Part 1: Executive Summary: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.

Abstract

HomeCirculationVol. 142, No. 16_suppl_2Part 1: Executive Summary: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyRedditDiggEmail Jump toFree AccessReview ArticlePDF/EPUBPart 1: Executive Summary: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Raina M. Merchant, MD, MSHP, Alexis A. Topjian, MD, MSCE, Ashish R. Panchal, MD, PhD, Adam Cheng, MD, Khalid Aziz, MBBS, MA, MEd(IT), Katherine M. Berg, MD, Eric J. Lavonas, MD, MS, David J. Magid, MD, MPH and 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 Raina M. MerchantRaina M. Merchant Search for more papers by this author , Alexis A. TopjianAlexis A. Topjian Search for more papers by this author , Ashish R. PanchalAshish R. Panchal Search for more papers by this author , Adam ChengAdam Cheng Search for more papers by this author , Khalid AzizKhalid Aziz Search for more papers by this author , Katherine M. BergKatherine M. Berg Search for more papers by this author , Eric J. LavonasEric J. Lavonas Search for more papers by this author , David J. MagidDavid J. Magid Search for more papers by this author and 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 Search for more papers by this author Originally published21 Oct 2020https://doi.org/10.1161/CIR.0000000000000918Circulation. 2020;142:S337–S357IntroductionThe 2020 American Heart Association (AHA) Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care provides a comprehensive review of evidence-based recommendations for resuscitation and emergency cardiovascular care. The initial guidelines for CPR were published in 1966 by an ad hoc CPR Committee of the Division of Medical Sciences, National Academy of Sciences—National Research Council.1 This occurred in response to requests from several organizations and agencies about the need for standards and guidelines regarding training and response.Since then, CPR guidelines have been reviewed, updated, and published periodically by the AHA.2–9 In 2015, the process of 5-year updates was transitioned to an online format that uses a continuous evidence evaluation process rather than periodic reviews. This allowed for significant changes in science to be reviewed in an expedited manner and then incorporated directly into the guidelines if deemed appropriate. The intent was that this would increase the potential for more immediate transitions from guidelines to bedside. The approach for this 2020 guidelines document reflects alignment with the International Liaison Committee on Resuscitation (ILCOR) and associated member councils and includes varying levels of evidence reviews specific to the scientific questions considered of greatest clinical significance and new evidence.Over a half-century after the initial guidelines were published, cardiac arrest remains a leading cause of mortality and morbidity in the United States and other countries worldwide. As reported in the AHA “Heart Disease and Stroke Statistics—2020 Update,” emergency medical services respond to more than 347 000 adults and more than 7000 children (less than 18 years of age) with out-of-hospital cardiac arrest (OHCA) each year in the United States.10 In-hospital cardiac arrest (IHCA) is estimated to occur in 9.7 per 1000 adult cardiac arrests (approximately 292 000 events annually) and 2.7 pediatric events per 1000 hospitalizations.11 In addition, approximately 1% of newly born infants in the United States need intensive resuscitative measures to restore cardiorespiratory function.12,13Overall, although both adult and pediatric IHCA outcomes have improved steadily since 2004, similar gains are not being seen in OHCA.10 The proportion of adult patients with return of spontaneous circulation (ROSC) following OHCA that is attended by emergency medical services has remained essentially unchanged since 2012.10Much of the variation in survival rates is thought to be due to the strength of the Chain of Survival (Figure 1), the critical actions that must occur in rapid succession to maximize the chance of survival from cardiac arrest.14 A sixth link, recovery, has been added to each Chain with this version of the guidelines to emphasize the importance of recovery and survivorship for resuscitation outcomes. Analogous Chains of Survival have also been developed for pediatric OHCA and for both adult and pediatric IHCA. 