ACLS Updates 2015 - Your · ACLS/ACS...

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  • ACLS/ACS Updates 2015 Advanced Cardiovascular Life Support


    Fareed Al Nozha, JBIM, ABIM, FKFSH&RC(Cardiology) Consultant Cardiologist Faculty, National CPR Committee, ACLS Program Head, SHA

    Dr Abdulhalim J. kinsara FRCP, FACC, FESC Ass Professor

    Head of Adult cardiology


    (ACLS) guidelines have evolved over the

    past several decades based on a combination

    of scientific evidence of variable strength

    and expert consensus. The (AHA) developed

    the most recent ACLS guidelines in 2010

    using the comprehensive review of

    resuscitation literature performed by the

    (ILCOR), and these were updated in 2015

    2 2015 Update ACLS/ACS

  • Emphasis on Chest Compressions

    Untrained lay rescuers should provide compression-only

    (Hands-Only) CPR, with or without dispatcher guidance,

    for adult victims of cardiac arrest. The rescuer should

    continue compression-only CPR until the arrival of an

    AED or rescuers with additional training. All lay rescuers

    should, at a minimum, provide chest compressions for

    victims of cardiac arrest. In addition, if the trained lay

    rescuer is able to perform rescue breaths, he or she should

    add rescue breaths in a ratio of 30 compressions to 2

    breaths. The rescuer should continue CPR until an AED

    arrives and is ready for use, EMS providers take over care

    of the victim, or the victim starts to move.

  • Chest Compression Rate

    In adult victims of cardiac arrest, it is reasonable for

    rescuers to perform chest compressions at a rate of 100

    to 120/min.

  • Chest Compression Depth

    2015 (New): During manual CPR, rescuers should perform

    chest compressions to a depth of at least 2 inches (5 cm.) for

    an average adult, while avoiding excessive chest

    compressions depths (greater than 2.4 inches [6 cm.])

  • Use of Social Media to Summon Rescuers

    2015 (New): It may be reasonable for communities to

    incorporate social media technologies that summon

    rescuers who are in close proximity to a victim of

    suspected OHCA and are willing and able to perform CPR

    Community Lay Rescuer AED Programs

    2015 (New): It is recommended that PAD programs for

    patients with OHCA be implemented in public locations

    where there is a relatively high likelihood of witnessed

    cardiac arrest (eg. airports, casinos, sports facilities).

  • When supplementary oxygen is available, it

    may be reasonable to use the maximal

    feasible inspired oxygen concentration during


    Evidence for possible detrimental effects of

    hyperoxia in the immediate post-cardiac

    arrest period should not be extrapolated to

    CPR context

  • Post-CPR:

    When resources are available to titrate FiO2,

    it is reasonable to decrease FiO2 when SaO2

    is 100% provided the SaO2 is maintained at

    94% or greater.

  • Standard-dose epinephrine (1 mg every 3 to

    5 minutes) may be reasonable for patients

    in cardiac arrest (Class IIb, LOE B-R).

    High-dose epinephrine is not recommended

    for routine use in cardiac arrest (Class III:

    No Benefit, LOE B-R).

  • For initial non-shockable rhythm: It may be reasonable

    to administer adrenaline as soon as feasible after the

    onset of cardiac arrest (Class Iib, LOE C-LD).

    For initial shockable rhyhtm: There is insufficient

    evidence to make a recommendation as to the optimal

    timing of adrenaline, particularly in relation to


  • Amiodarone may be considered for VF/pVT that is

    unresponsive to CPR, defibrillation, and a

    vasopressor therapy (Class IIb, LOE B-R).

    Lidocaine may be considered as an alternative to

    amiodarone for VF/pVT that is unresponsive to

    CPR, defibrillation, and vasopressor therapy (Class

    IIb, LOE C-LD).

  • none (of the antiarrhythmics) have yet

    been proven to increase long term survival or

    survival with good neurologic outcome. Thus

    establishing vascular access to enable drug

    administration should not compromise the

    quality of CPR or timely defibrillation, which

    are known to improve survival.

  • Ultrasound (cardiac or noncardiac)

    may be considered during the management of

    cardiac arrest, although its usefulness has

    not been well established (Class IIb, LOE CEO).

