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2025 AHA CPR & ECC Guidelines - Exam-Oriented Points

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ETHICS IN RESUSCITATION

• Principlism is the dominant ethical framework - based on 4 principles: Beneficence, Non-maleficence, Autonomy, Justice
• Shared decision-making is preferred when multiple medically reasonable options exist
• For adults in cardiac arrest, default = initiate CPR, EXCEPT when:
  • Serious risk of physical harm to the HCP
  • Objective signs of irreversible death
  • Advanced directive declining treatment
• Portable orders for life-sustaining treatment = best way to document a patient's wish to forgo CPR
• Surrogates use substituted judgement when patients cannot decide for themselves
• Moral distress in HCPs should be managed at the organizational level, not individually
• Family presence during CPR reduces complicated grief and improves psychological outcomes
• ECPR raises specific ethical issues: patient selection criteria, consent, cost, equitable access
• Organ donation should be considered in ALL post-arrest patients progressing to death
• Resuscitation research may use Exception from Informed Consent (EFIC) - IRBs, not investigators, determine this

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SYSTEMS OF CARE

• Single Chain of Survival now applies to BOTH IHCA and OHCA (adult + pediatric)
• Chain: Prevention → Recognition → CPR → Defibrillation → Advanced Resuscitation → Post-arrest Care → Recovery
• Safety huddles around high-risk patients reduce IHCA rates (new 2025 recommendation)
• Public naloxone access now recommended alongside public defibrillation access
• Telecommunicators: give Hands-Only CPR instructions for adults; conventional CPR (with breaths) for children
• No-No-Go framework is effective for recognizing OHCA
• Debriefing: Both hot (immediate) and cold (delayed) debriefing are recommended together

Team Composition

• OHCA: ALS-level clinician beneficial; sufficient team size for discrete roles
• IHCA: Code teams should include ALS-trained members; designated code teams with defined roles + simulation training

On-Scene Resuscitation

• Sustained ROSC should be achieved on scene before transport for most adults/children
• EMS systems should be prepared to perform termination of resuscitation on scene
• Intra-arrest transport for ECPR may be considered for highly selected adult OHCA patients

ECPR Systems

• Centers with ECPR should develop/reassess patient selection criteria for equitable access
• Peripheral ECPR cannulation requires experience with percutaneous technique
• Regionalization of ECPR is reasonable to optimize outcomes

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NEONATAL LIFE SUPPORT

Cord Management

• Intact cord milking in nonvigorous infants reduced cardiorespiratory support, HIE, and use of therapeutic hypothermia

Airway/Ventilation

• Priority in neonatal resuscitation = effective lung ventilation
• Initial peak inflation pressures: 20-30 cm H₂O (adjustable for effective ventilation)
• Ventilation rate: 30-60/min
• Video laryngoscopy is useful and increases intubation success
• Laryngeal mask is reasonable alternative to endotracheal tube for infants ≥34 weeks
• Pulse oximeter should be placed as soon as possible for infants needing respiratory support
• Target O₂ saturation starts at 2 minutes (not 1 min) because deferred cord clamping means reading unavailable at 1 min
• Target SpO₂: 65-70% at 2 min → 85-95% at 10 min
• Preterm <32 weeks: Start with 30-100% O₂ (titrate to targets)

Chest Compressions (Neonatal)

• Compress over lower third of sternum, above xiphoid
• Compression rate: coordinate 3:1 with ventilation
• Change compressors every 2-5 minutes to maintain quality
• 2-finger technique is no longer recommended (replaced by 2 thumb-encircling hands or heel-of-1-hand)
• Use 100% O₂ during chest compressions
• Cardiac monitor recommended before starting chest compressions
• IV route: UVC or IO
• Epinephrine every 3-5 minutes if HR <60/min

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PEDIATRIC BASIC LIFE SUPPORT

• Most pediatric cardiac arrest is NOT primary cardiac - results from respiratory failure or shock
• 2 thumb-encircling hands technique is superior for infant CPR (superior compression depth)
• Heel-of-1-hand is acceptable alternative if encirclement not possible
• 2-finger technique is no longer recommended for infant CPR
• Interruptions in CPR <10 seconds; pauses strongly associated with lower ROSC

