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Arrhyrthmias . Push hard (at least 2 inches [5 cml) and fast (100-120/min) and allow complete chest recoil. o Minimize interruptions in compressions. Yc! ilo o Avoid excessive ventilation. . Change compressor every 2 minutes, or sooner if fatigued. . lf no advanced airway,30:2 Asystole/PEA com pression-ventilation ratio. . Ouantitative waveform @ Shock EpinephrineASAP capnography - lf Prrco, is low or decreasing, reassess CPR quality.

. Push hard (at least 2 inches [5 cml) and fast (100-120/min) and allow complete chest recoil. o Minimize interruptions in compressions. Yc! ilo o Avoid excessive ventilation. . Change compressor every 2 minutes, or sooner if fatigued. . lf no advanced airway,30:2 Asystole/PEA com pression-ventilation ratio. . Ouantitative waveform @ Shock EpinephrineASAP capnography - lf Prrco, is low or decreasing, reassess CPR quality. . Biphasic: Manufacturer recommendation (e.9., inhial No of 12O-2OO Jl; if unknown, use maximum available. Second and subsequent doses Yer should be equivalent, and higher Yer Shock doses may be considered. o Monophasic 360 J

. Biphasic: Manufacturer recommendation (e.9., inhial No of 12O-2OO Jl; if unknown, use maximum available. Second and subsequent doses Yer should be equivalent, and higher Yer Shock doses may be considered. o Monophasic 360 J . Epinephrine lV/lO dose: 1 mg every 3-5 minutes . Amiodarone lVllO dose: First dose: 300-mg bolus. Second dose: 1 50 mg. No or Lidocaine lVllO dose: Yer First dose: 1-1 .5 mg/kg. Shock Second dose: 0.5-0.75 mg/kg.

. Epinephrine lV/lO dose: 1 mg every 3-5 minutes . Amiodarone lVllO dose: First dose: 300-mg bolus. Second dose: 1 50 mg. No or Lidocaine lVllO dose: Yer First dose: 1-1 .5 mg/kg. Shock Second dose: 0.5-0.75 mg/kg. o Endotracheal intubation or supraglottic advanced airway o Waveform capnography or capnometry to confirm and No monitor ETtube placement . Once advanced airway in place, o lf no signs of return of give 1 breath every 6 seconds spontaneous circulation (10 breaths/min) with continuous (ROSC), go to 10 or 1 1 chest compressions r lf ROSC, go to Post-Cardiac Arrest Care' . Consider appropriateness oI Goto5orT continued resuscitation o Pr:lse and blood pressure . Abrupt sustained increase in Percq (typically >40 mm Hg) . Spontaneous arterial pressure waves with intra-arterial monitoring

o Endotracheal intubation or supraglottic advanced airway o Waveform capnography or capnometry to confirm and No monitor ETtube placement . Once advanced airway in place, o lf no signs of return of give 1 breath every 6 seconds spontaneous circulation (10 breaths/min) with continuous (ROSC), go to 10 or 1 1 chest compressions r lf ROSC, go to Post-Cardiac Arrest Care' . Consider appropriateness oI Goto5orT continued resuscitation o Pr:lse and blood pressure . Abrupt sustained increase in Percq (typically >40 mm Hg) . Spontaneous arterial pressure waves with intra-arterial monitoring 'Hypovolemia . Hypoxia o Hydrogen ion (acidosis)

'Hypovolemia . Hypoxia o Hydrogen ion (acidosis) ' Hypo-/hyperkalemia 'Hypothermia o Tension pneumothorax o Tamponade, cardiac o Toxins o Thrombosis, pulmonary o Thrombosis, coronary Pnco, = partial pressure end{idal carbon dioxide; pW = pulseless ventricular tachycardia; VF = ventricular fibrillation. ahajournah.org/doi/1 0.1 1 61/C1R.000000000000091 6). nar resuscitation and emergency Grdiovascular care. Circulation. 2020;142:5374 [pMlD: 33081 529] doi:1 ()_1 1 61 /C|R.00000b000000091 6. @2020 AmeriGn Head A$ociation. 60

