Guideline sources The following summarized guidelines for the evaluation and management of cardiac arrest are prepared by our editorial team based on guidelines from the European Society for Trauma and Emergency Surgery (ESTES/ESAIC 2023), the European Society of Cardiology (ESC 2022; 2021; 2018), the Society for Cardiovascular Angiography and Interventions (SCAI/AHA/ACC 2022), the European Society of Intensive Care Medicine (ESICM/ERC 2022), the American Heart Association (AHA 2020; 2018), the United Kingdom Kidney Association (UKKA 2020), the Pathway (Pathway 2020), the American Heart Association (AHA/ACC 2020; 2013), the International Liaison Committee on Resuscitation (ILCOR 2019), the American College of Obstetricians and Gynecologists (ACOG 2019), the Wilderness Medical Society (WMS 2019; 2014), the Heart Rhythm Society (HRS 2019), the American Heart Association (AHA/HRS/ACC 2019; 2018), the European Society of Intensive Care Medicine (ESICM/SCCM 2018), the Canadian Association of Poison Control Centres (CAPCC/ESICM/CAEP/AAPCC/SCCM/CPS/EAPCCT/ESEM/CCCS/ACMT 2017), the Society of https://web.pathway.md/diseases/recY9C9KT1dKiqMcI 1/24 6/29/23, 3:44 AM Cardiac arrest Pathway Critical Care Medicine (SCCM 2016), and the Asia Pacific Heart Rhythm Society (APHRS/EHRA/HRS 2013). 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 26 26 26 27 28 28 29 30 Definition Cardiac arrest is defined as the functional loss of mechanical cardiac activity, leading to cessation of systemic circulation. 26 Epidemiology The most common cause of out-of-hospital cardiac arrest is ischemic heart disease, with up to 70% patients with out-of-hospital cardiac arrest having significant coronary artery disease on coronary angiography. In patients with in-hospital cardiac arrest, arrhythmias and myocardial ischemia represent the most common causes. Other causes of cardiac arrest include non-ischemic heart disease, as well as non-cardiac diseases (shock of any etiology, hypoxia, hypoglycemia, hypothermia, electrolyte and acid-base disturbances, drug overdose). 26 26 28 Pathophysiology In the United States, the incidence of cardiac arrest is estimated at 55 cases per 100,000 person- years. The incidence of in-hospital cardiac arrest is estimated at 1-6 cases per 1,000 hospital admissions. 26 27 Disease course Patients who achieve ROSC after cardiac arrest have a high mortality rate, owing to the development of post-cardiac arrest syndrome, which is characterized by multi-organ dysfunction, including post-cardiac arrest brain injury and post-cardiac arrest myocardial dysfunction. 29 Prognosis and risk of recurrence In patients with out-of-hospital cardiac arrest, 30-day survival is estimated at 5.8% in patients in whom CPR is not performed, and 13.5-13.8% in patients in whom CPR is performed. In patients with in-hospital cardiac arrest, 30-day survival is estimated at 28.3%. 28 30 Guidelines 1. Screening and diagnosis Recognition (lay rescuer): assume that a victim is in cardiac arrest if unconscious/unresponsive with absent or abnormal breathing (only gasping). B Recognition (healthcare provider): check for a pulse for 10 seconds if a victim is unconscious/unresponsive with absent or abnormal breathing (only gasping), and assume that the victim is in cardiac arrest if no definite pulse is felt. B https://web.pathway.md/diseases/recY9C9KT1dKiqMcI 2/24 6/29/23, 3:44 AM Cardiac arrest Pathway 2. Diagnostic investigations Cardiac imaging: As per AHA 2021 guidelines, obtain echocardiography by trained physicians immediately following a 12-lead ECG in patients presenting with cardiac arrest or hemodynamic instability of presumed cardiovascular origin. B As per AHA 2020 guidelines, consider obtaining ultrasound as an adjunct to standard evaluation if an experienced operator is present and the use of ultrasound does not interfere with the standard cardiac arrest treatment protocol. C 3. Respiratory support Supplemental oxygen: consider administering supplemental oxygen during CPR, if available, at the maximal feasible inspired oxygen concentration. C 4. Medical management Setting of care: consider managing adult patients with nontraumatic out-of-hospital cardiac arrest in cardiac arrest centers rather than in non-cardiac arrest centers. C Vascular access: consider attempting to establish IV access for drug administration in cardiac arrest. C Show 3 more Vasopressors: As per AHA 2020 guidelines, administer epinephrine in patients with cardiac arrest. B Show 5 more As per ILCOR 2019 guidelines, administer epinephrine during CPR. B Show 3 more As per ACC 2018 guidelines: Consider administering epinephrine (1 mg every 3-5 minutes) during CPR in patients in cardiac arrest. B Do not administer high-dose (> 1 mg high boluses) epinephrine in patients in cardiac arrest. D Landmark trials: PARAMEDIC2 In patients with out-of-hospital