THE EVIDENCED BASED 2015 CPR GUIDELINES

SAUDI HEART ASSOCIATION NATIONAL CPR COMMITTEE THE EVIDENCED BASED 2015 CPR GUIDELINES Page 1

Chapter 3 ACLS AND SPECIAL SITUATIONS CHAPTER The International Liaison Committee on Resuscitation (ILCOR) Advanced Life Support (ALS) Task Force performed detailed systematic reviews based on the recommendations of the Institute of Medicine of the National Academies and using the methodological approach proposed by the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) Working Group. Questions to be addressed (using the PICO [population, intervention, comparator, outcome] format)were prioritized by ALS Task Force members (by voting). Prioritization criteria included awareness of significant new data and new controversies or questions about practice. Questions about topics no longer relevant to contemporary practice or where little new research has occurred were given lower priority. The ALS Task Force prioritized 42 PICO questions for review. With the assistance of information specialists, a detailed search for relevant articles was performed in each of 3 online databases (PubMed, Embase, and the Cochrane Library). 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 2

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 non-shockable 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 Page 3

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. 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. Consensus on science There were no comparative studies of uterine displacement for women in cardiac arrest before delivery.no studies compared different maneuvers (eg,manual displacement versus left pelvic tilt) to achieve optimal uterine displacement for women in cardiac arrest before delivery. Physiologic reviews and studies of uterine displacement maneuvers in nonarrest pregnant women support that uterine displacement might be physiologically beneficial for women in cardiac arrest.any benefit would have to be weighed against the potential interference or delay with usual resuscitation care. 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. Page 4

2. LIPID THERAPY FOR CARDIAC ARREST In adult patients with cardiac arrest due to suspected drug toxicity (eg.local anesthetics, tricyclic antidepressants, others) does administration of IV lipid, compared with no IV lipid, change survival with favorable neurologic/functional outcome at discharge, 30, 60, 180 days, and / or 1 year ROSC. 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. Consensus on science We identified no human comparative studies in cardiac arrest and peri arrest states relevant to the therapy. Many case reports and case series described resuscitation that included administration of lipid. 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 Knowledge Gaps Comparisons are needed of patients with similar clinical characteristics who were treated and who were not treated with IV lipids after suspected drug toxicity. 3. OPIOID TOXICITY Among adults who are in cardiac arrest or respiratory arrest due to opioid toxicity in any setting,does any specific therapy (eg.naloxone, bicarbonate, or other drugs) compared with usual ALS, change survival with favorable neurologic/ functional outcome at discharge, 30, 60, 180 days and / or 1 year, ROSC? 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. Consensus on Science For the important outcome of survival with favorable neurologic outcome at discharge,30,60,180 days, and /or 1 year, ROSC,after opioid induced cardiac arrest,no study with comparative data beyond standard ALS care. Page 5

For the important outcome of survival with favorable neurologic outcome at discharge,30,60,180 days, and /or 1 year, ROSC,after opioid induced respiratory arrest,no comparative study was found. There were 12 studies of which 5 compared intramuscular and intranasal routes of naloxone administration, and 7 assessed the safety of naloxone use or we're observational studies of naloxone use. These studies report that naloxone is safe and effective in treatment of opioid induced respiratory depression, that complications are rare and dose related, and that mortality is rare when patients refuse transfer after initial naloxone administration. 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). Knowledge Gaps There is no data on the use of any additional ALS therapies in opioid induced cardiac arrest. In respiratory arrest, there is only evidence for the use of naloxone. No other change in sequence of interventions. Studies of naloxone use in respiratory arrest were observational,looked at safety, or compared routes of administration. 4. CARDIAC ARREST ASSOCIATED WITH PE Among adults who are in cardiac arrest due to PE or suspected PE in any setting,does any specific alteration in treatment algorithm (eg.fibrinolytics,or any other) compared with standard care (according to 2010 treatment algorithm) change survival with favorable neurologic/functional outcome at discharge, 30,60,180 days and/or 1 year survival only at discharge, 30,60,180 days and/or 1 year ROSC? 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. Consensus on science Fibrinolysis; For the critical outcome of survival with favorable neurologic status at 30,90,or 180 days,there was very low quality evidence from comparing fibrinolytic versus placebo during cardiac arrest. Page 6

