Acls Guidelines 2010 T_ Larabee(1)

8/2/2019 Acls Guidelines 2010 T_ Larabee(1)

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Todd M. Larabee, MDDepartment of Emergency Medicine

University of Colorado Denver SOM



Issues after 2005 Guideline changesILCOR ProcessHighlights of the 2010 Guidelines◦

BLS◦ ACLS◦ PALSSummary



Biggest changes in 2005 were 30:2compression ration and the change indefibrillation sequence

Growing emphasis on high-quality CPRImplementation of the 2005 guidelines didimprove outcomesImplementing new guidelines can take 18months-4 years



Since 2005, there’s been an emphasis tosimplify CPR recommendationsStress high-quality CPR

Stress utility/importance of bystander CPRNeed to remove barriers to performance of bystander CPRDe-emphasis on devices and drugs

Importance of post-cardiac arrest careImportance of continuing education andtraining



Objectives:◦ Provide a forum for discussion and coordination of

all aspects of cardiopulmonary and cerebralresuscitation worldwide.

◦ Foster scientific research in areas of resuscitation

where there is a lack of data or controversy exists.◦ Disseminate information on training and education

in resuscitation.◦ Provide a mechanism for collecting, reviewing and

sharing international resuscitation data.◦ Produce statements on specific issues related to

resuscitation that reflect international consensus.



Resuscitation Council of Asia (currentmembers Japan, Korea, Singapore,Taiwan)

http://www.interamericanheart.org/

http://www.resuscitationcouncil.co.za/

http://www.nzrc.org.nz/

http://www.resus.org.au/

http://ww2.heartandstroke.ca/splash/

http://www.erc.edu/

http://www.americanheart.org/



Task Forces generate worksheets/PICOquestions411 scientific evidence reviews on 277 topicsrelated to resuscitation and ECC356 “experts” from 29 countriesDebates/discussions via telephone/in-person/webinars

Creates the most current and comprehensivereview of resuscitation literature everpublished



In adult patients in cardiac arrest (asystole,pulseless electrical activity, pulseless VT andVF) (prehospital [OHCA], in-hospital [IHCA])

(P), does the use of vasopressors(epinephrine, norepinephrine, others) orcombination of vasopressors (I) comparedwith not using drugs (or a standard drugregimen) (C), improve outcomes (eg. ROSC,survival) (O).



Levels of Evidence for Therapeutic Interventions

LOE 1: Randomised Controlled Trials (or meta-analyses of RCTs)

LOE 2: Studies using concurrent controls without true randomisation (eg. “pseudo” -randomised)(or meta-analyses of such studies)

LOE 3: Studies using retrospective controlsLOE 4: Studies without a control group (eg. case series)

LOE 5: Studies not directly related to the specific patient/population (eg. differentpatient/population, animal models, mechanical models etc.)



Good

(Goetting and Paradis 1991)A-D(Grmec and Mally 2006)A-C

(Gonzalez, Ornato et al. 1989)E(Lindner, Prengel et al. 1996)A-D

Fair(Paradis, Martin

et al. 1991)E(Barton and Callaham 1991)A(Matok, Vardi et al. 2007)A-C

Poor (Guyette, Guimond et al. 2004)A,E

(Goetting and Paradis 1989)A

1 2 3 4 5

Level of evidence

Evidence Supporting Clinical Question

A = Return of spontaneous circulation C = Survival to hospital discharge E = Other endpointB = Survival of event D = Intact neurological survival Italics = Animal studies



Neutral evidence tableGood

(Aung and Htay 2005)A-D(Brown, Martin et al. 1992)A-D(Callaway, Hostler et al. 2006)A-D(Choux, Gueugniaud et al. 1995)A-D(Gueugniaud, David et al. 2008)A-D

(Gueugniaud, Mols et al. 1998)A-D(Lindner, Dirks et al. 1997)A-D(Lindner, Ahnefeld et al. 1991)A-C(Lipman, Wilson et al. 1993) A,B,E(Olson, Thakur et al. 1989)A-C(Olasveengen, Sunde et al. 2009)A-D(Callaham, Madsen et al. 1992)A-D(Lindner, Ahnefeld et al. 1991) A-C(Patrick, Freedman et al. 1995)A-D(Perondi, Reis et al. 2004)A-C(Sherman, Munger et al. 1997)A-C(Stiell, Hebert et al. 1992)A-D(Stiell, Hebert et al. 2001)A-E(Turner, Parsons et al. 1988)A-D(Wenzel, Krismer et al. 2004)A-D

(Carvolth and Hamilton1996)A-C

Fair(Patterson, Boenning et al. 2005)A-D(Silfvast, Saarnivaara et al. 1985)A(Vandycke and Martens 2000)A-D

(Takeo, Kosaku et al. 2009)A-D

(Herlitz, Ekstromet al. 1995)A-C

(Carpenter and Stenmark 1997)A-D

Poor

(Woodhouse, Cox et al. 1995)A-C

(Morris,Dereczyk et al.