cardiac arrest, epinephrine was superior to placebo with respect to the rate of survival at 30 days. Gavin D Perkins et al. N Engl J Med. 2018 Aug 23. https://web.pathway.md/diseases/recY9C9KT1dKiqMcI 3/24 6/29/23, 3:44 AM Cardiac arrest Pathway Nonvasopressor medications: As per AHA 2020 guidelines, consider administering amiodarone or lidocaine in patients with VF or pulseless VT unresponsive to defibrillation. C Show 2 more Updated evidence: COCA In adult patients with out-of-hospital cardiac arrest who received at least 1 dose of epinephrine during the cardiac arrest, calcium was not superior to saline with respect to sustained ROSC. Mikael Fink Vallentin et al. JAMA. 2021 Dec 14. As per ACC 2018 guidelines, consider administering IV lidocaine in patients with a witnessed cardiac arrest due to VF or polymorphic VT unresponsive to CPR, defibrillation, and vasopressor therapy. C As per AHA 2018 guidelines, consider administering amiodarone or lidocaine for VF/pulseless VT that is unresponsive to defibrillation. C As per SCCM 2018 guidelines, consider administering corticosteroids in patients with critical illness-related corticosteroid insufficiency in cardiac arrest. C Updated evidence: VAM-IHCA In adult patients with in-hospital cardiac arrest who received at least 1 dose of epinephrine during cardiac arrest, vasopressin and methylprednisolone were superior to placebo with respect to ROSC. Lars W Andersen et al. JAMA. 2021 Oct 26. Management of narrow-complex tachycardia (cardioversion): Perform synchronized cardioversion for acute treatment in patients with hemodynamically unstable supraVT. B Perform synchronized cardioversion for acute treatment in patients with hemodynamically stable supraVT if vagal maneuvers and pharmacological therapy are ineffective or contraindicated. B Management of narrow-complex tachycardia (pharmacotherapy): perform vagal maneuvers for acute treatment in patients with supraVT at a regular rate. B Show 3 more Management of wide-complex tachycardia (pharmacotherapy): consider administering IV adenosine in hemodynamically stable patients for treatment and aiding rhythm diagnosis when the cause of the regular, monomorphic rhythm cannot be determined. C Show 3 more https://web.pathway.md/diseases/recY9C9KT1dKiqMcI 4/24 6/29/23, 3:44 AM Cardiac arrest Pathway Management of wide-complex tachycardia (cardioversion): consider performing cardioversion or obtaining urgent expert consultation if pharmacological therapy fails in patients with hemodynamically stable wide-complex tachycardia. C Management of sustained polymorphic VT (defibrillation): perform immediate defibrillation in patients with sustained, hemodynamically unstable polymorphic VT. B Management of sustained polymorphic VT, pharmacotherapy: As per AHA 2020 guidelines, consider administering magnesium for the treatment of polymorphic VT associated with a long QT interval (torsades de pointes). C Show 2 more As per HRS/ACC/AHA 2018 guidelines, consider administering IV lidocaine in patients with a witnessed cardiac arrest due to VF or polymorphic VT unresponsive to CPR, defibrillation, and vasopressor therapy. C Management of atrial fibrillation/flutter (cardioversion): perform electric cardioversion in hemodynamically unstable patients with AF or atrial flutter with a rapid ventricular response. B Show 3 more Management of atrial fibrillation/flutter (pharmacotherapy): administer IV -blocker or nondihydropyridine calcium channel antagonist to slow the ventricular HR in the acute setting in patients with AF or atrial flutter with a rapid ventricular response without preexcitation. B Show 3 more Management of bradycardia (pharmacotherapy): evaluate for and treat reversible causes in patients presenting with acute symptomatic bradycardia. B Show 2 more Management of bradycardia (transvenous pacing): consider performing immediate pacing in unstable patients with high-degree AV block when IV/intraosseous access is not available. C Show 2 more 5. Therapeutic procedures Dispatch instructions: ensure that emergency medical call-takers provide CPR instructions (when deemed necessary) for adult patients in cardiac arrest. B Show 2 more Initiation of resuscitation (lay rescuer): activate the emergency response system first when alone and immediately initiate CPR after identifying a cardiac arrest. B Show 3 more Initiation of resuscitation (healthcare provider): Initiate chest compressions only when alone. B Consider initiating chest compressions and ventilation in all adult patients in cardiac arrest from either a cardiac or noncardiac cause. C https://web.pathway.md/diseases/recY9C9KT1dKiqMcI 5/24 6/29/23, 3:44 AM Cardiac arrest Pathway CPR technique (positioning): place the heel of one hand on the center (middle) of the victim's chest (the lower half of the sternum) and the heel of the other hand on top of the first so