The document discusses advancements in managing adult cardiac arrest beyond standard ACLS protocols, emphasizing high-quality CPR, continuous chest compressions, and alternative drugs for treatment. It critiques the efficacy of epinephrine and introduces hemodynamic directed dosing as a potentially superior approach. Furthermore, it highlights the importance of targeted temperature management post-resuscitation for improved outcomes.

2. Resuscitation 2015:
Beyond ACLS
Andrew J. Bowman, MSN, ACNP-BC, NRP

3. Faculty Disclosure
• Session goal: Discuss FOAMed & possible alternative
approaches to management of adult cardiac arrest
beyond standard ACLS
• Conflicts of interest: None
• Employer: Witham Health Services Emergency
Major Hospital Emergency
Hendricks Regional Health Emergency
• Sponsorship / commercial support: None

4. The Emergency Nurses Association is
accredited as a provider of continuing
nursing education by the American
Nurses Credentialing Center’s
Commission on Accreditation.

5. “DON’T BE A RESUSCITATION WANKER”

9. Joe Lex, MD
Professor of Clinical Emergency Medicine
Temple University School of Medicine
If you want to know how we practiced medicine/nursing
5 years ago …read a TEXTBOOK.
If you want to know how we practiced medicine/nursing
2 years ago …read a JOURNAL.
If you want to know how we practice medicine/nursing
NOW…go to a (GOOD) CONFERENCE.
If you want to know how we will practice
medicine/nursing TOMORROW … use FOAMed.

12. #

27. This is NOT your dentists’ ACLS

40. History of ACLS
1974…1980…1986…1992…2000…2005…2010…2015

43. PATIENT PRESENTS WITH ILLNESS OR INJURY
THROW IT AWAY!!!
FIND A FLOWCHART THAT MATCHES COMPLAINT
USE YOUR AWESOME ER NURSE BRAIN

44. What works?
High Quality CPR
• Proper Rate
• Proper Depth
• Full Recoil
Early Defibrillation

45. “High Performance” CPR

46. BSE
• ROSC
• Admission to ER
• Admission to Hospital
• Discharge alive from hospital

47. Discharge
Neurologically Intact

48. Cerebral Performance Category (CPC)
CPC1: Full recovery/Mild disability
CPC2: Moderate disability BUT
independent ADL’s
CPC3: Severe disability; dependent ADL’s
CPC4: Persistent vegetative state
CPC5: Dead

50. Ewy et al 2009
Journal of American College of
Cardiology
Cardiocerebral Resuscitation CCR
• Continuous Chest Compressions
• New EMS Algorithm/Approach
• Aggressive Post-ROSC Care

51. Continuous Compressions
Initial compression
only CPR for anyone
with witnessed
unexpected collapse

52. Cunningham et al. Cardiopulmonary resuscitation for
cardiac arrest: The importance of uninterrupted
chest compressions in cardiac arrest resuscitation.
American Journal of Emergency Medicine, 2012

53. Kern et al
Circulation 2002
Importance of continuous chest
compressions during cardiopulmonary
resuscitation: Improved outcome during a
simulated single lay-rescuer scenario.
Animal Study

54. CPR vs. CCC CPR
0
10
20
30
40
50
60
70
80
90
ROSC 24H Survival Neuro Intact
24H Survival
CPR
CCC CPR

55. New EMS Algorithm

57. New EMS Algorithm

58. CPR vs CCR CPR
0
10
20
30
40
50
60
2001 2002 2003 2004 2005 2006
Survivors
Neuro Intact
Kellum et al. Cardiocerebral resuscitation improves
neurologically intact survival of patients with
out-of-hospital cardiac arrest. Annals of Emergency
Medicine 2008, 52(3)

59. Cheskes, et al, "Perishock pause: an independent
predictor of survival from out-of-hospital
shockable cardiac arrest.", Circulation, 2011.
0
5
10
15
20
25
30
35
40
PreShock
<10 sec
>20 sec
CPR Survival PreShock Pause

60. Cheskes, et al, "Perishock pause: an independent
predictor of survival from out-of-hospital
shockable cardiac arrest.", Circulation, 2011.
0
5
10
15
20
25
30
35
PeriShock
<20 sec
>40 sec
CPR Survival PeriShock Pause

61. Cheskes, et al, "Perishock pause: an independent
predictor of survival from out-of-hospital
shockable cardiac arrest.", Circulation, 2011.
0
5
10
15
20
25
30
35
PostShock
<10 sec
>20 sec
CPR Survival PostShock Pause

62. Brouwer et al 2015
Circulation
Association between chest
compression interruptions and
outcomes of VF OHCA
– Prolonged pauses have a negative association
with survival
– Strategies shortening the longest pauses may
improve outcome

64. Pay attention to details of CPR
Team Leader Stays Free to Monitor
– Adequate compression rate
– Adequate compression depth
– Limit interruptions

66. High Quality CPR
– CCF > 80%
– Rate 100-120/min
– Compression depth >=5cm
– Avoid excessive ventilation
At Every Cardiac Arrest
– At least 1 method of CPR performance
– At least 1 method to monitor patient response
Coordinate Efforts
– Team leader oversees efforts

68. Defibrillation
• Humane Society 1774
• “The Institute for Affording Immediate
Relief for Persons Apparently Dead from
Drowning” (TIFAIRFPADFD)
• www.trauma.org

69. Defibrillation
Hands ON or Hands OFF?

70. Cunningham et al. Cardiopulmonary resuscitation for
cardiac arrest: The importance of uninterrupted
chest compressions in cardiac arrest resuscitation.
American Journal of Emergency Medicine, 2012

71. Larry Mellick, MD

73. Hands On or Hands Off
• 100 patients in arrest
• Only those with coronary perfusion
pressure (CPP) >15mmHg had ROSC
• ~Increased CPP increases chance of ROSC
» Paradis et al. "Coronary perfusion pressure and the return
of spontaneous circulation in human cardiopulmonary
resuscitation.", JAMA 1990.

