Ain't Nobody Got Time for That Epi, Fool: ACLS in the 20-Teens Comes of Age Disclosures Updated Syllabus

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Nathaniel Bryant
5 years ago
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HOSPITAL MEDICINE GROUP Disclosures Nothing to disclose Will

scientific evidence, but that will be highlighted and presented

arrest only So full of goodness a baby learned all she needed to

1 Ain't Nobody Got Time for That Epi, Fool: ACLS in the 20-Teens Comes of Age JASON PERSOFF, MD, SFHM UNIVERSITY OF COLORADO HOSPITAL MEDICINE GROUP Disclosures Nothing to disclose Will present topics that may differ from guidelines based on current scientific evidence, but that will be highlighted and presented as Off Label Will limit discussion to inpatient adult cardiac arrest only So full of goodness a baby learned all she needed to know from this exact talk Updated Syllabus

Learning Objectives Understand the science behind the changes made in

the European and American resuscitation guidelines and how they affect

advanced cardiac life support and be able to take these techniques

unladen swallow (African and European) The Airspeed of an Unladen

migrate Corum J, 2003 and Taylor G, 2003 Universal BLS Both ERC and

Compression location lower ½ of sternum Compression depth of 1½-2

2 Learning Objectives Understand the science behind the changes made in the latest resuscitation guidelines Recognize the differences between the European and American resuscitation guidelines and how they affect clinical practice published in November, 2015 Become fluent in advanced cardiac life support and be able to take these techniques back to their clinical practices Accurately identify the weight of an unladen swallow (African and European) The Airspeed of an Unladen European Swallow Answer: Between mph African swallows don t migrate Corum J, 2003 and Taylor G, 2003 Universal BLS Both ERC and AHA share identical algorithm Pulse Check for 10 sec** Narcan Compression location lower ½ of sternum Compression depth of 1½-2 inches Compression rate of cpm 30 Compression : 2 Ventilation Ratio** Shockable vs Not Shockable

BLS Controversies: The Pulse Check 2004 2005 Pulse absence determined correctly only 58% of the time by healthcare providers at 10 secs Eberle (1996) originally

with simultaneous assessment of breathing, pulse check by healthcare providers at 10s results in 98.9% sensitivity and 48.

compelling data to support the 10 second pulse check In early cardiac arrest, delays to determine pulse presence can result in up to 30 second or longer delays in

Guidelines advocated change from ABCs to CAB to reflect importance of compressions Are ventilations necessary for successful resuscitation?

3 BLS Controversies: The Pulse Check Pulse absence determined correctly only 58% of the time by healthcare providers at 10 secs Eberle (1996) originally found similar findings: 55% correctly identified pulse absence Would have resulted in no CPR nearly half the time Recommendation: Abolish pulse check When combined with simultaneous assessment of breathing, pulse check by healthcare providers at 10s results in 98.9% sensitivity and 48.9% specificity Would have resulted in no CPR <1% of the time Recommendation: Combine the pulse check with respiration check BLS Controversies: The Pulse Check No compelling data to support the 10 second pulse check In early cardiac arrest, delays to determine pulse presence can result in up to 30 second or longer delays in initiating CPR Off Label Recommendation If a person is unconscious and in distress, commence chest compressions immediately BLS Controversies: Ventilations 2010 Guidelines advocated change from ABCs to CAB to reflect importance of compressions Are ventilations necessary for successful resuscitation? 2015 ERC Guidelines continue to emphasize respirations as part of normal BLS 2015 AHA Guidelines conditionally approve passive insufflation (with a nonrebreather) with continuous chest compressions for certain out-of-hospital EMS situations

5mL Very successful in Arizona EMS (Ewy,

4 BLS Controversies: Ventilations Continuous chest compressions (CCC) Recommendation of CCC with oxygen provided passively through a non-rebreather Theory: no oxygenation without circulation BVM= mL Emphasis: proper CCC and electrical therapies CCC=41.5mL Very successful in Arizona EMS (Ewy, et al) 2007 Dead Space=162mL BLS Controversies: Ventilations Berg RA, et al. Circulation 2001; 104: Michard F. Anesthesiology 2005 BLS Controversies: Ventilations Bentley J, et al. Circulation 2008; 118: Suzuki M, et al. Resuscitation 2009; 80:109.

