ACLS:

2015 Update

Anything New?

Mitchell Shulman MDCM FRCPC CSPQEmergency Department, MUHCMaster Instructor ACLS, QHSFAssist Professor, Dept of Surgery

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Agenda

Problems with data

Call 1st? / Dispatch

The Basics: CPR, Intubation, Defibrillation

The Drugs

Putting it all together

Post- Resuscitation

Key Points

Cardiac Arrests Happen

Be prepared (yourself and your staff)

AED?

Pt’s families / partners: know what to do?

Warning! Problems with the Data

Research in ACLS is difficult / challenging

Few good studies (even less RCT)

Consent ???

Animal vs Human Rural vs Urban ….

2015 Guidelines Update

ILCOR prioritized reviews (166)

Grading of Recommendations, Assessment, Development and Evaluation (GRADE)

Systemic Evidence Evaluation and Review System (SEERS)

Public disclosure

Public comment

Update only

Future changes will be similar

www.ilcor.org/seers

Agenda

Problems with data

Call 1st? / Dispatch

The Basics: CPR, Intubation, Defibrillation

The Drugs

Putting it all together

Post- Resuscitation

Call 911 First vs

Call Fast: JUST CALL!

If no phone/reception/bystander:

Call first :sudden collapse victims of all ages(to get an AED there ASAP!)

Call fast :unresponsive pt (any age) where asphyxia is likely (e.g. submersion / near-drowning; overdose; lightning)

if in doubt, unwitnessed, or suspect > 4 min:

deliver about 2 min (5 cycles) of CPR before leaving the victim to call for an AED

Dispatchers / BCLS

Train them to recognize acute coronary syndromes (ACS)

Advise patients with ACS (w/o hx of ASA allergy / GI bleed)

chew 160 – 325 mg aspirinwhile waiting

Responsive?

If not:

Lay people:

Compression only CPR

Trained BCLS providers:C – A - B

Dispatchers / BCLS

Pulse check?

Long time to assess

Error rate (lay rescuer): 35%- detect a “pulse” 10% of cardiac arrests

- provide chest compressions 40% not in

cardiac arrest

Instead assess for signs of life(movement, breathing, coughing)

Trained provider: pulse check < 10 seconds

Agenda

Problems with data

Call 1st? / Dispatch

The Basics: CPR, Intubation, Defibrillation

The Drugs

Putting it all together

Post- Resuscitation

Mouth to mouth???

CPR world wide > 30 yrsno HIV or other blood

borne pathogens via mouth-to-mouth

no documented cases of saliva transmitting:HIV, Hep B / C during CPR

few cases of HIV transmission:

“sharps” injury; blood exposure to

non-intact skin

Mouth to mouth??

15 cases of documented disease transmission (direct mouth to mouth)

Mycobacterium tuberculosis

Neisseria meningitidisShigella sonneiSalmonella infantisNeisseria gonorrhea Streptococcus: saliva to non-intact skin

Herpes simplex

Chest compressions

Push Hard*, Push Fast*

Recommended rate:

30:2for all rescuers

responding alone to victims of any age(except newborns) before

advanced airway control

2 health care providers child/infant 15:2

*Rate: 100 – 120 / min*Depth: 2 – 2. 4 in

( 5 – 6 cm)

Intubate??

Why?Control airwayReduce risk of aspirationAdminister drugsVentilate without worrying

about timing

AlternativesLaryngeal mask airwayCombitube

Confirm ETT placement

Direct visualization

5 point clinical exam

Exhaled CO2 / esophageal detector device

Endotracheal tube holder

Continuous end-tidal CO2 monitoring

Ventilation

Advanced airway in place:

8 – 10 / min.

2 health care provider rescuersCompressor: 100 - 120 / minVentilator: 8 – 10 / min

Don’t stopDon’t pauseRotate compressor role ~ Q 2 min.

AED (Defibrillation)

AED’s do not require a prescription

Healthcare provider oversight not necessary

Defibrillation

Monophasic vsbiphasic ?

Monophasic: 360J

Biphasic: 120 - 200J

If in doubt: use max power available

Defibrillation

1 Shock

Immediate CPR for 2 minutes (start with chest

compressions)

Do NOT check for rhythm / pulse before restarting CPR

Agenda

Problems with data

Call 1st? / Dispatch

The Basics: CPR, Intubation, Defibrillation

The Drugs

Putting it all together

Post- Resuscitation

Vasopressors?

Only

after 1 shock 2 2 minutes of CPRw/o perfusing rhythm

Epinephrine: How much?

Class indeterminate !

optimal physiologic response:

.045 - .20 mg / kgbut HDE no statistical increase in rate of survival to hospital discharge

1 mg IV Q 3 – 5 min

Vasopressin?

No longer part of the algorhythmsArginine vasopressin = antidiuretic hormone

Why?PhysiologyStimulates smooth muscle V1 receptors

(non-adrenergic peripheral vasoconstrictor)

StudiesElevated endogenous levels in survivors of

cardiac arrest

Increased coronary perfusion pressure, vital organ

blood flow, cerebral oxygen delivery (animal models)

Vasopressin??

Why not?No survival

advantage over epinephrine

When?Perhaps severe

acidosis

Dose ?? 40 IU x 1

Lidocaine?