74. CPR vs CCR CPR
0
10
20
30
40
50
60
2001 2002 2003 2004 2005 2006
Survivors
Neuro Intact
Kellum et al. Cardiocerebral resuscitation
improves neurologically intact survival of
patients with out-of-hospital cardiac arrest.
Annals of Emergency Medicine 2008, 52(3)

75. Hands On or Hands Off
• 43 Hands On Shocks
• None “perceptible” to compressors
wearing polyethylene gloves
• 11.1% shocks exceeded allowable 0.5mA
» M.S. Lloyd, et al. "Hands-on defibrillation: an analysis of
electrical current flow through rescuers in direct contact
with patients during biphasic external defibrillation.",
Circulation, 2008

76. Hands On or Hands Off
• 4 types of medical grade gloves
• Single and double glove tested
• 7.5% single and 6.2% double allowed at
least 10mA current flow
» J.L. Sullivan, and F.W. Chapman, "Will medical examination
gloves protect rescuers from defibrillation voltages during
hands-on defibrillation?", Resuscitation, 2012.

77. Hands On or Hands Off
Weingart Mellick

78. Hands On or Hands Off?

79. Hands Off!!!

80. Hands Off!!!
• Continue compressions while charging
• Very brief HANDS OFF to defibrillate
• IMMEDIATE resumption of CPR

81. Unless??
• 82 hands on elective cardioversions
• Wearing Class I electrical gloves
• Peak energy “well below” 1mA
» Deakin et al. 2015. Achieving safe hands-on
defibrillation using electrical safety gloves - A
clinical evaluation. Resuscitation (February 26).

83. Hoch et al 1994
Journal of American College of
Cardiology
Refractory V-Fib
Double sequential defibrillation
– 2 sets defibrillation pads and defibrillators
– Near simultaneous discharge

84. Cabañas et al 2015
Prehospital Emergency Care
• Double sequential external
defibrillation in out of hospital
refractory VF
– “Refractory VF” = VF after 5 shocks
– 10 pts median age 76.5 (65-82)
– Median resuscitation time 51 mins (45-62)
– Dual defib converted 70% out of VF
– None with ROSC

85. Dual Sequential Defibrillation
Current Applications
– Wake County North Carolina (5 shocks)
– New Orleans (4 shocks)

87. PEA Arrest
The H’s
– Hypovolemia
– Hypoxia
– Hydrogen ions
– Hypothermia
– Hypokalemia
– Hyperkalemia
– Hypoglycemia
– Hyperglycemia
The T’s
– Toxins
– Tamponade
– Tension pneumothorax
– Thrombosis MI
– Thrombosis PE
– Trauma

88. Littmann et al 2013
Medical Principles & Practice
• A simplified and structured teaching tool
for the evaluation and management of
pulseless electrical activity.

93. ?

94. Epinephrine in arrest has minimal
supportive evidence
Has become the de facto “standard of
care”
Are we doing more harm than good?

95. 61 MG

96. • Pathophysiologic Benefits
– Alpha adrenergic effects
– Increases CPP and myocardial perfusion

97. • Pathophysiologic detriments
– Beta effects undesired
– Potential problem from beta agonist effects of
increased myocardial work and reduced
subendocardial perfusion
– Promotion of thrombogenesis and platelet
activation
– Impaired myocardial function
– Reduced microvascular perfusion

99. Stiell et al 2004
New England Journal of Medicine
• OPALS (Ottawa Prehospital
Advanced Life Support Study)
• Prospective before and after
• 12 months CPR + Defib
• 36 months ACLS
• ACLS = Significant increase ROSC
but no significant improvement
survival to discharge

100. Nakahara et al 2013
British Medical Journal
• Prehospital adrenaline improves long term
outcome with OHCA but increase of
neurologically intact survival was minimal

101. Jacobs et al 2011
Resuscitation
• RDCT
• Lost support of EMS providers
• Increased likelihood of ROSC
• No statistically significant
improvement in survival to
discharge

102. Machida et al 2012
Journal of Cardiology
• Adrenaline made no difference to survival
• Adrenaline made no difference to risk of
severe brain damage

103. Woodhouse et al 1995
Resuscitation
• High dose adrenaline did show
improvement to beneficial rhythm
• No improvement in immediate or
long term survival with high dose
or standard dose adrenaline
• “Patient reaching point of use of
adrenaline have uniformly poor
survival”

104. Ong et al 2007
Annals of Emergency Medicine
• No improvement with epinephrine
– ROSC
– Survival to admission
– Survival to discharge

105. Dumas et al 2014
Journal of the American
College of Cardiology
• Prehospital use of epinephrine in those
who achieved ROSC had lower chance of
survival
• Dose related

106. Herlitz et al 1995
Resuscitation
• Adrenaline for VF presentation
• Improved ROSC with adrenaline
• Discharge alive did not improve
• Same results in those who
converted to EMD (PEA) or
asystole

107. Holmberg et al 2002
Resuscitation
• