Transcript ACLS 2005

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, arrythmia algorithms, post –
resusc care
• Briefly review some Landmark papers.
• AEDs, ACS, CVA, toxicology and other special
resusc situations not included
ACLS 2005 Guidelines
VISIT www.circulationha.org
Circulation 2005. Dec 13: 112(24):
p3667-3813 and Supp 11: p 1-211.
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
CPR/BLS
Circulation 2005;112:IV-19-34IV-
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
• <1year, 1-8 year, >8 year (Lay rescuer)
• <1year, 1-adolescent, >adolescent to adult (HCP)
Part 3/4: CPR/Adult BLS
• Ventilations
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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
Part 3/4: CPR/Adult BLS
• Compressions
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–
–
–
–
–
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
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
ACLS 2005
Compress/
Ventilation ratio
Adult/
Adolescent
Child
Infant
Single
Layperson
30:2
30:2
30:2
Double
Layperson
30:2
30:2
30:2
Single HCP
30:2
30:2
30:2
Double HCP
30:2
15:2
15:2
After Advanced Airway Device Placed:
100 compression/min
10 breaths per minute (unsynchronized)
ACLS 2005
Compress/
Ventilation ratio
Adult/
Adolescent
Child
Infant
Single
Layperson
30:2
30:2
30:2
Double
Layperson
30:2
30:2
30:2
Single HCP
30:2
30:2
30:2
Double HCP
30:2
15:2
15:2
After Advanced Airway Device Placed:
100 compression/min
10 breaths per minute (unsynchronized)
Adult BLS Healthcare
Provider Algorithm
Circulation 2005;112:IV-19-34IV-
Electrical Therapies
Circulation 2005;112:IV-19-34IV-
Part 5: Electrical Therapy
Defibrillators
Monophasic
Biphasic
Rectilinear
Truncated Exponential
Part 5: Electrical Therapy
Truncated
Exponential
Rectilinear
Biphasic = increased ROSC, no increase
Survival to hospital discharge
Lifepak
• 12 and 20 are both biphasic (truncated
exponential)
Recommended Energy for
Defibrillation
Energy
Monophasic
Biphasic
Rectilinear
Biphasic
Truncated
Exponential
Biphasic
Unknown
1st shock
360J
120J
150J
200J
Subsequent
shocks
360J
= or >
120J
= or >
150J
= or >
200J
Peds: 2 J/kg then 4 J/kg
Lifepak 12 and 20
Timing of Defibrillation
• Shock First vs CPR First?
Evidence for CPR before
defibrillation
• Cobb JAMA 1999
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Prospective observational trial, N=1117
Pre-intervention = defibrillate ASAP
Post-intervention = 90 sec CPR before defib
Survival to d/c
Defib First CPR First
P
• Overall
• Response < 4min
• Response > 4min
24%
31%
17%
30%
32%
27%
.04
.87
.007
NNT
16
10
Evidence for CPR before
defibrillation
• Wik JAMA 2003
– Randomized clinical trial, N=200
– Defibrillate ASAP vs CPR X 3 min before defibrillation
– Survival to d/c
Defib First CPR First
P
NNT
• Overall
• Response < 5min
• Response > 5min
A priori subgroup analysis
15%
29%
4%
22%
23%
22%
.17
.61
.006
5.5
Evidence for CPR before
defibrillation
• Jacobs. Emerg Med Australasia. Feb 2005.
– Randomized clinical trial, N=256
– Defibrillate ASAP vs CPR X 90 sec before defibrillation
– Survival to d/c
Defib First CPR First OR 95%CI
• Overall
– Survival to d/c
5.1%
4.2%
.81
Defib First CPR First P
• Response < 5min
• Response > 5min
Post hoc subgroup analysis
0%
4.9%
12%
3.5%
.25
.74
(.3-2.6)
Timing of Defibrillation
• ACLS 2005 Recommendation
– CPR X 5 cycles of 30:2 (about 2 min)
recommended for out-of-hospital VF arrest
• Response time > 4-5 minutes
• Unwitnessed
ALS
Circulation 2005;112:IV-19-34IV-
Part 7.2: Management of
Cardiac Arrest
• ACLS Pulseless Algorithm 2005
– Vfib Algorithm
– PEA Algorithm
– Asystole Algorithm
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Notes on VF and pulseless VT
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•
•
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CPR 30:2 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;
112:IV-58-66IV-
Amiodarone for Vfib/pulseless VT
• ARREST TRIAL
• DBRCT, N=504
• Amio vs Placebo
• Survival
– Admission
– Discharge
PL Amio
• ALIVE TRIAL
• DBRCT, N = 347
• Amio vs Lidocaine
P
34% 44%
.03
13.4% 13.2% NS
Kudenchuk et. al. NEJM 1999. 341(12): p.871.