No study has demonstrated clinical efficacy

Use was supported by animal studies and extrapolation

Conflicting data in the literature

Compared unfavorably to Amiodarone

Lidocaine?

Successful in converting V tach to NSRonly 20- 30% (inferior to Procainamide and Amiodarone)

Advantages:ease of dosing / administrationwhen it works it works rapidlyminimal side effectslow cost

Consider 1 – 1.5 mg / kg 1st dose;

then 0.5 – 0.75 mg / kg IV

Max. 3 doses or 3 mg / kg

Amiodarone

History:structural analogue of thyroxinedeveloped in the 1960’s (anti-

anginal coronary vasodilator)

acutely: anti-sympathetic & Ca+

channel blockingchronically: prolongs action potential

duration (Class III)long elimination half-life (14 -59 days)large volume of distribution

Amiodarone

ARREST (Amiodarone for Resuscitation after Out-of-hospital Cardiac Arrest Due to Ventricular Fibrillation)

300 mgs (n= 246) vs placebo (n= 258)44% vs 34% survive to be admittedno difference in survival to hospital discharge

ALIVE (Amiodarone as compared with Lidocaine for Shock-Resistant ventricular Fibrillation)

5 mg/kg Amiodarone (n= 179) vs 1.5 mg/kg Lidocaine (n= 165)

22.8% vs 12% survival to admissionno difference in survival to discharge

Amiodarone

Problem:“attempts to defibrillate should not be

delayed by administration of Amiodarone”

significant time required to reconstitute & prepare (high viscosity, generates bubbles)

300 mg IV X 1; then 150 mg X 1

Anti-arrhythmics

Bottom line:

no anti-arrhythmic agent to date

has been demonstrated in clinical trials of

Vfib / pulseless Vtach to improve survival to hospital discharge !

CPR, CPR, CPRDefibrillate, defibrillate, defibrillate

Anti-arrhythmics

In the setting of tachycardia:all anti-arrhythmics are pro-arrhythmic

Stable, narrow complex, regular:adenosinediltiazem

Stable, narrow complex, irregular:diltiazembeta-blockers

Stable, wide complex:amiodaronemagnesium

Adenosine:6 mgs; 12 mgs

Diltiazem:0.25 mg/kg; 0.35 mg/kg

Metoprolol: 5 mg IV Q 5min. Tot: 15 mg

Amiodarone:150 mg; repeat PRNmax: 2.2 g IV / 24 hrs

Magnesium:1 – 2 grams in 50 - 100 ml D5W over 5 – 60 min IV.

Key Points

Cardiac Arrests Happen

Be prepared (yourself and your staff)

AED?

Pt’s families / partners: know what to do?

Agenda

Problems with data

Call 1st? / Dispatch

The Basics: CPR, Intubation, Defibrillation

The Drugs

Putting it all together

Post- Resuscitation

Let’s Put It All Together

Vfib / Vtach

1 shock (biphasic 120 – 200J; monophasic 360J)

Resume CPR at once (5 cycles)

Check rhythm

Shockable?

1 shock Resume CPR (5 cycles)

Epinephrine 1 mg IV / IO (repeat Q 3 – 5 min)

Check rhythm

Shockable?

1 shock Resume CPR

Amiodarone 300 mg IV/IO

Asystole / PEA

CPR 5 cycles

Epinephrine 1 mg IV / IO Q 3 – 5 min.

CPR 5 cycles

Check rhythm

Look for a treatable causeGive EPI FAST!Hypovolemia

HypoxiaHydrogen ionHypo/hyper K+HypoglycemiaHypothermia

ToxinsTamponade (cardiac)Tension (pneumo)Thrombosis (cor / pulm)Trauma

Symptomatic BradycardiaHR < 60 bpm + ………..

Prepare forTranscutaneous pacing

Consider Atropine 0.5 mg IV (total dose 3 mg)

Consider Epinephrine 2 – 10 microg/min

Dopamine 2 – 10 microg / kg / min

+ Acute altered mental status /Ongoing chest pain /Acute heart failure /Hypotension / signs of shock

Oxygen, IV access, Monitor, EKG

Glucagon? Beta –blocker or calcium channel blocker OD3 – 10 mgs over 3 -5 min, then infuse @ 3 mg/h

Agenda

Problems with data

Call 1st? / Dispatch

The Basics: CPR, Intubation, Defibrillation

The Drugs

Putting it all together

Post- Resuscitation

Post resuscitation

Don’t hyperventilate8 – 10 breaths / min

PETCO2 : 35- 40 mm Hg

Cool: 32- 36C for 24 hrs. *

Maintain BP Fluids; Epi / Norepi: 0.1 – 0.5 mcg / min

(70 kg = 7 – 35 mcg / min)

Maintain O2 saturation > 94%

Watch blood sugar

Treat fever

* Green, RS, CJEM 7(1) Jan. 2005 p. 42 – 7.

Key Points

Cardiac Arrests Happen

Be prepared (yourself and your staff)

AED?

Pt’s families / partners: know what to do?

The Most Important Message

“Any improvements resulting from advanced life support therapies are less substantial than the increases in survival rate reported from the successful deployment of lay rescuer CPR and Automated External Defibrillationprograms in the community.”