cpr2015 update: acs and special circumstances

2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and

Emergency Cardiovascular Care

Part 9: Acute Coronary SyndromesPart 10: Special Circumstances of Resuscitation

Part 9: Acute Coronary Syndromes

Diagnostic Interventions in ACS Therapeutic Interventions in ACS Reperfusion Decisions in STEMI Patients Hospital Reperfusion Decisions After ROSC

Part 9: Acute Coronary SyndromesDiagnostic Interventions in ACS

Prehospital ECG and Prehospital STEMI Activation of the Catheterization Laboratory

Prehospital 12-lead ECG should be acquired early for patients with possible ACS(Class I, LOE B-NR).

Prehospital notification of the receiving hospital (if fibrinolysis is the likely reperfusion strategy) and/or prehospital activation of the catheterization laboratory should occur for all patients with a recognized STEMI on prehospital ECG (Class I, LOE B-NR).

Possible ACS patient

ECG 12 lead STEMINotification

receiving hospital

+/- activate catherization labReperfusion

strategy

Computer-Assisted ECG STEMI Interpretation

Because of high false-negative rates, we recommend that computer-assisted ECG interpretation not be used as a sole means to diagnose STEMI (Class III: Harm, LOE B-NR).

We recommend that computer-assisted ECG interpretation may be used in conjunction with physician or trained provider interpretation to recognize STEMI (Class IIb, LOE C-LD).


Computer Human

Nonphysician STEMI ECG Interpretation

While transmission of the prehospital ECG to the ED physicianmay improve positive predictive value (PPV) and therapeutic decision-making regarding adult patients with suspected STEMI,

if transmission is not performed, it may be reasonable for trained nonphysicianECG interpretation to be used as the basis for decision-making, including activation of the catheterization laboratory, administration of fibrinolysis,and selection of destination hospital (Class IIa, LOE B-NR).


Consult ECG Train

Biomarkers in ACS

We recommend against using hs-cTnT and cTnI alone measured at 0 and 2 hours (without performing clinical risk stratification) to identify patients at low risk for ACS (Class III: Harm, LOE B-NR).

We recommend that hs-cTnI measurements that are less than the 99th percentile, measured at 0 and 2 hours, may be used together with low-risk stratification (TIMI score of 0 or 1 or low risk per Vancouver rule) to predict a less than 1% chance of 30-day MACE (Class IIa, LOE B-NR).

Major Adverse Cardiac Event (MACE)

BiomarkerClinical risk

stratification


Biomarkers in ACS

We recommend that negative cTnI or cTnT measurements at 0 and between 3 and 6 hours may be used together with very low-risk stratification to predict a less than 1% chance of 30-day MACE (Class IIa, LOE B-NR).

Very low-risk stratificationTIMI score of 0Low-risk score per vancouver ruleNorth american chest pain score of 0 and age less than 50 yearsLow-risk HEART score


Adjunctive Therapy in Patients with Suspected STEMI: ADP Inhibition

In patients with suspected STEMI intending to undergo PPCI,initiation of ADP inhibition may be reasonable in either theprehospital or in-hospital setting (Class IIb, LOE C-LD).

Part 9: Acute Coronary SyndromesTherapeutic Interventions in ACS

Clopidrogel

Prehospital Anticoagulants VS None in STEMI

While there seems to be neither benefit nor harm to administering heparin to patients with suspected STEMI before their arrival at the hospital, prehospitaladministration of medication adds complexity to patient care.

We recommend that EMS systems that do not currently administer heparin to suspected STEMI patients do not add this treatment, whereas those that do administer it may continue their current practice (Class Iib,LOE B-NR).

EMSX Heparin

Heparin Heparin

X Heparin

Current practice in suspected STEMI


Prehospital Anticoagulants for STEMI

In suspected STEMI patients for whom there is a planned PPCI reperfusion strategy, administration of unfractionated heparin (UFH) can occur either in the prehospitalor in-hospital setting (Class IIb, LOE B-NR).

STEMIPlanned PPCI

UFHPrehospital orIn-hospital




It may be reasonable to consider the prehospital administration of UFH in STEMI patients or the prehospital administration of bivalirudin in STEMI patients who are at increased risk of bleeding (Class IIb, LOE B-R).


BivalirudinCase with risk of bleeding


STEMIPlanned PPCI Target thrombin inhibitor



In systems in which UFH is currently administered in the prehospital setting for patients with suspected STEMI who are being transferred for PPCI, it is reasonable to consider prehospital administration of enoxaparin as an alternative to UFH(Class IIa, LOE B-R).


