SAUDI HEART ASSOCIATION NATIONAL CPR COMMITTEE THE EVIDENCED BASED 2015 CPR GUIDELINES (EXECUTIVE SUMMARY) Page 1
FORWARD Since 2000, the International Liaison Committee on Resuscitation (ILCOR) has published the International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations (CoSTR) every 5 years based on review of cardiopulmonary resuscitation (CPR) science. Seven task forces with representatives from the 7 member resuscitation organizations create the CoSTR that enables regional resuscitation organizations to create their individual guidelines. The different guidelines are based on the scientific evidence and incorporate or adjust for regional considerations. The Saudi Heart Association(SHA) adapted the 2010 guidelines published by ILCOR October 2010 and was summarized and uploaded to the SHA CPR portal since then. It was also printed for distribution to all CPR centers all over the Kingdom. It is our pleasure to present to you this work as a result of team work of the National CPR Committee at the Saudi Heart Association (SHA) and Evidenced Based multidisciplinary team. We adapted the 2015 Guidelines as per the International Liaison Committee Of Resuscitation consensus 0f science and treatment recommendation (ILCOR-CoSTR) which was published October 15, 2015 in the Circulation Journal. We modified some of the items of 2010 guidelines and kept some as it is depending on our national need in the Kingdom of Saudi Arabia. As an example, the sequence of A.B.C in children and infants were not changed because the most common cause of child and/or infant cardiac arrest is respiratory in origin, so respiratory assessment should take place at the beginning. Also there were no evidence yet support that the A-B-C sequence is superior to that of C-A-B sequence ( all studies were manikin based, no RCTS ones). This product is the first detailed evidenced based SHA guidelines which is going to be as guide for the practice of CPR in the kingdom. Your active support, opinion and participation are well taken and appreciated. Shout for help Look, listen, feel (if HCP or trained layperson) Not breathing normally? No signs of life? Page 2
3. ACLS AND SPECIAL SITUATIONS CHAPTER This will be a brief review of the most important changes in the guidelines. These guidelines are very similar to the 2010 guidelines. As the science is weak. Only 1% of recommendations were level A, meaning high quality evidence from more than one RCT. There are no changes important enough to warrant changing in the 2010 guidelines. There will be some modification in the ALS algorithm according to the strength of the evidence. Just keep providing good patient care. Page 3
CPR Emphasis on high quality CPR ; Keep going with good compressions at 30:2, maximizing compression time, with no pauses longer than 10 seconds. However, they have made some minor changes to their descriptions of good CPR: Not too fast. Maximum compression rate of 120. They don t won t compressions going too fast, as there is evidence that quality decreases with more than 120 compressions per minute. The new target is 100-120 compressions a minute (instead of at least 100) Not too deep. Maximum compression depth 6 cm. The new target is 5-6cm in adults (instead of at least 5cm) 10 breaths a minute. If an advanced airway (endotracheal tube, LMA, etc) is in place, everyone gets just 10 breaths a minute. This applies to children and infants as well. Medications: Vasopressin is OUT. A change that is unlikely to affect many providers. This change is not because vasopressin is in anyway worse than epinephrine, but because it has equivalent outcomes, so they only list epinephrine to simplify the algorithm. Give epinephrine early in non-shockable rhythms. Based on one observational study, they say if you are going to give epinephrine, you should probably get epinephrine on board as soon as possible in nonshockable rhythms. The vasopressin, epinephrine, steroid combination is not recommended. They discuss the trials that look at this and rate them as very low quality evidence. They say, we suggest against the routine use of steroids during CPR for OHCA (weak recommendation, very-low-quality evidence). The guidelines do recognize the equipoise concerning the role of drugs in improving outcomes from cardiac arrest. Naloxone added to the guidelines. In patients with known or suspected opioid addiction who are not breathing normally but have a pulse, it is reasonable for trained lay rescuers and BLS providers to administer naloxone. The doses listed are 2mg intranasally or 0.4mg IM. Providing a dose of naloxone may be reasonable based on the possibility that the patient may be in respiratory distress or hypoventilation. Special circumstances in ALS There are numerous special circumstances where additional interventions or modification to ALS may be required. the ILCOR ALS Task Force prioritized 5 topics for review. Cardiac arrest during pregnancy. Lipid therapy for cardiac arrest associated with overdose. Opioid toxicity. Page 4
