Step 4. One study of patients with laryngectomies showed that a pediatric face mask created a better peristomal seal than a standard ventilation mask. 1. 3. In what situations is attempted resuscitation of the drowning victim futile? The primary focus of cardiac arrest management for providers is the optimization of all critical steps required to improve outcomes. 2. No studies were found that specifically examined the use of ETCO. The use of an airway adjunct (eg, oropharyngeal and/or nasopharyngeal airway) may be reasonable in unconscious (unresponsive) patients with no cough or gag reflex to facilitate delivery of ventilation with a bag-mask device. 4. It is reasonable that selection of fixed versus escalating energy levels for subsequent shocks for presumed shock-refractory arrhythmias be based on the specific manufacturers instructions for that waveform. If a victim is unconscious/unresponsive, with absent or abnormal breathing (ie, only gasping), the lay rescuer should assume the victim is in cardiac arrest. Biphasic and monophasic shock waveforms are likely equivalent in their clinical outcome efficacy. The duration and severity of hypoxia sustained as a result of drowning is the single most important determinant of outcome. The paucity of information on the efficacy of IO drug administration during CPR was acknowledged in 2010, but since then the IO route has grown in popularity. Conversely, a regular wide-complex tachycardia could represent monomorphic VT or an aberrantly conducted reentrant paroxysmal SVT, ectopic atrial tachycardia, or atrial flutter. Energy setting specifications for cardioversion also differ between defibrillators. This creates a definitive airway so the air can't escape and end up in the stomach. Arrests without a primary cardiac origin (eg, from respiratory failure, toxic ingestion, pulmonary embolism [PE], or drowning) are also common, however, and in such cases, treatment for reversible underlying causes is important for the rescuer to consider.1 Some noncardiac etiologies may be particularly common in the in-hospital setting. The optimal timing for the performance of PMCD is not well established and must logically vary on the basis of provider skill set and available resources as well as patient and/or cardiac arrest characteristics. 2. Existing evidence, including observational and quasi-RCT data, suggests that pacing by a transcutaneous, transvenous, or transmyocardial approach in cardiac arrest does not improve the likelihood of ROSC or survival, regardless of the timing of pacing administration in established asystole, location of arrest (in-hospital or out-of-hospital), or primary cardiac rhythm (asystole, pulseless electrical activity). We do not recommend the routine use of rapid infusion of cold IV fluids for prehospital cooling of patients after ROSC. In a recent meta-analysis of 2 published studies (10 178 patients), only 0.01% (95% CI, 0.00%0.07%) of patients who fulfilled the ALS termination criteria survived to hospital discharge. 4. The American Heart Association is a qualified 501(c)(3) tax-exempt organization. The available evidence suggests no appreciable differences in success or major adverse event rates between calcium channel blockers and adenosine.2. After return of spontaneous breathing, patients should be observed in a healthcare setting until the risk of recurrent opioid toxicity is low and the patients level of consciousness and vital signs have normalized. 2. -Adrenergic blockers may be used in compensated patients with cardiomyopathy; however, they should be used with caution or avoided altogether in patients with decompensated heart failure. 1. These recommendations are supported by the 2019 focused update on ACLS guidelines.1. Mouth-to-nose ventilation may be necessary if ventilation through the victims mouth is impossible because of trauma, positioning, or difficulty obtaining a seal. Mechanical CPR devices deliver automated chest compressions, thereby eliminating the need for manual chest compressions. humidified oxygen? External chest compressions should be performed if emergency resternotomy is not immediately available. The Adult OHCA and IHCA Chains of Survival have been updated to better highlight the evolution of systems of care and the critical role of recovery and survivorship with the addition of a new link. Answer the dispatchers questions, and follow the telecommunicators instructions. If an advanced airway is in place, it may be reasonable for the provider to deliver 1 breath every 6 s (10 breaths/min) while continuous chest compressions are being performed. 