Valvular Heart Disease Device Therapy for Prevention of Sudden Death or effectively open (stenosis). VHD affects approximately 20 ICDs have demonstrated efficacy in the primary and second million persons in the United States. Although there are con ary prevention of SCD through their treatment, not preven genital forms, VHD is largely age dependent, with a prevalence tion. of VT/VF with defibrillation. Patients with sustained of 3'l, to 6'7, in persons aged 65 years or older. ventricular arrhythmias (>30 seconds) or cardiac arrest Many heart valve lesions progress slowly, causing patients without a reversible cause have a class 1 recommendation for to limit their activity unconsciousiy in response; therefore, a secondary prevention ICD placement. ICD placement is rec careful history and detailed physical examination are essen ommended for the primary prevention of SCD in patients with tial. Exertional dyspnea is the most common symptom. ischemic or nonischemic cardiomyopathy, ejection lraction Depending on the lesion and severity, other symptoms include less than 35'1,. and New York Heart Association functional angina, syncope, palpitations, Iower extremity edema, and class II or III heart failure. Patients with heart failure and inter increasing girth (ascites). Typical physical examination find ventricular conduction defects (predominantly left bundle ings for valvular and other cardiac lesions are described in branch block) often benefit from cardiac resynchronization Table 21. Twelve lead ECG, chest radiography, and transtho therapy or cardiac resynchronization therapy in combination racic echocardiography (TTE) are the essential tests used to with a defibrillator (see Heart Failure). evaluate VHD. In the past, ICDs were implanted almost exclusively using To facilitate the timing of monitoring and interr,zention, a transvenous approach. New techniques allow for implanta VHD is classified into four stages (A through D), which con tion of defibrillators in the lateral chest at the midaxillary line sider risk factors, presence of symptoms, Iesion severity, ven adjacent to the heart with tunneling of the lead under the skin tricular response to the volume or pressure overload caused by next to the sternum. Subcutaneous defibrillators have several the lesion, effect on the pulmonary or systemic circulation, advantages, including reduced risk for device infection. and heart rhl,thm changes (Table 22). Sur-veillance intervals for Infection is a major and chronic risk of implanted cardiac echocardiographic evaluation based on disease severity are devices. Pacemaker and defibrillator infections. even of the listed in Table 23 on page 64. pocket alone, must be managed aggressively to reduce mor Medical therapy, although often effective for syn.rptom bidity and mortality. However, device infection presentation palliation, has not been shown to prevent VHD progression may be insidious and underwhelming, potentially limited to or improve long term survival in patients with VHD. Surgery, only pain or erythema over the pocket. Nevertheless, any however, can be a life saving intervention in select patients, patient suspected ofhaving a cardiac device infection should and surgicai risk calculation is a key component of the be referred urgently for specialist evaluation. Empiric antibiot patient evaluation. Risk calculation involves assessment of ics alone (without blood cultures) may cloud or delay diagno- the patient's age, morbidities, frailty, and impediments spe sis, and diagnostic aspiration of the device pocket is never cific to the procedure under consideration (e.g.. previous indicated because of the risk for introducing infection in an chest irradiation for a sternotomy approach). Risk calculators uninfected pocket. Effective treatment of cardiac device infbc derived fiom national databases can assist in estimating risk tion usually includes complete extraction ol all hardware, for morbidity and mortality for surgical valve procedures. debridement of the pocket, sustained antibiotic therapy, and One such calculator, the Society o1'Thoracic Surgeons Adult re implantation at a new location after infection has been Cardiac Surgery Risk Calculator, is available at http:// eradicated. riskcalc.sts.org/stswebriskcalc. Although risk calculators contain many data inputs, frailty and some other important I(EY POITIS patient and procedural characteristics are not factored into . Implantable cardioverter-defibrillators are effective for the calculations. Therefore, a comprehensive approach is primary and secondary prevention ofsudden cardiac required for determining patient surgical risk and candidacy. death. Frailty, which is variably defined as a geriatric syndrome of . Infection of cardiac implanted devices may present decline in several physiologic systems and processes, por insidiously but requires urgent and specialized evalua tends an increased risk for mortality in patients undergoing tion, often necessitating complete hardware removal for surgery and can be measured preoperatively (see MKSAP 19 a durable cure. General Internal Medicine 1). For all patients in whom surgical or interuentional ther apy is being considered. a multidisciplinary approach with a heaft team consisting of a cardiologist, a surgeon, and an Valvular Heaft Disease interventional cardiologist is recommended. Evaluations in centers with specialized expertise in VHD (e.g.. a Heart Valve General Principles Center of Excellence) is also advised for patients in whom Valvular hearl disease (Vl{D) involves cardiac dysfunction due intervention is being considered when there are no symptoms, to structural or functional valve abnormalities resulting ftom multipie or complex morbidities are present, or surgical valve failure of the valves to either competently close (regurgitation) repair is lavored over valve replacement.