Cardiac arrest caused by PE. Cardiac arrest during coronary catheterization. 1. CARDIAC ARREST DURING PREGNANCY: Among pregnant women who are in cardiac arrest in any setting, do any specific intervention, compared with standard care (usual resuscitation practice) change survival with favorable neurological/functional outcome at discharge 30,60,180, days and or 1 year survival at discharge. Introduction The aim of this review was to asses whether commonly applied additions to the standard practice of resuscitation led to improved outcomes in pregnant women. Specific emphasis was placed on uterine displacement for the purpose of decreasing aorto-caval compression and to improve outcome in the mother and newborn. ILCOR Treatment Recommendations There is insufficient evidence to make a recommendation regarding the use of left lateral tilt and/or uterine displacement during CPR in the pregnant patient. SHA recommendation: we recommend to keep the same current practice of left lateral tilt during resuscitation of pregnant women Knowledge Gaps Research in the area of maternal resuscitation is lacking because cardiac arrest in pregnancy is rare. Most evidence is from non pregnant people, manikin or simulation studies and case reports. Systemic data collection in pregnant women who have experienced cardiac arrest will require a national or international registry and/or coordinated prospective population level surveillance to compile a sufficiently large and robust data to evaluate the effect of either uterine displacement or perimortem delivery on maternal ROSC, maternal survival, functionally intact neonatal survival. 2. LIPID THERAPY FOR CARDIAC ARREST Introduction Lipid therapy for cardiac arrest associated with drug toxicity, and in particular local anesthetic toxicity, is becoming increasingly common. Based on laboratory and preclinical data showing IV administration of lipid solutions can absorb lipid-soluble drugs, studies examined whether this therapy would be useful for cardiac arrest related to drug overdose. We set out to identify studies comparing outcomes with IV lipids to no IV lipids. ILCOR Treatment Recommendation We are unable to make any evidence based treatment recommendation about the use of IV lipid emulsion to treat toxin-induced cardiac arrest. SHA recommendation: we recommend that lipid emulsion (clinolipid,intralipid,and liposyn III) used as per its well known clinical indications Page 5
3. OPIOID TOXICITY Introduction Opioid toxicity is associated with respiratory depression that can lead to cardiorespiratory arrest. This is becoming an increasingly common cause of death in many countries. Administration of the opioid antagonist naloxone was the only intervention for which literature was identified. Treatment Recommendation ILCOR Recommendation: We recommend the use of naloxone by IV, intramuscular, subcutaneous, IO, or intranasal routes in respiratory arrest associated with opioid toxicity. The dose required will depend on the route. We can make no recommendation regarding the medication of standard ALS in opioid induced cardiac arrest. SHA Recommendation: (we recommend the administration of naloxone when opioid toxicity is high suspected either from the history or physical examination). 4. CARDIAC ARREST ASSOCIATED WITH PE Introduction The possible treatments for massive PE include fibrinolytic therapy, surgical embolectomy, and percutaneous mechanical thrombectomy. Most retrospective studies do not make subgroup analysis of patients with suspected or confirmed PE. These treatments were assessed separately as therapies during cardiac arrest as a consequence of PE. The reported outcomes and follow up of patients is very heterogeneous between studies. ILCOR Treatment Recommendations We suggest administering fibrinolytic drugs for cardiac arrest when PE is the suspected cause of cardiac arrest (weak recommendation,very low quality evidence). We suggest administering fibrinolytic drugs or surgical embolectomy or percutaneous mechanical thrombectomy for cardiac arrest when PE is the known cause of cardiac arrest (weak recommendation,very low quality evidence). SHA Recommendation: (fibrinolytic drugs is the drug of choice when PE is suspected or known. This due to it accessibility and protocol of administration. For centers where thrombectomy and /or surgical embolectomy is available, they can be considered as alternative treatment). 5. CARDIAC ARREST DURING CORONARY CATHETERIZATION Introduction We examined the literature For any studies comparing novel treatments during cardiac arrest that occur during cardiac catheterization in addition to standard ALS approaches (eg.defibrillation) to cardiac arrest. The search was intended to find studies about any changes in sequence of interventions or about routine use of advanced circulatory support techniques. Page 6
ILCOR Treatment Recommendation: We suggest the use of Extra corporal life support (ECLS) as a rescue treatment when initial therapy is failing for cardiac arrest that occurs during coronary catheterization (weak recommendation, very low evidence). SHA Recommendation: we suggest the use of automated mechanical chest compression devices as an alternative to high quality manual CPR in situation where manual chest compression is impractical (eg. During coronary catheterization, transporting patients) or the rescuer safety is not secured. We sugest the use of ECLS in such situation if the it is available. Knowledge Gaps There is lack of data about specific interventions to treat cardiac arrest during coronary catheterization. Page 7
