ACLS Guidelines 2010The rules and changes

Peter Cameron, MDThe Alfred Hospital/Monash UniversityMelbourne, Australia

The New ACLS Guideline

Published online Oct 18 2010Published in Circulation Nov 2 2010Similar endorsements from Australian/NZ/European and International Resuscitation Councils

1n 1960 Kouwenhoven & Knickerbocker - 14 patients survive arrest with CPR!2 years later direct current defibrillator introduced1966 first AHA guidelines2010 was the 50 anniversary of CPR

Smart People356 resuscitation experts 29 countries36 month period411 scientific reviews

the new recommendations do not imply that care using past guidelines is either unsafe or ineffectivestill insufficient data to demonstrate that any drugs or mechanical CPR devices improve long-term outcome after cardiac arrest

ACLS 2010 Guideline Review

Basic Life Support (BLS) Cardiac ArrestTachycardiasBradycardias

BLS

BLS Principles DRS ABCDNo change to Dangers and ResponseS Send for helpA open the AirwayB check Breathing but no need to deliver two rescue breathsC perform 30 Compressions for victims who are unresponsive and not breathing normally, followed by 2 breathsD attach an AED as soon as it is available

BLS Principles DRS ABCDCompressions before 2 initial rescue breathsSigns of life changed to unresponsive and not breathing normallyIf unwilling / unable to perform rescue breathing, then perform compression only CPRNew focus on maintenance of CPR quality change rescuers every two minutesPulse check downgraded for HCPs unreliable indicator of the need for resuscitation

BLS CompressionsOne or two handed technique for children (Australian Ambulance have adopted two)Push to a depth of at least 5 cms at a rate of at least 100 / minAllow full recoil of chest between compressions 30 Compressions : 2 ventilations for all age groups (1 or 2 rescuer)Apply AED (if available) now BLS skill taught as part of CPR programs

BLS Health Professional (Cont)CPR Rates:Single Rescuer: 30 Compressions : 2 ventilations at a rate of > 100 per minute for all age groups (Approx 5 cycles every 2 minutes

BLS Health Professional (Cont)AED - Apply and follow the promptsContinue until signs of life briefly check (?pulse) every two minutes (dont pause CPR for more than 10 seconds!!)Change compressor every 2 minutes to avoid fatigue

AEDAED - Single shock strategy 2 minutes CPR before reanalysisNo need to reprogram energy levels should follow those programmed by manufacturer for their specific deviceReasonable to continue to utilise older devices until replaced as part of normal life cycle any resuscitation is better than none

Choking (FBAO)

CPR Changes EmphasisePush hard, push fast, minimise interruptions; allow full chest recoil, and dont hyperventilate

RationaleAlthough ventilations are impt part of resuscitation, evidence shows that compressions are the critical element in adult resuscitation. In the A-B-C sequence, compressions are often delayed.If a pulse is not detected within 10 seconds, do start compressions without further delay.

Compression DepthsCompression depths are:Adult- at least 2 inches (5cm)Children- at least 1/3 the depth of the chest (appx 2 inches (5cm)Infants- at least 1/3 the depth of the chest, approx 1 1/2 inches (4cm)

Airway & BreathingCricoid pressure is no longer routinely recommended for use with ventilationsRandomized control trials demonstrated cricoid pressure still allows for aspiration. It is also difficult to train providers to perform the maneuver correctly.

ALS PrinciplesTo provide critical blood flow to the vital organs with high quality chest compressionsDefibrillation as soon as possible provides the best chance of survival in victims with VF or pulseless VT (cf. CPR prior to defib)Return of spontaneous circulation as rapidly as possibleIntensive care support aimed to achieve the best outcomes

ALS Principles Key revisions IHigh quality chest compressions with minimal interruptions; continuing compressions during defibrillator chargingSingle (non-stacked) shocks, but stacked shocks may be considered for HPC witnessed arrest*, during cardiac catheterisation or after cardiac surgeryPrecordial thump is de-emphasisedIV or IO drug administration (ETT de-emphasised)*Where a monitor / defibrillator is connected at the time

ALS Principles Key revisions IIAdrenaline 1mg for VF/VT after the second shock once chest compressions have restarted and then every 3-5 min (alternate blocks of CPR)Amiodarone 300mg after third shockAtropine no longer recommended for routine use in asystole or PEALess emphasis on early intubationCapnography to confirm and continually monitor tracheal tube placement, quality of CPR, and to provide early indication of ROSC