BLS Controversies: Ventilations Interruptions in chest compressions to perform ventilations result in negative physiological effects, particularly

patient with agonal gasping, however, continuous chest compressions are ideal But how do we achieve the balance between the need for chest

$fraction, but recommend >0.$

5 BLS Controversies: Ventilations Interruptions in chest compressions to perform ventilations result in negative physiological effects, particularly with positive pressure ventilations Continuous chest compressions fail to provide any tidal volume and thus limit ability for gas exchange In the patient with agonal gasping, however, continuous chest compressions are ideal But how do we achieve the balance between the need for chest compressions and ventilations that optimizes outcomes for the patient? BLS Controversies: Ventilations Chest Compression Fraction Percent of time performing compressions Guidelines do not have a specific compression fraction, but recommend >0.6 BLS Controversies: Ventilations So long as chest compressions are emphasized, minimal interruptions to chest compressions do not appear to affect outcomes Nicol G, Leroux B, and Wang H. NEJM 2015; 373:

BLS Controversies: Ventilations Off Label Recommendations Chest compressions and

arrest When a patient is gasping, caution should be used to ensure ventilations

insufflation Passive insufflation is of no benefit in those who are not gasping

secured airway A ventilation every 6 seconds is used following an advanced airway

6 BLS Controversies: Ventilations Off Label Recommendations Chest compressions and electrical therapies should always come first in adult inpatients in cardiac arrest When a patient is gasping, caution should be used to ensure ventilations augment the gasp (never fighting it) and clinicians should consider passive insufflation Passive insufflation is of no benefit in those who are not gasping Guidelines A 30:2 compression:ventilation ratio is used when a patient has no secured airway A ventilation every 6 seconds is used following an advanced airway at the maximal oxygen delivery Minimize interruptions to chest compressions at all cost Airways Airways

7 Airways Airways Airways 2015

$at a fraction of at least 0.$ 6 Consider passive insufflation for deep agonal respirations (OL) No advanced airway->compressions:ventilations 30:2 With advanced airway->compressions continuous with one

6 Consider passive insufflation for deep agonal respirations (OL) No advanced airway->compressions:ventilations 30:2 With advanced airway->compressions continuous with one

Compressions Both ERC and AHA emphasize compression quality as the most important aspect of resuscitation Start ASAP Push Hard But not too hard?

8 Airways Summary So Far If an adult inpatient appears to be in cardiac arrest, proceed with continuous chest compressions until help arrives (OL) Chest compressions delivered at a fraction of at least 0.6 Consider passive insufflation for deep agonal respirations (OL) No advanced airway->compressions:ventilations 30:2 With advanced airway->compressions continuous with one ventilation every 6 seconds Advanced airway will eventually need to be obtained (whether it s ET or SGA), but there s no rush (OL) BLS: Quality Compressions BLS: Quality Compressions Both ERC and AHA emphasize compression quality as the most important aspect of resuscitation Start ASAP Push Hard But not too hard? Poor quality recommendation by AHA based on risk of injury with compressions >2 inches Pump Fast Target compressions/minute But not too fast decreases recoil and results in shallow compressions Good Recoil Minimize Interruptions Maintain chest compression fraction >0.6 (AHA) Target EtCO2 >10mmHg and systolic-diastolic difference of >20mmHg (AHA)

9 BLS: Quality Compressions BLS: Quality Compressions Wouldn t a machine provide superior compressions to humans? Multiple RCTs have failed to show superiority of compression devices Bonnes JL, et al. Ann Emer Med 2015; 1-12 BLS: Quality Compressions New Class I recommendation for EtCO2 to confirm ET tube placement along with ultrasound and exam ERC Guidelines

$BLS: Quality Compressions Techniques to maximize chest compression fraction >0.$ analysis Many continue to advocate not interrupting compressions for shock Some studies find that

analysis Many continue to advocate not interrupting compressions for shock Some studies find that

you don t die while doing compressions Edelson DP, et al. Resuscitation 2010; 81: 1521-1526.

essential components in ACLS Major changes in both guidelines: Emphasis on quality CPR Rotate

10 BLS: Quality Compressions Techniques to maximize chest compression fraction >0.6 includes delivery of shocks Minimize the pre-shock pause by charging during compressions prior to analysis Many continue to advocate not interrupting compressions for shock Some studies find that fatal current could transmit to rescuer Some don t And even some are making awesome new gloves so you don t die while doing compressions Edelson DP, et al. Resuscitation 2010; 81: BLS: Quality Compressions Future Directions Universal ACLS ERC and AHA have many of the same essential components in ACLS Major changes in both guidelines: Emphasis on quality CPR Rotate rescuers every 2 minutes Discontinuation of vasopressin Failure to recommend steroids Emphasis on EtCO2 Change in post-arrest hypothermia goals