Device Therapy for Prevention of Sudden Death or effectively open (stenosis). VHD affects approximately 20 ICDs have demonstrated efficacy in the primary and second million persons in the United States. Although there are con ary prevention of SCD through their treatment, not preven genital forms, VHD is largely age dependent, with a prevalence tion. of VT/VF with defibrillation. Patients with sustained of 3'l, to 6'7, in persons aged 65 years or older. ventricular arrhythmias (>30 seconds) or cardiac arrest Many heart valve lesions progress slowly, causing patients without a reversible cause have a class 1 recommendation for to limit their activity unconsciousiy in response; therefore, a secondary prevention ICD placement. ICD placement is rec careful history and detailed physical examination are essen ommended for the primary prevention of SCD in patients with tial. Exertional dyspnea is the most common symptom. ischemic or nonischemic cardiomyopathy, ejection lraction Depending on the lesion and severity, other symptoms include less than 35'1,. and New York Heart Association functional angina, syncope, palpitations, Iower extremity edema, and class II or III heart failure. Patients with heart failure and inter increasing girth (ascites). Typical physical examination find ventricular conduction defects (predominantly left bundle ings for valvular and other cardiac lesions are described in branch block) often benefit from cardiac resynchronization Table 21. Twelve lead ECG, chest radiography, and transtho therapy or cardiac resynchronization therapy in combination racic echocardiography (TTE) are the essential tests used to with a defibrillator (see Heart Failure). evaluate VHD. In the past, ICDs were implanted almost exclusively using To facilitate the timing of monitoring and interr,zention, a transvenous approach. New techniques allow for implanta VHD is classified into four stages (A through D), which con tion of defibrillators in the lateral chest at the midaxillary line sider risk factors, presence of symptoms, Iesion severity, ven adjacent to the heart with tunneling of the lead under the skin tricular response to the volume or pressure overload caused by next to the sternum. Subcutaneous defibrillators have several the lesion, effect on the pulmonary or systemic circulation, advantages, including reduced risk for device infection. and heart rhl,thm changes (Table 22). Sur-veillance intervals for Infection is a major and chronic risk of implanted cardiac echocardiographic evaluation based on disease severity are devices. Pacemaker and defibrillator infections. even of the listed in Table 23 on page 64. pocket alone, must be managed aggressively to reduce mor Medical therapy, although often effective for syn.rptom bidity and mortality. However, device infection presentation palliation, has not been shown to prevent VHD progression may be insidious and underwhelming, potentially limited to or improve long term survival in patients with VHD. Surgery, only pain or erythema over the pocket. Nevertheless, any however, can be a life saving intervention in select patients, patient suspected ofhaving a cardiac device infection should and surgicai risk calculation is a key component of the be referred urgently for specialist evaluation. Empiric antibiot patient evaluation. Risk calculation involves assessment of ics alone (without blood cultures) may cloud or delay diagno- the patient's age, morbidities, frailty, and impediments spe sis, and diagnostic aspiration of the device pocket is never cific to the procedure under consideration (e.g.. previous indicated because of the risk for introducing infection in an chest irradiation for a sternotomy approach). Risk calculators uninfected pocket. Effective treatment of cardiac device infbc derived fiom national databases can assist in estimating risk tion usually includes complete extraction ol all hardware, for morbidity and mortality for surgical valve procedures. debridement of the pocket, sustained antibiotic therapy, and One such calculator, the Society o1'Thoracic Surgeons Adult re implantation at a new location after infection has been Cardiac Surgery Risk Calculator, is available at http:// eradicated. riskcalc.sts.org/stswebriskcalc. Although risk calculators contain many data inputs, frailty and some other important I(EY POITIS patient and procedural characteristics are not factored into . Implantable cardioverter-defibrillators are effective for the calculations. Therefore, a comprehensive approach is primary and secondary prevention ofsudden cardiac required for determining patient surgical risk and candidacy. death. Frailty, which is variably defined as a geriatric syndrome of . Infection of cardiac implanted devices may present decline in several physiologic systems and processes, por insidiously but requires urgent and specialized evalua tends an increased risk for mortality in patients undergoing tion, often necessitating complete hardware removal for surgery and can be measured preoperatively (see MKSAP 19 a durable cure. General Internal Medicine 1). For all patients in whom surgical or interuentional ther apy is being considered. a multidisciplinary approach with a heaft team consisting of a cardiologist, a surgeon, and an Valvular Heaft Disease interventional cardiologist is recommended. Evaluations in centers with specialized expertise in VHD (e.g.. a Heart Valve General Principles Center of Excellence) is also advised for patients in whom Valvular hearl disease (Vl{D) involves cardiac dysfunction due intervention is being considered when there are no symptoms, to structural or functional valve abnormalities resulting ftom multipie or complex morbidities are present, or surgical valve failure of the valves to either competently close (regurgitation) repair is lavored over valve replacement. 51