Advanced Cardiac Life Support (ACLS) Science Update 2015

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1 Advanced Cardiac Life Support (ACLS) Science Update 2015 What s New in ACLS for 2015? Adult CPR CPR remains (Compressions, Airway, Breathing Chest compressions has priority over all other actions Chest compression rate change from at least 100 to to per minute Clarified compression depth for adults from at least 2 to at least 2 but not greater that 2.4 inches (6cm) Recognizes that CPR can be initiated while calling 911 via a cell phone Adult CPR Further reinforcement that gasps are not considered breathing and is a likely indicator of cardiac arrest Where EMS services have adopted bundles of care involving continuous chest compressions, the use of passive ventilation techniques may be considered as part of that bundle for victims of out of hospital cardiac arrest Allows for up to cycles of 200 continuous compressions with passive oxygen administration and airway adjunct Minimizing Interruptions Compression interruptions should be for no more than seconds Interruptions can be minimized by continuing compressions while the defibrillator is Other Changes in CPR The routine use of the impedance threshold device (ITD) ( ) as an adjunct to conventional CPR is not recommended. The routine use of mechanical chest compression devices is not recommended, but special settings where this technology may be useful are identified such as CPR, in EMS units, shortage of manpower, etc. Extracorporeal CPR Extracorporeal CPR (ECPR) is a method of CPR that passes the patient s through an external device to provide oxygen guidelines states ECPR may be considered for some cardiac arrest patients where CPR is ineffective and can be rapidly implemented Extracorporeal CPR Unchanged CPR Reinforces changing compressors every 2 minutes to achieve optimum compressions Child and Infant Depths Child: depth of chest ( about 2 ) Infant depth of chest ( about 1 ½ ) Reinforces team approach for treating cardiac arrests 1

2 Allowing chest is a critical component Steps of BLS Survey 1. Check for 2. Activate emergency response (call 911) and get AED 3. Check Pulse and breathing simultaneously Check pulse for 5 to 10 seconds; no longer than 10 seconds Begin chest compressions if pulseless ( ) 4. Defibrillation CPR with Advanced Airways For 2015, recommendation is to ventilate once every seconds ( /minute) when an advanced airway is in place Compressions should be performed at per minute with pauses for ventilations Respiratory Arrest Adult patients WITH a perfusing rhythm should be ventilated once every to seconds to per minute Chains of Survival Supplemental Oxygen The 2015 guidelines further reinforce that oxygen should not be administered to perfusing patients with cardiac or stroke issues when their O2 sats are > % unless there are signs of hypoxia. If oxygen is required, O2 sats should be maintained between and % to avoid hyperoxia which can lead to oxygen toxicity Vasopressin Vasopressin has been from the Adult Cardiac Arrest Algorithm 2015 Update. Waveform Capnography Provides monitoring of CPR effectiveness < mmhg has been shown to have no chance of ROSC < mmhg indicates ineffective compressions ETCO2 readings should be as as possible during CPR These readings based on patients properly intubated with ETT ETCO2 (1 of 2) Low end-tidal carbon dioxide (ETCO2) in intubated patients after minutes of CPR is associated with a very low likelihood of resuscitation. While this parameter should not be used in isolation for decision making, providers may consider low ETCO2 after 20 minutes of CPR in combination with other factors to help determine when to resuscitation ETCO2 (2 of 2) Monitoring of the patient s PETCO2 is the BEST way to monitor effectiveness of 2

3 Even more so than checking for a Continuous waveform capnography is the MOST reliable method to confirm and monitor correct placement Induced Hypothermia Post resuscitation hypothermia is no longer recommended in the pre-hospital setting Still indicated in the hospital setting for all comatose adult patients with ROSC Recommended targeted temperature is to C (89.6 to 96.8 F) for at least hours Post Resuscitation It may be reasonable to avoid and immediately correct hypotension (systolic blood pressure less than 90mmHg SBP, mean arterial pressure less than 65 mm Hg) during post cardiac arrest care. mmhg is the minimum SBP one should attempt to achieve with fluid resuscitation or drug therapy Acute Coronary Syndromes Acute Coronary Syndromes is the most common condition that causes cardiac For STEMI patients, ED door-to-balloon time for percutaneous coronary intervention is a maximum of minutes Obtaining a 12 lead EKG as early as possible is key for dealing with Acute Coronary Syndromes Administration of oral at mg is reinforced Acute Coronary Syndromes Greater emphasis on pre-hospital recognition of and activation of the cath lab assisted ECG interpretation may be used in conjunction with interpretation by a physician or trained provider to recognize STEMI Narcan The AHA recommends training first aid providers in the use of IN or IM Narcan should be carried by all first responders where a high incidence of opioid narcotic overdoses occur When performing CPR on suspected narcotic overdose patients, the administration of Narcan is recommended Opioid-Associated Algorithm Stroke Fibrinolytic Therapy is the same as thrombolytic therapy such as tpa Non- CT MUST be obtained prior to administration of fibrinolytic therapy to verify ischemic stroke; not hemorrhagic stroke Should be within minutes of hospital arrival Stroke 3