Post Resuscitation CareRecognition that a post resuscitation care protocol may improve survival following ROSCAvoid hyperoxaemia oxygen titration to Sa02 94-98%Primary PCI in appropriate patients with sustained ROSCNormoglycaemic glucose control (BSL >10 mmol/l should be treated but hypoglycaemia avoided)Therapeutic hypothermia to include comotose survivors of cardiac arrest of any rhythm

Single Shock Defibrillation StrategySingle shock strategy continues to be recommended to improve outcome by reducing interruption of chest compressionsMonophasic 360J / Biphasic 200 J (Adult)Monophasic / Biphasic 4J/kg (Paed)Exception is health professional witnessed VF/VT.Salvo of three stacked shocks (Mono 360J / Biphasic 200J; with rhythm checks between shocks) Followed by CPR and single shock strategy if unsuccessful

PLS Principles Key revisions IRecognition that HCPs cannot reliably determine the presence of a pulse in < 10s. Compress at least 1/3 AP diameter (Approx. 5cms in children and 4cms in infants)Defibrillation is a single shock of 4J/kg (mono or bi). Staked shocks as per adultIV or IO drug administration (ETT de-emphasised)Cuffed tracheal tubes ok for short term

Newborn Resuscitation IFor uncomplicated babies, a delay in cord clamping of at least one minute from delivery is recommended For term infants, air should be used initially.Recommended CV ratio remains 3:1 Very prem infants should be placed in / under a polyethylene bag or sheet to the neck

Newborn Resuscitation IIAdrenaline IV dose 20-30 mcg/kg. (ET would require at least 50-100 mcg/kg to achieve a similar effect to 10 mcg/kg IV)Infants with evolving moderate severe hypoxic ischaemic encephalopathy should be treated with therapeutic hypothermia following immediate resuscitationCapnography most reliable method to confirm and continually monitor tracheal tube placement in neonates with spontaneous circulation

DefibrillationAFIB cardioversion : Biphasic 120-200J Monophasic 200J.AFlutter cardioversion/SVT: 50-100J either monophasic or biphasic.If the initial cardioversion shock fails, providers should increase the dose in a stepwise fashion.

AED UseChildren 1-8yrs, pediatric dose attenuator should be used if available. Otherwise, standard AED may be used.Infants (1

Stable monomorphic VT responds well to monophasic or biphasic synchronized shocks at 100J.If no response to first shock, increase dose in stepwise fashion.Polymorphic VT is unstable as an arrest rhythm and require unsynchronized shocks.

V FibShock 200 J every 2 minutesCPR for 2 minutes while admin RxVentilate, IV Epi, Amiodarone 300mg

The RationaleTrue effective dose (lower or upper limit) known but doses (4J/kg-9J/kg) have been found to have no significant adverse effects.

Give Oxygen when neededSupplementary oxygen is not needed for pts without evidence of respiratory distress or when oxyhemoglobin saturation is >93%EMS providers administer oxygen during the initial assessment of pts with suspected ACS/ However, there is insufficient evidence to support its routine use in uncomplicated ACS. If the pt is dyspneic, is hypoxemic, or has obvious signs of heart failure, providers should titrate oxygen therapy to maintain O2 sat >93%

Airway and BreathingContinuous quantitative waveform capnography is now recommended for intubated pts throughout the periarrest period. Useful in confirming ETT placement and for monitoring CPR quality and detected ROSC based on end tidal CO2 values.

SUMMARYLook, listen, feel - removedHealthcare providers briefly check for breathing when checking responsiveness to detect signs of cardiac arrest. After delivery of 30 compressions, lone rescuers open the victims airway and deliver 2 breaths.Encourage hands only CPR for untrainedContinuous CPR for advanced providersDo GREAT CPRAND C-A-B - radical but rational!