1997) E(Gonzalez,

Ornato et al.1988)E

(Dieckmann and Vardis1995)A-D

(Mally, Jelatancev et al.2007)A-C, E

(Callaham, Barton et al.1991)B-E

(Ong, Tan et al. 2007)A-D1 2 3 4 5

Level of evidence

A = ROSC C = Survival to hospital discharge E = Other endpoint

B = Survival of event D = Intact neurological survival



Opposing evidence table

Good(Behringer, Kittler et al.

1998)A,D

Fair

Poor

(Rivers, Wortsman et al.1994)A, B, E

(Chang, Ma et al.2007)E

(Duncan, Meaney et al.2009)A-E

1 2 3 4 5

Level of evidence

A = Return of spontaneous circulation C = Survival to hospital discharge E = Other endpointB = Survival of event D = Intact neurological survival Italics = Animal studies



“Look, listen, feel” removed from algorithm◦ delaysEarly activation of EMSCompression-only CPR for the untrained lay-

rescuerHigh-quality CPRMinimize interruptionsDeemphasis on pulse checks during CPR



C-A-B not A-B-C◦ Most arrest are adult; most survivors are

VF/VT◦

Emphasis on performing high-quality CPRand early defibrillation◦ Delay in “C” when attempting “A”◦ May remove barriers to bystander CPR



Untrained lay-person◦ Hands-only CPR◦ Continue until AED/trained personnel availableTrained lay-person◦ Hands-only CPR◦ If willing to perform ventilations with 30:2 ratio◦ Continue until AED/trained personnel availableHealthcare Provider◦

CPR including ventilations with 30:2 ratio◦ Can tailor sequence of interventions based on

cause of arrest



CPR Techniques and Devices◦ No adjunct has been shown to be superior to

manual CPR◦ ITD (ResQPOD) improved ROSC and short-term

survival◦ Load-band CPR (Autopulse) with no change in 4-hr survival and worsened neurologic outcomes

◦ Mechanical piston devices with varying degrees of success

◦ All require additional equipment and training;training needs to be ongoing

◦ More research needed



Electrical Therapy◦ Emphasis on AEDs and addition of AEDs to

enhance the chain of survival◦ CPR before defibrillation remains unclear◦ Continuing with 1-shock protocol with

minimizing CPR interruptions



Successful ACLS is predicated on good BLS◦ High-quality CPR with minimal interruptions◦ Early defibrillationFifth link in “Chain of Survival”: Post -Cardiac Arrest Care◦ Multidisciplinary care from BLS to discharge for

good neurologic outcomeQualitative waveform capnography



Airway Management:◦ Qualitative waveform capnography recommended◦ Suppraglottic airway devices are supported as

airway alternative◦

Cricoid pressure is no longer recommendedSymptomatic Dysrrhythmias◦ Adenosine is safe for diagnostics in stable,

undifferentiated wide-complex monomorphic

tachycardia◦ For stable or unstable bradycardia, IV chronotropic

agents recommended as equally effective asexternal pacing



Notice on the charts:◦ Vascular access, drug delivery, advanced airway

placement are recommended but should notinterrupt CPR

◦ Atropine no longer recommended for PEA/asystole◦ Real-time monitoring of CPR quality

Mechanical parametersPhysiologic parameters

◦ Post-arrest care now a component of the algorithm



Post Cardiac-Arrest Care◦ Multidisciplinary team◦ Structured, integrated, bundled system of careKey Objectives◦ Optimize cardiopulmonary function and vital organ

perfusion after ROSC◦ Transport to an appropriate critical care unit withcomprehensive post-cardiac arrest care system

◦ Identify/intervention for ACS◦ Temperature control for improving neurologic

outcomes◦ Prevention and treatment of multi-organ

dysfunction



Emphasis on asphyxial arrest combinedwith chest compressionsCompression-only CPR for bystanders

unwilling or unable to perform ventilationsC-A-B for ease of teaching (A-B-Ccontinues in Neonatal Resuscitation)High-quality CPR



Deemphasis on pulse checksUpdated formula for cuffed tubes in infantsand young children◦

Uncuffed: 4 + (age/4) if > 2yr3.5 up to 1 yr, 4.0 if >1yr◦ Cuffed: 3.5 + (age/4) if >2yr

3.0 up to 1yr, 3.5 if >1yr

Safety and value of cricoid pressurequestioned; can discontinue if impedesairway



Capnography recommendedOptimal defibrillation energy dose uncertain-recommending 2-4J/kg (either waveform)Concerns of hyperoxemia after ROSC



Fewer, less dramatic changes than in 2005Circulation more important than ventilation inmost instancesC-A-B

Goodbye AtropinePost resuscitation care and neurologicoutcomes focus



Thanks for listening.

Acls Guidelines 2010 T_ Larabee(1)

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