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ACLS 2005 What is new and why?

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ACLS 2005 What is new and why? Morbidity Rounds Feb 15, 2006 Rob Hall MD, FRCPC Overview Goal = review major changes to CPR, ALS, electrical therapies, cardiac arrest ... – PowerPoint PPT presentation

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Title: ACLS 2005 What is new and why?


1
ACLS 2005What is new and why?
  • Morbidity Rounds
  • Feb 15, 2006
  • Rob Hall MD, FRCPC

2
Overview
  • Goal review major changes to CPR, ALS,
    electrical therapies, cardiac arrest, arrythmia
    algorithms, post resusc care
  • Briefly review some Landmark papers.
  • AEDs, ACS, CVA, toxicology and other special
    resusc situations not included

3
ACLS 2005 Guidelines
  • VISIT www.circulationha.org
  • Circulation 2005. Dec 13 112(24) p3667-3813 and
    Supp 11 p 1-211.

4
Global Comments
  • BACK TO THE BASICS
  • Increased emphasis on CPR
  • Decreased emphasis on drugs
  • SIMPLER
  • Consistent ratios for CPR
  • Less algorithms (PEA/Asystole out)
  • Tachycardia much simpler
  • EVIDENCE BASED
  • Nice to see Landmark papers incorporated.
  • Recognition of importance of survival to
    discharge vs survival to admission

5
CPR/BLS
Circulation 2005112IV-19-34IV-
6
Part 3/4 CPR/Adult BLS
  • Lay Rescuers
  • Lay rescuers not taught artificial respirations
    or pulse checks
  • Lay rescuers taught to look for normal
    breathing
  • Lay rescuers not taught the jaw thrust
  • Age definitions
  • Neonatal age applies to baby deliver up until
    they leave hospital
  • Different age cut offs for Lay rescuers
  • lt1year, 1-8 year, gt8 year (Lay rescuer)
  • lt1year, 1-adolescent, gtadolescent to adult (HCP)

7
Part 3/4 CPR/Adult BLS
  • Ventilations
  • Less important than compressions (EARLY)
  • Ventilate enough to make chest rise
  • Rate about 10 per minute after advanced airway
  • AVOID over - ventilation (decreased venous
    return, decreased cardiac output)
  • AVOID rapid/forceful breaths
  • AVOID interruption of compressions after advanced
    airway placed

LOW AND SLOW ventilations
8
Part 3/4 CPR/Adult BLS
  • Compressions
  • More important than ventilation
  • Rate about 100 compressions per minute
  • Push hard enough to compress the chest
  • Allow full recoil of chest
  • Allow equal time for compression and recoil
  • MINIMIZE interruptions in compressions
  • Synchronicity
  • Unsynchronized ventilation/compression after
    advanced airway placed

HARD AND FAST compressions
9
ED Interruptions in Compressions
  • Transfer to ED bed
  • Pulse checks
  • Placing patient on the monitor and defibrillator
  • Rhythm checks
  • Vascular access
  • Airway management
  • Defibrillation
  • Drug delivery
  • Bedside ultrasound
  • ABG draw
  • Physical examination
  • Changeover of compressor
  • We should minimize CPR interruptions

10
ACLS 2000
After Advanced Airway Device Placed 5
compressions to 1 ventilation (synchronized)
11
ACLS 2005
After Advanced Airway Device Placed 100
compression/min 10 breaths per minute
(unsynchronized)
12
ACLS 2005
After Advanced Airway Device Placed 100
compression/min 10 breaths per minute
(unsynchronized)
13
Adult BLS Healthcare Provider Algorithm
Circulation 2005112IV-19-34IV-
14
Electrical Therapies
Circulation 2005112IV-19-34IV-
15
Part 5 Electrical Therapy
16
Part 5 Electrical Therapy
Truncated Exponential
Rectilinear
Biphasic increased ROSC, no increase Survival
to hospital discharge
17
Lifepak
  • 12 and 20 are both biphasic (truncated
    exponential)

18
Recommended Energy for Defibrillation
Lifepak 12 and 20
Peds 2 J/kg then 4 J/kg
19
Recommended Energy for Cardioversion for Lifepak
12/20
20
Timing of Defibrillation
  • Shock First vs CPR First?

