Resuscitation guidelines 2010 &

ACLS Updates

Delivered ByDelivered By The American Heart AssociationThe American Heart Association

Presented ByPresented ByDr Hesham Mohamed AllamDr Hesham Mohamed Allam

INTRODUCTIONINTRODUCTION

EditorialResuscitation guidelines

2010:a scientific consensus

Anaesthesia, 2010, 65, pages 1163–1172

Sudden cardiac death is a major killer of adults, and coronary heart disease – which kills as many as 99 000 per annum in the UK [1] – is the underlying cause in the majority of those over 40 years of age.

In some countries, survival for patients who collapse in ventricular fibrillation (VF) is as high as 35% in some countries, in the UK this is not the case.

from the beginning of 2008, more than 300 worksheets were completed, collating and evaluating all available published scientific papers on the questions posed.

In February 2010, the worksheets were reviewed and consensus positions were agreed.

Thus major differences were eliminated, which leaded to ease in implementation and avoided fatigue and confusion within the health care providers’ community.

In the 2005 guidelines, the focus was on cardiac compressions and simplification of approach, to allow more effective teaching in clinical practice.

Change in the new guidelines is that there is now a chapter on pre-hospital cardiac arrest, recognising:

The different aetiologies of these events The unique challenges they pose for both the public

witness and the healthcare community The high impact this phase has on subsequent patient

outcome.

Key questions before the 2010 guidelinesincluded whether: Compression only CPR is the best choice for laybystanders.

Pre-hospital intubation should be phased out in favour of supraglottic airway devices.

Should be compressions before defibrillation in non-witnessed resuscitation attempts.

Therapeutic hypothermia is now established for patients with VF and ventricular tachycardia (VT), but should it be extended to non-shockable rhythms?

What is the real place of drugs in resuscitation?

Can we more quickly predict those who are likely to survive?

Changes in 2010 Changes in 2010 UpdateUpdate

THE QUALITY OF CHEST COMPRESSION

In basic life support, compression depth has been increased to between 5 & 6 cm.

The use of feedback technology( separate units or integrated into defibrillators) promoted, to assist in the delivery of high-quality compressions.

Previous studies on both suggested that to achieve ROSC, CPP of over 15 mmHg during chest compressions are required and that the depth previously recommended of 4–5 cm for chest compressions was inadequate.

Minimizing of disruption in the compression sequence

Defibrillation should take a maximum period of five seconds, with charging during chest compressions.

For tracheal intubation, ten seconds’ hands-off time for the passage of the tube is the onlypoint at which compressions are paused.

Pulse checks are only undertaken where there are signs suggestive of ROSC.

AIRWAY MANAGEMENTAIRWAY MANAGEMENT

The emphasis on tracheal intubation continues to decrease in favour of supraglottic airway devices due to:

Concerns about complications of intubation. Long pauses in compressions without basic airway management

and unrecognised oesophageal intubation, especially in those who perform the skill infrequently.

Intubation for cardiac arrest patients in an emergency is challenging

Delaying intubation until after ROSC is suggested as a possible Approach.

Many studies have shown that use of a supraglottic device in the cardiac arrest situation is quick and easy without significant change in the outcome.

Professionals are advised to use both primary clinical and secondary adjunct confirmation techniques to confirm the correct placement of tracheal tubes.

However, with the low output produced by chest compressions, digital display of end-tidal CO2 alone is not very reliable, and the presence of CO2 is more positive than its absence.

The current guidelines for all age groups recommend that it should be used as enabling confirmation of tracheal tube placement, it also indicates good quality chest compressions and is an early indicator of ROSC.

USE & TIMING OF USE & TIMING OF DRUGSDRUGS

The use and timing of drugs have been simplified.

Adrenaline is given after the third shock at the same time as amiodarone, easier to remember than in separate cycles.

Atropine, long given for asystole and slow PEA, is discontinued, it remains for peri-arrest management.

The tracheal route of drug administration is not recommended except in neonates following the widespread introductionof intraosseous devices.

FIBRINOLYSIS?FIBRINOLYSIS?

Fibrinolysis is recommended for patients presenting with a likely diagnosis of pulmonary embolus, as well as other likely thrombotic aetiologies.

This is based on expert consensus, although the study was curtailed due to lack of a benefit trend in all-comer cardiac arrest patients.

POST-RESUSCITATIO CARE

Outcomes for out of-hospital cardiac arrest survivors are extremely variable between institutions, due to variable approaches and different standards of care.

Individual elements of care include:

Early Re-perfusion therapy ( use of angioplasty and primary reperfusion in comatose post-cardiac arrest patients without proven ST-elevation myocardial infarction will be controversial to some, andnot all hospitals will be able to deliver it ).

Wider use of Therapeutic Hypothermia ( was incorporated into the 2005 guidelines for comatose adult survivors of out-of-hospital cardiac arrest presenting in either VF or VT ).

Titrated Oxygen therapy ( Oxygen therapy is increasingly recognised as being potentially harmful, early titration of inspired oxygen against arterial gases or oxygen saturation is recommended especially in neonatal care ).

Moderate Glucose control ( Tight glucose control was thought to be beneficial, but, may lead to masked hypoglycaemic episodes and therefore the guidance on this has been relaxed ).