Enoxaparinalternative


STEMIPlanned PPCI

BivalirudinCase with risk of bleeding

Routine Supplementary Oxygen Therapy in Patients Suspected of ACS

The provision of supplementary oxygen to patients suspected ACS who are normoxichas not been shown to reduce mortality or hasten the resolution of chest pain. Withholding supplementary oxygen in these patients has been shown to minimally reduce infarct size.

The usefulness of supplementary oxygen therapy has not been established in normoxicpatients. In the prehospital, ED, and hospital settings, the withholding of supplementary oxygen therapy in normoxic patients with suspected or confirmed acute coronary syndrome may be considered (Class IIb, LOE C-LD).

NormoxicACS patient

O2


Prehospital triage

Transport directly

Prehospital Fibrinolysis, Hospital Fibrinolysis, andPrehospital Triage to PCI Center

Where prehospital fibrinolysis is available as part of a STEMI system of care, and in-hospital fibrinolysis is the alternative treatment strategy, it is reasonable to administer prehospitalfibrinolysis when transport times are more than 30 minutes (Class IIa, LOE B-R).

Where prehospital fibrinolysis is available as part of the STEMI system of care and direct transport to a PCI center is available, prehospital triage and transport directly to a PCI center may be preferred because of the small relative decrease in the incidence of intracranial hemorrhage without evidence of mortality benefit to either therapy (Class IIb, LOE B-R).

PrehospitalFibrinolysis

in-hospital = alternative txtransport time > 30 min

PCI centeravailable center

Part 9: Acute Coronary SyndromesReperfusion Decisions in STEMI Patients

ED Fibrinolysis + Immediate PCI VS Immediate PCI Alone

In the treatment of patients with suspected STEMI, the combined application of fibrinolytic therapy followed by immediate PCI (as contrasted with immediate PCI alone) is not recommended (Class III: Harm, LOE B-R).

Fibrinolysis Immediate PCI


Delayed PCI VS Fibrinolysis Stratified by Time from Symptom onset

PPCI is the preferred reperfusion strategy when time from symptom onset is less than 12 hours and time to PPCI from first medical contact in these patients is anticipated to be less than 120 minutes. Regardless of whether time of symptom onset is known, the interval between first medical contact and reperfusion should not exceed 120 minutes (Class I, LOE C-EO).


PCI

Onset < 12 hr

Time to PCI < 120 min


In STEMI patients presenting within 2 hours of symptom onset, immediate fibrinolysisrather than PPCI may be considered when the expected delay to PPCI is more than 60 minutes (Class IIb, LOE C-LD).


Fibrinolysis

Onset < 2 hr

Expected delay to PCI > 60min


In STEMI patients presenting within 2 to 3 hours after symptom onset, either immediate fibrinolysis or PPCI involving a possible delay of 60 to 120 minutes might be reasonable(Class IIb, LOE C-LD).


ImmediateFibrinolysis

Onset 2-3 hr

PCIPossible delay 60 -120 min

OR


In STEMI patients presenting within 3 to 12 hours after symptom onset, performance of PPCI involving a possible delay of up to 120 minutes may be considered rather than initialfibrinolysis (Class IIb, LOE C-LD).


PCI

Onset 3- 12 hr

Time to PCI < 120 min

> 6 hours after symptom onset Fibrinolysis significantly less effectiveLonger delay to PPCI may be the better option


In STEMI patients, when delay from first medical contact to PPCI is anticipated to exceed 120 minutes, a strategy of immediate fibrinolysis followed by routine early (within 3 to 24 hours) angiography and PCI if indicated may be reasonable for patients with STEMI (Class IIb, LOE B-R).


immediate fibrinolysis

Early CAG

STEMI

Time to PCI > 120 min

Reperfusion Therapy for STEMI in Non–PCI-Capable Hospitals

In adult patients presenting with STEMI in the emergency department of a non–PCI-capable hospital, we recommend immediate transfer without fibrinolysisfrom the initial facility to a PCI center, instead of immediate fibrinolysis at the initial hospital with transfer only for ischemia-driven PCI. (Class I, LOE B-R).

Immediate transfer

PCI center

Fibrinolysis

Non–PCI-Capable

Hospitals

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When STEMI patients cannot be transferred to a PCI-capable hospital in a timely manner, fibrinolytic therapy with routine transfer for angiography may be an acceptable alternative to immediate transfer to PPCI (Class IIb, LOE C-LD).

