Emergency Cardiac Care Guidelines 2015

Emergency Cardiac Care Guidelines 2015 VACEP 2016 William Brady, MD University of Virginia

Guidelines 2015 Basic Life Support & Advanced Cardiac Life Support Acute Coronary Syndrome Pediatric Advanced Life Support

Adult Cardiac Arrest BLS & ACLS

Cardiac Arrest Chain of Survival In- & Out-of-hospital Settings Emphasis on early recognition & care In-hospital - primary providers Out-of-hospital - lay rescuers

Social Media Enhanced Lay Response to Cardiac Arrest Smartphone-based technology Operated by 911 centers Intent & EMS perception Reduce time to compressions Reduce time to AED use Largely endorsed by public safety agencies No EMS-based complaints

Social Media - Community Notification NEJM 2015;372:2316

AHA Statement It may be reasonable for communities to incorporate social media technologies that summon rescuers who are in close proximity to a victim of suspected OHCA and are willing and able to perform CPR.

Compressions - Rate & Depth Rate is inversely associated with depth Rate range 100 to 120/min Correlates with survival Extremes associated with lower survival Depth at least 2 inches Correlates with survival >2.4 inches associated with more injury

AHA Statement In adult victims of cardiac arrest, it is reasonable for rescuers to perform chest compressions at a rate of 100 to 120/min. During manual CPR, rescuers should perform chest compressions to a depth of at least 2 inches (5cm) for an average adult, while avoiding excessive chest compression depths (>2.4 inches [6 cm]).

Compression-only CPR CPR Components: compression > ventilation Early vs late in resuscitation Early compression & defibrillation Late marginal benefit with ventilations Witnessed & shockable

AHA Statement For witnessed OHCA with a shockable rhythm, EMS systems may use a strategy of up to 3 cycles of 200 continuous compressions with passive oxygen insufflation and airway adjuncts.

Chest Compression Feedback Real-time monitoring of compressions Rate Depth Quality Feedback provided Philips Q-CPR AHA statement: It may be reasonable to use audiovisual feedback devices during CPR for real-time optimization of CPR performance.

Compressions or Defibrillation First? 9933 patients Early vs late defibrillation Outcome survival to D/C with neuro status No difference noted in survival to D/C with neuro status Early Late Patient # 5290 4643 Survival with Neurologic Status 273 (5.9%) 310 (5.9%)

AHA Statement For witnessed adult cardiac arrest when an AED [or MFD] is immediately available, it is reasonable that the defibrillator be used as soon as possible. For adults with unmonitored cardiac arrest or for whom an AED is not immediately available, it is reasonable that CPR be initiated while the defibrillator equipment is being retrieved and applied and that defibrillation be attempted as soon as the device is ready for use.

Minimizing Compression Interruptions Interrupted compressions adversely impact perfusion CNS perfusion not adequate for 45 sec of compressions Each 10 sec non-compression period reduces survival by 5%

Continuous Chest Compressions Chest Compression Fraction Out-of-hospital cardiac arrest Chest compression fraction = #1029 VF victims Increasing CCF associated with better outcome Depth & rate were inversely related Higher rates of ROSC Increased rate Increased depth Compression Total Resuscitation #2103 non-vf/vt victims Increasing CCF associated with better outcome Adjusted OR for ROSC for each CCF category 41-60% -- 1.14 61-80% -- 1.42 81-100% - 1.48 Stiell et al, Crit Care Med, epub Jan 2012 Vaillancourt et al, Resuscitation, 2011;82:1501-7 Bottom line = improved outcome ~ more compressions

Interruptions During Chest Compressions Negative impact on Perfusion 100 Systolic Blood Pressure (mmhg) 80 40 0 Time Multiple compression interruptions adversely affect perfusion Interruptions During Chest Compressions Negative impact on Perfusion 100 Sustained compressions produce most optimum levels of perfusion Systolic Blood Pressure (mmhg) 80 40 0 Time

AHA Statement Rescuers should attempt to minimize the frequency and duration of interruptions in compressions to maximize the number of compressions delivered per minute. For adults in cardiac arrest who receive CPR without an advanced airway, it may be reasonable to perform CPR with the goal of a chest compression fraction as high as possible, with a target of at least 60%.

