ACLS: 2015 Update - Amazon S3 .ACLS: 2015 Update Anything New? Mitchell Shulman MDCM FRCPC CSPQ...

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Transcript of ACLS: 2015 Update - Amazon S3 .ACLS: 2015 Update Anything New? Mitchell Shulman MDCM FRCPC CSPQ...

  • ACLS:

    2015 Update

    Anything New?

    Mitchell Shulman MDCM FRCPC CSPQEmergency Department, MUHCMaster Instructor ACLS, QHSFAssist Professor, Dept of Surgery

  • Copyright 2017 by Sea Courses

    Inc.

    All rights reserved. No part of this document may be reproduced, copied, stored, or transmitted in any form or by any means graphic, electronic, or mechanical,

    including photocopying, recording, or information storage and retrieval systems without prior written

    permission of Sea Courses Inc. except where permitted by law.

    Sea Courses is not responsible for any speaker or participants statements, materials, acts or omissions.

  • CME Faculty

    Disclosure

    Dr. Shulman has no affiliation with the manufacturer of any commercial product or provider of any commercial service discussed in this CME activity.

  • Agenda

    Problems with data

    Call 1st? / 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?

    Pts families / partners: know what to do?

  • Warning! Problems with the Data

    Research in ACLS is difficult / challenging

    Few good studies (even less RCT)

    Consent ???

    Animal vs Human Rural vs Urban .

  • 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

    http://www.ilcor.org/

  • Agenda

    Problems with data

    Call 1st? / 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 aspirinwhile waiting

  • Responsive?

    If not:

    Lay people:

    Compression only CPR

    Trained BCLS providers:C A - B

    Dispatchers / BCLS

  • 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 1st? / Dispatch

    The Basics: CPR, Intubation, Defibrillation

    The Drugs

    Putting it all together

    Post- Resuscitation

  • Mouth to mouth???

    CPR world wide > 30 yrsno HIV or other blood

    borne pathogens via mouth-to-mouth

    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 meningitidisShigella sonneiSalmonella infantisNeisseria gonorrhea Streptococcus: saliva to non-intact skinHerpes simplex

  • Chest compressions

    Push Hard*, Push Fast*

    Recommended rate:

    30:2for all rescuers

    responding alone to victims of any age(except newborns) before

    advanced airway control

    2 health care providers child/infant 15:2

    *Rate: 100 120 / min*Depth: 2 2. 4 in

    ( 5 6 cm)

  • Intubate??

    Why?Control airwayReduce risk of aspirationAdminister drugsVentilate without worrying

    about timing

    AlternativesLaryngeal mask airwayCombitube

  • Confirm ETT placement

    Direct visualization

    5 point clinical exam

    Exhaled CO2 / esophageal detector device

    Endotracheal tube holder

    Continuous end-tidal CO2 monitoring

    http://images.google.ca/imgres?imgurl=http://www.elektronmedikal.com.tr/URUNresimleri/DALE/endotracheal.jpg&imgrefurl=http://www.elektronmedikal.com.tr/englishdaletube.htm&h=189&w=154&sz=15&tbnid=fbLg2YBq_W8J:&tbnh=96&tbnw=79&start=12&prev=/images%3Fq%3Dendotracheal%2Btube%2Bholder%26hl%3Den%26lr%3D%26sa%3DG

  • Ventilation

    Advanced airway in place:

    8 10 / min.

    2 health care provider rescuersCompressor: 100 - 120 / minVentilator: 8 10 / min

    Dont stopDont pauseRotate compressor role ~ Q 2 min.

  • AED (Defibrillation)

    AEDs do not require a prescription

    Healthcare provider oversight not necessary

  • Defibrillation

    Monophasic vsbiphasic ?

    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 1st? / Dispatch

    The Basics: CPR, Intubation, Defibrillation

    The Drugs

    Putting it all together

    Post- Resuscitation

  • Vasopressors?

    Only

    after 1 shock 2 2 minutes of CPRw/o perfusing rhythm

  • Epinephrine: How much?

    Class indeterminate !

    optimal physiologic response:

    .045 - .20 mg / kgbut HDE no statistical increase in rate of survival to hospital discharge

    1 mg IV Q 3 5 min

  • Vasopressin?

    No longer part of the algorhythmsArginine vasopressin = antidiuretic hormone

    Why?PhysiologyStimulates smooth muscle V1 receptors

    (non-adrenergic peripheral vasoconstrictor)

    StudiesElevated endogenous levels in survivors of

    cardiac arrest

    Increased coronary perfusion pressure, vital organ

    blood flow, cerebral oxygen delivery (animal models)

  • Vasopressin??

    Why not?No survival

    advantage over epinephrine

    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 NSRonly 20- 30% (inferior to Procainamide and Amiodarone)

    Advantages:ease of dosing / administrationwhen it works it works rapidlyminimal side effectslow cost

    Consider 1 1.5 mg / kg 1st dose; then 0.5 0.75 mg / kg IV Max. 3 doses or 3 mg / kg

  • Amiodarone

    History:structural analogue of thyroxinedeveloped in the 1960s (anti-anginal coronary vasodilator)

    acutely: anti-sympathetic & Ca+

    channel blockingchronically: prolongs action potential

    duration (Class III)long elimination half-life (14 -59 days)large volume of distribution

  • Amiodarone

    ARREST (Amiodarone for Resuscitation after Out-of-hospital Cardiac Arrest Due to Ventricular Fibrillation)

    300 mgs (n= 246) vs placebo (n= 258)44% vs 34% survive to be admittedno 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 admissionno difference in survival to discharge

  • Amiodarone

    Problem:attempts to defibrillate should not be

    delayed by administration of Amiodarone

    significant time required to reconstitute & prepare (high viscosity, generates bubbles)

    300 mg IV X 1; then 150 mg X 1

  • 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, CPRDefibrillate, defibrillate, defibrillate

  • Anti-arrhythmics

    In the setting of tachycardia:all anti-arrhythmics are pro-arrhythmic

    Stable, narrow complex, regular:adenosinediltiazem

    Stable, narrow complex, irregular:diltiazembeta-blockers

    Stable, wide complex:amiodaronemagnesium

    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 PRNmax: 2.2 g IV / 24 hrs

    Magnesium:1 2 grams in 50 - 100 ml D5W over 5 60 min IV.

  • Key Points

    Cardiac Arrests Happen

    Be prepared (yourself and your staff)

    AED?

    Pts families / partners: know what to do?

  • Agenda

    Problems with data

    Call 1st? / Dispatch

    The Basics: CPR, Intubation, Defibrillation

    The Drugs

    Putting it all together

    Post- Resuscitation

  • Lets 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 CPRAmiodarone 300 mg IV/IO