ACLS: Medications Reaffirmation that NO VASOPRESSOR has ever been shown to improve survival to hospital discharge neurologically intact Vasopressin has been dumped to simplify guidelines and due to

resuscitation Jacobs IG, et al. Resuscitation 2011; 82: 1138-1143 ACLS: Medications What happened to vasopressin-steroids-epinephrine? Mentzelopoulos SD, et al.

11 ACLS: Medications Reaffirmation that NO VASOPRESSOR has ever been shown to improve survival to hospital discharge neurologically intact Vasopressin has been dumped to simplify guidelines and due to non-superiority Epinephrine continues to be recommended based on one RCT in out of hospital cardiac arrest and other small case studies (Class IIb) Epi should be administered as soon as possible in resuscitation Jacobs IG, et al. Resuscitation 2011; 82: ACLS: Medications What happened to vasopressin-steroids-epinephrine? Mentzelopoulos SD, et al. JAMA 2013; 310 (3): ACLS: Medications The ONLY medication trial powered to examine neurologic outcome in cardiac arrest resulted in a NNT=8 Epinephrine 1 mg Vasopressin 20 IU Methylprednisolone 40mg And in post-resuscitation shock, addition of hydrocortisone Not recommended at all by ERC, but still received a IIb rating by AHA Off Label Recommendation Little harm, possible benefit, needs verification

ACLS: Post-Resuscitation Care Near-Normothermia Prior studies on hypothermia (target temp 32-34 deg) improves neurological outcomes and mortality for comatose patients following a VF/VT arrest New

NEJM 2013; 369 (23): 2197-2206 ACLS: Post-Resuscitation Care New recommendations: Targeted Temperature Management Maintenance of body temp 32-36 degrees for ALL patients postcardiac arrest regardless

12 ACLS: Post-Resuscitation Care Near-Normothermia Prior studies on hypothermia (target temp deg) improves neurological outcomes and mortality for comatose patients following a VF/VT arrest New data suggest a more heat-tolerant temperature of 36 deg with equivalent end-points Nielsen N, et al. NEJM 2013; 369 (23): ACLS: Post-Resuscitation Care New recommendations: Targeted Temperature Management Maintenance of body temp degrees for ALL patients postcardiac arrest regardless of rhythm (Class I AHA, ERC also recommends) Avoidance of fevers For any ST elevation, early PCI is also now strongly encouraged Prognostication Wrap Up If an adult inpatient appears to be in cardiac arrest, proceed with continuous chest compressions until help arrives (OL) Chest compressions delivered at a fraction of at least 0.6 Consider passive insufflation for deep agonal respirations (OL) No advanced airway->compressions:ventilations 30:2 With advanced airway->compressions continuous with one ventilation every 6 seconds Advanced airway will eventually need to be obtained (whether it s ET or SGA), but there s no rush (OL) Compressions should be started immediately without a pulse check (OL) Start now, push hard, pump fast, have good recoil Minimize the pre-shock pause Use EtCO2 to gauge quality CPR and ROSC (Semi OL)

Wrap Up Medications remain unproven Epinephrine may only work well if given early on in a cardiac arrest Vasopressin, steroids, and epinephrine (with hydrocortisone continued for post-resuscitation

13 Wrap Up Medications remain unproven Epinephrine may only work well if given early on in a cardiac arrest Vasopressin, steroids, and epinephrine (with hydrocortisone continued for post-resuscitation shock) are probably harmless and may offer significant benefit (OL) Vasopressin by itself is no longer recommended in any guidelines Post-resuscitation care emphasizes broad range of hypothermia (32-36 degrees) Percutaneous intervention is strongly encouraged for presumed cardiac cause Coronary CT may be sufficient in patients without ST segment elevation

High-Functioning EMS CPR Teams. Sally A Taylor - Paramedic Atlantic Partners EMS

High-Functioning EMS CPR Teams Cardiac Arrest Management Sally A Taylor - Paramedic Atlantic Partners EMS Insanity: Doing the same thing over and over and expecting a different result. John Dryden The