Part 3: Adult Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.

Abstract

HomeCirculationVol. 142, No. 16_suppl_2Part 3: Adult Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyRedditDiggEmail Jump toFree AccessResearch ArticlePDF/EPUBPart 3: Adult Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Ashish R. Panchal, MD, PhD, Chair, Jason A. Bartos, MD, PhD, José G. Cabañas, MD, MPH, Michael W. Donnino, MD, Ian R. Drennan, ACP, PhD(C), Karen G. Hirsch, MD, Peter J. Kudenchuk, MD, Michael C. Kurz, MD, MS, Eric J. Lavonas, MD, MS, Peter T. Morley, MBBS, Brian J. O’Neil, MD, Mary Ann Peberdy, MD, Jon C. Rittenberger, MD, MS, Amber J. Rodriguez, PhD, Kelly N. Sawyer, MD, MS and Katherine M. Berg, MD, Vice Chair Ashish R. PanchalAshish R. Panchal Search for more papers by this author , Jason A. BartosJason A. Bartos Search for more papers by this author , José G. CabañasJosé G. Cabañas Search for more papers by this author , Michael W. DonninoMichael W. Donnino Search for more papers by this author , Ian R. DrennanIan R. Drennan Search for more papers by this author , Karen G. HirschKaren G. Hirsch Search for more papers by this author , Peter J. KudenchukPeter J. Kudenchuk Search for more papers by this author , Michael C. KurzMichael C. Kurz Search for more papers by this author , Eric J. LavonasEric J. Lavonas Search for more papers by this author , Peter T. MorleyPeter T. Morley Search for more papers by this author , Brian J. O’NeilBrian J. O’Neil Search for more papers by this author , Mary Ann PeberdyMary Ann Peberdy Search for more papers by this author , Jon C. RittenbergerJon C. Rittenberger Search for more papers by this author , Amber J. RodriguezAmber J. Rodriguez Search for more papers by this author , Kelly N. SawyerKelly N. Sawyer Search for more papers by this author and Katherine M. BergKatherine M. Berg Search for more papers by this author and On behalf of the Adult Basic and Advanced Life Support Writing Group Originally published21 Oct 2020https://doi.org/10.1161/CIR.0000000000000916Circulation. 2020;142:S366–S468Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: October 21, 2020: Previous Version of Record Top 10 Take-Home Messages for Adult Cardiovascular Life SupportOn recognition of a cardiac arrest event, a layperson should simultaneously and promptly activate the emergency response system and initiate cardiopulmonary resuscitation (CPR).Performance of high-quality CPR includes adequate compression depth and rate while minimizing pauses in compressions,Early defibrillation with concurrent high-quality CPR is critical to survival when sudden cardiac arrest is caused by ventricular fibrillation or pulseless ventricular tachycardia.Administration of epinephrine with concurrent high-quality CPR improves survival, particularly in patients with nonshockable rhythms.Recognition that all cardiac arrest events are not identical is critical for optimal patient outcome, and specialized management is necessary for many conditions (eg, electrolyte abnormalities, pregnancy, after cardiac surgery).The opioid epidemic has resulted in an increase in opioid-associated out-of-hospital cardiac arrest, with the mainstay of care remaining the activation of the emergency response systems and performance of high-quality CPR.Post–cardiac arrest care is a critical component of the Chain of Survival and demands a comprehensive, structured, multidisciplinary system that requires consistent implementation for optimal patient outcomes.Prompt initiation of targeted temperature management is necessary for all patients who do not follow commands after return of spontaneous circulation to ensure optimal functional and neurological outcome.Accurate neurological prognostication in brain-injured cardiac arrest survivors is critically important to ensure that patients with significant potential for recovery are not destined for certain poor outcomes due to care withdrawal.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 optimize transitions of care to home and to the outpatient setting.PreambleIn 2015, approximately 350 000 adults in the United States experienced nontraumatic out-of-hospital cardiac arrest (OHCA) attended by emergency medical services (EMS) personnel.1 Approximately 10.4% of patients with OHCA survive their initial hospitalization, and 8.2% survive with good functional status. The key drivers of successful resuscitation from OHCA are lay rescuer cardiopulmonary resuscitation (CPR) and public use of an automated external defibrillator (AED). Despite recent gains, only 39.2% of adults receive layperson-initiated CPR, and the general public applied an AED in only 11.9% of cases.1 Survival rates from OHCA vary dramatically between US regions and EMS agencies.2,3 After significant improvements, survival from OHCA has plateaued since 2012.Approximately 1.2% of adults admitted to US hospitals suffer in-hospital cardiac arrest (IHCA).1 Of these patients, 25.8% were discharged from the hospital alive, and 82% of survivors have good functional status at the time of discharge. Despite steady improvement in the rate of survival from IHCA, much opportunity remains.The International Liaison Committee on Resuscitation (ILCOR) Formula for Survival emphasizes 3 essential components for good resuscitation outcomes: guidelines based on sound resuscitation science, effective education of the lay public and resuscitation providers, and implementation of a well-functioning Chain of Survival.4These guidelines contain recommendations for basic