Immediatetransfer

Fibrinolysis

Non–PCI-Capable

Hospitals2 PCI center

alternative



PCI centerAll Post-Fibrinolysis Pt.

When fibrinolytic therapy is administered to STEMI patient in non–PCI hospital, it may be reasonable to transport all postfibrinolysis patients for early routine angiography in the first 3 to 6 hrs and up to 24 hours rather than transport postfibrinolysis patients only when they require ischemia-guided angiography (Class IIb, LOE B-R).


PCI After ROSC With and Without ST Elevation

CAG

OHCA + + ST elevation

Coronary angiography should be performed emergently (rather than later in the hospital stay or not at all) for OHCA patients with suspected cardiac etiology of arrest and ST elevation on ECG (Class I, LOE B-NR).

Part 9: Acute Coronary SyndromesHospital Reperfusion Decisions After ROSC


CAG


Emergency coronary angiography is reasonable for select (eg, electrically or hemodynamically unstable) adult patients who are comatose after OHCA of suspected cardiac origin but without ST elevation on ECG (Class IIa, LOE B-NR).

OHCA + Coma + M



CAG


Coronary angiography is reasonable in post–cardiac arrest patients where coronary angiography is indicated regardless of whether the patient is comatose or awake (Class IIa, LOEC-LD).

OHCA + Coma + M

Post arrest Pt + indication to CAG Awake/Coma


Part 10: Special Circumstances of Resuscitation

Cardiac Arrest Associated with Pregnancy

Cardiac Arrest Associated with Pulmonary Embolism

Cardiac or Respiratory Arrest Associated with Opioid Overdose

Role of Intravenous Lipid Emulsion Therapy in Management of Cardiac Arrest Due to Poisoning

Cardiac Arrest During Percutaneous Coronary Intervention

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Cardiac Arrest Associated with Pregnancy

The most common causes of maternal cardiac arrest Hemorrhage Cardiovascular diseases Amniotic fluid embolism Sepsis Aspiration pneumonitis PE Eclampsia

Important iatrogenic causes Hypermagnesemia Anesthetic complications

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BLS Modification: Relief of Aortocaval Compression

Priorities for the pregnant woman in cardiac arrest are provision of high-quality CPR and relief of aortocaval compression (Class I, LOE C-LD).

If the fundus height is at or above the level of the umbilicus, manual LUD can be beneficial in relieving aortocaval compression during chest compressions (Class IIa, LOE C-LD).

Lateral Uterine Displacement (LUD)

High-quality CPR Relief of aortocavalcompression

ALS Modification: Emergency Cesarean Delivery in Cardiac Arrest

PMCD should be summoned as soon as cardiac arrest is recognized in a woman in the second half of pregnancy (Class I, LOE C-LD).

Perimortem Cesarean Delivery (PMCD)

Systematic preparation and training are the keys to a successful response to such rare and complex events.

Care teams that may be called upon to manage these situations should develop and practice standard institutional responses to allow for smooth delivery of resuscitative care (Class I, LOE C-EO).


During cardiac arrest, if the pregnant woman with a fundus height at or above the umbilicus has not achieved ROSC with usual resuscitation measures plus manual LUD, it is advisable to prepare to evacuate the uterus while resuscitation continues (Class I, LOE C-LD).

In situations such as nonsurvivable maternal trauma or prolonged pulselessness in which maternal resuscitative efforts are obviously futile, there is no reason to delay performing PMCD (Class I, LOE C-LD).

FH at or above umbilicus

PMCD

No ROSC

Resuscitation + manual LUD

Nonsurvivable maternal TM

Prolonged pulselessness

Resuscitative effort = futile


PMCD should be considered at 4 minutes after onset of maternal cardiac arrest or resuscitative efforts (for the unwitnessed arrest)if there is no ROSC (Class IIa, LOE C-EO).

Cardiac Arrest Associated with Pulmonary Embolism

Confirmed Pulmonary Embolism

Thrombolysis, surgical embolectomy, and mechanical embolectomyare reasonable emergency treatment options (Class IIa, LOE C-LD).

Thrombolysis can be beneficial even when chest compressions have been provided (Class IIa, LOE C-LD)


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Suspected Pulmonary Embolism

Thrombolysis may be considered when cardiac arrest is suspectedto be caused by PE (Class IIb, LOE C-LD).

