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Transcript of Interactive with ACLS! Reviewing the Basics and a 2015 Update Interactive with ACLS! Reviewing the...

  • Interactive with ACLS!

    Reviewing the Basics and a 2015

    Update

    Dan Israel, PharmD

    Nick Wolters, PharmD

    April 22, 2016

    Grandview Medical Center: Dayton, OH

  • Objectives

    • Describe the pharmacist’s role in code response

    • Review pharmacotherapy treatment options in ACLS

    • Summarize key changes in the 2015 AHA Guidelines for CPR and ECC

    • Review key pharmacologic components of crash carts

  • Pharmacist Role in Code Response

    • Lower mortality when part of

    CPR teams

    • Roles

    – Medication dosing

    – Medication procurement &

    preparation

    – Critical thinking

    Bond et al. Clinical pharmacy services and hospital mortality rates. Pharmacotherapy. 1999 May;19(5):556-64

    www.mayo.edu/mshs/careers/pharmacy/pha

    rmacy-practice-residency-in-emergency-

    medicine-minnesota

  • TERMS

    • ROSC – Return of Spontaneous Circulation

    • OHCA – Outside Hospital Cardiac Arrest

    • VT/VF – Ventricular Tachycardia/Ventricular Fibrillation

    • CPR – Cardiopulmonary Resuscitation

  • ACLS Cardiac Arrest Algorithm.

    Robert W. Neumar et al. Circulation. 2010;122:S729-S767

    Copyright © American Heart Association, Inc. All rights reserved.

  • Adult Cardiac Arrest Algorithm―2015 Update.

    Mark S. Link et al. Circulation. 2015;132:S444-S464

    Copyright © American Heart Association, Inc. All rights reserved.

    “Evolutionary, not

    revolutionary”

  • Patient Case

    • Tragedy strikes

    – A pharmacy resident, functioning on caffeine,

    anxiety, and stress starts to feel “funny”

    – Walks from his office to the ED… I don’t feel so good…

  • “A turn for the worse”

    • Suddenly Dan becomes unresponsive….

    • A quick look to the monitor shows:

    CODE BLUE!!!

  • The Code

    • What should the team do now?

    A. One round (30:2) of CPR

    B. Defibrillate at 200 J for biphasic shock

    C. Give 1 dose of Epinephrine 1mg IV

  • SHOCK HIM!!!

    • 2015 re-emphasis: Shock first if AED

    immediately available and shockable rhythm

    analyzed, otherwise start CPR first

    • Rationale: Survival benefit from defibrillation

    is time dependent

    Larsen MP, Eisenberg M, Cummins RO, Hallstrom AP. Predicting Survival from out-of-hospital cardiac arrest: a graphic

    model. Ann Emerg Med 1993; 22:1652-1658.

  • Adult Cardiac Arrest Algorithm―2015 Update.

    Mark S. Link et al. Circulation. 2015;132:S444-S464

    Copyright © American Heart Association, Inc. All rights reserved.

    “Evolutionary, not

    revolutionary”

  • Chest Compression Rate

    • 2010: “It is reasonable for lay rescuers and

    HCPs to perform chest compressions at a rate

    of at least 100 beats/min”

    • 2015: “In adult victims or cardiac arrest, it is

    reasonable for rescuers to perform chest

    compressions at a rate of 100 – 120

    beats/min”

    Kleinman ME, et al. Part 5: Adult Basic Life Support and Cardiopulmonary Resuscitation Quality 2015 American Heart Association Guidelines

    Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015;132[suppl 2]:S414–S435

  • Chest Compression Rate • 10,371 patients with OHCA

    • ROSC in 34% patients – 9% survived until hospital

    discharge

    Idris AH, et al. Chest compression rate and survival following out-of-hospital cardiac arrest. Crit Care Med. 2015 Apr;43(4):840-8

    ROSC Survival to Discharge

    Rate Categories

    (compressions/min) OR (95% CI) p OR (95% CI) p

    140 (n=244) 1.08 (0.79–1.47) 0.640 0.95 (0.53–1.70) 0.864

    Adjusted model (including compression depth and fraction) n=6,399

  • Chest Compression Rate

    • Reduction in quality chest compressions

    – Proportion of compressions 140 beats/min: 70%

    Idris AH, et al. Chest compression rate and survival following out-of-hospital cardiac arrest. Crit Care Med. 2015 Apr;43(4):840-8

  • Chest Compression Depth

    • 2010: “The adult sternum should be

    depressed at least 2 inches”

    • 2015: “During manual CPR, rescuers should

    perform chest compressions to a depth of at

    least 2 inches (5cm) for an average adult,

    while avoiding excessive chest compression

    depths (>2.4in)”

    Kleinman ME, et al. Part 5: Adult Basic Life Support and Cardiopulmonary Resuscitation Quality 2015 American Heart Association Guidelines

    Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015;132[suppl 2]:S414–S435

  • Chest Compression Depth

    • 9,136 patients with OHCA

    40.3mm 55.3mm

    Maximum survival was

    in the depth interval of

    40.3 – 55.3mm

    Stiell et al. What Is the Optimal Chest Compression Depth During Out of-Hospital

    Cardiac Arrest Resuscitation of Adult Patients? Circulation. 2014;130:1962-1970

  • Chest Compression Depth • 170 adult resuscitated patients

    – Recorded compression quality; compared to chest CT or Xray during post-resuscitation care

    – 32% (n=54 had sustained injuries) • Mainly rib and sternal fractures

    – Compression Depth (% injured) • 60mm – 49%

    Hellevuo H, Sainio M, Nevalainen R, Huhtala H, Olkkola KT, Tenhunen J, Hoppu S. Deeper chest

    compression - more complications for cardiac arrest patients? Resuscitation. 2013;84:760–765

  • THE CODE CONTINUES

  • Adult Cardiac Arrest Algorithm―2015 Update.

    Mark S. Link et al. Circulation. 2015;132:S444-S464

    Copyright © American Heart Association, Inc. All rights reserved.

    “Evolutionary, not

    revolutionary”

  • Adult Cardiac Arrest: Vasopressors

    • 2010: “One dose of vasopressin 40 units IV/ IO

    may replace either the first or second dose of

    epinephrine in the treatment of cardiac arrest”

    • 2015: “Vasopressin in combination with

    epinephrine offers no advantage as a substitute

    for standard-dose epinephrine in cardiac arrest”

    Link MS, et al. Part 7: Adult Advanced Cardiovascular Life Support 2015 American Heart Association Guidelines Update for Cardiopulmonary

    Resuscitation and Emergency Cardiovascular Care. Circulation. 2015;132:S444–S464.

  • Vasopressin versus epinephrine

    Mukoyama, et al.

    R

    Patients with out of

    hospital cardiac

    arrest

    Epinephrine 1mg q5-10mins

    (max 4mg) n=158

    Vasopressin 40 IU q5-10

    mins (max: 160 IU) n=178

    Prospective randomized control (Tokyo, Japan)

    Primary End Point: survival to hospital discharge; ROSC; 24-h survival

    Mukoyama T, Kinoshita K, Nagao K, Tanjoh K. Reduced effectiveness of vasopressin in repeated doses for patients

    undergoing prolonged cardiopulmonary resuscitation. Resuscitation. 2009;80:755–761

  • Mukoyama, et al. study

    • Outcomes

    Outcome Vasopressin Epinephrine P-Value

    ROSC 51 (28%) 42 (26.6%) 0.762

    24-h survival 30 (16.9%) 32 (20.3%) 0.423

    Survival to

    discharge

    10 (5.6%) 6 (3.8%) 0.431

    Mukoyama T, Kinoshita K, Nagao K, Tanjoh K. Reduced effectiveness of vasopressin in repeated doses for patients

    undergoing prolonged cardiopulmonary resuscitation. Resuscitation. 2009;80:755–761

  • Combination: Vasopressin vs

    Epinephrine

    R

    Epinephrine 1mg

    PLUS

    standard of care*

    n= 353

    Vasopressin 40 IU

    PLUS

    Standard of care*

    n= 374

    Randomized double blind control trial (Singapore)

    Primary End Point: survival to hospital discharge; ROSC;

    Ong ME, et al. Resuscitation. 2012;83:953–960.

    Patients with out of

    hospital cardiac

    arrest

    *Meaning 2005 ACLS guidelines

    (Epinephrine 1mg given ~95% after study drug)

  • Combination study

    • Outcomes

    • No difference in cerebral performance category at 30 days and 1 year post arrest

    Outcome Epinephrine Vasopressin Adjusted P-

    Value

    ROSC 106 (30%) 119 (31.8%) 0.331

    Survival to admission 59 (16.7%) 83 (22.2%) 0.051

    Survival to discharge

    or 30 days post arrest

    8 (2.3%) 11 (2.9%) 0.271

    Ong ME, Tiah L, Leong BS, et al. A randomised, double-blind, multi-centre trial comparing vasopressin and adrenaline in

    patients with cardiac arrest presenting to or in the Emergency Department. Resuscitation. 2012;83:953–960.

  • NEJM: Vasopressin vs Epinephrine

    R

    Epinephrine 1mg PLUS

    Vasopressin 40 IU

    n= 1442

    Epinephrine 1mg

    PLUS

    Placebo

    n= 1452

    Randomized double blind control trial

    Primary End Point: survival to hospital discharge; ROSC;

    Patients with out of

    hospital cardiac

    arrest

    Gueugniaud PY, David JS, Chanzy E, et al. Vasopressin and epinephrine vs. epinephrine alon