that the hands are overlapped for chest compressions. B Show 3 more CPR technique (opening the mouth, healthcare provider): open the airway using a head tilt- chin lift maneuver if no cervical spine injury is suspected. B Show 4 more CPR technique (opening the mouth, lay rescuer): Open the airway using a head tilt-chin lift maneuver, if trained and feeling confident in performing both compressions and ventilation, if no cervical spine injury is suspected. B Do not use immobilization devices in patients with head and neck trauma because their use by untrained rescuers may be harmful. D CPR technique (advanced airways): consider using either bag-mask ventilation or an advanced airway strategy during CPR in adult patients with cardiac arrest in any setting, depending on the situation and skill set of the provider. C Show 5 more Landmark trials: AIRWAY-2 In adult patients who had a nontraumatic out-of-hospital cardiac arrest and were treated by a participating paramedic, supraglottic airway device was not superior to tracheal intubation with respect to good outcome; mRS score range of 0-3. Jonathan R Benger et al. JAMA. 2018 Aug 28. CPR technique (compression depth and rate): perform chest compressions to a depth of at least 5 cm (2 in) in average adult patients while avoiding excessive chest compression depths (> 6 cm; 2.4 in) during manual CPR. B Show 3 more CPR technique (compression fraction and pauses): ensure that total preshock and postshock pauses in chest compressions are as short as possible. B Show 5 more CPR technique, ventilation: As per AHA 2020 guidelines, consider providing tidal volumes of approximately 500-600 mL, or enough to produce visible chest rise, in adult patients in cardiac arrest receiving ventilation. C Show 6 more As per ILCOR 2019 guidelines, consider using bag-mask ventilation or an advanced airway strategy during CPR in adult patients with cardiac arrest in any setting. C Show 3 more https://web.pathway.md/diseases/recY9C9KT1dKiqMcI 6/24 6/29/23, 3:44 AM Cardiac arrest Pathway CPR technique (compression-to-ventilation ratio): consider performing CPR with cycles of 30 compressions and 2 breaths by healthcare providers before placement of an advanced airway (supraglottic airway or tracheal tube). C Show 3 more CPR technique (mechanical devices): do not use mechanical CPR devices routinely. D Consider using mechanical CPR devices in specific settings where the delivery of high-quality manual compressions may be challenging or dangerous for the provider, as long as rescuers strictly limit interruptions in CPR during deployment and removal of the device. D Show 2 more CPR technique (interposed abdominal compression CPR): consider performing interposed abdominal compression CPR during in-hospital resuscitation when sufficient personnel trained in its use are available. C CPR technique (precordial thump): Do not perform precordial thump routinely in patients with established cardiac arrest. D Consider performing precordial thump at the onset of a rescuer-witnessed, monitored, unstable ventricular tachyarrhythmia when a defibrillator is not immediately available, while not delaying CPR or shock delivery. C CPR technique (percussion pacing): consider performing fist (percussion) pacing as a temporizing measure in exceptional circumstances such as witnessed, monitored in-hospital arrest (cardiac catheterization laboratory) for bradyasystole before a loss of consciousness, while not delaying definitive therapy. C CPR technique (cough CPR): consider performing "cough" CPR as a temporizing measure for the witnessed, monitored onset of a hemodynamically significant tachyarrhythmia or bradyarrhythmia before a loss of consciousness, while not delaying definitive therapy. C CPR technique, extracorporeal CPR: As per AHA 2020 guidelines, insufficient evidence to recommend the routine use of extracorporeal CPR in patients with cardiac arrest. Consider performing extracorporeal CPR in selected patients with cardiac arrest if the suspected cause of cardiac arrest is potentially reversible during a limited period of mechanical cardiorespiratory support. I As per ILCOR 2019 guidelines: Consider performing extracorporeal CPR as a rescue therapy in selected patients with cardiac arrest when conventional CPR is failing in settings in which it can be implemented. C Consider performing extracorporeal CPR in selected infant and pediatric patients with in- hospital cardiac arrest refractory to conventional CPR in settings where resuscitation systems allow extracorporeal CPR to be well performed and implemented. C Defibrillation: perform defibrillation (using biphasic or monophasic waveforms) for the treatment of tachyarrhythmias requiring a shock. B Show 14 more Electrical pacing: do not perform electric pacing routinely in patients with established cardiac arrest. D https://web.pathway.md/diseases/recY9C9KT1dKiqMcI 