1. We recommend structured assessment for anxiety, depression, posttraumatic stress, and fatigue for cardiac arrest survivors and their caregivers. In the ASPIRE trial (1071 patients), use of the load-distributing band device was associated with similar odds of survival to hospital discharge (adjusted odds ratio [aOR], 0.56; CI, 0.311.00; A 2013 Cochrane review of 10 trials comparing ACD-CPR with standard CPR found no differences in mortality and neurological function in adults with OHCA or IHCA. When performed with other prognostic tests, it may be reasonable to consider extensive areas of reduced apparent diffusion coefficient (ADC) on brain MRI at 2 to 7 days after cardiac arrest to support the prognosis of poor neurological outcome in patients who remain comatose. When performed with other prognostic tests, it may be reasonable to consider quantitative pupillometry at 72 h or more after cardiac arrest to support the prognosis of poor neurological outcome in patients who remain comatose. Studies on push-dose epinephrine for bradycardia specifically are lacking, although limited data support its use for hypotension. 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. Flumazenil, a specific benzodiazepine antagonist, restores consciousness, protective airway reflexes, and respiratory drive but can have significant side effects including seizures and arrhythmia.1 These risks are increased in patients with benzodiazepine dependence and with coingestion of cyclic antidepressant medications. 3. 1. 2. It can be beneficial for rescuers to avoid leaning on the chest between compressions to allow complete chest wall recoil for adults in cardiac arrest. These topics were identified as not only areas where no information was identified but also where the results of ongoing research could impact the recommendation directly. Evidence suggests that patients who are comatose after ROSC benefit from invasive angiography, when indicated, as do patients who are awake. If this is not known, defibrillation at the maximal dose may be considered. maintain proficiency? The Level of Evidence (LOE) is based on the quality, quantity, relevance, and consistency of the available evidence. The 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. Gently lift their chin forward with your other hand. 2. However, an oral airway is preferred because of the risk of trauma with a nasopharyngeal airway. The ILCOR systematic review included studies regardless of TTM status, and findings were correlated with neurological outcome at time points ranging from hospital discharge to 12 months after arrest.4 Quantitative pupillometry is the automated assessment of pupillary reactivity, measured by the percent reduction in pupillary size and the degree of reactivity reported as the neurological pupil index. Since this topic was last updated in detail in 2015, at least 2 randomized trials have been completed on the effect of steroids on shock and other outcomes after ROSC, only 1 of which has been published to date. EEG patterns that were evaluated in the 2020 ILCOR systematic review include unreactive EEG, epileptiform discharges, seizures, status epilepticus, burst suppression, and highly malignant EEG. 2. IV infusion of epinephrine is a reasonable alternative to IV boluses for treatment of anaphylaxis in patients not in cardiac arrest. Full resuscitative measures, including extracorporeal rewarming when available, are recommended for all victims of accidental hypothermia without characteristics that deem them unlikely to survive and without any obviously lethal traumatic injury. 2. How is CPR performed differently when an advanced airway is in place? One expected challenge faced through this process was the lack of data in many areas of cardiac arrest research. What are the optimal pharmacological treatment regimens for the management of postarrest seizures? 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.. 2. Emergent electric cardioversion and defibrillation are highly effective at terminating VF/VT and other tachyarrhythmias. 1. Time taken for rhythm analysis also disrupts CPR. The 2019 focused update on ACLS guidelines addressed the use of advanced airways in cardiac arrest and noted that either bag-mask ventilation or an advanced airway strategy may be considered during CPR for adult cardiac arrest in any setting.1 Outcomes from advanced airway and bag-mask ventilation interventions are highly dependent on the skill set and experience of the provider (Figure 7). If the chest is compressed during ventilations, most of the Continue reading "CPR with an Advanced Airway" Two randomized, placebo-controlled trials, enrolling over 8500 patients, evaluated the efficacy of epinephrine for OHCA.1,2 A systematic review and meta-analysis of these and other studies3 concluded that epinephrine significantly increased ROSC and survival to hospital discharge. 