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.15Download figureDownload PowerPointFigure 1. The American Heart Association Chains of Survival. CPR indicates cardiopulmonary resuscitation.This executive summary provides an overview of and orientation to the 2020 AHA Guidelines, which are organized around the Utstein Formula for Survival (Figure 2).16Download figureDownload PowerPointFigure 2. The Utstein Formula for Survival, emphasizing the 3 components essential to improving survival.16Each section in this summary describes the scope of each guideline Part, along with a list of the most significant and impactful new or updated recommendations for that Part. Each section also includes a list of critical knowledge gaps that highlights important research questions and significant opportunities for enhancing the Chain of Survival. This executive summary does not contain extensive external reference citations; the reader is referred to Parts 2 through 7 for more detailed reviews of the scientific evidence and corresponding recommendations.15,17–21Coronavirus Disease 2019 (COVID-19) GuidanceTogether with other professional societies, the AHA has provided interim guidance for basic life support (BLS) and advanced life support (ALS) in adults, children, and neonates with suspected or confirmed COVID-19 infection. Because the evidence and guidance are evolving with the COVID-19 situation, that information is maintained separately from the ECC guidelines. Readers are directed to the AHA website22 for the most recent guidance.Evidence Evaluation and Guidelines Development19The 2020 Guidelines are based on the extensive evidence evaluation performed in conjunction with ILCOR and the affiliated ILCOR member councils. Three different types of evidence reviews (systematic reviews, scoping reviews, and evidence updates) were used in the 2020 process. Each of these resulted in a description of the literature that facilitated guideline development.23–28 The ILCOR evidence reviews used Grading of Recommendations Assessment, Development, and Evaluation methodology and terminology.29 These AHA treatment recommendations followed standard AHA processes and nomenclature, which are described fully in “Part 2: Evidence Evaluation and Guidelines Development.”19Each AHA writing group reviewed all relevant and current AHA guidelines for CPR and emergency cardiovascular care,30–41 pertinent 2020 International Consensus on CPR and Emergency Cardiovascular Care Science With Treatment Recommendations evidence evaluations and recommendations,42–48 and all relevant evidence update worksheets to determine whether current guidelines should be reaffirmed, updated, or retired or if new recommendations were needed. The writing groups then drafted, reviewed, and approved recommendations, assigning to each a Class of Recommendation (COR; ie, strength) and Level of Evidence (LOE; ie, quality) (as outlined in Table 3 in Part 2 of this supplement).19The 2020 Guidelines contain 491 recommendations (Table). Despite recent improvements in support for resuscitation research, 51% of these recommendations 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. With reference to these gaps, we acknowledge the importance of addressing the values and preferences of our key stakeholders: the patients, families, and teams who are involved in the process of resuscitation.Table. Recommendations in the 2020 GuidelinesClassificationAdult Basic and Advanced Life SupportPediatric Basic and Advanced Life SupportNeonatal ResuscitationResuscitation Education ScienceSystems of CareTotalPercentClass (Strength) of Recommendation 1 (strong)7853165916133% 2a (moderate)574214131013527% 2b (weak)89302111615832% 3: No benefit (moderate)151300194% 3: Harm (strong)114300184%Level (Quality) of Evidence A2121061% B-R3738715511% B-NR57198589720% C-LD1237024151524851% C-EO313715118517% Total250130572925491EO indicates expert opinion; LD, limited data; NR, nonrandomized; and R, randomized.The 2020 Guidelines are organized into knowledge chunks, grouped into discrete modules of information on specific topics or management issues.49 Each modular knowledge chunk includes a table of recommendations, a brief introduction or synopsis, recommendation-specific supportive text, hyperlinked references, and, when relevant, figures, flow diagrams of algorithms, and additional tables.AbbreviationsAbbreviationMeaning/PhraseACLSadvanced cardiovascular life supportAEDautomated external defibrillatorAHAAmerican Heart AssociationALSadvanced life supportBLSbasic life supportCORClass of RecommendationCPRcardiopulmonary resuscitationIHCAin-hospital cardiac arrestILCORInternational Liaison Committee on ResuscitationLOELevel of EvidenceOHCAout-of-hospital cardiac arrestPPVpositive-pressure ventilationROSCreturn of spontaneous circulationAdult Basic and Advanced Life Support20“Part 3: Adult Basic and Advanced Life Support” includes a comprehensive set of recommendations for the care of