ACLS Guidelines 2010The rules andchangesPeter Cameron, MDThe Alfred Hospital/MonashUniversityMelbourne, Australia
The New ACLS Guideline • Published online Oct 18 2010 • Published in Circulation Nov 2 2010 • Similar 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 introduced• 1966 first AHA guidelines• 2010 was the 50 anniversary of CPR
Smart People • 356 resuscitation experts • 29 countries • 36 month period • 411 scientific reviews
• “the new recommendations do not imply that care using past guidelines is either unsafe or ineffective”• “still insufficient data to demonstrate that any drugs or mechanical CPR devices improve long-term outcome after cardiac arrest”
ACLS 2010 GuidelineReview • Basic Life Support (BLS) • Cardiac Arrest • Tachycardias • Bradycardias
BLS Principles – DRS ABCD• No change to Dangers and Response• S – Send for help• A – open the Airway• B – check Breathing but no need to deliver two rescue breaths• C – perform 30 Compressions for victims who are unresponsive and not breathing normally, followed by 2 breaths• D – attach an AED as soon as it is available
BLS Principles – DRS ABCD• Compressions before 2 initial rescue breaths• “Signs of life” changed to “unresponsive and not breathing normally”• If unwilling / unable to perform rescue breathing, then perform compression only CPR• New focus on maintenance of CPR quality – change rescuers every two minutes• Pulse check downgraded for HCPs – “unreliable indicator of the need for resuscitation”
BLS – Compressions• One 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 / min• Allow 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 – <18 seconds/cycle) – Two Rescuer: Adult – 30:2 at rate of 100 per minute – Two Rescuer: Child (0-14) 15:2 at rate of 100 per minute (Approx 10 cycles every 2 minutes)• Pause to allow ventilations (until intubated or LMA insitu)
BLS – Health Professional (Cont)• AED - Apply and follow the prompts• Continue until signs of life – briefly check (?pulse) every two minutes (don’t pause CPR for more than 10 seconds!!)• Change compressor every 2 minutes to avoid fatigue
AED• AED - Single shock strategy• 2 minutes CPR before reanalysis• No need to reprogram energy levels – should follow those programmed by manufacturer for their specific device• Reasonable to continue to utilise older devices until replaced as part of normal life cycle – any resuscitation is better than none
CPR Changes Emphasise “Push hard, push fast, minimise interruptions; allow full chest recoil, and don’t hyperventilate”
Rationale • Although 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 Depths • Compression 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 & Breathing • Cricoid pressure is no longer routinely recommended for use with ventilations • Randomized control trials demonstrated cricoid pressure still allows for aspiration. It is also difficult to train providers to perform the maneuver correctly.
ALS Principles• To provide critical blood flow to the vital organs with high quality chest compressions• Defibrillation 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 possible• Intensive care support aimed to achieve the best outcomes
ALS Principles – Key revisions I• High quality chest compressions with minimal interruptions; continuing compressions during defibrillator charging• Single (non-stacked) shocks, but stacked shocks may be considered for HPC witnessed arrest*, during cardiac catheterisation or after cardiac surgery• Precordial thump is de-emphasised• IV or IO drug administration (ETT de-emphasised) *Where a monitor / defibrillator is connected at the time
ALS Principles – Key revisions II • Adrenaline 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 shock • Atropine no longer recommended for routine use in asystole or PEA • Less emphasis on early intubation • Capnography to confirm and continually monitor tracheal tube placement, quality of CPR, and to provide early indication of ROSC
Post Resuscitation Care• Recognition that a “post resuscitation care’ protocol may improve survival following ROSC• Avoid hyperoxaemia – oxygen titration to Sa02 94-98%• Primary PCI in appropriate patients with sustained ROSC• Normoglycaemic 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 DefibrillationStrategy• Single shock strategy continues to be recommended to improve outcome by reducing interruption of chest compressions – Monophasic 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 – Keyrevisions I• Recognition 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 adult• IV or IO drug administration (ETT de-emphasised)• Cuffed tracheal tubes ok for short term
Newborn Resuscitation I• For 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 II• Adrenaline 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 resuscitation• Capnography most reliable method to confirm and continually monitor tracheal tube placement in neonates with spontaneous circulation
Defibrillation • AFIB 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 Use • Children 1-8yrs, pediatric dose attenuator should be used if available. Otherwise, standard AED may be used. • Infants (1<yr) a manual defibrillator is preferred over above option.