2. For asthmatic patients with cardiac arrest, sudden elevation in peak inspiratory pressures or difficulty ventilating should prompt evaluation for tension pneumothorax. Patients with 12-lead identification of ST-segment elevation myocardial infarction (STEMI) should have coronary angiography for possible PCI, highlighting the importance of obtaining an ECG for diagnostic purposes. Like all patients with cardiac arrest, the immediate goal is restoration of perfusion with CPR, initiation of ACLS, and rapid identification and correction of the cause of cardiac arrest. Do antiarrhythmic drugs, when given in combination for cardiac arrest, improve outcomes from cardiac The BLS TOR rule recommends TOR when all of the following criteria apply before moving to the ambulance for transport: (1) arrest was not witnessed by EMS providers or first responder; (2) no ROSC obtained; and (3) no shocks were delivered. The 2015 Guidelines Update recommended emergent coronary angiography for patients with ST-segment elevation on the post-ROSC ECG. Studies of mechanical CPR devices have not demonstrated a benefit when compared with manual CPR, with a suggestion of worse neurological outcome in some studies. CT indicates computed tomography; EEG, electroencephalogram; MRI, magnetic resonance imaging; NSE, neuron-specific enolase; ROSC, return of spontaneous circulation; SSEP, somatosensory evoked potential; and TTM, targeted temperature management. It can represent any aberrantly conducted supraventricular tachycardia (SVT), including paroxysmal SVT caused by atrioventricular (AV) reentry, aberrantly conducted atrial fibrillation, atrial flutter, or ectopic atrial tachycardia. Because chest compression fraction of at least 60% is associated with better resuscitation outcomes, compression pauses for ventilation should be as short as possible. It is critical for community members to recognize cardiac arrest, phone 9-1-1 (or the local emergency response number), perform CPR (including, for untrained lay rescuers, compression-only CPR), and use an AED.3,4 Emergency medical personnel are then called to the scene, continue resuscitation, and transport the patient for stabilization and definitive management. 1. For patients with a sinus tachycardia (heart rate greater than 100/min, P waves), no specific drug treatment is needed, and clinicians should focus on identification and treatment of the underlying cause of the tachycardia (fever, dehydration, pain). A 2017 ILCOR systematic review found that a ratio of 30 compressions to 2 breaths was associated with better survival than alternate ratios, a recommendation that was reaffirmed by the AHA in 2018. Recommendations 1 and 5 are supported by the 2018 focused update on ACLS guidelines.1 Recommendation 2 last received formal evidence review in 2015.20 Recommendations 3 and 4 last received formal evidence review in 2010.21. Adult/Child/Infant. In patients with -adrenergic blocker overdose who are in refractory shock, administration of high-dose insulin with glucose is reasonable. When performed with other prognostic tests, it may be reasonable to consider bilaterally absent corneal reflexes at 72 h or more after cardiac arrest to support the prognosis of poor neurological outcome in patients who remain comatose. Once reliable measurement of peripheral blood oxygen saturation is available, avoiding hyperoxemia by titrating the fraction of inspired oxygen to target an oxygen saturation of 92% to 98% may be reasonable in patients who remain comatose after ROSC. Endotracheal drug administration may be considered when other access routes are not available. It is reasonable for prehospital ALS providers to use the adult ALS TOR rule to terminate resuscitation efforts in the field for adult victims of OHCA. The combination of adenosines short-lived slowing of AV node conduction, shortening of refractoriness in the myocardium and accessory pathways, and hypotensive effects make it unsuitable in hemodynamically unstable patients and for treating irregularly irregular and polymorphic wide-complex tachycardias. Furthermore, many research studies have methodological limitations including small sample sizes, single-center design, lack of blinding, the potential for self-fulfilling prophecies, and the use of outcome at hospital discharge rather than a time point associated with maximal recovery (typically 36 months after arrest).3. In 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. Although data specific to patients with ROSC after cardiac arrest from anaphylaxis was not identified, an observational study of anaphylactic shock suggests that IV infusion of epinephrine (515 g/min), along with other resuscitative measures such as volume resuscitation, can be successful in the treatment of anaphylactic shock. 