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Page 1: Interactive with ACLS! Reviewing the Basics and a 2015 Update€¦ · Interactive with ACLS! Reviewing the Basics and a 2015 Update Dan Israel, PharmD Nick Wolters, PharmD April 22,

Interactive with ACLS!

Reviewing the Basics and a 2015

Update

Dan Israel, PharmD

Nick Wolters, PharmD

April 22, 2016

Grandview Medical Center: Dayton, OH

Page 2: Interactive with ACLS! Reviewing the Basics and a 2015 Update€¦ · Interactive with ACLS! Reviewing the Basics and a 2015 Update Dan Israel, PharmD Nick Wolters, PharmD April 22,

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

Page 3: Interactive with ACLS! Reviewing the Basics and a 2015 Update€¦ · Interactive with ACLS! Reviewing the Basics and a 2015 Update Dan Israel, PharmD Nick Wolters, PharmD April 22,

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

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TERMS

• ROSC – Return of Spontaneous Circulation

• OHCA – Outside Hospital Cardiac Arrest

• VT/VF – Ventricular Tachycardia/Ventricular Fibrillation

• CPR – Cardiopulmonary Resuscitation

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ACLS Cardiac Arrest Algorithm.

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

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

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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”

Page 7: Interactive with ACLS! Reviewing the Basics and a 2015 Update€¦ · Interactive with ACLS! Reviewing the Basics and a 2015 Update Dan Israel, PharmD Nick Wolters, PharmD April 22,

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…

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“A turn for the worse”

• Suddenly Dan becomes unresponsive….

• A quick look to the monitor shows:

CODE BLUE!!!

Page 10: Interactive with ACLS! Reviewing the Basics and a 2015 Update€¦ · Interactive with ACLS! Reviewing the Basics and a 2015 Update Dan Israel, PharmD Nick Wolters, PharmD April 22,

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

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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.

Page 12: Interactive with ACLS! Reviewing the Basics and a 2015 Update€¦ · Interactive with ACLS! Reviewing the Basics and a 2015 Update Dan Israel, PharmD Nick Wolters, PharmD April 22,

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”

Page 13: Interactive with ACLS! Reviewing the Basics and a 2015 Update€¦ · Interactive with ACLS! Reviewing the Basics and a 2015 Update Dan Israel, PharmD Nick Wolters, PharmD April 22,

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

Page 14: Interactive with ACLS! Reviewing the Basics and a 2015 Update€¦ · Interactive with ACLS! Reviewing the Basics and a 2015 Update Dan Israel, PharmD Nick Wolters, PharmD April 22,

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

<80 (n=335) 0.97 (0.74–1.27) 0.811 0.89 (0.53–1.50) 0.659

80-99 (n=1,933) 0.99 (0.86–1.13) 0.841 0.73 (0.57–0.93) 0.011

100-119 (n=2,932) Reference group Reference group

120-139 (n=955) 0.98 (0.82–1.16) 0.781 0.63 (0.45–0.88) 0.007

>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

Page 15: Interactive with ACLS! Reviewing the Basics and a 2015 Update€¦ · Interactive with ACLS! Reviewing the Basics and a 2015 Update Dan Israel, PharmD Nick Wolters, PharmD April 22,

Chest Compression Rate

• Reduction in quality chest compressions

– Proportion of compressions <1.5in (38mm)

• 100 – 119 beats/min: 35%

• 120 – 139 beats/min: 50%

• >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

Page 16: Interactive with ACLS! Reviewing the Basics and a 2015 Update€¦ · Interactive with ACLS! Reviewing the Basics and a 2015 Update Dan Israel, PharmD Nick Wolters, PharmD April 22,

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

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Chest Compression Depth

• 9,136 patients with OHCA

40.3mm55.3mm

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

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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)

• <50mm - 28%

• 50-60mm – 27%

• >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

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THE CODE CONTINUES

Page 20: Interactive with ACLS! Reviewing the Basics and a 2015 Update€¦ · Interactive with ACLS! Reviewing the Basics and a 2015 Update Dan Israel, PharmD Nick Wolters, PharmD April 22,

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”

Page 21: Interactive with ACLS! Reviewing the Basics and a 2015 Update€¦ · Interactive with ACLS! Reviewing the Basics and a 2015 Update Dan Israel, PharmD Nick Wolters, PharmD April 22,

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.