4 Fibrinolytic therapy is used ONLY for ischemic strokes within hours of onset of S/S; 4 hours in certain situations Should be started as soon as possible with no contraindications EMS providers can expedite patient care and reduce the time for treatment by alerting the hospital as early as possible Excessive Ventilations Excessive Ventilations cause: Increased intrathoracic pressure Decreased venous return cardiac output To correct this: Avoid Tidal volume should not exceed ml Just enough to make chest rise Normally about of a bag squeeze Team Dynamics and Communication Communications should be conducted with respect The team leader should clearly tasks If a team member cannot perform his/her delegated task, he/she should ask for a new role Use closed loop communications orders back If anyone sees another about to make a mistake, any/all team members should that team member immediately ACLS Review Handling Mega-Code Treatment Priorities 1. -Drugs/Fluids -Pacing/cardioversion 2. -Drugs/Fluids -Cardioversion/Defibrillation 3. Blood -Drugs -Fluids Treating Cardiac Arrest ABC s (CAB s) Defibrillator Venous Access IV 4

5 IO Intubation or Airway VF/Pulseless VT Treatment of VF/Pulseless VT If witnessed, defibrillation is indicated If unwitnessed, it is reasonable to perform at least minutes of CPR prior to defibrillation Drugs should be delivered during CPR as soon as possible after rhythm check The timing of drug delivery is LESS important than is the need to minimize interruptions in chest compressions Treatment of VF/Pulseless VT 1mg, remains the first line drug and is given every 3 to 5 minutes Amiodarone is the preferred antiarrhythmic mg IV/IO. May be repeated once at 150mg Treatment of Asystole/PEA Epinephrine given every to minutes and attempt to determine and correct cause (5 H s and 5 T s) No other drug is given unless cause can be determined Treatment of Asystole/PEA Search for 5H s and 5 T s 5 H s Hypoxia Hydrogen Ion (Acidosis) Hypo/Hyperkalemia Treatment of Asystole/PEA 5 T s Tamponade Pneumothorax Thrombosis (coronary or pulmonary) Trauma Treatment for Symptomatic Bradycardia Recommended dosage for is 0.5mg IV Repeated, as needed, every 3-5 minutes to a total of 3mg or drips may be administered as alternative to pacemaker Pacing?? 5

6 Confirm Capture Titrate pacer or drip to BP > systolic Treatment for Symptomatic Tachycardia A single algorithm established with 2 main branches QRS QRS Besides drugs and electrical therapy, treat possible contributing factors 5 H s and 5 T s SVT s Stable -Valsalva -Adenosine mg repeated at mg if no change Unstable -Sedation? -Synchronized cardioversion J, 200J, 300J, and 360J V-Tach With Pulse (Stable) Amiodarone - mg over minutes -Repeat once if needed Sedation? Synchronized 100J, 200J, 300J, 360J V-Tach With Pulse (Unstable) Synchronized cardioversion 100J, 200J, 300J, 360J Amiodarone - mg over minutes -Repeat once if needed If pulses are lost, immediate is required and then follow V-Fib/Pulseless V-Tach Algorithm Pulseless Electrical Activity Epinephrine 1mg every 3-5 minutes Fluid challenge, - cc Consider cause ( s and s) Review Medical Emergency (MET) Primary purpose is to and treat early clinical deterioration; thus improving patient outcomes Used in hospital settings Review Remember that the questions on the exam are intended for physicians as well. Some treatments are correct even though these treatments are NOT commonly used in EMS. 6

7 The strips may NOT be 6 second strips Read each question carefully 7

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