life support (BLS) and advanced life support (ALS) for adult patients and are based on the best available resuscitation science. The Chain of Survival, introduced in Major Concepts, is now expanded to emphasize the important component of survivorship during recovery from cardiac arrest, requires coordinated efforts from medical professionals in a variety of disciplines and, in the case of OHCA, from lay rescuers, emergency dispatchers, and first responders. In addition, specific recommendations about the training of resuscitation providers are provided in “Part 6: Resuscitation Education Science,” and recommendations about systems of care are provided in “Part 7: Systems of Care.”IntroductionScope of the GuidelinesThese guidelines are designed primarily for North American healthcare providers who are looking for an up-to-date summary for BLS and ALS for adults as well as for those who are seeking more in-depth information on resuscitation science and gaps in current knowledge. The BLS care of adolescents follows adult guidelines. This Part of the 2020 American Heart Association (AHA) Guidelines for CPR and Emergency Cardiovascular Care includes recommendations for clinical care of adults with cardiac arrest, including those with life-threatening conditions in whom cardiac arrest is imminent, and after successful resuscitation from cardiac arrest.Some recommendations are directly relevant to lay rescuers who may or may not have received CPR training and who have little or no access to resuscitation equipment. Other recommendations are relevant to persons with more advanced resuscitation training, functioning either with or without access to resuscitation drugs and devices, working either within or outside of a hospital. Some treatment recommendations involve medical care and decision-making after return of spontaneous circulation (ROSC) or when resuscitation has been unsuccessful. Importantly, recommendations are provided related to team debriefing and systematic feedback to increase future resuscitation success.Organization of the Writing GroupThe Adult Cardiovascular Life Support Writing Group included a diverse group of experts with backgrounds in emergency medicine, critical care, cardiology, toxicology, neurology, EMS, education, research, and public health, along with content experts, AHA staff, and the AHA senior science editors. Each recommendation was developed and formally approved by the writing group.The AHA has rigorous conflict of interest policies and procedures to minimize the risk of bias or improper influence during the development of guidelines. Before appointment, writing group members disclosed all commercial relationships and other potential (including intellectual) conflicts. These procedures are described more fully in “Part 2: Evidence Evaluation and Guidelines Development.” Disclosure information for writing group members is listed in Appendix 1.Methodology and Evidence ReviewThese guidelines are based on the extensive evidence evaluation performed in conjunction with the ILCOR and 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. A more comprehensive description of these methods is provided in “Part 2: Evidence Evaluation and Guidelines Development.”Class of Recommendation and Level of EvidenceAs with all AHA guidelines, each 2020 recommendation is assigned a Class of Recommendation (COR) based on the strength and consistency of the evidence, alternative treatment options, and the impact on patients and society (Table 1). The Level of Evidence (LOE) is based on the quality, quantity, relevance, and consistency of the available evidence. For each recommendation, the writing group discussed and approved specific recommendation wording and the COR and LOE assignments. In determining the COR, the writing group considered the LOE and other factors, including systems issues, economic factors, and ethical factors such as equity, acceptability, and feasibility. These evidence-review methods, including specific criteria used to determine COR and LOE, are described more fully in “Part 2: Evidence Evaluation and Guidelines Development.” The Adult Basic and Advanced Life Support Writing Group members had final authority over and formally approved these recommendations.Table 1. Applying Class of Recommendation and Level of Evidence to Clinical Strategies, Interventions, Treatments, or Diagnostic Testing in Patient Care (Updated May 2019)*This table defines the Classes of Recommendation (COR) and Levels of Evidence (LOE). COR indicates the strength the writing group assigns the recommendation, and the LOE is assigned based on the quality of the scientific evidence. The outcome or result of the intervention should be specified (an improved clinical outcome or increased diagnostic accuracy or incremental prognostic information).Classes of RecommendationCOR designations include Class 1, a strong recommendation for which the potential benefit greatly outweighs the risk; Class 2a, a moderate recommendation for which benefit most likely outweighs the risk; Class 2b, a weak recommendation for which it’s unknown whether benefit will outweigh the risk; Class 3: No Benefit, a moderate recommendation signifying that there is equal likelihood of benefit and risk; and Class 3: Harm, a strong recommendation for which the risk outweighs the potential benefit.Suggested phrases for writing Class 1 recommendations includeIs recommendedIs indicated/useful/effective/beneficialShould be performed/administered/otherComparative-effectiveness