7/24 6/29/23, 3:44 AM Cardiac arrest Pathway Monitoring of resuscitation: consider using audiovisual feedback devices during CPR for real- time optimization of CPR performance. C Show 4 more Discontinuation of resuscitation: use basic life support termination of resuscitation rule by basic life support emergency medical services when considering termination of resuscitation where advanced life support is not available or may be significantly delayed. B Show 5 more 6. Perioperative care Perioperative cardiac arrest (choice of approach): Perform closed chest cardiac compression in patients with cardiac arrest. B Consider performing open chest cardiac massage if a ROSC has not been achieved with closed chest cardiac compression and veno-arterial ECMO is not available. C Perioperative cardiac arrest (post-cardiac surgery): perform external chest compressions if emergency resternotomy is not immediately available. B Show 5 more Perioperative cardiac arrest (hemorrhage): consider performing simultaneous hemorrhage control, massive transfusion, and closed chest compression. B Show 2 more Perioperative cardiac arrest (pulseless rhythms): Perform immediate defibrillation in patients with cardiac arrest presenting with VF or pulseless VT in the perioperative setting. B Perform emergency temporary pacing in patients with asystole with P-waves. Address reversible causes without delay. B Perioperative cardiac arrest (tension pneumothorax): perform immediate decompression of suspected tension pneumothorax. B Show 2 more Perioperative cardiac arrest (cardiac tamponade): Obtain point-of-care ultrasound to confirm the diagnosis in patients with suspected cardiac tamponade. B Perform immediate decompression of the pericardium in case of cardiac tamponade. Perform either US-guided pericardiocentesis or resuscitative thoracotomy (in case of hemopericardium) to achieve immediate decompression. B Perioperative cardiac arrest (pulmonary embolism): consider performing veno-arterial ECMO to restore circulation and oxygenation as a bridge to definitive treatment. Consider performing thrombolysis if ECMO is not available. B Perioperative cardiac arrest (gas embolism during laparoscopy): https://web.pathway.md/diseases/recY9C9KT1dKiqMcI 8/24 6/29/23, 3:44 AM Cardiac arrest Pathway Perform closed chest cardiac compression in patients with a gas embolism developing a cardiac arrest. B Consider performing open chest cardiac massage if a ROSC has not been achieved with closed chest cardiac compression and veno-arterial ECMO is not available. C Perioperative cardiac arrest (REBOA and resuscitative thoracotomy): consider performing immediate REBOA in patients with exsanguinating infra-diaphragmatic hemorrhage not controllable by other means. Consider performing resuscitative thoracotomy with cross-clamping of the descending aorta or REBOA. C Perioperative cardiac arrest (monitoring): consider obtaining end-tidal CO monitoring in intubated patients during CPR to predict the likelihood of ROSC and survival and guide CPR despite the lack of absolute cut-off values. C Show 2 more Perioperative cardiac arrest (health professional training): Consider implementing a coordinated protocol to improve the quality of mechanical CPR when training for perioperative cardiac arrest. C Consider providing simulation training for healthcare providers to increase the likelihood of the ROSC. C 7. Specific circumstances Pregnant patients (planning and preparation): plan team for cardiac arrest in pregnancy in collaboration with the obstetric, neonatal, emergency, anesthesiology, intensive care, and cardiac arrest services. B Show 2 more Pregnant patients (resuscitation): prioritize providing high-quality CPR and performing left lateral uterine displacement to relieve aortocaval compressiom in pregnant patients in cardiac arrest. B Show 3 more Pregnant patients, resuscitative hysterotomy: as per AHA 2020 guidelines, consider preparing to evacuate the uterus while continuing resuscitation if the pregnant patient with a fundus height at or above the umbilicus has not achieved ROSC with usual resuscitation measures plus manual left lateral uterine displacement. B Show 2 more Neonatal patients (therapeutic temperature management): consider administering targeted therapeutic management in the post-cardiac arrest period to maintain a central temperature < 37.5 C in infants and pediatric patients with out-of-hospital cardiac arrest. C Neonatal patients (supplemental oxygen): Consider administering 21% oxygen in infants at 35 weeks of gestation receiving respiratory support at birth. C Do not administer 100% oxygen. B https://web.pathway.md/diseases/recY9C9KT1dKiqMcI 9/24 6/29/23, 3:44 AM Cardiac arrest Pathway Consider administering lower oxygen concentrations (21-30%) in preterm infants (< 35 weeks of gestation) receiving respiratory