffed endotracheal tube can improve capnography and ventilation in patients with poor pulmonary compliance and decrease the need for endotracheal tube changes. “It is reasonable to choose cuffed endotracheal tubes over uncuffed endotracheal tubes for intubating infants and children (Class 2a, LOE C-LD),” according to the AHA.

The guidelines do not recommend routine use of cricoid pressure during endotracheal intubation of pediatric patients (Class 3: No benefit, LOE C-LD), and if cricoid pressure is used, the AHA recommends discontinuing it if it interferes with ventilation or the speed or ease of intubation (Class 3: Harm, LOE C-LD).

Neonatal Life Support

The 2020 guidelines state that 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 (Class 2a, LOE B-R).

For newborns receiving resuscitation, in the absence of heart rate and when all resuscitation steps have been performed, cessation of resuscitation efforts should be discussed with the healthcare team and the family.

“A reasonable timeframe for this change in goals of care is around 20 minutes after birth (Class 1, LOE C-LD),” stated the AHA. “Newly born babies who have failed to respond to resuscitative efforts by approximately 20 minutes of age have a low likelihood of survival.”

Resuscitation Education Science

The 2020 guidelines also include recommendations regarding several instructional design features of resuscitation training, including deliberate practice, spaced learning, booster training, teamwork and leadership training, and in situ education.

“The addition of booster training sessions (ie, brief, frequent sessions focused on repetition of prior content) to resuscitation courses is associated with improved CPR skill retention over 12 months,” according to the AHA.

It is also recommended training middle school- and high school-aged children in how to perform high-quality CPR (Class 1, LOE C-LD).

“Training school-age children to perform CPR instills confidence and a positive attitude toward responding to an OHCA event,” stated the AHA. “Targeting this population with CPR training helps to build the future cadre of community-based, trained lay rescuers.”

Systems of Care

The AHA recommends that emergency dispatch systems should alert willing bystanders to nearby events that may require CPR or automated external defibrillator (AED) use with mobile phone technology (Class 1, LOE B-NR).

“Despite the recognized role of lay rescuers in improving OHCA outcomes, most communities experience low rates of bystander CPR and AED use,” noted the AHA. “Mobile phone technology, such as text messages and mobile phone apps, is available to summon trained members of the general public to nearby events to assist in CPR and to direct those responders to the nearest AED.”

Clinical registries that collect information on the processes and outcomes of care also can be used to identify opportunities to improve the quality of care.

Summary

“In this executive summary, we presented an overview of the guidelines process, recommendations, and knowledge gaps that can be translated into practice,” stated the AHA. “Future efforts can focus on evaluating the feasibility and acceptability of recommendations, their cost-effectiveness, and their impact on equity, although such evaluations are outside the scope of this document.”

The 2020 guidelines were developed by the Adult Basic and Advanced Life Support, the Pediatric Basic and Advanced Life Support, the Neonatal Life Support, the Resuscitation Education Science, and the Systems of Care writing groups.

Disclosures: One of the study authors reported an affiliation with the pharmaceutical industry. Please see the original reference for a full list of disclosures.

Reference

Merchant RM, Topjian AA, Panchal AR, et al; on behalf of the Adult Basic and Advanced Life Support, Pediatric Basic and Advanced Life Support, Neonatal Life Support, Resuscitation Education Science, and Systems of Care Writing Groups. Part 1: Executive summary: 2020 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2020;142(suppl 2):S337-S357. doi: 10.1161/CIR.0000000000000918