Mechanical CPR Devices Basic device configurations Piston-type / band-type Gas-driven & electric-powered Capability Chest compression in all / ventilation in some Advantages High quality, uninterrupted compressions Defibrillation during compressions Fewer personnel Does not fatigue nor become distracted

Mechanical CPR Devices Systematic review 10 EMS studies Quality of literature? Insufficient evidence to support or refute Other studies suggest Ong, Scan J Trauma Resus Emerg Med, Jun 2012 Better quality CPR Improved objective measurements (e.g. ETCO2) Significant assist with fewer personnel Easier / safer for CPR during transport

AHA Statement Manual chest compressions remain the standard of care as compared to mechanical chest compression devices. Mechanical chest compression devices may be beneficial in certain circumstances, such as resourcelimited situations, CPR during transports, and transition to E-CPR.

Epinephrine

Epinephrine Equivocal literature base Minimal impact on outcome Most optimal use Non-shockable rhythms Early in resuscitation Niche application

AHA Statement It may be reasonable to administer epinephrine as soon as feasible after the onset of cardiac arrest with initial non-shockable rhythm.

Vasopressin Improved rate of ROSC No impact on ultimate survival No harm No benefit Removed from ACLS algorithm

AHA Statement Vasopressin has been deleted from the ACLS Cardiac Arrest algorithm. The Dodo Bird

Lidocaine post-rosc No impact on ROSC during resuscitation Yet, once resuscitated? #1721 OHCA patients witnessed VF/VT 75% received lidocaine at ROSC Endpoints: re-arrest, hosp admit, & survival Therapy VT / VF Recur PEA / Asystole Recur Hosp Admit D/C Alive p Value Lidocaine 16.7 3.2 93.5 62.4 None 37.4 7.8 84.9 44.5 <0.0001 95%CI 0.34 (0.26-0.44) 0.47 (0.29-0.78) 1.88 (1.28-2.76) 1.49 (1.15-1.95) Propensity matched analysis reduced re-arrest Kudenchuk et al, Resuscitation 2013

AHA Statement Inadequate evidence to support the routine use of lidocaine during or after cardiac arrest. It may be reasonable to consider immediately after ROSC from cardiac arrest due to VF/pVT.

E-CPR Resuscitative ECMO Limited literature base / Early promising results Patient selection: prehospital vs hospital Resource very intensive Rapid application mandatory Impact on metrics?

AHA Statement E-CPR may be considered among select cardiac arrest patients not responding to initial conventional CPR, where it can be rapidly implemented.

Regionalized Care of Cardiac Arrest Resuscitation Centers Emerging concept Strategies focused / multidisciplinary / specialistoriented General - aggressive critical care support Specific - targeted temperature management Specific - early coronary angiography / PCI

Resuscitation Centers: pre- / post-rx Increased rates of hypothermia & PCI Survival / Neuro outcome All patients - 8.9% / 5.9% to 14.4% / 8.9% Witnessed / Shockable rhythms - 21.4% to 39.2% / 19.4% to 29.8% Ann EM 2014;64:496

AHA Statement A regionalized approach to OHCA resuscitation that includes the use of cardiac resuscitation centers may be considered.

Post-cardiac Arrest Management Coronary reperfusion Targeted temperature management Critical care

Post-Resuscitation Care Targeted Temperature Management

STEMI After ROSC ACS is a frequent cause of cardiac arrest HIGH RISK If resuscitated PCI improves survival (10% to 50%) with good neuro function Presenting mental status is not predictive Coma is not uncommon among survivors with good outcome Challenging, difficult-to-answer question

STEMI After ROSC JACC 2015;66:63 Interventional Council ACC

STEMI After ROSC JACC 2015;66:63 Interventional Council ACC

AHA Statement 1 of 3 STEMI post-rosc Coronary angiography should be performed emergently (rather than later in the hospital stay or not at all) for OHCA patients with suspected cardiac etiology of arrest and ST elevation on ECG.