For the important outcome of survival to hospital discharge, very low quality evidence from 2 retrospective observational studies showed there was no difference in discharge rates. For the important outcome of ROSC,very low quality evidence from 2 studies showed benefit for the use of fibrinolytic drugs compared with controls in patients with PE, ROSC was reported to be significantly higher in a retrospective analysis. In a separate study,rosc showed favorable results for the use of fibrinolytic drugs. Surgical Embolectomy; We found very low quality evidence from 2 case series with no control group and a total of 21 patients requiring CPR with a 30 day survival rate of 12.5% and 71.4% respectively. Percutaneous Mechanical Thrombectomy; For the important outcome of ROSC,very low quality evidence from 1 case series of 7 patients with cardiac arrest with no control group,rosc was achieved in 6 of 7 patients (85.7%) treated with percutaneous Mechanical thrombectomy. 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). Values, preferences,and Task Force Insights In making these recommendations,we acknowledge the use of thrombolytic drugs surgical embolectomy or percutaneous mechanical thrombectomy, or a combination for known PE in non cardiac arrest patients. We acknowledge the potential risk of bleeding after fibrinolysis and place value in the choice of intervention taking into account location, availability of intervention, and contraindications to fibrinolysis. Knowledge Gaps There is a paucity of data on the topic of pulmonary embolus and its diagnosis and management during cardiac arrest. Further high quality studies are required. 5. CARDIAC ARREST DURING CORONARY CATHETERIZATION Among adults who have a cardiac arrest in the cardiac catheterization laboratory,does any special intervention or change in care (eg. Catheterization during CPR, cardiopulmonary bypass, ballon pump, different timing of shock), compared with standard resuscitation care (eg.cpr, drugs, and shocks according to 2010 treatment algorithm), change survival with favorable neurologic/functional outcome at discharge, 30,60,180 days,and/or 1 year, survival only at discharge, 30,60,180 days, and/or 1 year, ROSC? Page 7

Introduction We examined the literature For any studies comparing novel treatments during cardiac arrest that occur during cardiac catherization 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. Consensus on Science There were no comparative studies evaluating the survival benefit of mechanical CPR, however individual non-comparative case series reported variable survival rates. For the critical outcomes of survival with favorable neurologic/functional outcome at discharge,30,60,90,180 days, and 1 year,and the outcomes of survival at 30,60,90,180 days,and 1year,no studies were identified. For thea critical outcomes of survival to discharge and survival to 6 months, and the important outcome of ROSC, very low quality evidence was found. 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 8

Chapter 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 (32-36C) 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: Page 9

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 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 post-resuscitation period. Basically, follow your O2 sat During arrest, when the O2 sat is unreliable, they recommend using a 100% FiO2 Page 10

ADVANCED LIFE SUPPORT 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 hypothermia 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 11

TACHYCARDIA ALGORITHM (WITH PULSE) 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 3.Myocardial ischemia 4.Heart failure Stable Is QRS narrow (< 0.12 sec)? Amiodarone 300 mg IV over 10-20 min and repeat shock; followed by: Amiodarone 900 mg over 24 h Broad Narrow Irregular Broad QRS Is QRS regular? Regular Regular Narrow QRS Is QRS regular? Irregular Seek expert help Use vagal maneuvers Adenosine 6 mg rapid IV bolus; If unsuccessful give 12 mg; If unsuccessful give further 12 mg. Monitor ECG continuously Irregular narrow complex tachycardia Probable atrial fibrillation Control rate with: B-Blocker or diltiazem Consider digoxin or amiodarone If evidence of heart failure Anticoagulate If duration > 48h Possibilities Include: If Ventricular Tachycardia: AF with bundle branch block treat as for Amiodarone 300 mg IV over 20-60 narrow complex min; then 900 mg over 24 h If previously confirmed Pre-excited AF consider amiodarone SVT with bundle branch block or Polymorphic VT (uncertain monomorphic rhythm): (e.g. torsades de pointes Give adenosine as for regular give magnesium 2 g over 10 min narrow complex tachycardia *Attempted electrical cardioversion is always undertaken under sedation or anesthesia Normal sinus rhythm restored? Yes Probable re-entry PSVT: Record 12 lead ECG in sinus rhythm If recurs, give adenosine again &. consider choice of antiarrhythmic prophylaxis No Seek expert help Possible atrial flutter Control rate (e.g. B-Blocker) Page 12

BRADYCARDIA ALGORITHM 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 Yes Assess for evidence of instability signs : 1. Shock 2. Syncope 3. Myocardial ischemia 4. Heart failure No 500mcg IV Satisfactory Yes response? 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