support at birth. Consider titrating oxygen concentration subsequently based on pulse oximetry. C Patients with electrolyte abnormalities: As per AHA 2020 guidelines, administer IV calcium in addition to standard advanced cardiovascular life support care in patients with cardiac arrest with known or suspected hyperkalemia. B Show 3 more As per UKKA 2020 guidelines, treat hyperkalemia urgently in patients with severe hyperkalemia (K+ 6.5 mmol/L) and in patients with ECG changes suggestive of severe hyperkalemia. B Show 10 more Patients with pulmonary embolism: Consider performing thrombolysis, surgical embolectomy, or mechanical embolectomy as emergency treatment options in patients with confirmed PE as the precipitant of cardiac arrest. C Consider performing thrombolysis when cardiac arrest is suspected to be caused by PE. C Patients with asthma: obtain prompt evaluation for tension pneumothorax in patients with asthma with cardiac arrest, sudden elevation in peak inspiratory pressures, or difficulty ventilating. B Show 2 more Patients with anaphylaxis: undertake standard resuscitative measures and administer immediate epinephrine in patients in cardiac arrest secondary to anaphylaxis. B Show 7 more Patients with beta-blocker overdose: As per AHA 2020 guidelines: Consider administering the following agents in patients with -blocker overdose in refractory shock: high-dose insulin with glucose C IV glucagon C IV calcium. C Consider performing ECMO in patients with -blocker overdose in shock refractory to pharmacological therapy. C As per ACC 2019 guidelines: Consider administering high-dose insulin to increase HR and improve symptoms in patients with bradycardia associated with symptoms or hemodynamic compromise because of - blocker overdose. C Consider administering glucagon to increase HR and improve symptoms in patients with bradycardia associated with symptoms or hemodynamic compromise because of -blocker overdose. C Patients with calcium channel blocker overdose: https://web.pathway.md/diseases/recY9C9KT1dKiqMcI 10/24 6/29/23, 3:44 AM Cardiac arrest Pathway As per AHA 2020 guidelines: Consider administering the following agents in patients with CCB overdose in refractory shock IV calcium C high-dose insulin with glucose C IV glucagon. C Consider performing ECMO in patients with CCB overdose in shock refractory to pharmacological therapy. C As per AAPCC 2017 guidelines, administer the following in addition to standard advanced cardiac life-support in patients with CCB poisoning in cardiac arrest: IV calcium, even if previously administered lipid-emulsion therapy, if not administered previously. B Show 4 more Patients with sodium channel blocker overdose: Consider administering sodium bicarbonate for cardiac arrest or life-threatening cardiac conduction delays (QRS prolongation > 120 ms) due to sodium channel blocker/TCA overdose. C Consider performing ECMO for cardiac arrest or refractory shock due to sodium channel blocker/TCA overdose. C Patients with cardiac glycoside overdose: administer antidigoxin Fab antibodies in patients with severe cardiac glycoside toxicity. B Patents with local anesthetic overdose: consider administering IV lipid emulsion concomitant with standard resuscitative care in patients with local anesthetic systemic toxicity and particularly in patients having premonitory neurotoxicity or cardiac arrest due to bupivacaine toxicity. C Patients with opioid overdose: maintain rescue breathing or bag-mask ventilation until spontaneous breathing returns and continue standard basic life support and/or advanced cardiovascular life support measures if return of spontaneous breathing does not occur in patients in respiratory arrest. B Show 3 more Patients with cocaine overdose: Consider administering benzodiazepines, alpha-blockers, CCBs, nitroglycerin, and/or morphine in patients with cocaine-induced hypertension, tachycardia, agitation, or chest discomfort. C Avoid using pure -blockers in the setting of cocaine toxicity. D Patients with benzodiazepine overdose: do not use flumazenil in patients with undifferentiated coma. D Patients with cyanide poisoning: consider administering hydroxocobalamin and 100% oxygen, with or without sodium thiosulfate, for cyanide poisoning. C Patients with carbon monoxide poisoning: consider administering hyperbaric oxygen therapy for the treatment of acute CO poisoning in patients with severe toxicity. C https://web.pathway.md/diseases/recY9C9KT1dKiqMcI 11/24 6/29/23, 3:44 AM Cardiac arrest Pathway Patients with accidental hypothermia: As per AHA 2020 guidelines, undertake full resuscitative measures, including extracorporeal rewarming when available, in all victims of accidental hypothermia without characteristics suggesting that they are unlikely to survive and without any obviously lethal traumatic injury. B Show 3 more As per WMS 2019 