3. Routine measurement of arterial blood gases during CPR has uncertain value. The theory is that the heart will respond to electric stimuli by producing myocardial contraction and generating forward movement of blood, but clinical trials have not shown pacing to improve patient outcomes. Prompt systemic anticoagulation is generally indicated for patients with massive and submassive PE to prevent clot propagation and support endogenous clot dissolution over weeks. In cardiac arrest secondary to anaphylaxis, standard resuscitative measures and immediate administration of epinephrine should take priority. 1. 3. See answer (1) Best Answer. IV administration of a -adrenergic blocker or nondihydropyridine calcium channel antagonist is recommended to slow the ventricular heart rate in the acute setting in patients with atrial fibrillation or atrial flutter with rapid ventricular response without preexcitation. 2. For example, patients with severe hypoxia and impending respiratory failure may suddenly develop a profound bradycardia that leads to cardiac arrest if not addressed immediately. Operationally, the timing for prognostication is typically at least 5 days after ROSC for patients treated with TTM (which is about 72 hours after normothermia) and should be conducted under conditions that minimize the confounding effects of sedating medications. 1. The drugs hypotensive and tissue refractorinessshortening effects can accelerate ventricular rates in polymorphic VT and, when atrial fibrillation or flutter are conducted by an accessory pathway, risk degeneration to VF. With the airway open, pinch the nostrils shut, and cover the person's mouth with a CPR face mask to make a seal. A systematic review of the literature identified 5 small prospective trials, 3 retrospective studies, and multiple case reports and case series with contradictory results. 3. The main focus in adult cardiac arrest events includes rapid recognition, prompt provision of CPR, defibrillation of malignant shockable rhythms, and post-ROSC supportive care and treatment of underlying causes. Based on limited case reports and small case series, there is concern that patients with concomitant preexcitation and atrial fibrillation or atrial flutter may develop VF in response to accelerated ventricular response after the administration of AV nodal blocking agents such as digoxin, nondihydropyridine calcium channel antagonists, -adrenergic blockers, or IV amiodarone. Immediate defibrillation is the treatment of choice when torsades is sustained or degenerates to VF. Agonal breathing is described by lay rescuers with a variety of terms including, Protracted delays in CPR can occur when checking for a pulse at the outset of resuscitation efforts as well as between successive cycles of CPR. Symptoms typically occur within minutes, and findings may include arrhythmias, apnea, hypotension with bradycardia, seizures, and cardiovascular collapse.1 Lactic acidosis is a sensitive and specific finding.2,3 Immediate antidotes include hydroxocobalamin and nitrites; however, the former has a much better safety profile. Is there a consistent threshold value for prognostication for GWR or ADC? While hemodynamically stable rhythms afford an opportunity for evaluation and pharmacological treatment, the need for prompt electric cardioversion should be anticipated in the event the arrhythmia proves unresponsive to these measures or rapid decompensation occurs. Give one breath, blowing for about 1 second, watching for chest rise Your adult friend suddenly collapses at home, and you determine she needs CPR. This may include vasopressor agents such as epinephrine (discussed in Vasopressor Medications During Cardiac Arrest) as well as drugs without direct hemodynamic effects (nonpressors) such as antiarrhythmic medications, magnesium, sodium bicarbonate, calcium, or steroids (discussed here). The recommended dose of epinephrine in anaphylaxis is 0.2 to 0.5 mg (1:1000) intramuscularly, to be repeated every 5 to 15 min as needed. Because of the limitation in exhalational air flow, delivery of large tidal volumes at a higher respiratory rate can lead to progressive worsening of air trapping and a decrease in effective ventilation. When the victim is hypothermic, pulse and respiratory rates may be slow or difficult to detect. The writing group acknowledges the following contributors: Julie Arafeh, RN, MSN; Justin L. Benoit, MD, MS; Maureen Chase; MD, MPH; Antonio Fernandez; Edison Ferreira de Paiva, MD, PhD; Bryan L. Fischberg, NRP; Gustavo E. Flores, MD, EMT-P; Peter Fromm, MPH, RN; Raul Gazmuri, MD, PhD; Blayke Courtney Gibson, MD; Theresa Hoadley, MD, PhD; Cindy H. Hsu, MD, PhD; Mahmoud Issa, MD; Adam Kessler, DO; Mark S. Link, MD; David J. Magid, MD, MPH; Keith Marrill, MD; Tonia Nicholson, MBBS; Joseph P. Ornato, MD; Garrett Pacheco, MD; Michael Parr, MB; Rahul Pawar, MBBS, MD; James Jaxton, MD; Sarah M. Perman, MD, MSCE; James Pribble, MD; Derek Robinett, MD; Daniel Rolston, MD; Comilla Sasson, MD, PhD; Sree Veena Satyapriya, MD; Travis Sharkey, MD, PhD; Jasmeet Soar, MA, MB, BChir; Deb Torman, MBA, MEd, AT, ATC, EMT-P; Benjamin Von Schweinitz; Anezi Uzendu, MD; and Carolyn M. Zelop, MD. Care Science With Treatment Recommendations (CoSTR).1. Multiple RCTs have compared high-dose with standard-dose epinephrine, and although some have shown higher rates of ROSC with high-dose epinephrine, none have shown improvement in survival to discharge or any longer-term outcomes. 