Foreign-Body Airway Obstruction (FBAO) - KEY CHANGES

• Back blows are now the first maneuver (evidence shows improved clearance, fewer injuries vs. abdominal thrusts)

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ADULT BASIC LIFE SUPPORT

• High-quality CPR + early defibrillation = most important interventions
• CPR ratio: 30 compressions : 2 breaths (for lay rescuers and HCPs before advanced airway)
• Tidal volume: enough to produce visible chest rise (avoid hypo- or hyperventilation)
• For adult respiratory arrest: 1 breath every 6 seconds (10 breaths/min)
• Patient position: firm surface, torso at rescuer's knee level
• Mechanical CPR devices are NOT routinely recommended; may be considered where manual CPR is dangerous/difficult

Head/Neck Trauma Airway

• Jaw thrust preferred; if cannot open airway with jaw thrust + adjunct, use head tilt-chin lift

Defibrillation Pads

• For women: adjust bra position rather than removing it (to reduce barriers to public AED use)

CPR in Obesity

• Use same CPR technique as non-obese patients (no modifications needed)

Adult FBAO (Updated Algorithm)

• 5 back blows → 5 abdominal thrusts (cycles until expelled or unresponsive)
• For pregnant or obese patients: use chest thrusts instead of abdominal thrusts
• If unresponsive → start CPR; check for visible object before giving breaths

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PEDIATRIC ADVANCED LIFE SUPPORT

Epinephrine

• For non-shockable rhythms: administer as early as possible (time to first dose <3 min associated with better outcomes)
• For shockable rhythms: give after initial defibrillation attempts fail

ETCO₂ Monitoring

• ETCO₂ ≥20 mmHg during CPR = associated with ROSC and survival to discharge
• A single ETCO₂ cutoff value should NOT be used alone to end resuscitation efforts

Invasive Arterial Pressure During CPR

• Target diastolic BP: ≥25 mmHg (infants) / ≥30 mmHg (children ≥1 year)

Post-Arrest Blood Pressure Targets (Pediatric)

• Maintain systolic and MAP >10th percentile for age
• Hypotension = systolic BP <5th percentile; occurs in 25-50% of children post-ROSC

Prognostication (Pediatric)

• Use multimodal approach - no single test is sufficient
• EEG up to 72 hours post-arrest: reasonable to use for favorable or unfavorable prognosis
• Cough/gag reflexes and pain response: not well established for neurologic prognosis
• Infants/children surviving arrest should be evaluated for physical, cognitive, and emotional needs within the first year

SVT Management

• Vagal maneuvers → Adenosine → Synchronized cardioversion
• If unresponsive to all and expert not available: IV procainamide, amiodarone, or sotalol

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ADULT ADVANCED LIFE SUPPORT

Vascular Access

• Attempt IV first; if unsuccessful → IO is reasonable
• IO vs IV: no statistically significant difference in outcomes but lower odds of sustained ROSC with IO

Vasopressors

• Epinephrine is the vasopressor of choice
• For shockable rhythm: give epinephrine after initial defibrillation attempts fail
• Vasopressin alone or vasopressin + epinephrine = no advantage over epinephrine alone

Non-Vasopressor Medications

• β-blockers, bretylium, procainamide, sotalol for VF/pulseless VT = uncertain benefit

Defibrillation

Adjuncts

• Head-up CPR: NOT recommended outside clinical trials

Termination of Resuscitation

• In tiered EMS (BLS + ALS): Universal termination of resuscitation rule is reasonable
• Criteria: arrest not witnessed by EMS, no shock delivered, no ROSC

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POST-CARDIAC ARREST CARE (ADULT)

Hemodynamics

• Avoid hypotension; maintain MAP ≥65 mmHg
• No single vasopressor has proven superior

Temperature Control

• Deliberate temperature control goal: 32°C-37.5°C
• Duration: at least 36 hours for patients unresponsive to verbal commands
• Both hypothermic (32-34°C) and normothermic (36-37.5°C) strategies acceptable