guidelines, attempt CPR unless contraindications exist. Recognize that fixed, dilated pupils, apparent rigor mortis, and dependent lividity are not contraindications to resuscitation in patients with severe hypothermia. A Show 9 more Patients after drowning: As per AHA 2020 guidelines, initiate CPR by rescuers, including rescue breathing, as soon as an unresponsive submersion victim is removed from the water. B Show 3 more As per WMS 2019 guidelines, establish an airway and provide oxygen in the initial resuscitation. Administer positive pressure ventilation in addition to chest compressions using the traditional Airway-Breathing-Circulation model of resuscitation for the patient in cardiac arrest. B Show 4 more Patients after lightning injury: initiate resuscitation in victims of lightning strike immediately if the scene otherwise is deemed safe. Recognize that these victims do not carry residual electrical charge. Use the basic and advanced life support algorithms, including trauma when appropriate, as the standard of care. Follow current advanced life support guidelines for lightning victims requiring resuscitation. B 8. Follow-up and surveillance Post-resuscitation care (early care): implement a comprehensive, structured, multidisciplinary system of care in a consistent manner for the treatment of post-cardiac arrest patients. B Show 6 more Updated evidence: BOX In comatose adults who had been resuscitated after an out-of-hospital cardiac arrest of presumed cardiac cause, high BP target was not superior to low BP target with respect to death from any cause or hospital discharge with a Cerebral Performance Category of 3 or 4 at day 90. Jesper Kjaergaard et al. N Engl J Med. 2022 Oct 20. Post-resuscitation care, targeted temperature management: As per ESICM/ERC 2022 guidelines, do not administer rapid infusion of large volumes of cold IV fluid immediately after ROSC in a prehospital setting. D https://web.pathway.md/diseases/recY9C9KT1dKiqMcI 12/24 6/29/23, 3:44 AM Cardiac arrest Pathway Show 5 more As per AHA 2020 guidelines, administer targeted temperature management in adult patients not following commands after ROSC from out-of-hospital cardiac arrest with any initial rhythm. B Show 5 more Updated evidence: TTM2 In adults with coma who had an out-of-hospital cardiac arrest, hypothermia was not superior to normothermia with respect to death from any cause at 6 months. Josef Dankiewicz et al. N Engl J Med. 2021 Jun 17. As per ESC 2018 guidelines: Do not administer a rapid infusion of large volumes of cold IV fluids immediately after the ROSC in the prehospital setting. D Administer targeted temperature management early after resuscitation of cardiac arrest in patients remaining unresponsive. B As per AHA/ACC 2013 guidelines, administer therapeutic hypothermia as soon as possible in comatose patients with STEMI and out-of-hospital cardiac arrest caused by VF or pulseless VT, including in patients after primary PCI. B Landmark trials: TTM In unconscious adults after out-of-hospital cardiac arrest of presumed cardiac cause, cooling to 33 degree C was not superior to cooling to 36 degree C with respect to a all-cause death. Nielsen N et al. N Engl J Med. 2013 Dec 5. Post-resuscitation care (neuromuscular blockade): insufficient evidence to recommend the routine use of neuromuscular blocking agents in patients undergoing therapeutic hypothermia following cardiac arrest. Show 4 more Post-resuscitation care (management of seizures): obtain and interpret prompt EEG for the diagnosis of seizures in all comatose patients after ROSC. B Show 4 more Post-resuscitation care, therapies with no evidence for benefit: As per AHA 2020 guidelines, insufficient evidence to recommend a specific target range of glucose management in adult patients with ROSC after cardiac arrest. I Show 3 more Landmark trials: ANTHARTIC https://web.pathway.md/diseases/recY9C9KT1dKiqMcI 13/24 6/29/23, 3:44 AM Cardiac arrest Pathway In adult patients in ICUs who were being mechanically ventilated after out-of-hospital cardiac arrest related to initial shockable rhythm and treated with targeted temperature management at 32 to 34 C, antibiotic was superior to control with respect to early ventilator-associated pneumonia. Bruno Fran ois et al. N Engl J Med. 2019 Nov 7. As per AHA 2018 guidelines, insufficient evidence to support or refute the routine use of - blockers or lidocaine early (within the first hour) after ROSC. I Post-resuscitation evaluation (rhythm monitoring): Retrieve recordings from cardiac implantable electronic devices and wearable monitors in all sudden cardiac arrest survivors. B Obtain repeated 12-lead ECGs during stable rhythm (including high precordial lead ECG) and continuous cardiac monitoring in sudden cardiac arrest survivors. B Post-resuscitation evaluation (cardiac imaging): Obtain echocardiography for evaluation