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2015 American Heart Association Guidelines Update
for Cardiopulmonary Resuscitation and
Emergency Cardiovascular Care
Part 9: Acute Coronary Syndromes
Part 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 Syndromes
Diagnostic 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 STEMI
Notification
receiving
hospital
+/- activate catherization lab
Reperfusion
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).
Part 9: Acute Coronary Syndromes
Diagnostic Interventions in ACS
Computer Human
Nonphysician STEMI ECG Interpretation
While transmission of the prehospital ECG to the ED physician
may 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 nonphysician
ECG 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).
Part 9: Acute Coronary Syndromes
Diagnostic Interventions in ACS
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)
Biomarker
Clinical risk
stratification
Part 9: Acute Coronary Syndromes
Diagnostic Interventions in ACS
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 stratification
TIMI score of 0
Low-risk score per vancouver rule
North american chest pain score of 0 and age less
than 50 years
Low-risk HEART score
Part 9: Acute Coronary Syndromes
Diagnostic Interventions in ACS
Part 9: Acute Coronary Syndromes
 Diagnostic Interventions in ACS
 Therapeutic Interventions in ACS
 Reperfusion Decisions in STEMI Patients
 Hospital Reperfusion Decisions After ROSC
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 the
prehospital or in-hospital setting (Class IIb, LOE C-LD).
Part 9: Acute Coronary Syndromes
Therapeutic 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, prehospital
administration 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).
EMS
X Heparin
Heparin Heparin
X Heparin
Current practice in
suspected STEMI
Part 9: Acute Coronary Syndromes
Therapeutic Interventions in ACS
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 prehospital
or in-hospital setting (Class IIb, LOE B-NR).
STEMI
Planned PPCI
UFH
Prehospital or
In-hospital
Part 9: Acute Coronary Syndromes
Therapeutic Interventions in ACS
UFH
Prehospital or
In-hospital
Prehospital Anticoagulants for STEMI
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).
UFH
Prehospital or
In-hospital
Bivalirudin
Case with risk of bleeding
Part 9: Acute Coronary Syndromes
Therapeutic Interventions in ACS
STEMI
Planned PPCI Target thrombin inhibitor
UFH
Prehospital or
In-hospital
Prehospital Anticoagulants for STEMI
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).
UFH
Prehospital or
In-hospital
Enoxaparin
alternative
Part 9: Acute Coronary Syndromes
Therapeutic Interventions in ACS
STEMI
Planned PPCI
Bivalirudin
Case with risk of bleeding
Routine Supplementary Oxygen Therapy in
Patients Suspected of ACS
The provision of supplementary oxygen to patients suspected ACS who are normoxic
has 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 normoxic
patients. 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).
Normoxic
ACS patient
O2
Part 9: Acute Coronary Syndromes
Therapeutic Interventions in ACS
Part 9: Acute Coronary Syndromes
 Diagnostic Interventions in ACS
 Therapeutic Interventions in ACS
 Reperfusion Decisions in STEMI Patients
 Hospital Reperfusion Decisions After ROSC
Prehospital triage
Transport directly
Prehospital Fibrinolysis, Hospital Fibrinolysis, and
Prehospital 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 prehospital
fibrinolysis 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).
Prehospital
Fibrinolysis
in-hospital = alternative tx
transport time > 30 min
PCI center
available center
Part 9: Acute Coronary Syndromes
Reperfusion 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
Part 9: Acute Coronary Syndromes
Reperfusion Decisions in STEMI Patients
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).
Part 9: Acute Coronary Syndromes
Reperfusion Decisions in STEMI Patients
PCI
Onset < 12 hr
Time to PCI < 120 min
Delayed PCI VS Fibrinolysis Stratified by Time from Symptom onset
In STEMI patients presenting within 2 hours of symptom onset, immediate fibrinolysis
rather than PPCI may be considered when the expected delay to PPCI is more than 60
minutes (Class IIb, LOE C-LD).
Part 9: Acute Coronary Syndromes
Reperfusion Decisions in STEMI Patients
Fibrinolysis
Onset < 2 hr
Expected delay to PCI > 60min
Delayed PCI VS Fibrinolysis Stratified by Time from Symptom onset
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).
Part 9: Acute Coronary Syndromes
Reperfusion Decisions in STEMI Patients
Immediate
Fibrinolysis
Onset 2-3 hr
PCI
Possible delay 60 -120 min
OR
Delayed PCI VS Fibrinolysis Stratified by Time from Symptom onset
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 initial
fibrinolysis (Class IIb, LOE C-LD).
