ACLS: 2015 Update Anything New? Mitchell Shulman MDCM FRCPC CSPQ Emergency Department, MUHC Master Instructor ACLS, QHSF Assist Professor, Dept of Surgery
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Agenda Problems with data Call 1 st? / Dispatch The Basics: CPR, Intubation, Defibrillation The Drugs Putting it all together Post- Resuscitation
Key Points Cardiac Arrests Happen Be prepared (yourself and your staff) AED? Pt s families / partners: know what to do?
Research in ACLS is difficult / challenging Few good studies (even less RCT) Consent??? Animal vs Human Rural vs Urban. Warning! Problems with the Data
2015 Guidelines Update ILCOR prioritized reviews (166) Grading of Recommendations, Assessment, Development and Evaluation (GRADE) Systemic Evidence Evaluation and Review System (SEERS) Public disclosure Public comment Update only Future changes will be similar www.ilcor.org/seers
Agenda Problems with data Call 1 st? / Dispatch The Basics: CPR, Intubation, Defibrillation The Drugs Putting it all together Post- Resuscitation
Call 911 First vs Call Fast: JUST CALL! If no phone/reception/bystander: Call first : sudden collapse victims of all ages (to get an AED there ASAP!) Call fast : unresponsive pt (any age) where asphyxia is likely (e.g. submersion / near-drowning; overdose; lightning) if in doubt, unwitnessed, or suspect > 4 min: deliver about 2 min (5 cycles) of CPR before leaving the victim to call for an AED
Dispatchers / BCLS Train them to recognize acute coronary syndromes (ACS) Advise patients with ACS (w/o hx of ASA allergy / GI bleed) chew 160 325 mg aspirin while waiting
Dispatchers / BCLS Responsive? Lay people: If not: Compression only CPR Trained BCLS providers: C A - B
Pulse check? Long time to assess Error rate (lay rescuer): 35% - detect a pulse 10% of cardiac arrests - provide chest compressions 40% not in cardiac arrest Instead assess for signs of life (movement, breathing, coughing) Trained provider: pulse check < 10 seconds
Agenda Problems with data Call 1 st? / Dispatch The Basics: CPR, Intubation, Defibrillation The Drugs Putting it all together Post- Resuscitation
Mouth to mouth??? CPR world wide > 30 yrs no HIV or other blood borne pathogens via mouth-tomouth no documented cases of saliva transmitting: HIV, Hep B / C during CPR few cases of HIV transmission: sharps injury; blood exposure to non-intact skin
Mouth to mouth?? 15 cases of documented disease transmission (direct mouth to mouth) Mycobacterium tuberculosis Neisseria meningitidis Shigella sonnei Salmonella infantis Neisseria gonorrhea Streptococcus: Herpes simplex saliva to non-intact skin
Chest compressions Push Hard*, Push Fast* Recommended rate: 30:2 for all rescuers responding alone to victims of any age (except newborns) before advanced airway control *Rate: 100 120 / min *Depth: 2 2. 4 in ( 5 6 cm) 2 health care providers child/infant 15:2
Intubate?? Why? Control airway Reduce risk of aspiration Administer drugs Ventilate without worrying about timing Alternatives Laryngeal mask airway Combitube
Confirm ETT placement Direct visualization 5 point clinical exam Exhaled CO 2 / esophageal detector device Endotracheal tube holder Continuous end-tidal CO 2 monitoring
Ventilation Advanced airway in place: 8 10 / min. 2 health care provider rescuers Compressor: 100-120 / min Ventilator: 8 10 / min Don t stop Don t pause Rotate compressor role ~ Q 2 min.