of cardiac structure and function in all sudden cardiac arrest survivors. B Obtain coronary imaging and cardiac MRI with late gadolinium enhancement for evaluation of cardiac structure and function in all sudden cardiac arrest survivors without a clear underlying cause. B Post-resuscitation evaluation, coronary angiography: As per ESC 2022 guidelines, obtain coronary angiography in electrically unstable patients after sudden cardiac arrest with suspicion of ongoing myocardial ischemia. B As per SCAI/AHA/ACC 2022 guidelines, perform revascularization to improve survival in patients with significant coronary artery disease and VF, polymorphic VT, or cardiac arrest. B As per ESC 2021 guidelines, consider obtaining delayed as opposed to immediate angiography in hemodynamically stable patients without ST-segment elevation successfully resuscitated after out-of-hospital cardiac arrest. C As per AHA 2020 guidelines, obtain emergent coronary angiography in all patients with cardiac arrest with a suspected cardiac cause of arrest and ST-segment elevation on ECG. B Show 2 more Updated evidence: EMERGE In survivors of out-of-hospital cardiac arrest without ST-segment elevation on ECG, emergency coronary angiogram was not superior to delayed coronary angiogram with respect to survival with cerebral performance category of 2 at day 180. Caroline Hauw-Berlemont et al. JAMA Cardiol. 2022 Jul 1. https://web.pathway.md/diseases/recY9C9KT1dKiqMcI 14/24 6/29/23, 3:44 AM Cardiac arrest Pathway As per HRS/ACC/AHA 2018 guidelines: Consider obtaining CT or invasive coronary angiography to confirm the presence or absence of ischemic heart disease and guide decisions for myocardial revascularization in patients recovered from unexplained sudden cardiac arrest. B Evaluate patients with sustained ventricular arrhythmia and survivors of sudden cardiac arrest for ischemic heart disease, and perform revascularization as appropriate. B As per ESC 2018 guidelines, consider obtaining urgent angiography, and performing PCI if indicated, in patients with resuscitated cardiac arrest without diagnostic ST-segment elevation but with a high suspicion of ongoing myocardial ischemia. C Show 2 more As per AHA/ACC 2013 guidelines, obtain immediate coronary angiography and perform primary PCI in patients with out-of-hospital cardiac arrest after resuscitation, if the initial ECG shows STEMI. B Post-resuscitation evaluation (provocation tests): Obtain sodium channel blocker testing and exercise testing in sudden cardiac arrest survivors without a clear underlying cause. B Consider obtaining ergonovine, acetylcholine, or hyperventilation testing for the diagnosis of coronary vasospasm in sudden cardiac arrest survivors. C Post-resuscitation evaluation, genetic testing: As per ESC 2022 guidelines, obtain genetic testing in patients survived sudden cardiac arrest due to ventricular arrhythmia. B As per HRS/ACC/AHA 2018 guidelines: Obtain further evaluation for genetic arrhythmia syndromes in young patients (aged < 40 years) with unexplained sudden cardiac arrest, unexplained near-drowning, or recurrent exertional syncope in the absence of ischemic or other structural heart diseases. B Consider offering genetic counseling in patients and family members requiring genetic testing for risk stratification for sudden cardiac arrest or sudden cardiac death. B Post-resuscitation evaluation (evaluation for extra-cardiac causes): evaluate sudden cardiac arrest survivors without obvious extra-cardiac causes by a multidisciplinary team. B Show 2 more Neuroprognostication (general principles): ensure a multimodal approach for neuroprognostication based on a combination of findings (rather than a single finding) in patients remaining comatose after cardiac arrest. B Show 3 more Neuroprognostication (clinical evaluation): Consider assessing the following at 72 hours after cardiac arrest, in combination with other prognostic tests, to support the prognosis of poor neurological outcome in patients remaining comatose: bilaterally absent of pupillary light reflex bilaterally absent of corneal reflexes https://web.pathway.md/diseases/recY9C9KT1dKiqMcI 15/24 6/29/23, 3:44 AM Cardiac arrest Pathway quantitative pupillometry status myoclonus. C Show 3 more Neuroprognostication (laboratory evaluation): Consider assessing for high serum values of NSE within 72 hours after cardiac arrest, in combination with other prognostic tests, to support the prognosis of poor neurological outcome in patients remaining comatose. C Insufficient evidence regarding the usefulness of S100 calcium-binding protein, Tau, neurofilament light chain, and GFAP for neuroprognostication. I Neuroprognostication (electroencephalography): insufficient evidence regarding the prognostic value of seizures when evaluated with other prognostic tests in patients remaining comatose after cardiac arrest. I