Cardiac or Respiratory Arrest Associated with Opioid Overdose

Opioid Overdose Response Education and Naloxone Training and Distribution

It is reasonable to provide opioid overdose response education,either alone or coupled with naloxone distribution and training, to persons at risk for opioid overdose (Class Iia,LOE C-LD).


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10.3 : Cardiac or Respiratory Arrest Associated with Opioid Overdose

It is reasonable to base this training on first aid and non–healthcare provider BLS recommendations rather than on more advanced practices intended for healthcare providers (Class IIa, LOE C-EO).


First Aid and Non–Healthcare Provider BLS Modification:Administration of Naloxone

Empiric administration of IM or IN naloxone to all unresponsive opioid-associated life-threatening emergency patients may be reasonable as an adjunct to standard first aid and non–healthcare provider BLS protocols (Class IIb, LOE C-EO).

Standard resuscitation should not be delayed for naloxone administration.

However, family members and friends of those known to be addicted to opiates are likely to have naloxone available and ready to use if someone known or suspected to be addicted to opiates is found unresponsive and not breathing normally or only gasping. Victims who respond to naloxone administration should access advanced healthcare services (Class I, LOE C-EO).


Healthcare Provider BLS Modification: Administration of Naloxone

Respiratory Arrest pulse no normal breathing or gasping

it is reasonable for appropriately trained BLS healthcare providers to administer IM or IN naloxone (Class IIa, LOE C-LD).

Cardiac Arrestno definite pulse

cardiac arrestundetected weak or slow pulse.

Managed as cardiac arrest patients.Standard resuscitative measures should take priority over naloxoneadministration (Class I, LOE C-EO), with a focus on high-quality CPR


Cardiac Arrest

It may be reasonable to administer IM or IN naloxone based on the possibility that the patient is not in cardiac arrest (Class IIb, LOE C-EO).

Responders should not delay access to more-advanced medical services while awaiting the patient’s response to naloxone or other interventions (Class I, LOE C-EO).

Unless the patient refuses furthercare, victims who respond to naloxoneadministration should access advanced healthcare services (Class I, LOE C-EO).

Healthcare Provider BLS Modification: Administration of Naloxone


Respiratory Arrest Support ventilation NaloxoneBag-mask ventilation until spontaneous breathing returnsStandard ACLS measures if return of spontaneous breathing does not occur (Class I, LOE C-LD).

ACLS Modification: Administration of Naloxone

Cardiac ArrestWe can make no recommendation regarding the administration of naloxone in confirmed opioid-associated cardiac arrest.

Patients with opioid-associated cardiac arrest are managed in accordance with standard ACLS practices


Observation and Post-Resuscitation Care

ACLS Modification: Administration of Naloxone

• Low risk of recurrent opioid toxicity

• Normal : level of consciousness and vital signs(Class I, LOE C-LD).

ObservedUntil…

• small doses or an infusion of naloxone (Class IIa, LOE C-LD).

• longer periods of observation in patient with life-threatening overdose of a long-acting or sustained-release opioid.

RecurrentOpioid toxicity

• may be considered in order to achieve the specific therapeutic goals of reversing the effects of long-acting opioids (Class IIb, LOEC-EO).

Naloxonein post cardiac arrest


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Role of Intravenous Lipid Emulsion Therapy in Management of Cardiac Arrest Due to Poisoning

It may be reasonable to administer ILE, concomitant with standard resuscitative care, to patients with local anesthetic Systemic toxicity and particularly to patients who have premonitory neurotoxicity or cardiac arrest due to bupivacaine toxicity (Class IIb, LOE C-EO).

It may be reasonable to administer ILE to patients with other forms of drug toxicity who are failing standard resuscitative measures (Class Iib,LOE C-EO).


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Intravenous Lipid Emulsion

Local anesthetic systemic toxicity

Bupivacaine toxicityneurotoxicity or cardiac arrest

Drug toxicity Failing standard resuscitative

Cardiac Arrest During Percutaneous Coronary Intervention

It may be reasonable to use mechanical CPR devices to provide chest compressions to patients in cardiac arrest during PCI (Class IIb, LOE C-EO).

It may be reasonable to use ECPR as a rescue treatment when initial therapy is failing for cardiac arrest that occurs during PCI (Class IIb, LOE C-LD).

ECPR : Extracorporeal cardiopulmonary resuscitation


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cpr2015 update: acs and special circumstances

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