    If a qualified sonographer is present and

    use of ultrasound does not interfere with the

    standard cardiac arrest treatment protocol,

    then ultrasound may be considered as an

    adjunct to standard patient evaluation (Class

    IIb, LOE C-EO).

  • 14

  • Cardiopulmonary resuscitation (CPR) and

    early defibrillation for treatable arrhythmias

    remain the cornerstones of basic and

    advanced cardiac life support (ACLS).

    Excellent chest compressions without

    interruption are the key to successful CPR

    15 2015 Update ACLS/ACS

    ACLS Updates 2015

  • The performance of teams providing ACLS

    improves when there is a single designated

    leader who asks for and accepts helpful

    suggestions from members of the team, and

    when the team practices clear, closed-loop


    16 2015 Update ACLS/ACS

    ACLS Updates 2015

  • 17 2015 Update ACLS/ACS

  • Summary

    of Key Issues and Major Changes

    The combined use of vasopressin and epinephrine

    offers no advantage to using standard-dose

    epinephrine in cardiac arrest. Also, vasopressin

    does not offer an advantage over the use of

    epinephrine alone. Therefore, to simplify the

    algorithm, vasopressin has been removed from

    the ACLS Algorithm2015 Update.

    18 2015 Update ACLS/ACS

  • Low ETCO2 in intubated patients after 20 minutes

    of CPR is associated with a very low likelihood of

    resuscitation. While this parameter should not be

    used in isolation for decision making, providers

    may consider low ETCO2 after 20 minutes of CPR

    in combination with other factors to help determine

    when to terminate resuscitation.


    of Key Issues and Major Changes

    19 2015 Update ACLS/ACS

  • Steroids may provide some benefit when bundled

    with vasopressin and epinephrine in treating IHCA.

    While routine use is not recommended pending

    follow-up studies, it would be reasonable for a

    provider to administer the bundle for IHCA.


    of Key Issues and Major Changes

    20 2015 Update ACLS/ACS

  • When rapidly implemented, ECPR can prolong

    viability, as it may provide time to treat

    potentially reversible conditions or arrange for

    cardiac transplantation for patients who are not

    resuscitated by conventional CPR.


    of Key Issues and Major Changes

    21 2015 Update ACLS/ACS

  • In cardiac arrest patients with nonshockable rhythm

    and who are otherwise receiving epinephrine, the

    early provision of epinephrine is suggested.


    of Key Issues and Major Changes

    22 2015 Update ACLS/ACS

  • Studies about the use of lidocaine after ROSC are

    conflicting, and routine lidocaine use is not


    However, the initiation or continuation of lidocaine

    may be considered immediately after ROSC from

    VF/pVT cardiac arrest.


    of Key Issues and Major Changes

    23 2015 Update ACLS/ACS

  • One observational study suggests that - blocker

    use after cardiac arrest may be associated with

    better outcomes than when - blockers are not


    Although this observational study is not strong

    enough evidence to recommend routine use, the

    initiation or continuation of an oral or intravenous

    (IV) -blocker may be considered early after

    hospitalization from cardiac arrest due to VF/p VT.


    of Key Issues and Major Changes

    24 2015 Update ACLS/ACS

  • 2015 Update ACLS/ACS 25

    Targeted temperature management

    Upgraded the strength of recommendation to the highest

    level for using targeted temperature management in all

    comatose patients who achieve ROSC regardless of the

    presenting rhythm or whether the arrest occurred in the

    out-of-hospital or hospital environment.

    The AHA also expanded the targeted temperature range

    to 32 C to 36 C.

  • 2015 Update ACLS/ACS 26

    Targeted temperature management

    New recommendation is for EMS to no longer initiate the

    cooling process with chilled saline infusion.

    Five randomized controlled trials using chilled IV fluids

    following ROSC , one trial using chilled IV fluids during

    the resuscitation attempt , and one trial using intra-nasal

    cooling could find no survival or neurological recovery

    benefits offered by prehospital cooling.

    In one of the chilled saline trials, initiating cooling in the

    field actually increased the risk of re-arrest and post-

    resuscitation pulmonary edema

  • Acute Coronary Syndromes 2015

    Recommendations will be limited to the prehospital

    and emergency department phases of care.

    In-hospital care is addressed by guidelines for the

    management of myocardial infarction published