adult victims of OHCA and IHCA. We reaffirm the critical steps in the Chain of Survival, expand on the postresuscitative care section with the addition of an updated algorithm, and introduce a new link in the Chain of Survival, for recovery and survivorship. The main focus in managing adult cardiac arrest includes rapid recognition, prompt provision of CPR, and defibrillation of ventricular fibrillation and pulseless ventricular tachycardia. Since 2010, the AHA has directed efforts at minimizing the time to provision of chest compressions by focusing the universal sequence of responses on compressions followed by airway and breathing. The 2020 Guidelines continue to highlight the critical importance of chest compressions and leverage current relevant evidence to optimize care and improve survival. Additional recommendations relevant to adult resuscitation appear in “Part 7: Systems of Care.”18Adult Basic and Advanced Life Support: Significant New, Updated, and Reaffirmed RecommendationsCPR reaffirmed: Provision of CPR has long been the hallmark of cardiac arrest management. Updated evidence from an analysis of over 12 500 patients50 reaffirms the importance of chest compression quality as well as the following:– During manual CPR, rescuers should perform chest compressions to a depth of at least 2 inches, or 5 cm, for an average adult while avoiding excessive chest compression depths (greater than 2.4 inches, or 6 cm)(Class 1, LOE B-NR).51–54– It is reasonable for rescuers to perform chest compressions at a rate of 100 to 120/min (Class 2a, LOE B-NR).50,55Furthermore, from a new systematic review,44 we recommend that lay rescuers initiate CPR for presumed cardiac arrest because the risk of harm to patients is low if they are not in cardiac arrest (Class 1, LOE C-LD).56–59Double sequential defibrillation: Along with CPR, early defibrillation is critical to survival when sudden cardiac arrest is caused by ventricular fibrillation or pulseless ventricular tachycardia. However, rescuers may encounter victims who are refractory to defibrillation attempts. Double sequential defibrillation—shock delivery by 2 defibrillators nearly simultaneously—has emerged as a new technological approach to manage these patients.60–64 At this time, a systematic review reveals that the usefulness of double sequential defibrillation for refractory shockable rhythm has not been established (Class 2b, LOE C-LD).48Intravenous (IV) before intraosseous (IO): The peripheral IV route has been the traditional approach for giving emergency pharmacotherapy, although the IO route has grown in popularity and is increasingly implemented as a first-line approach for vascular access. New evidence suggests some uncertainty about the efficacy of the IO route compared with the IV route.65–69 Therefore, it is reasonable for providers to first attempt establishing IV access for drug administration in cardiac arrest (Class 2a, LOE B-NR). IO access may be considered if attempts at IV access are unsuccessful or not feasible (Class 2b, LOE B-NR).Early epinephrine administration reaffirmed: In 2 randomized clinical trials,70,71 administration of epinephrine increased ROSC and survival, leading to a recommendation that epinephrine be administered for patients in cardiac arrest (Class 1, LOE B-R).40,72 Uncertainty about the effect of epinephrine on neurological outcome, in addition to the variation in outcomes based on timing and initial rhythm, supported the following new concepts:– With respect to timing, for cardiac arrest with a nonshockable rhythm, it is reasonable to administer epinephrine as soon as feasible (Class 2a, C-LD).– With respect to timing, for cardiac arrest with a shockable rhythm, it may be reasonable to administer epinephrine after initial defibrillation attempts have failed (Class 2b, C-LD).The Adult Cardiac Arrest Algorithm has been updated to emphasize the early administration of epinephrine for patients with nonshockable rhythms.Individualized management of resuscitation: Not all cardiac arrest events are identical, and specialized management may be critical for optimal patient outcome, such as when the primary etiology of arrest is respiratory, a gravid uterus impedes venous return, or resuscitation involves a viable fetus. In the Special Circumstances of Resuscitation section, we highlight 2 such areas (opioid overdose and cardiac arrest in pregnancy):– Opioid overdose: The opioid epidemic has resulted in an increase in respiratory and cardiac arrests due to opioid overdose.73 To address this public health crisis, we present 2 new algorithms for the management of opioid-associated emergencies, highlighting that lay rescuers and trained