• Survival Lido Amio
– Admission
– Discharge
P
12% 23% .009
3.8% 6.8% NS
Dorian et. al. NEJM 2002. 346(12): p.884.
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
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Why Vasopressin?
Or why not……
• Linder. Lancet 1997.
– N=40, out of hospital Vfib, vasopressin vs epi
– Increased survival to admission not discharge
• Stiell. Lancet 2001.
– N=200, in-hospital Vfib/PEA/asystole
– Vasopressin vs epi
– No difference in survival to discharge (power
0.8)
Vasopressin
• Wenzel. NEJM 2004. 350(2). P 105-113.
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–
–
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DBRCT, N= 1186
Out-of-hospital vfib/PEA/asystole
Vasopressin 40IU vs Epinephrine 1mg
Survival all patients
AVP EPI
• Admission
• Discharge
– Survival Asystole
• Admission
• Discharge
P
36%
10%
31%
10%
.06
.99
AVP
EPI
P NNT
29%
4.7%
20%
1.5%
.02
.04 31
Problem = multiple subgroup analysis (29);
suspected type I (alpha) error
ALS
Tachy/Brady
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Bradycardia Algorithm
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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
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 …………..
ACLS 2005 Approach
Tachycardia
STABLE
Narrow
Regular
Irregular
UNSTABLE
Cardiovert
Wide
Regular
Irregular
ACLS Tachycardia Algorithm
Circulation 2005;112:IV-67-77IV-
Wide QRS Tachycardia
Stable
Wide QRS
Regular
Irregular
Vtach
Regular SVT + aberrancy
Torsades
Irregular SVT + abberancy
Amiodarone
Cardioversion
Torsades
AFIB + BBB
AFIB + WPW
Adenosine for SVT+a
Procaine a 1st line option
Lidocaine NOT 1st line
Sotalol NOT 1st line
Defibrillate
Magnesium
Stop Rx, correct lytes,
treat ischemia
Treat as per Afib
AVOID AVN blockers
Amidarone
Prolonged QTc:
Pacing, isoproterenol,
Lidocaine
Normal baseline QTc:
Amio or Lidocaine
AFIB + WPW
• Tijunelis. CJEM 2005. Vol7(4)p. 262-5.
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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
Part 7.5: Postresuscitation
• Should we induced
hypothermia post cardiac
arrest?
Induced Hypothermia:
NEJM Feb 2002 --what is the evidence?
• Austrian Study
– RCT, N=136
– Witnessed VF/pulseless VT
– Excluded: Sats < 85%, hypotension
> 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, N=77
– Initial VF rhythm then comatose
– Excluded: SBP<90 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
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
What really matters?
CPR/BLS/Defib
Circulation 2005;112:IV-19-34IV-
Why the emphasis on CPR and
defibrillation?
• OPALS study
– Stiell. NEJM 2004. 351(7). P 647-656.
BLS + Rapid Defibrillation
N = 1391
12 months
ALS care (ETT,iv,drugs)
N = 4247
36 months
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
Admission
11%
15%
p.001
Survival to
Discharge
5.0%
5.1%
p.83
Why the emphasis on CPR and
defibrillation?
• OPALS study
– Stiell. NEJM 2004. 351(7). P 647-656.
– Logistic Regression
OR for survival
• Witnessed arrest
• Bystander CPR
• AED < 8min
4.4
3.7
3.4
Take home points
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•
•
•
One shock (not three) for VF
Lower energy with biphasic defibrillators
Less emphasis on drugs
More emphasis on CPR
– CPR 30:2 ratio
– CPR before defibrillation for response times > 4
minutes
– Quality CPR with minimal interruptions
– Should we call ourselves CPR-coaches?
– Why isn’t CPR taught in high-school?