Part 9: Acute Coronary Syndromes
Reperfusion Decisions in STEMI Patients
PCI
Onset 3- 12 hr
Time to PCI < 120 min
> 6 hours after symptom onset
Fibrinolysis significantly less effective
Longer delay to PPCI may be the better option
Delayed PCI VS Fibrinolysis Stratified by Time from Symptom onset
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).
Part 9: Acute Coronary Syndromes
Reperfusion Decisions in STEMI Patients
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 fibrinolysis
from 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
1
Part 9: Acute Coronary Syndromes
Reperfusion Decisions in STEMI Patients
Reperfusion Therapy for STEMI in Non–PCI-Capable Hospitals
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).
Immediate
transfer
 Fibrinolysis
Non–PCI-
Capable
Hospitals
2 PCI center
alternative
Part 9: Acute Coronary Syndromes
Reperfusion Decisions in STEMI Patients
Reperfusion Therapy for STEMI in Non–PCI-Capable Hospitals
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).
Part 9: Acute Coronary Syndromes
Reperfusion Decisions in STEMI Patients
Part 9: Acute Coronary Syndromes
 Diagnostic Interventions in ACS
 Therapeutic Interventions in ACS
 Reperfusion Decisions in STEMI Patients
 Hospital Reperfusion Decisions After ROSC
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 Syndromes
Hospital Reperfusion Decisions After ROSC
PCI After ROSC With and Without ST Elevation
CAG
OHCA + + ST elevation
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
Part 9: Acute Coronary Syndromes
Hospital Reperfusion Decisions After ROSC
PCI After ROSC With and Without ST Elevation
CAG
OHCA + + ST elevation
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 9: Acute Coronary Syndromes
Hospital Reperfusion Decisions After ROSC
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
1
2
3
4
5
Part 10: Special Circumstances of Resuscitation
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
1
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 aortocaval
compression
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).
ALS Modification: Emergency Cesarean Delivery in Cardiac Arrest
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
ALS Modification: Emergency Cesarean Delivery in Cardiac Arrest
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 embolectomy
are 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)
Part 10: Special Circumstances of Resuscitation
2
Suspected Pulmonary Embolism
Thrombolysis may be considered when cardiac arrest is suspected
to 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).
Part 10: Special Circumstances of Resuscitation
3
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).
10.3 : Cardiac or Respiratory Arrest Associated with
Opioid Overdose
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).
10.3 : Cardiac or Respiratory Arrest Associated with
Opioid Overdose
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 Arrest
no definite pulse
cardiac arrest
undetected weak or slow pulse.
Managed as cardiac arrest patients.
Standard resuscitative measures should take priority over naloxone
administration (Class I, LOE C-EO), with a focus on high-quality CPR
10.3 : Cardiac or Respiratory Arrest Associated with
Opioid Overdose
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 naloxone
administration should access advanced healthcare services (Class I, LOE C-EO).
Healthcare Provider BLS Modification: Administration of Naloxone
10.3 : Cardiac or Respiratory Arrest Associated with
Opioid Overdose
Respiratory Arrest
 Support ventilation
 Naloxone
Bag-mask ventilation until spontaneous breathing returns
Standard ACLS measures  if return of spontaneous breathing does not occur
(Class I, LOE C-LD).
ACLS Modification: Administration of Naloxone
Cardiac Arrest
We 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
10.3 : Cardiac or Respiratory Arrest Associated with
Opioid Overdose
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).
Observed
Until…
• 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.
Recurrent
Opioid toxicity
• may be considered in order to achieve
the specific therapeutic goals of reversing the
effects of long-acting opioids (Class IIb, LOEC-EO).
Naloxone
in post cardiac arrest
10.3 : Cardiac or Respiratory Arrest Associated with
Opioid Overdose
10.3 : Cardiac or Respiratory Arrest Associated with
Opioid Overdose
1669
10.3 : Cardiac or Respiratory Arrest Associated with
Opioid Overdose
1669
10.3 : Cardiac or Respiratory Arrest Associated with
Opioid Overdose
10.3 : Cardiac or Respiratory Arrest Associated with
Opioid Overdose
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).