responders should not delay activating emergency response systems while awaiting the patient’s response to naloxone or other interventions (Class 1, LOE E-O). Additionally, for patients known or suspected to be in cardiac arrest, in the absence of a proven benefit from the use of naloxone, standard resuscitative measures should take priority over naloxone administration, with a focus on high-quality CPR (compressions plus ventilation) (Class 1, LOE E-O).73– Cardiac arrest in pregnancy: We present updated recommendations and a new algorithm highlighting the concept that the best outcomes for both mother and fetus are through successful maternal resuscitation.74 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). Priorities for treating the pregnant woman in cardiac arrest should include provision of high-quality CPR and relief of aortocaval compression through left lateral uterine displacement (Class 1, LOE C-LD). If the pregnant woman with a fundus height at or above the umbilicus has not obtained ROSC with usual resuscitation measures plus manual left lateral uterine displacement, it is advisable to prepare to evacuate the uterus while resuscitation continues (Class 1, LOE C-LD).75–79 To accomplish delivery early, ideally within 5 minutes after the time of arrest, it is reasonable to immediately prepare for perimortem cesarean delivery while initial BLS and advanced cardiovascular life support (ACLS) interventions are being performed (Class 2a, LOE C-EO), although provider skill set and available personnel and resources may also logically influence this timing.74Point-of-care ultrasound for prognostication: Many have attempted to leverage the use of new technologies like portable ultrasound machines to provide guidance in making decisions on futility and termination of resuscitation. However, on the basis of a synthesis of the evidence,48 we suggest against the use of point-of-care ultrasound for prognostication during CPR (Class 3: No benefit, LOE C-LD). This recommendation does not preclude the use of ultrasound to identify potentially reversible causes of cardiac arrest or detect ROSC.Postresuscitative care: Post–cardiac arrest care, a critical component of the Chain of Survival, demands a comprehensive, structured, multidisciplinary system of care that should be implemented in a consistent manner for the treatment of post–cardiac arrest patients (Class 1, LOE B-NR).40,80 We present a new algorithm that describes the initial stabilization phase and additional emergency activities after ROSC. Key considerations include blood pressure management, monitoring for and treatment of seizures, and targeted temperature management.Improving neuroprognostication: Accurate neurological prognostication in cardiac arrest survivors who do not regain consciousness with ROSC is critically important to ensure that patients with significant potential for recovery are not destined for certain poor outcomes due to care withdrawal.81 With updated systematic reviews on multiple aspects of neuroprognostication,48 in patients who remain comatose after cardiac arrest, we recommend that neuroprognostication involve a multimodal approach and not be based on any single finding (Class 1, LOE B-NR).48,81 To assist in this process, we have developed evidence-based guidance to facilitate multimodal prognostication. This includes the following:– In patients who remain comatose after cardiac arrest, we recommend that neuroprognostication be delayed until adequate time has passed to ensure avoidance of confounding by medication effect or a transiently poor examination in the early postinjury period (Class 1, LOE B-NR).82– In patients who remain comatose after cardiac arrest, it is reasonable to perform multimodal neuroprognostication at a minimum of 72 hours after the return to normothermia, though individual prognostic tests may be obtained earlier than this (Class 2a, LOE B-NR).48Further, we provide specific guidance on the use of clinical examination, serum biomarkers, electrophysiological tests, and neuroimaging for neuroprognostication.Recovery and survivorship: Finally, we have added an additional link in the Chain of Survival: recovery from cardiac arrest. Recovery expectations and survivorship plans that address treatment, surveillance, and rehabilitation need to be provided to cardiac arrest survivors and their caregivers at hospital discharge to address the sequelae of cardiac arrest and optimize transitions of care to independent physical, social, emotional, and role function.83 Recommendations that are critically important to this concept include the following:– We recommend structured assessment for anxiety, depression, posttraumatic