4. POST RESUSCITATION Temperature Management After Cardiac Arrest Sudden cardiac arrest is one of the leading causes of death in adults around the world. Although incidence varies from country to country, cardiac arrest affects several million people annually, with an average survival rate of <10%. 1,2 The ILCOR Advanced Life Support (ALS) Task Force conducted a systemic review and meta-analyses to address 3 key questions about temperature management in the post-cardiac arrest patient: 1. For patients who remain comatose after return of spontaneous circulation (ROSC), should targeted temperature management be used? 2. If targeted temperature management is used, what is the optimal timing of initiation? 3. If targeted temperature management is used, what is the optimal duration of therapy? Recommendations: Based on the published evidence to date, the ALS Task Force of ILCOR made the following recommendations in February 2015: We recommend targeted temperature management as opposed to no targeted temperature management for adults with OHCA with an initial shockable rhythm who remain unresponsive after ROSC (strong recommendation, low-quality evidence). We suggest targeted temperature management for adults with OHCA with an initial non-shockable rhythm who remain unresponsive after ROSC (weak recommendation, low-quality evidence). We suggest targeted temperature management for adults with IHCA with any initial rhythm who remain unresponsive after ROSC (weak recommendation, very low-quality evidence). We recommend selecting and maintaining a constant target temperature between 32 C and 36 C for those patients in whom targeted temperature management is used (strong recommendation, moderate-quality evidence). We recommend against routine use of prehospital cooling with rapid infusion of large volumes of cold intravenous fluid immediately after ROSC (strong recommendation, moderate-quality evidence). We suggest that if targeted temperature management (32-36 C) is used, duration should be at least 24 hours as done in the 2 largest randomized controlled trials. Capnography Waveform capnography receives a little more attention than in the past. They say: Waveform capnography is the most reliable method to confirm and continuously monitor tracheal tube placement An end-tidal CO2 less than 10 mmhg after 20 minutes is associated with extremely low chance of survival, but should not be used alone in the decision to stop resuscitation Page 8
Waveform capnography can be used to monitor the ventilation rate Waveform capnography can be used to monitor the quality of CPR. (High quality compressions should produce an end-tidal CO2 of at least 12-15 mmhg). A rise in end-tidal CO2 can be used as an early indication of ROSC Oxygen: They are looking for the Goldilocks zone: not too little, not too much. They specifically recommend against hypoxia and hyperoxia in the postresuscitation period. Basically, follow your O2 sat During arrest, when the O2 sat is unreliable, they recommend using a 100% FiO2 Page 9
UNRESPONSIVE? NOT BREATHING OR ONLY OCCASIONAL GASPS CALL RESUSCITATION TEAM CPR 30:2 ATTACH AED OR DEFIBRILLATOR PADS/MONITOR MINIMIZE INTERRUPTIONS ASSESSES RHYTHM SHOCKABLE (VF /PULSELESS VT) RETURN OF SPONTANEOUS CIRCULATION NO SHOCK DVISED 1 SHOCK Immediate post cardiac arrest treatment - use abcde approach - controlled oxygenation and ventilation - 12 lead ecg - treat precipitating cause - temperature control i therapeutic IMMEDIATELY RESUME: CPR 30:2 FOR 2 MIN MINIMIZE INTERRUPTIONS IMMEDIATELY RESUME: CPR 30:2 FOR 2 MIN MINIMIZE INTERRUPTIONS DURING CPR Ensure high-quality CPR: rate, depth, recoil Plan actions before interrupting CPR Give oxygen Consider advanced airway and capnography Continuous chest compressions when advanced airway In place Vascular access intravenous, intraosseous) Give epinephrine every 3-5 min Amiodarone 300 mg IV bolus for refractory VF/ pulseless VT Correct reversible causes REVERSIBLE CAUSES Hypoxia Hypovolemia Hypo- / hyperkalemia / metabolic Hypothermia Thrombosis - coronary or pulmonary Tamponade - cardiac Toxins Tension pneumothorax Page 10
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TACHYCARDIA Assess using the ABCDE approach Ensure oxygen given and obtain IV access Monitor ECG, BP, Sp02,record 12 lead ECG Identify and treat reversible causes (e.g. electrolyte abnormalities) *Synchronized DC Shock One attempt Unstable Assess for evidence of instability signs: 1.Shock 2.Syncop Stab Amiodarone 300 mg IV over 10-20 min and repeat shock; followed by: Amiodarone 900 mg over 24 h Broad Irregular Broad QRS?Is QRS regular Regular Regular Seek expert help Use vagal maneuvers Adenosine 6 mg rapid I If unsuccessful give 12 If unsuccessful give fur mg. Monitor ECG continuou Possibilities Include: AF with bundle branch block treat as for narrow complex Pre-excited AF consider amiodarone Polymorphic VT (e.g. torsades de pointes give magnesium 2 g over 10 min If Ventricular Tachycardia: Amiodarone 300 mg IV over 20-60 min; then 900 mg over 24 h If previously confirmed SVT with bundle branch block or (uncertain monomorphic rhythm): Give adenosine as for regular narrow complex tachycardia Attempted electrical cardioversion is always undertaken under sedation or anesthesia*?normal sinus rhythm Yes Probable re-entry PSVT: Record 12 lead ECG in If recurs, give adenosin consider choice of anti prophylaxis Page 12
BRADYCARDIA Assess using the ABCDE approach Ensure oxygen given and obtain IV access Monitor ECG, BP, Sp02,record 12 lead ECG Identify and treat reversible causes (e.g. electrolyte abnormalities) Atropine 500mcg IV Yes Assess for evidence of instability signs: 1. Shock 2. Syncope 3. Myocardial ischemia No Satisfactory response? Yes ON Interim measure: Atropine 500 mcg IV repeat to maximum of 3 mg Isoprenaline 5 mcg/min epinephrine 2-10 mcg/min Alternative drugs* OR Dopamine/dobutamine infusion (alternative to transcutaneous pacing) Yes?Risk of asystole Recent asystole- Mobitz 2 AV block- Complete heart block with broad- QRS Ventricular pause > 3s- No Seek Expert help Arrange transvenous pacing Observe * Alternative drugs include: Dopamine Glucagon (if beta-blocker or calcium channel blocker overdose) Page 13