AHA Statement 2 of 3 No STEMI post-rosc suspected cardiogenic Emergency coronary angiography is reasonable for select (eg, electrically or hemodynamically unstable) adult patients who are comatose after OHCA of suspected cardiac origin but without ST elevation on ECG.

AHA Statement 3 of 3 Presenting Mental Status Coronary angiography is reasonable in post cardiac arrest patients for whom coronary angiography is indicated, regardless of whether the patient is comatose or awake.

Targeted Temperature Management Targeted Temperature Management (TTM) between 32 C and 36 C Continue TTM beyond 24 hours if patient still comatose Routine prehospital TTM is not recommended (no benefit / possible complications)

AHA Statement All comatose (ie, lacking meaningful response to verbal commands) adult patients with ROSC after cardiac arrest should have TTM, with a target temperature between 32 C and 36 C selected and achieved, then maintained constantly for at least 24 hours.

Targeted Temperature Management Most Appropriate Candidates Cardiogenic & reversible issues most appropriate VT / VF vs PEA / asystole Reversible vs less reversible

Post-ROSC Critical Care Oxygenation It is recommended to use situation-specific maximal oxygen therapy during cardiac arrest resuscitation. After ROSC, it is recommended to adjust oxygen therapy to maintain oxygen saturations in the 95 to 97% range. Persistent hyperoxia should be avoided. Hemodynamic support It may be reasonable to avoid & immediately correct hypotension (systolic BP < 90 mm, MAP < 65 mm) during post cardiac arrest care. Glucose control Avoidance of fever Seizure therapy

AHA Statements Prehospital ECG Trained non-physicians may perform ECG interpretation to determine whether or not the tracing shows evidence of STEMI. Computer-assisted ECG interpretation may be used in conjunction with interpretation by a physician or trained provider to recognize STEMI. Prehospital notification of the receiving hospital and/or prehospital activation of the catheterization laboratory should occur for all patients with a STEMI identified on prehospital ECG.

AHA Statements Prehospital ECG Trained non-physicians may perform ECG interpretation to determine whether or not the tracing shows evidence of STEMI. Computer-assisted ECG interpretation may be used in conjunction with interpretation by a physician or trained provider to recognize STEMI. Prehospital notification of the receiving hospital and/or prehospital activation of the catheterization laboratory should occur for all patients with a STEMI identified on prehospital ECG.

AHA Statements 1 of 2 Troponins & Safe Discharged from ED High-sensitivity troponin T and I measured at 0 and 2 hours (without performing clinical risk stratification) should not be used alone to exclude the diagnosis of ACS, but high-sensitivity troponin I measurements that are less than the 99th percentile, measured at 0 & 2 hours, may be used together with low-risk stratification scores, such as TIMI score of 0 or 1, or low risk per Vancouver rule, to predict a less than 1% chance of 30-day major adverse cardiac event (MACE).

AHA Statements 1 of 2 Troponins & Safe Discharged from ED High-sensitivity troponin T and I measured at 0 and 2 hours (without performing clinical risk stratification) should not be used alone to exclude the diagnosis of ACS, but high-sensitivity troponin I measurements that are less than the 99th percentile, measured at 0 & 2 hours, may be used together with low-risk stratification scores, such as TIMI score of 0 or 1, or low risk per Vancouver rule, to predict a less than 1% chance of 30-day major adverse cardiac event (MACE).

AHA Statements - 2 of 2 Troponins & Safe Discharged from ED Negative troponin I or troponin T measurements at 0 and between 3 and 6 hours may be used together with very lowrisk stratification (TIMI score of 0, low risk score per Vancouver rule, North American Chest Pain score of 0 and age less than 50 years, or low-risk HEART score) to predict a less than 1% chance of 30-day MACE.