• 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 Fib • Shock 200 J every 2 minutes • CPR for 2 minutes while admin Rx • Ventilate, IV Epi, Amiodarone 300mg
The Rationale • True 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 needed • Supplementary 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 it’s 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 Breathing • Continuous 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.
SUMMARY• Look, listen, feel - removed• Healthcare providers briefly check for breathing when checking responsiveness to detect signs of cardiac arrest.• After delivery of 30 compressions, lone rescuers open the victim’s airway and deliver 2 breaths.• Encourage hands only CPR for untrained• “Continuous” CPR for advanced providers• Do GREAT CPR• AND C-A-B - radical but rational!
CARDIAC ARREST• A few changes in emphasis…
IV • “ provision of high-quality CPR and rapid defibrillation are of primary importance and drug administration is of secondary importance” • 20ml Bolus after drug
IO Access • Reasonable to establish access if IV access is not readily available
Emergence of SupraglotticDevices • CPR more important than airway initially • Put in a supraglottic if intubation is going to be “hard” • LMA • King LT
Capnography • 100% sensitive and specific for tracheal intubation • Helps count 8-10 breaths minute • Predictor of outcome
No Atropine in PEA/Asystole • “Available evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit”
Drugs= Transcutaneous Pacing • It hurts! • No better than drugs • Ok to go from drugs to TV pacing • NOT ROUTINE in arrest
Vasopressors • VF continues after epi and CPR - vasopressor • Amiodarone is first line • Not proven to result in long term outcome • Lidocaine is useless also
Epinephrine • Never any evidence that it works! • Abstract 1: A Randomized placebo controlled trial of adrenaline in cardiac arrest- the PACA trial • Conclusion: 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.
SUMMARY• Atropine OUT for PEA/Asystole• CPR first and fast• Airway- supraglottic emerges• Still have amiodarone even though it don’t work• Hope lies in a reversible cause
Pearl 1: Don’tcardiovert to sinusrhythm
Pearl 2: Rates<150 don’t usuallycause instability in normal healthyhearts
Pearl 3: Manyarrhythmias caused byhypoxia- Fix that first
Pearl 4: If unstable use electricity- exceptnarrow complex when adenosine may beok
Pearl 5: IF THEY ARE PRETTYSTABLE - GET A 12 LEAD ECG
Adenosine vs. CCB • “ More rapid and less severe side effects than calcium blockers”
Adenosine in Wide ComplexTachycardia • “recent evidence suggests that adenosine is relatively safe for both treatment and diagnosis”
Adenosine • May 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/Comments • Not for irregular or polymorphic • SVT should slow or convert • VT usually will not
Wide, Regular, Stable OtherChoices • Cardioversion, Procainamide, Amiodarone, Sotalol • Generally only try one! • Procaine 20-50mg/hour (17mg/kg or QRS 50% narrowed, or hypotension)
Wide Complex Regular:Amiodarone • An option- better than lidocaine • 150 mg IV over 10 minutes Can repeat 2.2 g IV total in 24 hours
Morphine • Morphine 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.
Atropine • Atropine is not recommended for PEA/Asystole. • Use of atropine unlikely to have a therapeutic benefit
Atropine • First Dose-->0.5mg bolus • Repeat every 3-5 minutes • Max Dose 3mg
If Atropine Fails • Transcutaneous Pacing • or • Dopamine 2-10 mcg per minute • Epinephrine 2-10mcg per minute
When NOT to use Atropine • Cardiac Transplant- ineffective or brady • Wide complex Type 2 or 3 blocks
Chronotropic Drugs • For 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 PEA • Hypoxia • Tension PTX • Hypovolemia • Cardiac Tamponade • Toxic-Metabolic
EMD- PEA 5 Step Management • Oxygenate and Ventilate • Secure IV Access • Look for 3 Causes (ECG, Temp, Vol status) • Epinephrine (1mg q 3mins) • Review all 5 causes
5 Possible Ultrasound Findings • Tamponde • Hypovolemia • Massive PE • Cardiogenic Shock • Normal->Lung view
Causes of PEA- 4 chamber view • Pericardial Effusion + RV Strain=Tamponade • RV Strain=LV Strain=Hypovolemia • RV dil + RA dil vs LV Strain=PE • Poor contractility= Cardiogenic Shock • Nl = Lung view
Implementation• Current Guidelines still OK• Up to each organisation to determine when to implement changes