phrases include treatment/strategy A is recommended/indicated in preference to treatment B, and treatment A should be chosen over treatment B.Suggested phrases for writing Class 2a recommendations includeIs reasonableCan be useful/effective/beneficialComparative-effectiveness phrases include treatment/strategy A is probably recommended/indicated in preference to treatment B, and it is reasonable to choose treatment A over treatment B.For comparative-effectiveness recommendations (COR 1 and 2a; LOE A and B only), studies that support the use of comparator verbs should involve direct comparisons of the treatments or strategies being evaluated.Suggested phrases for writing Class 2b recommendations includeMay/might be reasonableMay/might be consideredUsefulness/effectiveness is unknown/unclear/uncertain or not well-establishedSuggested phrases for writing Class 3: No Benefit recommendations (generally, LOE A or B use only) includeIs not recommendedIs not indicated/useful/effective/beneficialShould not be performed/administered/otherSuggested phrases for writing Class 3: Harm recommendations includePotentially harmfulCauses harmAssociated with excess morbidity/mortalityShould not be performed/administered/otherLevels of EvidenceFor LOEs, the method of assessing quality is evolving, including the application of standardized, widely-used, and preferably validated evidence grading tools; and for systematic reviews, the incorporation of an Evidence Review Committee. LOE designations include Level A, Level B-R, Level B-NR, Level C-LD, and Level C-EO.Those categorized as Level A are derived fromHigh-quality evidence from more than 1 randomized clinical trial, or RCTMeta-analyses of high-quality RCTsOne or more RCTs corroborated by high-quality registry studiesThose categorized as Level B-R (randomized) are derived fromModerate-quality evidence from 1 or more RCTsMeta-analyses of moderate-quality RCTsThose categorized as Level B-NR (nonrandomized) are derived fromModerate-quality evidence from 1 or more well-designed, well-executed nonrandomized studies, observational studies, or registry studiesMeta-analyses of such studiesThose categorized as Level C-LD (limited data) are derived fromRandomized or nonrandomized observational or registry studies with limitations of design or executionMeta-analyses of such studiesPhysiological or mechanistic studies in human subjectsThose categorized as Level C-EO (expert opinion) are derived fromConsensus of expert opinion based on clinical experienceCOR and LOE are determined independently (any COR may be paired with any LOE).A recommendation with LOE C does not imply that the recommendation is weak. Many important clinical questions addressed in guidelines do not lend themselves to clinical trials. Although RCTs are unavailable, there may be a very clear clinical consensus that a particular test or therapy is useful or effective.Table 1. Applying Class of Recommendation and Level of Evidence to Clinical Strategies, Interventions, Treatments, or Diagnostic Testing in Patient Care (Updated May 2019)*Unfortunately, despite improvements in the design and funding support for resuscitation research, the overall certainty of the evidence base for resuscitation science is low. Of the 250 recommendations in these guidelines, only 2 recommendations are supported by Level A evidence (high-quality evidence from more than 1 randomized controlled trial [RCT], or 1 or more RCT corroborated by high-quality registry studies.) Thirty-seven recommendations are supported by Level B-Randomized Evidence (moderate evidence from 1 or more RCTs) and 57 by Level B-Nonrandomized evidence. The majority of recommendations are based on Level C evidence, including those based on limited data (123 recommendations) and expert opinion (31 recommendations). Accordingly, the strength of recommendations is weaker than optimal: 78 Class 1 (strong) recommendations, 57 Class 2a (moderate) recommendations, and 89 Class 2b (weak) recommendations are included in these guidelines. In addition, 15 recommendations are designated Class 3: No Benefit, and 11 recommendations are Class 3: Harm. Clinical trials in resuscitation are sorely needed.Guideline StructureThe 2020 Guidelines are organized into knowledge chunks, grouped into discrete modules of information on specific topics or management issues.5 Each modular knowledge chunk includes a table of recommendations that uses standard AHA nomenclature of COR and LOE. A brief introduction or short synopsis is provided to put the recommendations into context with important background information and overarching management or treatment concepts. Recommendation-specific text clarifies the rationale and key study data supporting the recommendations. When appropriate, flow diagrams or additional tables are included. Hyperlinked references are provided to facilitate quick access and review.Document Review and ApprovalEach of the 2020 Guidelines documents was submitted for blinded peer review to 5 subject-matter experts nominated by the AHA. Before appointment, all peer reviewers were required to disclose relationships with industry and any other conflicts of interest, and all disclosures were reviewed by AHA staff. Peer reviewer feedback was provided for guidelines in draft format and again in final format. All guidelines were reviewed and approved for publication by the AHA Science Advisory and Coordinating Committee and the AHA Executive Committee. Disclosure information for peer reviewers is listed in Appendix 2.