21
Evidence for CPR before defibrillation
  • Cobb JAMA 1999
  • Prospective observational trial, N1117
  • Pre-intervention defibrillate ASAP
  • Post-intervention 90 sec CPR before defib
  • Survival to d/c Defib First CPR
    First P NNT
  • Overall 24 30 .04 16
  • Response lt 4min 31 32 .87
  • Response gt 4min 17 27
    .007 10

22
Evidence for CPR before defibrillation
  • Wik JAMA 2003
  • Randomized clinical trial, N200
  • Defibrillate ASAP vs CPR X 3 min before
    defibrillation
  • Survival to d/c Defib First CPR
    First P NNT
  • Overall 15 22 .17
  • Response lt 5min 29 23 .61
  • Response gt 5min 4 22
    .006 5.5

A priori subgroup analysis
23
Evidence for CPR before defibrillation
  • Jacobs. Emerg Med Australasia. Feb 2005.
  • Randomized clinical trial, N256
  • Defibrillate ASAP vs CPR X 90 sec before
    defibrillation
  • Survival to d/c Defib First CPR First
    OR 95CI
  • Overall 5.1 4.2 .81
    (.3-2.6)
  • Survival to d/c Defib First CPR First
    P
  • Response lt 5min 0 12 .25
  • Response gt 5min 4.9 3.5
    .74

Post hoc subgroup analysis
24
Timing of Defibrillation
  • ACLS 2005 Recommendation
  • CPR X 5 cycles of 302 (about 2 min) recommended
    for out-of-hospital VF arrest
  • Response time gt 4-5 minutes
  • Unwitnessed

25
Part 6 CPR Techniques and Devices
  • Non-traditional CPR and devices not universally
    recommended
  • Recognition of growing evidence
  • Optional for Health Care Providers
  • Active Compression-Decompression CPR
  • Mechanic pistons
  • Load Distributing Band CPR/Vest CPR
  • Research
  • Thoracic-Abdominal Compression-Decompression CPR

26
ALS
Circulation 2005112IV-19-34IV-
27
Part 7.2 Management of Cardiac Arrest
  • ACLS Pulseless Algorithm 2005
  • Vfib Algorithm
  • PEA Algorithm
  • Asystole Algorithm

28
Circulation 2005 112IV-58-66IV-
29
Notes on VF and pulseless VT
  • CPR 302 until defibrillator ready
  • One shock, not three
  • 150J (not 360J) Lifepak 12/20
  • CPR X 2min right after shock (no rhythm check)
  • Timing of intubation not specified
  • Timing of vasopressor not specified
  • Epinephrine 1mg or vasopressin 40IU
  • Timing of antiarrythmic not specified
  • Amiodarone 300mg or Lidocaine 1.5 mg/kg

Circulation 2005 112IV-58-66IV-
30
Amiodarone for Vfib/pulseless VT
  • ARREST TRIAL
  • DBRCT, N504
  • Amio vs Placebo
  • Survival PL Amio P
  • Admission 34 44 .03
  • Discharge 13.4 13.2 NS
  • ALIVE TRIAL
  • DBRCT, N 347
  • Amio vs Lidocaine
  • Survival Lido Amio P
  • Admission 12 23 .009
  • Discharge 3.8 6.8 NS

Kudenchuk et. al. NEJM 1999. 341(12) p.871.
Dorian et. al. NEJM 2002. 346(12) p.884.
31
Notes on pulseless PEA/asystole
  • Focus is on quality CPR and look for and treat
    reversible causes
  • Atropine
  • Epinephrine or Vasopressin
  • PACING is OUT!
  • Three RCTS of prehospital transcutaneous pacing
    showed no benefit

Circulation 2005 112IV-58-66IV-
32
Why Vasopressin? Or why not
  • Linder. Lancet 1997.
  • N40, out of hospital Vfib, vasopressin vs epi
  • Increased survival to admission not discharge
  • Stiell. Lancet 2001.
  • N200, in-hospital Vfib/PEA/asystole
  • Vasopressin vs epi
  • No difference in survival to discharge (power
    0.8)