AED s do not require a prescription AED (Defibrillation) Healthcare provider oversight not necessary
Defibrillation Monophasic vs biphasic? Monophasic: 360J Biphasic: 120-200J If in doubt: use max power available
Defibrillation 1 Shock Immediate CPR for 2 minutes (start with chest compressions) Do NOT check for rhythm / pulse before restarting CPR
Agenda Problems with data Call 1 st? / Dispatch The Basics: CPR, Intubation, Defibrillation The Drugs Putting it all together Post- Resuscitation
Vasopressors? Only after 1 shock 2 2 minutes of CPR w/o perfusing rhythm
Epinephrine: How much? Class indeterminate! 1 mg IV Q 3 5 min optimal physiologic response:.045 -.20 mg / kg but HDE no statistical increase in rate of survival to hospital discharge
Vasopressin? No longer part of the algorhythms Arginine vasopressin = antidiuretic hormone Why? Physiology Stimulates smooth muscle V 1 receptors (non-adrenergic peripheral vasoconstrictor) Studies Elevated endogenous levels in survivors of cardiac arrest Increased coronary perfusion pressure, vital organ blood flow, cerebral oxygen delivery (animal models)
Why not? No survival advantage over epinephrine Vasopressin?? When? Perhaps severe acidosis Dose?? 40 IU x 1
Lidocaine? No study has demonstrated clinical efficacy Use was supported by animal studies and extrapolation Conflicting data in the literature Compared unfavorably to Amiodarone
Lidocaine? Successful in converting V tach to NSR only 20-30% (inferior to Procainamide and Amiodarone) Advantages: ease of dosing / administration when it works it works rapidly minimal side effects low cost Consider 1 1.5 mg / kg 1 st dose; then 0.5 0.75 mg / kg IV Max. 3 doses or 3 mg / kg
Amiodarone History: structural analogue of thyroxine developed in the 1960 s (antianginal coronary vasodilator) acutely: anti-sympathetic & Ca + channel blocking chronically: prolongs action potential duration (Class III) long elimination half-life (14-59 days) large volume of distribution
Amiodarone ARREST (Amiodarone for Resuscitation after Out-ofhospital Cardiac Arrest Due to Ventricular Fibrillation) 300 mgs (n= 246) vs placebo (n= 258) 44% vs 34% survive to be admitted no difference in survival to hospital discharge ALIVE (Amiodarone as compared with Lidocaine for Shock-Resistant ventricular Fibrillation) 5 mg/kg Amiodarone (n= 179) vs 1.5 mg/kg Lidocaine (n= 165) 22.8% vs 12% survival to admission no difference in survival to discharge
Amiodarone 300 mg IV X 1; then 150 mg X 1 Problem: attempts to defibrillate should not be delayed by administration of Amiodarone significant time required to reconstitute & prepare (high viscosity, generates bubbles)
Anti-arrhythmics Bottom line: no anti-arrhythmic agent to date has been demonstrated in clinical trials of Vfib / pulseless Vtach to improve survival to hospital discharge! CPR, CPR, CPR Defibrillate, defibrillate, defibrillate
Anti-arrhythmics In the setting of tachycardia: all anti-arrhythmics are pro-arrhythmic Stable, narrow complex, regular: adenosine diltiazem Stable, narrow complex, irregular: diltiazem beta-blockers Stable, wide complex: amiodarone magnesium Magnesium: 1 2 grams in 50-100 ml D5W over 5 60 min IV. Adenosine: 6 mgs; 12 mgs Diltiazem: 0.25 mg/kg; 0.35 mg/kg Metoprolol: 5 mg IV Q 5min. Tot: 15 mg Amiodarone: 150 mg; repeat PRN max: 2.2 g IV / 24 hrs
Key Points Cardiac Arrests Happen Be prepared (yourself and your staff) AED? Pt s families / partners: know what to do?
Agenda Problems with data Call 1 st? / Dispatch The Basics: CPR, Intubation, Defibrillation The Drugs Putting it all together Post- Resuscitation
Let s Put It All Together
Vfib / Vtach 1 shock (biphasic 120 200J; monophasic 360J) Resume CPR at once (5 cycles) Check rhythm Shockable? 1 shock Resume CPR (5 cycles) Epinephrine 1 mg IV / IO (repeat Q 3 5 min) Check rhythm Shockable? 1 shock Resume CPR Amiodarone 300 mg IV/IO
Asystole / PEA Hypovolemia Hypoxia Hydrogen ion Hypo/hyper K+ Hypoglycemia Hypothermia CPR 5 cycles Look for a treatable cause Give EPI FAST! Epinephrine 1 mg IV / IO Q 3 5 min. Toxins Tamponade (cardiac) Tension (pneumo) Thrombosis (cor / pulm) Trauma CPR 5 cycles Check rhythm
Symptomatic Bradycardia HR < 60 bpm +.. Oxygen, IV access, Monitor, EKG + Acute altered mental status / Ongoing chest pain / Acute heart failure / Hypotension / signs of shock Prepare fortranscutaneous pacing Consider Atropine 0.5 mg IV (total dose 3 mg) Consider Epinephrine 2 10 microg/min Dopamine 2 10 microg / kg / min Glucagon? Beta blocker or calcium channel blocker OD 3 10 mgs over 3-5 min, then infuse @ 3 mg/h
Agenda Problems with data Call 1 st? / Dispatch The Basics: CPR, Intubation, Defibrillation The Drugs Putting it all together Post- Resuscitation
Post resuscitation Don t hyperventilate 8 10 breaths / min PETCO 2 : 35-40 mm Hg Cool: 32-36C for 24 hrs. * Maintain BP Fluids; Epi / Norepi: 0.1 0.5 mcg / min (70 kg = 7 35 mcg / min) Maintain O 2 saturation > 94% Watch blood sugar Treat fever * Green, RS, CJEM 7(1) Jan. 2005 p. 42 7.
Key Points Cardiac Arrests Happen Be prepared (yourself and your staff) AED? Pt s families / partners: know what to do?
The Most Important Message Any improvements resulting from advanced life support therapies are less substantial than the increases in survival rate reported from the successful deployment of lay rescuer CPR and Automated External Defibrillation programs in the community.