Oxygenation/Ventilation Targets

• SpO₂: 90-98% (PaO₂ 60-105 mmHg)
• PaCO₂: 35-45 mmHg
• Avoid hypoglycemia (<70 mg/dL) and hyperglycemia (>180 mg/dL)

Diagnostics

• 12-lead ECG immediately
• Head-to-pelvis CT may be reasonable to investigate etiology and complications
• Echocardiography/point-of-care ultrasound may be reasonable to identify significant diagnoses

Coronary Angiography

• Recommended before hospital discharge in survivors with:
  • Suspected cardiac etiology
  • Initial shockable rhythm
  • Unexplained LV systolic dysfunction
  • Evidence of severe myocardial ischemia

Temporary Mechanical Circulatory Support

• Consider in highly selected patients with refractory cardiogenic shock after ROSC

Myoclonus

• Treatment to suppress myoclonus without EEG correlate = NOT recommended (risk of side effects outweighs unknown benefit)

Neuroprognostication (Adult)

• Multimodal approach; impressions delayed ≥72 hours after ROSC or normothermia
• Continuous EEG background without discharges within 72 hours may support favorable prognosis
• Neurofilament light chain added as a serum biomarker

Recovery & Survivorship

• Survivors and caregivers should have structured assessment and treatment for emotional distress before discharge (approximately 1/4 experience distress)

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SPECIAL CIRCUMSTANCES

Life-Threatening Asthma

• ECLS may be reasonable if refractory to standard therapy
• Volatile anesthetics may be considered in refractory asthma (adults and children)

Life-Threatening Hyperkalemia

• IV calcium effectiveness in cardiac arrest from hyperkalemia = not well established
• Must weigh against time for CPR, defibrillation, and epinephrine

Hypothermia

• Severe hypothermia (<28°C) can mimic death
• ECLS rewarming: use prognostication scores (HOPE, ICE) to guide decision
• For <28°C NOT in cardiac arrest: ECLS rewarming is reasonable

Life-Threatening Hyperthermia

• Ice water immersion (1-5°C) is the preferred cooling method
• Target cooling rate: ≥0.15°C/min (0.27°F/min)
• Applies to environmental, sympathomimetic, and cocaine-induced hyperthermia

Left Ventricular Assist Devices (LVAD)

• If unresponsive with impaired perfusion: perform chest compressions
• Assess perfusion by: skin color/temp, capillary refill, MAP, PetCO₂
• Attempt LVAD function restoration simultaneously if second rescuer available

Cardiac Arrest in Pregnancy

• Begin preparation for resuscitative delivery at recognition of cardiac arrest
• Goal: complete delivery within 5 minutes
• ECPR is reasonable in pregnant patients not responsive to standard resuscitation
• Massive transfusion with balanced strategy for suspected amniotic fluid embolism

Opioid Overdose

• Naloxone may be reasonable in cardiac arrest with suspected opioid overdose - provided it does not interfere with high-quality CPR
• Survivors should receive naloxone + instruction on its use at discharge
• Public policies should allow lay rescuer naloxone possession and administration with civil/criminal immunity

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EDUCATION SCIENCE

• Feedback devices are recommended during CPR training for BOTH HCPs and lay rescuers (moderate-large effect on CPR quality metrics)
• Rapid-cycle deliberate practice: may be incorporated into BLS/ALS training for HCPs
• Teamwork and leadership training is recommended with emphasis on communication, workload management
• VR may support knowledge acquisition but should NOT be used to teach CPR skills
• Augmented reality may be considered for real-time CPR feedback in BLS training
• Gamified learning may be used for both HCPs and lay rescuers
• CPR training should begin in children <12 years to increase willingness and confidence
• Scripted debriefing may be reasonable for instructors during resuscitation education
• Cognitive aids: reasonable for HCPs; NOT recommended for lay rescuers (associated with significant delays in starting CPR)

Disparities in CPR Education - KEY POINTS

• Focus CPR training on:
  • Racial/ethnic populations and high-density neighborhoods
  • Women (address barriers including discomfort with chest exposure)
  • Low socioeconomic status populations
  • Linguistically isolated communities (materials in diverse languages)

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QUICK-HIT EXAM FACTS (Most Commonly Tested)