33
Vasopressin
  • Wenzel. NEJM 2004. 350(2). P 105-113.
  • DBRCT, N 1186
  • Out-of-hospital vfib/PEA/asystole
  • Vasopressin 40IU vs Epinephrine 1mg
  • Survival all patients AVP EPI P
  • Admission 36 31 .06
  • Discharge 10 10 .99
  • Survival Asystole AVP EPI P NNT
  • Admission 29 20 .02
  • Discharge 4.7 1.5 .04 31

Problem multiple subgroup analysis (29)
suspected type I (alpha) error
34
ALS Tachy/Brady
Circulation 2005112IV-19-34IV-
35
Bradycardia Algorithm
Circulation 2005112IV-67-77IV-
36
Bradycardia Notes
  • No major changes
  • Increased emphasis on early pacing for unstable
    patients
  • Atropine unlikely to work with infranodal
    blocks/escape rhythms
  • 2nd degree type II AVB
  • 3rd degree AVB
  • Wide QRS escape rhythm

37
Tachycardia Algorithm
  • General Comments
  • Much simpler
  • Cardiac function/Ejection Fraction decision
    branches removed
  • Less drugs listed at each box
  • Less emphasis on trying to distinguish Vtach vs
    SVT aberrancy
  • Nice approach ..

38
(No Transcript)
39
ACLS Tachycardia Algorithm
Circulation 2005112IV-67-77IV-
40
Wide QRS Tachycardia
41
AFIB WPW
  • Tijunelis. CJEM 2005. Vol7(4)p. 262-5.
  • Literature review of Afib WPW treated with
    amiodarone
  • No controlled studies
  • 10 case reports
  • 7/10 developed Vfib or unstable VT
  • AMIODARONE NOT SAFE for AFIB WPW
  • CARDIOVERSION is the treatment of choice

42
Part 7.5 Postresuscitation
  • Should we induced hypothermia post cardiac arrest?

43
Induced HypothermiaNEJM Feb 2002 --what is the
evidence?
  • Austrian Study
  • RCT, N136
  • Witnessed VF/pulseless VT
  • Excluded Sats lt 85, hypotension gt 30 min,
    coagulopathy, etc
  • 32-34 degrees X 24hrs
  • Result cool warm NNT
  • Neurofn 6mo 55 39 6
  • Mortality 6mo 41 55 7
  • Australian Study
  • RCT, N77
  • Initial VF rhythm then comatose
  • Excluded SBPlt90 despite epi, non-primary-cardiac
    etiologies
  • 33 degrees X 18hrs
  • Result cool warm NNT
  • Survival 49 26 4
  • Outcome survival to discharge home or
    neurorehab unit

44
Part 7.5 Postresuscitation
  • ACLS 2005 Guideline for Induced Hypothermia
  • Recommended for post Vfib arrest with ROSC but
    remains comatose
  • Consider for non-VF arrest

45
What really matters? CPR/BLS/Defib
Circulation 2005112IV-19-34IV-
46
Why the emphasis on CPR and defibrillation?
  • OPALS study
  • Stiell. NEJM 2004. 351(7). P 647-656.

BLS Rapid Defibrillation
ALS care (ETT,iv,drugs)
N 1391 12 months
N 4247 36 months
47
Why the emphasis on CPR and defibrillation?
  • OPALS study
  • Stiell. NEJM 2004. 351(7). P 647-656.

BLS Rapid Defibrillation
ALS care (ETT,iv,drugs)
Survival to 11 15 p.001 Admission Survival
to 5.0 5.1 p.83 Discharge
48
Why the emphasis on CPR and defibrillation?
  • OPALS study
  • Stiell. NEJM 2004. 351(7). P 647-656.
  • Logistic Regression OR for survival
  • Witnessed arrest 4.4
  • Bystander CPR 3.7
  • AED lt 8min 3.4

49
Take home points
  • One shock (not three) for VF
  • Lower energy with biphasic defibrillators
  • Less emphasis on drugs
  • More emphasis on CPR
  • CPR 302 ratio
  • CPR before defibrillation for response times gt 4
    minutes
  • Quality CPR with minimal interruptions
  • Should we call ourselves CPR-coaches?
  • Why isnt CPR taught in high-school?
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