stress, and fatigue for cardiac arrest survivors and their caregivers (Class 1, LOE B-NR)83–87– 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).83,88–90– We recommend that cardiac arrest survivors and their caregivers receive comprehensive, multidisciplinary discharge planning, to include medical and rehabilitative treatment recommendations and return to activity/work expectations (Class 1, LOE C-LD).83Knowledge GapsSome of the most pertinent gaps in adult resuscitation research include the following:What are optimal strategies to enhance lay rescuer performance of CPR?For patients with an arterial line in place, does targeting CPR to a particular blood pressure improve outcomes?Can artifact-filtering algorithms for analysis of ECG rhythms during CPR in a real-time clinical setting decrease pauses in chest compressions and improve outcomes?Does preshock waveform analysis lead to improved outcome?Does double sequential defibrillation and/or alternative defibrillator pad positioning affect outcome in cardiac arrest with shockable rhythm?Is the IO route of drug administration safe and efficacious in cardiac arrest, and does efficacy vary by IO site?Does epinephrine, when administered early after cardiac arrest, improve survival with favorable neurological outcome?Does the use of point-of-care cardiac ultrasound during cardiac arrest improve outcomes?Is targeting a specific partial pressure of end-tidal carbon dioxide (ETCO2) value during CPR beneficial, and what degree of rise in ETCO2 indicates ROSC?Which populations are most likely to benefit from extracorporeal CPR?Does the treatment of nonconvulsive seizures, which are common in postarrest patients, improve patient outcomes?Do neuroprotective agents improve favorable neurological outcome after cardiac arrest?What is the most efficacious management approach for postarrest cardiogenic shock, including pharmacological, catheter intervention, or implantable device?Does targeted temperature management, compared with strict normothermia, improve outcomes?What is the optimal duration for targeted temperature management before rewarming?What is the best approach to rewarming postarrest patients after treatment with targeted temperature management?Are glial fibrillary acidic protein, serum tau protein, and neurofilament light chain measurements valuable for neuroprognostication?Do more uniform definitions for status epilepticus, malignant electroencephalogram patterns, and other electroencephalogram patterns enable better comparisons of their prognostic values across studies?Is there a consistent threshold value for prognostication for gray-white ratio or apparent diffusion coefficient?What do survivor-derived outcome measures of the impact of cardiac arrest survival look like, and how do they differ from current generic or clinician-derived measures?Does hospital-based protocolized discharge planning for cardiac arrest survivors improve access to/referral to rehabilitation services or patient outcomes?Is there benefit to naloxone administration in patients with opioid-associated cardiac arrest who are receiving CPR with ventilation?What is the ideal initial dose of naloxone in a setting where fentanyl and fentanyl analogues are responsible for a large proportion of opioid overdose?In cases of suspected opioid overdose managed by a non–healthcare provider who is not capable of reliably checking a pulse, is initiation of CPR beneficial?What is the ideal timing of perimortem cesarean delivery for a pregnant woman in cardiac arrest?Which patients with cardiac arrest due to “suspected” pulmonary embolism benefit from emergency thrombolysis during resuscitation?Pediatric Basic and Advanced Life Support21Part 4 of the 2020 Guidelines, “Pediatric Basic and Advanced Life Support,” includes recommendations for the treatment of pediatric OHCA and IHCA, including postresuscitation care and survivorship. The causes, treatment, and outcomes of cardiac arrest in children differ from cardiac arrest in adults. For example, pediatric cardiac arrests are more often due to respiratory causes. These guidelines contain recommendations for pediatric BLS and ALS, excluding the newborn period, and are based on the best available resuscitation science. Expansions to pediatric ALS recommendations include care of the child with pulmonary hypertension, congenital heart disease, and post–cardiac arrest recovery. This summary highlights the new and updated recommendations in pediatric BLS and ALS since 2015 that we believe will have a significant impact on process and on patient-related outcomes from cardiac arrest. Additional recommendations related to pediatric resuscitation