Capnography is recommended as is the use of therapeutic hypothermia for babies with encephalopathy.

GUIDELINES FOR GUIDELINES FOR PAEDIATRIC PATIENTSPAEDIATRIC PATIENTS

Diminution in the importance of a pulse check by healthcare providers in confirming cardiac arrest.

Lay bystanders are encouraged to perform compression-only CPR, whereas for trained rescuers, the Compression:Ventilation ratio of 3:1 remains.

Use of automated external defibrillator in infants is suggested.

Use of drugs is brought in line with the adult algorithm.

DISADVATAGESDISADVATAGES

1. Step-changes between iterations of guidelines inevitably mean that more than one change to ‘standard CPR’ occurs.

2. Some trials were undertaken where multiple variables acted as confounders; consequently, clear answers to important questions could not always be gained.

3. Major limitation in the timeframe for the process. The worksheets were compiled over the period 2008 to mid-2009 and therefore important papers published recently will not have been included.

2010 American Heart Association Guidelines for CardiopulmonaryResuscitation and Emergency

Cardiovascular Care

Airway Controland Ventilation

Ventilation and Oxygen Administration

During CPR During CPR, oxygen delivery to the heart and brain is

limited by blood flow rather than by arterial oxygen content.

Rescue breaths are less important than chest compressions during the first few minutes of resuscitation and could lead to interruption in chest compressions.

Increase in intra-thoracic pressure that accompanies positive pressure ventilation decreases CPR efficacy.

Advanced airway placement in cardiac arrest should not delay initial CPR and defibrillation for VF cardiac arrest

Oxygen Administration During CPR

It is unknown whether 100% inspired oxygen is beneficial or whether titrated oxygen is better.

Prolonged exposure to 100% inspired oxygen has potential toxicity.

Passive oxygen delivery via mask with an opened airway during the first 6 minutes of CPR provided by (EMS) resulted in improved survival.

In theory, as ventilation requirements are lower during cardiac arrest, oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway.

All healthcare providers should be able to provide ventilation with a bag-mask device during CPR or when the patient demonstrates cardiorespiratory compromise.

Airway control with an advanced airway, which may include an ETTor a supraglottic airway device, is a fundamental ACLS skill.

Prolonged interruptions in chest compressions should be avoided during advanced airway placement.

All providers should be able to confirm and monitor correct placement of advanced airways.

Training, frequency of use, and monitoring of success and complications are more important than the choice of a specific advanced airway device for use during CPR.

Management of Cardiac Arrest

Cardiac arrest can be caused by 4 rhythms: ventricular fibrillation (VF), pulseless ventricular tachycardia (VT), pulseless electric activity (PEA), and asystole.

VF represents disorganized electric activity, whereas pulseless VT represents organized electric activity of the ventricular myocardium. Neither generates significant forward blood flow.

PEA encompasses a heterogeneous group of organized electric rhythms associated with either absence of mechanical ventricular activity or mechanical ventricular activity that is insufficient to generate a clinically detectable pulse.

Asystole ( ventricular asystole ) represents absence of detectable ventricular electric activity with or without atrial electric activity.

For VF/pulseless VT, attempted defibrillation within minutes of collapse. For victims of witnessed VF arrest, early CPR and rapid defibrillation can significantly increase the chance for survival to hospital discharge.

Other ACLS therapies such as some medications and advanced airways, although associated with an increased rate of ROSC, have not been shown to increase the rate of survival to hospital discharge.

Combination of higher quality CPR and post arrest interventions such as therapeutic hypothermia and early percutaneous coronary intervention (PCI), doesn’t necessarily improves the outcome.

Periodic pauses in CPR should be as brief as possible and only as necessary to assess rhythm, shock VF/VT, perform a pulse check when an organized rhythm is detected, or place an advanced airway.

Monitoring and optimizing quality of CPR is encouraged and includes:

Optimizing chest compression rate and depth, adequacy of relaxation, and minimization of pauses.

Monitoring partial pressure of end-tidal CO2 [PETCO2], arterial pressure during the relaxation phase of chest compressions, or [ScvO2] when feasible.

In the absence of an advanced airway, a synchronized compression–ventilation ratio of 30:2 is recommended at a compression rate of at least 100 per minute.

After placement of an advanced airway, the provider performing chest compressions should deliver at least 100 compressions per minute without pauses for ventilation.

The provider delivering ventilations should give 1 breath every 6 to 8 seconds (8 to 10 breaths per minute) and should avoid delivering an excessive number of ventilations.

ADULT CARDIAC ARREST ADULT CARDIAC ARREST ALGORITHMALGORITHM

MANAGEMENT OF SYMPTOMATIC BRADYCARDIA &

TACHYCARDIA

Preface The goal of therapy for bradycardia or tachycardia is

to rapidly identify and treat patients who are hemodynamically unstable. Drugs or,

Drugs or, pacing may be used to control unstable or symptomatic bradycardia.

Cardioversion or drugs or both may be used to control unstable or symptomatic tachycardia.

ACLS providers should closely monitor stable patients pending

expert consultation and should be prepared to aggressivelytreat those with evidence of decompensation.

BRADYARRHYTHMIABRADYARRHYTHMIA

TACHYARRHYTHMIATACHYARRHYTHMIA

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