Show 3 more Neuroprognostication (neuroimaging): Consider assessing for reduced gray-white ratio on brain CT after cardiac arrest, in combination with other prognostic tests, to support the prognosis of poor neurological outcome in patients remaining comatose. C Consider assessing for extensive areas of restricted diffusion and reduced apparent diffusion coefficient on brain MRI at 2-7 days after cardiac arrest, in combination with other prognostic tests, to support the prognosis of poor neurological outcome in patients remaining comatose. C Recovery and survivorship: obtain structured assessment for anxiety, depression, posttraumatic stress, and fatigue in cardiac arrest survivors and their caregivers. B Show 3 more Post-cardiac arrest ICD implantation (ischemic heart disease): perform ICD placement in patients with ischemic heart disease survived sudden cardiac arrest due to VT/VF, B if the expected meaningful survival is > 1 year. B Post-cardiac arrest ICD implantation, coronary artery spasm: As per ESC 2022 guidelines, consider performing ICD placement in sudden cardiac arrest survivors with coronary artery spasm. C As per HRS/ACC/AHA 2018 guidelines: Consider performing ICD placement in patients resuscitated from sudden cardiac arrest due to coronary artery spasm, if medical therapy is ineffective or not tolerated and the meaningful survival is > 1 year. C Consider performing ICD placement in addition to medical therapy in patients resuscitated from sudden cardiac arrest due to coronary artery spasm, if the expected meaningful survival is > 1 year. C Post-cardiac arrest ICD implantation, cardiomyopathies: As per ESC 2022 guidelines, perform ICD placement in patients with dilated cardiomyopathy survived sudden cardiac arrest due to VT/VF or experienced hemodynamically not-tolerated sustained monomorphic VT. B https://web.pathway.md/diseases/recY9C9KT1dKiqMcI 16/24 6/29/23, 3:44 AM Cardiac arrest Pathway As per ACC/AHA 2020 guidelines, perform ICD placement in patients with hypertrophic cardiomyopathy and previous documented cardiac arrest or sustained VT. B As per HRS 2019 guidelines, perform ICD placement in patients with cardiac amyloidosis survived a cardiac arrest, if the expected meaningful survival is > 1 year. B As per HRS/ACC/AHA 2018 guidelines, perform ICD placement in patients with non-ischemic cardiomyopathy survived sudden cardiac arrest due to VT/VF, B if the expected meaningful survival is > 1 year. B Show 4 more Post-cardiac arrest ICD implantation, Brugada syndrome: As per HRS/ACC/AHA 2018 guidelines, perform ICD in patients with Brugada syndrome with spontaneous type 1 Brugada ECG pattern survived cardiac arrest, sustained ventricular arrhythmia, or with a recent history of syncope presumed due to ventricular arrhythmia, if the expected meaningful survival is > 1 year. B As per APHRS/EHRA/HRS 2013 guidelines, perform ICD placement in patients with Brugada syndrome survived a cardiac arrest, or with a documented spontaneous sustained VT with or without syncope. A Post-cardiac arrest ICD implantation (short QT syndrome): Perform ICD placement in patients with short QT syndrome survived cardiac arrest or sustained ventricular arrhythmia, if the expected meaningful survival is > 1 year. B Consider performing ICD placement in patients with a cardiac channelopathy survived sudden cardiac arrest, if the expected meaningful survival is > 1 year. B Post-cardiac arrest ICD implantation, early repolarization pattern: As per HRS/ACC/AHA 2018 guidelines, perform ICD placement in patients with an early repolarization pattern on ECG and cardiac arrest or sustained ventricular arrhythmia, if the expected meaningful survival is> 1 year. B As per ESC 2018 guidelines, consider performing ICD implantation in patients with an early repolarization pattern and suspected arrhythmic syncope in the presence of a family history of early repolarization pattern with cardiac arrest. C Post-cardiac arrest ICD implantation (adult congenital heart disease): perform ICD placement in patients with adult congenital heart disease after sudden cardiac arrest due to VT or VF in the absence of reversible causes, if the expected meaningful survival is > 1 year. B Post-cardiac arrest ICD implantation (idiopathic VT/VF): perform ICD placement in patients resuscitated from sudden cardiac arrest due to idiopathic polymorphic VT or VF, if the expected meaningful survival is > 1 year. B 9. Quality improvement Public access defibrillation: https://web.pathway.md/diseases/recY9C9KT1dKiqMcI 17/24 6/29/23, 3:44 AM Cardiac arrest Pathway Ensure public access defibrillation is available at sites where cardiac arrest is more likely to occur. B Promote community training in basic life support to increase bystander CPR rate and automated external defibrillator use. B Clinical findings Symptoms Past medical history Fainting