Clinical progress note: AHA ACLS/PALS/NRP updates and cardiac arrest management in the time of COVID-19.

INTRODUCTION

Despite advances in technology and research, cardiac arrest remains a leading cause of death around the world. It is estimated that 292,000 adults, 15,200 children, and 1% of newborns admitted to U.S. hospitals suffer an in‐hospital cardiac arrest (IHCA), and hospitalists are often at the forefront of management. The most basic principles of cardiac arrest management are still the prevailing determinants of survival: high‐quality chest compressions and rapid defibrillation. The American Heart Association (AHA) and the International Liaison Committee on Resuscitation have moved from updating basic life support (BLS), advanced cardiac life support (ACLS), pediatric advanced life support (PALS), and neonatal resuscitation program (NRP) guidelines from every five years to a continuously updated review, with the most recent updates released in October of 2020. Given the unpredictable nature of cardiac arrests, there is a paucity of clinical trials and strong evidence to support current recommendations. Specifically noted within the 2020 guidelines is that 51% of recommendations are based on limited data and 17% are based on expert opinion.

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. , , The highlights of these updated guidelines and COVID‐19 recommendations that are most relevant to hospitalist practice are summarized below.

2020 ACLS UPDATES SUMMARY

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 CO2 (ETCO2) 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.

Table 1

AHA ACLS 2020 updates summary table

ACLS Update	2020 Update
Adult bradycardia algorithm	Atropine dose increased to 1 mg (from 0.5 to 1 mg) every 3–5 min with a max dose of 3 mg on the algorithm
Vasopressors	Nonshockable rhythms: Give 1 mg epi as soon as feasible (Class 2a, C‐LD) Shockable rhythms: Give 1 mg epi after initial defibrillation attempts have failed (Class 2b, C‐LD). Per the published ACLS algorithm, epi is given after the second defibrillation attempt
Route of medication delivery	Intravenous (IV) delivery of medications is preferable to intraosseous (IO) due to efficacy concerns. IO may be used if IV is not readily available (Class 2a, LOE B‐NR)
Improving neuroprognostication	Perform multimodal neuroprognostication at a minimum of 72 h after return to normothermia (Class 2a, LOE B‐NR)
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 ETCO2 (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
Cardiac arrest in pregnancy	Priorities include the provision of high‐quality CPR and relief of aortocaval compression through left lateral uterine displacement (the uterus is cupped or pushed upward and leftward off maternal vessels while the patient is supine) 4 (Class 1, LOE C‐LD) If no ROSC within 5 min, consider immediate perimortem cesarean delivery

Abbreviations: AHA, American Heart Association; ACLS, advanced cardiac life support.

Priorities include the provision of high‐quality CPR and relief of aortocaval compression through left lateral uterine displacement (the uterus is cupped or pushed upward and leftward off maternal vessels while the patient is supine) (Class 1, LOE C‐LD)

2020 PALS UPDATES SUMMARY

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. , 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 (Table 2).

Table 2

AHA PALS and NRP 2020 updates summary table

	2020 Updates
PALS update
Respiratory rate (RR) in PALS	With an advanced airway, it may be reasonable to target a RR of 1 breath every 2–3 s (20–30 breaths per minute) (Class 2b, LOE C‐LD)
Epinephrine in PALS	Use of epinephrine within 5 min from the start of chest compressions is reasonable (Class 2a, LOE C‐LD)
Electroencephalography (EEG) use in postcardiac arrest care	When resources are available, continuous EEG monitoring is recommended for the detection of seizures in patients that remain encephalopathic after cardiac arrest (Class 1, LOE C‐LD)
NRP update
Vascular access	Umbilical vein is the recommended route at the time of delivery for babies requiring vascular access. Intraosseous access is an alternative if umbilical vein or other IV access is not feasible (Class 1, LOE C‐EO)
Intubation for meconium	For nonvigourous newborns delivered through meconium‐stained amniotic fluid, routine laryngoscopy with or without tracheal suctioning is not recommended. Endotracheal suctioning is only indicated if airway obstruction is suspected after positive pressure ventilation (Class 3: No benefit, LOE C‐LD)
Skilled provider present	Every birth should be attended by at least 1 person who can perform the initial steps of newborn resuscitation and whose only responsibility is to the newborn
Termination of resuscitation	For newborns who have not responded to resuscitation efforts after 20 min, termination of resuscitation can be considered. (Class 1: LOE C‐LD)

Abbreviations: AHA, American Heart Association; NRP, neonatal resuscitation program; PALS, pediatric advanced life support.