can be found in “Part 7: Systems of Care.”Significant New and Updated RecommendationsRespiratory rate: Respiratory rates during pediatric CPR have previously been extrapolated from adult data, because of lack of pediatric studies. New data about respiratory rates during CPR in children are now available. Although limited, these data support a higher respiratory rate for children with an advanced airway than was previously recommended.91 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. Rates exceeding these recommendations may compromise hemodynamics (Class 2b, LOE C-LD).91 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).91Cuffed endotracheal tubes: 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).92–98Cricoid pressure: Although cricoid pressure may be useful in certain circumstances, routine use can impede visualization during laryngoscopy and chest rise with bag-mask ventilation. Clinical studies show that routine use of cricoid pressure reduces the rate of first-attempt intubation success. Routine use of cricoid pressure is not recommended during endotracheal intubation of pediatric patients (Class 3: No benefit, LOE C-LD),99,100 and if cricoid pressure is used, discontinue if it interferes with ventilation or the speed or ease of intubation (Class 3: Harm, LOE C-LD).99,100Early epinephrine: The goal of epinephrine administration during CPR is to optimize coronary perfusion pressure and maintain cerebral perfusion pressure. Earlier administration of epinephrine during CPR may increase survival-to-discharge rates. For pediatric patients in any setting, it is reasonable to administer the initial dose of epinephrine within 5 minutes from the start of chest compressions (Class 2a, LOE C-LD).101–104Diastolic blood pressure to guide CPR: For patients with continuous invasive arterial blood pressure monitoring in place at the time of cardiac arrest, it is reasonable for providers to use diastolic blood pressure to assess CPR quality (Class 2a, LOE C-LD).105 Although ideal blood pressure targets during CPR are not known, diastolic blood pressure is the main driver of coronary blood flow and may be used to guide interventions if an arterial line is in place.Seizures after cardiac arrest: Post–cardiac arrest seizures are common. Many are nonconvulsive, which can be detected only with electroencephalography monitoring. When resources are available, continuous electroencephalography monitoring is recommended for the detection of seizures after cardiac arrest in patients with persistent encephalopathy (Class 1, LOE C-LD).106–109 It is recommended to treat clinical seizures that follow cardiac arrest (Class 1, LOE C-LD).110,111 It is reasonable to treat nonconvulsive status epilepticus that follows cardiac arrest, in consultation with experts (Class 2a, LOE C-EO).110,111Recovery and survivorship: New neurological morbidity after cardiac arrest is common and should be addressed with ongoing assessment and intervention to support patients after hospital discharge. It is recommended that pediatric cardiac arrest survivors be evaluated for rehabilitation services (Class 1, LOE C-LD).112–117 It is reasonable to refer pediatric cardiac arrest survivors for ongoing neurological evaluation for at least the first year after cardiac arrest (Class 2a, LOE C-LD).81,83,115,117–122Septic shock: Previous AHA guidelines for the management of septic shock included aggressive (20 mL/kg) fluid boluses and lacked additional guidance. In these 2020 Guidelines, a more tailored approach to fluid administration is suggested, and vasopressor recommendations are provided.– In patients with septic shock, it is reasonable to administer fluid in 10-mL/kg or 20-mL/kg aliquots with frequent reassessment (Class 2a, LOE C-LD).123 Providers should reassess the patient after every fluid bolus to assess for fluid responsiveness and for signs of volume overload (Class 1, LOE C-LD).123–125– Either isotonic crystalloids or colloids can be effective as the initial fluid choice for resuscitation (Class 2a, LOE B-R).126 Either balanced or unbalanced solutions can be effective as the fluid choice for resuscitation (Class 2a, LOE B-NR).127–129– In infants and children with fluid-refractory septic shock, it is reasonable to use either epinephrine or norepinephrine as an initial vasoactive infusion (Class 2a, LOE C-LD).130–135Opioid overdose: Although most victims of opioid overdose are adults, young children suffer opioid overdose from exploratory behavior, and adolescents through opioid abuse or self-harm exposure. Opioid overdose causes respiratory depression, which can progress to respiratory arrest and then cardiac arrest. Pediatric opioid ove