Part 10: Special Circumstances of Resuscitation
4
Intravenous Lipid
Emulsion
Local anesthetic
systemic toxicity
Bupivacaine toxicity
neurotoxicity 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
Part 10: Special Circumstances of Resuscitation
5

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CPR2015 update: ACS and Special circumstances

  • 1. 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Part 9: Acute Coronary Syndromes Part 10: Special Circumstances of Resuscitation
  • 2. Part 9: Acute Coronary Syndromes  Diagnostic Interventions in ACS  Therapeutic Interventions in ACS  Reperfusion Decisions in STEMI Patients  Hospital Reperfusion Decisions After ROSC
  • 3. Part 9: Acute Coronary Syndromes Diagnostic 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 STEMI Notification receiving hospital +/- activate catherization lab Reperfusion strategy
  • 4. 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). Part 9: Acute Coronary Syndromes Diagnostic Interventions in ACS Computer Human
  • 5. Nonphysician STEMI ECG Interpretation While transmission of the prehospital ECG to the ED physician may 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 nonphysician ECG 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). Part 9: Acute Coronary Syndromes Diagnostic Interventions in ACS Consult ECG Train
  • 6. 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) Biomarker Clinical risk stratification Part 9: Acute Coronary Syndromes Diagnostic Interventions in ACS
  • 7. 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 stratification TIMI score of 0 Low-risk score per vancouver rule North american chest pain score of 0 and age less than 50 years Low-risk HEART score Part 9: Acute Coronary Syndromes Diagnostic Interventions in ACS
  • 8. Part 9: Acute Coronary Syndromes  Diagnostic Interventions in ACS  Therapeutic Interventions in ACS  Reperfusion Decisions in STEMI Patients  Hospital Reperfusion Decisions After ROSC
  • 9. 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 the prehospital or in-hospital setting (Class IIb, LOE C-LD). Part 9: Acute Coronary Syndromes Therapeutic Interventions in ACS Clopidrogel
  • 10. 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, prehospital administration 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). EMS X Heparin Heparin Heparin X Heparin Current practice in suspected STEMI Part 9: Acute Coronary Syndromes Therapeutic Interventions in ACS
  • 11. 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 prehospital or in-hospital setting (Class IIb, LOE B-NR). STEMI Planned PPCI UFH Prehospital or In-hospital Part 9: Acute Coronary Syndromes Therapeutic Interventions in ACS UFH Prehospital or In-hospital
  • 12. Prehospital Anticoagulants for STEMI 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). UFH Prehospital or In-hospital Bivalirudin Case with risk of bleeding Part 9: Acute Coronary Syndromes Therapeutic Interventions in ACS STEMI Planned PPCI Target thrombin inhibitor UFH Prehospital or In-hospital
  • 13. Prehospital Anticoagulants for STEMI 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). UFH Prehospital or In-hospital Enoxaparin alternative Part 9: Acute Coronary Syndromes Therapeutic Interventions in ACS STEMI Planned PPCI Bivalirudin Case with risk of bleeding
  • 14. Routine Supplementary Oxygen Therapy in Patients Suspected of ACS The provision of supplementary oxygen to patients suspected ACS who are normoxic has 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 normoxic patients. 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). Normoxic ACS patient O2 Part 9: Acute Coronary Syndromes Therapeutic Interventions in ACS
  • 15. Part 9: Acute Coronary Syndromes  Diagnostic Interventions in ACS  Therapeutic Interventions in ACS  Reperfusion Decisions in STEMI Patients  Hospital Reperfusion Decisions After ROSC
  • 16. Prehospital triage Transport directly Prehospital Fibrinolysis, Hospital Fibrinolysis, and Prehospital 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 prehospital fibrinolysis 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). Prehospital Fibrinolysis in-hospital = alternative tx transport time > 30 min PCI center available center Part 9: Acute Coronary Syndromes Reperfusion Decisions in STEMI Patients
  • 17. 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 Part 9: Acute Coronary Syndromes Reperfusion Decisions in STEMI Patients
  • 18. 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). Part 9: Acute Coronary Syndromes Reperfusion Decisions in STEMI Patients PCI Onset < 12 hr Time to PCI < 120 min
  • 19. Delayed PCI VS Fibrinolysis Stratified by Time from Symptom onset In STEMI patients presenting within 2 hours of symptom onset, immediate fibrinolysis rather than PPCI may be considered when the expected delay to PPCI is more than 60 minutes (Class IIb, LOE C-LD). Part 9: Acute Coronary Syndromes Reperfusion Decisions in STEMI Patients Fibrinolysis Onset < 2 hr Expected delay to PCI > 60min
  • 20. Delayed PCI VS Fibrinolysis Stratified by Time from Symptom onset 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). Part 9: Acute Coronary Syndromes Reperfusion Decisions in STEMI Patients Immediate Fibrinolysis Onset 2-3 hr PCI Possible delay 60 -120 min OR