2020 NRP UPDATES SUMMARY

There were four updates for NRP. , 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).

ACLS GUIDELINES FOR IN‐HOSPITAL TERMINATION OF RESUSCITATION

Knowing when to terminate a resuscitation attempt remains a challenge. Several clinical decision rules have been developed to assist in this decision, most notably the UN10 rule which uses three intra‐arrest variables (unwitnessed arrest, nonshockable rhythm, and 10 min of CPR without ROSC) to predict survival. The 2020 guidelines made a strong recommendation against the use of the UN10 rule as the sole strategy for stopping resuscitation. They recommend using the clinicians' experience, the clinical exam, and the patient's prearrest condition and wishes to inform their decision to terminate resuscitative attempts. In intubated patients, failure to achieve an ETCO2 of >10 mmHg after 20 min of CPR may be used to inform a multimodal decision to terminate resuscitation efforts.

COVID‐19 UPDATES FOR ACLS, PALS, AND NRP

In January 2022, the AHA released updated interim guidance for BLS and ACLS in adults, children, and neonates with suspected or confirmed COVID‐19. The initial guidance released early in the pandemic in April 2020 recommended donning appropriate personal protective equipment (PPE) prior to any resuscitative attempt in suspected or confirmed cases. However, the October 2021 guidance recommended not delaying chest compressions or defibrillation to don provider PPE, but did recommend appropriate PPE as soon as feasible, and especially prior to any ventilation strategies. Given the emergence of new, more transmissible strains, the AHA returned to the initial guidance of ensuring adequate PPE is worn prior to any resuscitative attempts. In addition, the AHA aligns with the World Health Organization and the Center for Disease Control and Prevention in that it now considers all components of resuscitation (chest compressions, ventilation, and defibrillation) to be aerosol‐generating (Table 3).

Table 3

COVID‐19 ACLS guidance summary ,

Recommendation/scenario	Strategy
Reduce provider exposure to COVID‐19	Don appropriate PPE prior to performing any resuscitative attempts, including chest compressions, defibrillation, bag‐mask ventilation, intubation and positive pressure ventilation Consider using mechanical compression devices if available and personnel are already trained Relieve initial resuscitation personnel with providers
Prioritize oxygenation and ventilation strategies with lower aerosolization risk	Attach a HEPA filter to any manual or mechanical ventilation device Intubate early and connect to a ventilator with HEPA filter Use the most skilled and experienced provider to intubate Consider the use of video laryngoscopy if available and if the operator is experienced Avoid endotracheal administration of meds
Intubated patients at the time of cardiac arrest	Leave on mechanical ventilation with appropriate adjusted settings with a HEPA filter
Prone patient at the time of arrest	Without an advanced airway: attempt to place in supine position first With an advanced airway: if unable to be safely turned, place pads in AP position and perform compressions over T7/T10 vertebral bodies

Abbreviations: ACLS, advanced cardiac life support; PPE, personal protective equipment.

IN SUMMARY

The goals of these updates were to incorporate recently published studies and provide graded recommendations based on the strength of the evidence. Addressing the COVID‐19 pandemic, the AHA recommends strategies to keep healthcare workers safe, including donning appropriate PPE prior to any resuscitation attempt and encouraging vaccination with a booster. Significant gaps in knowledge surrounding cardiac resuscitation remain. Ongoing research and innovation are vital to achieve the goals of improved survival and quality of life.

CONFLICTS OF INTEREST

The authors have reported no conflicts of interest.