Page 22: Interactive with ACLS! Reviewing the Basics and a 2015 Update€¦ · Interactive with ACLS! Reviewing the Basics and a 2015 Update Dan Israel, PharmD Nick Wolters, PharmD April 22,

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

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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

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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)

Page 25: Interactive with ACLS! Reviewing the Basics and a 2015 Update€¦ · Interactive with ACLS! Reviewing the Basics and a 2015 Update Dan Israel, PharmD Nick Wolters, PharmD April 22,

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.

Page 26: Interactive with ACLS! Reviewing the Basics and a 2015 Update€¦ · Interactive with ACLS! Reviewing the Basics and a 2015 Update Dan Israel, PharmD Nick Wolters, PharmD April 22,

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 alone in cardiopulmonary

resuscitation. N Engl J Med. 2008;359:21–30.

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NEJM combination study

• Outcomes

Outcome Combination Epinephrine

only

P-Value

ROSC 413 (28.6%) 428 (29.5%) 0.62

Survival to admission 299 (20.7%) 310 (21.3%) 0.69

Survival to discharge 24 (1.7%) 33 (2.3%) 0.24

1-year survival 18 (1.3%) 30 (2.1%) 0.09

Good neurologic

recovery at discharge

9 (37.5%) 17 (51.5%) 0.29

Gueugniaud PY, David JS, Chanzy E, et al. Vasopressin and epinephrine vs. epinephrine alone in cardiopulmonary

resuscitation. N Engl J Med. 2008;359:21–30.

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Vasopressor Summary

• Vasopressin offers no advantage as a substitute or in combination with epinephrine

• Vasopressin has been removed from the ACLS 2015 adult cardiac arrest algorithm to simplify ACLS regimen

• Epinephrine is the catecholamine/vasopressorof choice in adult 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.

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ROSC

I got a pulse!!

http://www.rcrmctraining.org/job_education/alaris/etco2/t1

/p04.htm

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Lidocaine after ROSC

• 2010: Not recommended

• 2015: “Currently inadequate evidence to

support the routine use of lidocaine after

cardiac arrest. However, the initiation or

continuation of lidocaine may be considered

immediately after ROSC from cardiac arrest

due to VF/pVT”

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.

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Lidocaine after ROSC

• Retrospective multi-variate cohort analysis

• Study Group: Witnessed OHCA due to VT/VF

• Intervention: Lidocaine upon first documented

ROSC in absence of VT/VF

– Primary outcome:

• Re-arrest from recurrent VF/VT after initial ROSC,

• Admission to hospital,

• Survival to hospital discharge

Kudenchuk PJ, Newell C, White L, et al. Prophylactic lidocaine for post resuscitation care of patients with out-of-hospital

ventricular fibrillation cardiac arrest. Resuscitation. 2013;84:1512–1518

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• Limitations

– Lidocaine group: shorter time from EMS dispatch to ROSC (18.6 mins vs. 25.2 mins; P<0.001)

– Independent association (not-causal)

Outcomes Lidocaine

(N=1296)

Non-recipients

(N=425)

Re-arrests 19.9% 45.2% P<0.0001

Shocks over course of

resuscitation

4.3 + 3.9 6.6 + 5.7 P<0.0001

Epinephrine required

after ROSC

13.1% 27.1% P<0.0001

Survived to admission 93.5% 84.9% P<0.0001

Survived to discharge 62.4% 44.5% P<0.0001

Kudenchuk PJ, Newell C, White L, et al. Prophylactic lidocaine for post resuscitation care of patients with out-of-hospital

ventricular fibrillation cardiac arrest. Resuscitation. 2013;84:1512–1518

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Half way there…Living on a prayer?