  • 21. Delayed PCI VS Fibrinolysis Stratified by Time from Symptom onset 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 initial fibrinolysis (Class IIb, LOE C-LD). Part 9: Acute Coronary Syndromes Reperfusion Decisions in STEMI Patients PCI Onset 3- 12 hr Time to PCI < 120 min > 6 hours after symptom onset Fibrinolysis significantly less effective Longer delay to PPCI may be the better option
  • 22. Delayed PCI VS Fibrinolysis Stratified by Time from Symptom onset 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). Part 9: Acute Coronary Syndromes Reperfusion Decisions in STEMI Patients immediate fibrinolysis Early CAG STEMI Time to PCI > 120 min
  • 23. 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 fibrinolysis from 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 1 Part 9: Acute Coronary Syndromes Reperfusion Decisions in STEMI Patients
  • 24. Reperfusion Therapy for STEMI in Non–PCI-Capable Hospitals 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). Immediate transfer  Fibrinolysis Non–PCI- Capable Hospitals 2 PCI center alternative Part 9: Acute Coronary Syndromes Reperfusion Decisions in STEMI Patients
  • 25. Reperfusion Therapy for STEMI in Non–PCI-Capable Hospitals 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). Part 9: Acute Coronary Syndromes Reperfusion Decisions in STEMI Patients
  • 26. Part 9: Acute Coronary Syndromes  Diagnostic Interventions in ACS  Therapeutic Interventions in ACS  Reperfusion Decisions in STEMI Patients  Hospital Reperfusion Decisions After ROSC
  • 27. 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 Syndromes Hospital Reperfusion Decisions After ROSC
  • 28. PCI After ROSC With and Without ST Elevation CAG OHCA + + ST elevation 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 Part 9: Acute Coronary Syndromes Hospital Reperfusion Decisions After ROSC
  • 29. PCI After ROSC With and Without ST Elevation CAG OHCA + + ST elevation 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 9: Acute Coronary Syndromes Hospital Reperfusion Decisions After ROSC
  • 30. 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 1 2 3 4 5
  • 31. Part 10: Special Circumstances of Resuscitation 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 1
  • 32. 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 aortocaval compression
  • 33. 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).
  • 34. ALS Modification: Emergency Cesarean Delivery in Cardiac Arrest 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
  • 35. ALS Modification: Emergency Cesarean Delivery in Cardiac Arrest 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).
  • 36. Cardiac Arrest Associated with Pulmonary Embolism Confirmed Pulmonary Embolism Thrombolysis, surgical embolectomy, and mechanical embolectomy are 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) Part 10: Special Circumstances of Resuscitation 2 Suspected Pulmonary Embolism Thrombolysis may be considered when cardiac arrest is suspected to be caused by PE (Class IIb, LOE C-LD).
  • 37. 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). Part 10: Special Circumstances of Resuscitation 3
  • 38. 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).
  • 39. 10.3 : Cardiac or Respiratory Arrest Associated with Opioid Overdose 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).
  • 40. 10.3 : Cardiac or Respiratory Arrest Associated with Opioid Overdose 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 Arrest no definite pulse cardiac arrest undetected weak or slow pulse. Managed as cardiac arrest patients. Standard resuscitative measures should take priority over naloxone administration (Class I, LOE C-EO), with a focus on high-quality CPR
  • 41. 10.3 : Cardiac or Respiratory Arrest Associated with Opioid Overdose 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 naloxone administration should access advanced healthcare services (Class I, LOE C-EO). Healthcare Provider BLS Modification: Administration of Naloxone
  • 42. 10.3 : Cardiac or Respiratory Arrest Associated with Opioid Overdose Respiratory Arrest  Support ventilation  Naloxone Bag-mask ventilation until spontaneous breathing returns Standard ACLS measures  if return of spontaneous breathing does not occur (Class I, LOE C-LD). ACLS Modification: Administration of Naloxone Cardiac Arrest We 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
  • 43. 10.3 : Cardiac or Respiratory Arrest Associated with Opioid Overdose 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). Observed Until… • 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. Recurrent Opioid toxicity • may be considered in order to achieve the specific therapeutic goals of reversing the effects of long-acting opioids (Class IIb, LOEC-EO). Naloxone in post cardiac arrest
  • 44. 10.3 : Cardiac or Respiratory Arrest Associated with Opioid Overdose
  • 45. 10.3 : Cardiac or Respiratory Arrest Associated with Opioid Overdose 1669
  • 46. 10.3 : Cardiac or Respiratory Arrest Associated with Opioid Overdose 1669
  • 47. 10.3 : Cardiac or Respiratory Arrest Associated with Opioid Overdose
  • 48. 10.3 : Cardiac or Respiratory Arrest Associated with Opioid Overdose
  • 49. 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). Part 10: Special Circumstances of Resuscitation 4 Intravenous Lipid Emulsion Local anesthetic systemic toxicity Bupivacaine toxicity neurotoxicity or cardiac arrest Drug toxicity Failing standard resuscitative
  • 50. 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 Part 10: Special Circumstances of Resuscitation 5