1. 2. Active compression-decompression CPR might be considered for use when providers are adequately trained and monitored. Given the potential for the rapid development of oropharyngeal or laryngeal edema, immediate referral to a health professional with expertise in advanced airway placement, including surgical airway management, is recommended. A systematic review of the literature evaluated all case reports of cardiac arrest in pregnancy about the timing of PMCD, but the wide range of case heterogeneity and reporting bias does not allow for conclusions. This device provides adequate ventilation comparable to an ET tube. These recommendations are supported by the 2020 CoSTR for ALS.11, Recommendation 1 last received formal evidence review in 2010 and is supported by the Guidelines for the Use of an Insulin Infusion for the Management of Hyperglycemia in Critically Ill Patients from the Society for Critical Care Medicine.49 Recommendation 2 is supported by the 2020 CoSTR for ALS.11 Recommendations 3 and 4 last received formal evidence review in 2015.24. 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.) 1. When performed with other prognostic tests, it may be reasonable to consider bilaterally absent N20 somatosensory evoked potential (SSEP) waves more than 24 h after cardiac arrest to support the prognosis of poor neurological outcome. 1. 1. The combitube has two separate balloons that must be inflated and two separate ports. -Enough to make the victim's chest rise. Though effective for treating a wide-complex tachycardia known to be of supraventricular origin and not involving accessory pathway conduction, verapamils negative inotropic and hypotensive effects can destabilize VT. 1. 5. In patients with calcium channel blocker overdose who are in refractory shock, administration of calcium is reasonable. responsible for a large proportion of opioid overdose? Survivorship after cardiac arrest is the journey through rehabilitation and recovery and highlights the far-reaching impact on patients, families, healthcare partners, and communities (Figure 11).13. A patent airway is essential to facilitate proper ventilation and oxygenation. Data on the relative benefit of continuous versus intermittent EEG are limited. After cardiac arrest is recognized, the Chain of Survival continues with activation of the emergency response system and initiation of CPR. Neuroimaging may be helpful after arrest to detect and quantify structural brain injury. When performed with other prognostic tests, it may be reasonable to consider burst suppression on EEG in the absence of sedating medications at 72 h or more after arrest to support the prognosis of poor neurological outcome. The literature supports prioritizing defibrillation and CPR initially and giving epinephrine if initial attempts with CPR and defibrillation are not successful. 1. However, the most critical feature in the diagnosis and treatment of polymorphic VT is not the morphology of rhythm but rather what is known (or suspected) about the patients underlying QT interval. Atrial fibrillation is an SVT consisting of disorganized atrial electric activation and uncoordinated atrial contraction. When an IV line is in place, it is reasonable to consider the IV route for epinephrine in anaphylactic shock, at a dose of 0.05 to 0.1 mg (0.1 mg/mL, aka 1:10 000). Immediate pacing might be considered in unstable patients with high-degree AV block when IV/IO access is not available. Benzodiazepine overdose causes CNS and respiratory depression and, particularly when taken with other sedatives (eg, opioids), can cause respiratory arrest and cardiac arrest. These recommendations are supported by Cardiac Arrest in Pregnancy: a Scientific Statement From the AHA9 and a 2020 evidence update.30, This topic was reviewed in an ILCOR systematic review for 2020.1 PE is a potentially reversible cause of shock and cardiac arrest. Place 2 fingers on the lower half of the breastbone in the middle of the chest and press down by one-third of the depth of the chest (you may need to use one hand to do CPR depending on the size of the infant). bradycardia? No controlled studies examine the effect of IV calcium for calcium channel blocker toxicity. 1. 