The document summarizes the key updates to the 2015 American Heart Association (AHA) Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Some of the main updates include: emphasizing high-quality chest compressions at a rate of 100-120/min and depth of at least 2 inches; administering epinephrine as soon as possible for non-shockable rhythms; using an end-tidal carbon dioxide level below 10 mmHg after 20 minutes of CPR to predict low likelihood of resuscitation; performing targeted temperature management at 32-36°C for at least 24 hours on all comatose cardiac arrest patients; and considering percutaneous coronary intervention emergently for out-

1. ACLS Guidelines 2015
Wanda Rivera Bou MD, FAAEM, FACEP
Assistant Professor
Department of Emergency Medicine
University of Puerto Rico School of Medicine
AHA - ACLS National Faculty

2. Disclosure Information
Wanda Rivera Bou, MD
■ I have no financial relationships with drug or
device manufacturing companies

3. Objectives: Will discuss
n Identify the ACLS 2015 science updates
n Describe the rationale for the science
updates
n Therapeutic interventions

4. International Liaison Committee on
Resuscitation

5. Highlights of the 2015 AHA Guidelines Update for CPR and ECC

6. New AHA Adult Chains of Survival
IN-HOSPITAL
(note new Surveillance
and Prevention link)
OUT OF HOSPITAL
Including EMS

7. Adult BLS and CPR Quality
n There is continued emphasis on the
characteristics of high-quality CPR:
l compressing the chest at an adequate rate and depth
l allowing complete chest recoil after each compression
l minimizing interruptions in compressions
l avoiding excessive ventilation

8. Chest Compression Rate
n It is reasonable to perform compressions at a
rate of 100-120/min
Idris A.H et al, Circulation. 2012;125:3004-3012
ü Observational study
ü Dec, 2005 – May, 2007
ü Sharp decline in survival
Metronome
with rate > 140/min

11. Idris et al, Critical Care Medicine, 2015:43 (4): 840
Rapid Compression Rate can
Compromise Depth

12. Chest Compression Depth
n Chest compression to at least 2 inches (5 cm),
avoiding chest compression depths > 2.4
inches (6 cm)
Stiell I.G et al, Circulation. 2014;130:1962-1970
Small study: more injuries with
compressions greater than 2.4
inches (6cm).
(Hellevuo et al, Resuscitation, 2013)
•Difficult to judge depth
without devices
•Rescuers typically don’t
“push hard” enough

13. Highlights of the 2015 AHA Guidelines Update for CPR and ECC
BLS for
HCP

14. For BLS and ACLS algorithms, please referred to
http://eccguidelines.heart.org

15. Bystander CPR
Early CPR Increases Survival

17. Adult BLS and CPR Quality
n Minimizing interruptions with a goal of chest
compression fraction of at least 60%
n CCF = It is the percentage of time in which
chest compressions are done by rescuers
during a cardiac arrest
n Fewer pauses in CPR increase the chances of
surviving a cardiac arrest (less than 10 sec)

18. Ventilation During CPR with an
Advanced Airway
n It would be reasonable to deliver 1 breath
every 6 sec (10 breath/min)

19. ACLS Summary of Key Issues (New)
n Vasopressin and Epinephrine
n ETCO2 for Prediction of Fail Resuscitation
n Steroids (ICHA and OCHA)
n B-Adrenergic Blocking Drugs
n Lidocaine
n PCI
n ECMO
n Targeted Temperature Management

20. Vasopressin and Epinephrine
n Vasopressin was removed for simplicity
n No benefit of vasopressin over epinephrine
n Epinephrine - timing of administration
l It is reasonable to administer as soon as possible
after the onset of cardiac arrest due to an initial
nonshockable rhythm (PEA/Asystole)

21. n Low ETCO2 (< 10 mmHg) in intubated pts
after 20 mins of CPR is associated with a low
likelihood of resuscitation (shouldn’t be used
in isolation)
ETCO2

22. Steroids
n There are no data to recommend for or
against the routine use alone for IHCA (Class
IIb, LOE C-LD)
n Uncertain benefit for OHCA

23. Post-Cardiac Arrest Drug Therapy:
New
n B-blocker
l There is inadequate evidence to support routine use
after cardiac arrest
n Lidocaine
l There is inadequate evidence to support the routine
use after cardiac arrest

24. PCI
n Should be performed emergently for OHCA pts
with suspected cardiac etiology and STEMI
(Class I, LOE B-NR)
n Reasonable for select pts after OHCA with
suspected cardiac etiology but w/o STE on ECG
(Class II a, LOE B-NR)
n Reasonable in post-cardiac arrest pts for whom
angiography is indicated regardless of whether
is comatose or awake (Class II a, LOE C-LD)

25. ECMO
n May be considered for select pts, in settings
where it can be rapidly implemented (Class
IIb, LOE C-LD)

26. Targeted Temperature
Management
n All comatose pts with ROSC should have a
TTM for at least 24 hrs
l TT between 32ºC-36ºC, maintained constantly
n Continuing TM beyond 24 hrs
l Is reasonable in comatose pts to actively prevent
fever
n Out of Hospital Cooling
l Not recommended
Nielsen N. et al, N Engl J Med. 2013;369:2197-2206

27. PROGNOSTICATION for poor
outcome USING CLINICAL EXAM
n The earliest time for prognostication in pts
treated with TTM, may be 72 hrs after return
of normothermia (Class II b, LOE C-EO)
n The earliest time for prognostication in pts not
treated with TTM is 72 hrs after cardiac arrest
(Class I, LOE B-NR)

28. Updated Recommendations:
Special Circumstances
n Naloxone administration in combination with
BLS care for opioid-associated life-threatening
emergencies
n Intravenous lipid emulsion considered for
treatment of local anesthetic systemic toxicity
n Refined recommendations regarding uterine
displacement for CPR during pregnancy

29. Take-Home Messages
n Lay provider care saves lives
n Defibrillation as early as possible
n Medications have modest benefit
n Advanced Airway is a lower priority early in
cardiogenic arrest
l If performed, don’t interrupt more important
interventions (compressions, defibrillation)

30. Take-Home Messages
n Post-resuscitation care is a key component of
management
l Targeted Temperature Management
l Coronary Reperfusion
n Do not forget your basic critical care skills

31. wandabou@me.com