AHA Statements - 2 of 2 Troponins & Safe Discharged from ED Negative troponin I or troponin T measurements at 0 and between 3 and 6 hours may be used together with very lowrisk stratification (TIMI score of 0, low risk score per Vancouver rule, North American Chest Pain score of 0 and age less than 50 years, or low-risk HEART score) to predict a less than 1% chance of 30-day MACE.

Supplemental Oxygen - AMI As in post-rosc, avoid hyperoxia Supplemental oxygen is needed if: Respiratory distress and / or Demonstrated hypoxia Persistent / excessive hyperoxia - worsened outcome Larger AMI Worsened cardiac function post-mi

AHA Statement It is suggested that hyperoxia be avoided in patients with STEMI. Oxygen levels can be monitored using either arterial blood gas analysis or oxygen saturation determinations.

STEMI Reperfusion

Reperfusion Therapy in STEMI CHOICE DEPENDENT UPON AGE STEMI LOCATION MI TIME STABILITY LYTIC CANDIDATE REPERFUSION STRATEGY CARDIOLOGIST HOSPITAL ACCESS & TIME TO THERAPY

Reperfusion Therapy in STEMI CHOICE DEPENDENT UPON AGE STEMI LOCATION MI TIME STABILITY LYTIC CANDIDATE REPERFUSION STRATEGY CARDIOLOGIST HOSPITAL ACCESS & TIME TO THERAPY

STEMI PCI vs Fibrinolysis PCI is preferred strategy if available in timely fashion Timely fashion - dependent upon STEMI duration < 2 hr PCI within 60 minutes 2-3 hr PCI within 60-120 minutes 3-12 hr PCI within 120 minutes If PCI is not available in timely fashion, then consider lytic RX if a candidate If lytic contra-indications PCI is only option

PCI vs Fibrinolysis STEMI PCI Available? YES NO PCI Lytic Candidate? YES Lysis NO Consider Transfer

PCI vs Fibrinolysis Early (<2 hr) in STEMI Course STEMI Within 60 minutes? PCI Available? YES NO PCI >60 minute Lytic Candidate? YES NO Lysis Consider Transfer

PCI vs Fibrinolysis Early (2-3 hr) in STEMI Course STEMI Within 60-120 minutes? PCI Available? YES NO PCI >60-120 minute Lytic Candidate? YES NO Lysis Consider Transfer

PCI vs Fibrinolysis Later (3-12 hr) in STEMI Course STEMI Within 120 minutes? PCI Available? YES NO PCI >120 minute Lytic Candidate? YES NO Lysis Consider Transfer

Pediatric Cardiac Arrest BLS & PALS

Pediatric Basic Life Support 1 of 2 It is reasonable to use the recommended adult chest compression rate of 100 to 120/min for infants and children. Significant knowledge gaps exist / based upon limited data. It is reasonable that rescuers provide chest compressions that depress the chest at least one third the AP diameter of the chest in pediatric patients (infants [younger than 1 year] to children up to the onset of puberty). Do not depress greater than 2.4 inches (6 cm).

Pediatric Basic Life Support 2 of 2 It may be reasonable to maintain the sequence with C-A-B over A-B-C. Significant knowledge gaps exist / based upon limited data. Conventional CPR (rescue breaths and chest compressions) should be provided for infants and children in cardiac arrest. The asphyxial nature of most pediatric cardiac arrests necessitates ventilation as part of effective CPR.

Pediatric Cardiac Arrest Resuscitation Amiodarone or lidocaine is an acceptable antiarrhythmic agent for shock-refractory pediatric VF & VT in children. Epinephrine continues to be recommended as a vasopressor in pediatric cardiac arrest. For pediatric patients with cardiac diagnoses & IHCA in settings with existing extracorporeal membrane oxygenation protocols, E-CPR may be considered.

Many Thanks Many Thanks wjbrady@virginia.edu