CARDIAC ARRESTA few changes in emphasis

IV provision of high-quality CPR and rapid defibrillation are of primary importance and drug administration is of secondary importance20ml Bolus after drug

IO AccessReasonable to establish access if IV access is not readily available

Emergence of Supraglottic DevicesCPR more important than airway initiallyPut in a supraglottic if intubation is going to be hardLMAKing LT

Capnography100% sensitive and specific for tracheal intubationHelps count 8-10 breaths minute Predictor of outcome

No Atropine in PEA/AsystoleAvailable evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit

Drugs= Transcutaneous PacingIt hurts!No better than drugsOk to go from drugs to TV pacing NOT ROUTINE in arrest

Seek Reversible Causes5HsHypoxiaHypovolemiaHyperacidosisHyperkalemiaHypothemia5TsThrombus (MI)Thrombus (PE)Tension PTXToxinsTamponade

VasopressorsVF continues after epi and CPR - vasopressorAmiodarone is first lineNot proven to result in long term outcomeLidocaine is useless also

EpinephrineNever any evidence that it works!Abstract 1: A Randomized placebo controlled trial of adrenaline in cardiac arrest- the PACA trialConclusion: The use of adrenaline in cardiac arrest was associated w significant increase in the proportion of pts achieving ROSC however this improvement did not extend to survival to hospital discharge. As our results are unable to rule out a clinically meaningful benefit of adrenaline in terms of survival to hospital discharge, further investigation into the post resuscitation period for those achieving ROSC is required in order to identify management strategies to improve survival.

SUMMARYAtropine OUT for PEA/AsystoleCPR first and fastAirway- supraglottic emergesStill have amiodarone even though it dont workHope lies in a reversible cause

Tachycardia

Pearl 1: Dont cardiovert to sinus rhythm

Pearl 2: Rates

Pearl 3: Many arrhythmias caused by hypoxia- Fix that first

Pearl 4: If unstable use electricity- except narrow complex when adenosine may be ok

Pearl 5: IF THEY ARE PRETTY STABLE - GET A 12 LEAD ECG

Adenosine vs. CCB More rapid and less severe side effects than calcium blockers

Adenosine in Wide Complex Tachycardiarecent evidence suggests that adenosine is relatively safe for both treatment and diagnosis

AdenosineMay be considered in the initial diagnosis of stable, undifferentiated, regular, monomorphic, wide-complex tachycardia. Not to be used if the pattern is irregular.New evidence of safety and potential efficacy. Help diagnose and treat SVT with aberrant conduction.

Caveats/CommentsNot for irregular or polymorphicSVT should slow or convertVT usually will not

Wide, Regular, Stable Other ChoicesCardioversion, Procainamide, Amiodarone, SotalolGenerally only try one!Procaine 20-50mg/hour (17mg/kg or QRS 50% narrowed, or hypotension)

Wide Complex Regular:AmiodaroneAn option- better than lidocaine150 mg IV over 10 minutes Can repeat 2.2 g IV total in 24 hours

Wide Irregular TachycardiasAtrial fibrillation - BBBAtrial fib - accessory pathway Polymorphic VT

Polymorphic VTDefibrillation

3 Types of Polymorphic VTProlonged QT : MagnesiumFamilial : IV Magnesium Pacing Beta-blockers No IsoprelIschemic: Amiodarone, BB, revascularization

Tachycardia

MorphineMorphine should be given with caution to pts with unstable angina.Morphine is indicated in STEMI when CP unresponsive to nitrates. Morphine found to be associated with an increase mortality with angina and unstable angina large registry.

BRADYCARDIA

AtropineAtropine is not recommended for PEA/Asystole.Use of atropine unlikely to have a therapeutic benefit

AtropineFirst Dose-->0.5mg bolusRepeat every 3-5 minutesMax Dose 3mg

If Atropine FailsTranscutaneous Pacing or Dopamine 2-10 mcg per minuteEpinephrine 2-10mcg per minute

When NOT to use AtropineCardiac Transplant- ineffective or bradyWide complex Type 2 or 3 blocks

Chronotropic DrugsFor symptomatic or unstable bradycardia, chronotropic drug infusion are recommended as an alternative to pacing.Epi, Dopamine acceptable alternative to external transcutaneous pacing when atropine is ineffective.

5 Reversible Causes of PEAHypoxiaTension PTXHypovolemiaCardiac TamponadeToxic-Metabolic

EMD- PEA 5 Step ManagementOxygenate and VentilateSecure IV AccessLook for 3 Causes (ECG, Temp, Vol status)Epinephrine (1mg q 3mins)Review all 5 causes

5 Possible Ultrasound FindingsTampondeHypovolemiaMassive PECardiogenic ShockNormal->Lung view

Causes of PEA- 4 chamber viewPericardial Effusion + RV Strain=TamponadeRV Strain=LV Strain=HypovolemiaRV dil + RA dil vs LV Strain=PEPoor contractility= Cardiogenic ShockNl = Lung view

Implementation Current Guidelines still OKUp to each organisation to determine when to implement changes

Questions