• Patient is unresponsive…

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Targeted Temperature Management

• 2010: “comatose adult patients with ROSC after out-of-hospital VF cardiac arrest should be cooled to 32C to 34C for 12-24 hours. Induced hypothermia also may be considered for comatose adult patients with ROSC after IHCA (In-Hospital Cardiac Arrest) of any initial rhythm or after OHCA with an initial rhythm of pulseless electrical activity or asystole”

• 2015: “all comatose patients with ROSC after cardiac arrest should have TTM, with a target temperature between 32-36 selected and achieved, then maintained constantly for 24 hours”

• 2015: “Recommend AGAINST the use of routine prehospitalcooling of patients after ROSC with rapid infusion of cold IV fluids”

Callaway et al. Part 8: Post–Cardiac Arrest Care 2015 American Heart Association Guidelines Update for

Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015;132(suppl 2):S465–S482

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Targeted Temperature Management

• 936 patients with OHCA

– 33°C – 473 patients

• 235 died (50%)

– 36°C – 466 patients

• 225 died (48%)

Nielsen et al. Targeted Temperature Management at 33°C versus 36°C after Cardiac Arrest. N Engl J Med 2013;369:2197-206

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Targeted Temperature Management

• Pre-hospital cooling– Kim et al.

• Found an increase in pulmonary edema and re-arrest among patients treated with a goal of prehospital infusion of 2 L of cold fluids

• Targeted temperatures– Higher temperatures might be preferred in patients for

whom lower temperatures convey some risk (bleeding)

– Lower temperatures might be preferred when patients have clinical features that are worsened at higher temperatures (seizures, cerebral edema)

Kim F, Nichol G, Maynard C, Hallstrom A, Kudenchuk PJ, Rea T, Copass MK, Carlbom D, Deem S, Longstreth WT Jr, Olsufka M, Cobb LA. Effect of prehospital

induction of mild hypothermia on survival and neurological status among adults with cardiac arrest: a randomized clinical trial. JAMA. 2014;311:45–52

Callaway et al. Part 8: Post–Cardiac Arrest Care 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency

Cardiovascular Care. Circulation. 2015;132(suppl 2):S465–S482

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Naloxone

• 2015: “For patients with known or suspected

opioid addiction who are unresponsive with

no normal breathing but a pulse, it is

reasonable for appropriately trained lay

rescuers and BLS providers…to administer

intramuscular (IM) or intranasal (IN)

naloxone”

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

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NaloxoneNaloxoneNaloxoneNaloxone

• Available in IV, IM, SQ, IN, Nebulizer

• Most common forms in BLS or out of hospital situations

• Intranasal: initial dose 2mg repeated every 3 to 5 minutes as needed

• Auto-injector (single dose): 0.4mg IM repeated every 3 to 5 minutes as needed

Lavonas EJ, Drennen IR, Gabrielli A, et al. Part 10 Special Circumstances of Resuscitation 2015 American Heart

Associateion Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.

Circulation. 2015;132[suppl 2]:S501-S518.

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Summary

• Compression Rate: 100-120 compressions/min

• Compression Depth: 2in-2.4in

• Vasopressin removed from algorithm

• Lidocaine?

• Targeted temperature management 32°C-36°C

• Naloxone addition

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Other Updates

• BLS/CPR– Check for pulse and look for normal respirations at the

same time• 5-10 seconds maximum

– Ventilation rate with advanced airway• 1 breath every 6secs; no pausing of compressions

– Full chest recoil between chest compressions

– Manual compressions remain standard• Mechanical chest compression devices no demonstrated benefit

• ACLS– No routine use of O2 in ACS with normal O2 Saturation

(SPO2<94%)

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

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Source: Grandview Team Pharmacy

DOPAMINE SODIUM

BICARB

DEXTROSE

NORMAL SALINE

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Source: Grandview Team Pharmacy

EPINEPHRINE ATROPINE

LIDOCAINE

NALOXONE

NOREPINEPHRINE CALCIUM

CHLORIDE

MAGNESIUM

DIPHENHYDRAMINE

AMIODARONE

ADENOSINE

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Interactive with ACLS!

Reviewing the Basics and a 2015

Update

Dan Israel, PharmD

Nick Wolters, PharmD

April 22, 2016

Grandview Medical Center: Dayton, OH