4. How long after mild drowning events should patients be observed for late-onset respiratory effects? This topic last received formal evidence review in 2010.10, Local anesthetic overdose (also known as local anesthetic systemic toxicity, or LAST) is a life-threatening emergency that can present with neurotoxicity or fulminant cardiovascular collapse.1,2 The most commonly reported agents associated with LAST are bupivacaine, lidocaine, and ropivacaine.2, By definition, LAST is a special circumstance in which alternative approaches should be considered in addition to standard BLS and ALS. If an advanced airway is used, a supraglottic airway can be used for adults with OHCA in settings with low tracheal intubation success rates or minimal training opportunities for endotracheal tube placement. CPR involves performing chest compressions and, in some cases, rescue ("mouth-to-mouth") breathing. 3. Magnesium may be considered for treatment of polymorphic VT associated with a long QT interval (torsades de pointes). Throughout the recommendation-specific text, the need for specific research is identified to facilitate the next steps in the evolution of these questions. What is the validity and reliability of ETCO. 2. To accomplish delivery early, ideally within 5 min after the time of arrest, it is reasonable to immediately prepare for perimortem cesarean delivery while initial BLS and ACLS interventions are being performed. During cardiac arrest, if the pregnant woman with a fundus height at or above the umbilicus has not achieved ROSC with usual resuscitation measures plus manual left lateral uterine displacement, it is advisable to prepare to evacuate the uterus while resuscitation continues. 2. Because the duration of action of naloxone may be shorter than the respiratory depressive effect of the opioid, particularly long-acting formulations, repeat doses of naloxone, or a naloxone infusion may be required. One large RCT in OHCA comparing bag-mask ventilation with endotracheal intubation (ETI) in a physician-based EMS system showed no significant benefit for either technique for 28-day survival or survival with favorable neurological outcome. Rate control is more common in the emergency setting, using IV administration of a nondihydropyridine calcium channel antagonist (eg, diltiazem, verapamil) or a -adrenergic blocker (eg, metoprolol, esmolol). 2. Based on the training of the rescuers, and only if scene safety can be maintained for the rescuer, sometimes ventilation can be provided in the water (in-water resuscitation), which may lead to improved patient outcomes compared with delaying ventilation until the victim is out of the water. The initial phases of resuscitation once cardiac arrest is recognized are similar between lay responders and healthcare providers, with early CPR representing the priority. overdose with naloxone? 4. 2. The use of mechanical CPR devices may be considered 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. 1. If pharmacological therapy is unsuccessful for the treatment of a hemodynamically stable wide-complex tachycardia, cardioversion or seeking urgent expert consultation is reasonable. Outcomes from IHCA are overall superior to those from OHCA,5 likely because of reduced delays in initiation of effective resuscitation. 3. The 2020 CoSTR recommends that seizures be treated when diagnosed in postarrest patients. This topic last underwent formal evidence review in 2010.7, These recommendations are supported by the 2020 CoSTR for BLS.21, This recommendation is supported by the 2020 CoSTR for BLS.21. AED indicates automated external defibrillator; ALS, advanced life support; BLS, basic life support; and CPR, cardiopulmonary resuscitation. These recommendations are supported by the 2020 CoSTR for BLS.1. Torsades de pointes is a form of polymorphic VT that is associated with a prolonged heart ratecorrected QT interval when the rhythm is normal and VT is not present. doi: 10.1161/CIR.0000000000000916, On behalf of the Adult Basic and Advanced Life Support Writing Group. medications? The clinical signs associated with severe hyperkalemia (more than 6.5 mmol/L) include flaccid paralysis, paresthesia, depressed deep tendon reflexes, or shortness of breath.13 The early electrocardiographic signs include peaked T waves on the ECG followed by flattened or absent T waves, prolonged PR interval, widened QRS complex, deepened S waves, and merging of S and T waves.4,5 As hyperkalemia progresses, the ECG can develop idioventricular rhythms, form a sine-wave pattern, and develop into an asystolic cardiac arrest.4,5 Severe hypokalemia is less common but can occur in the setting of gastrointestinal or renal losses and can lead to life-threatening ventricular arrhythmias.68 Severe hypermagnesemia is most likely to occur in the obstetric setting in patients being treated with IV magnesium for preeclampsia or eclampsia.
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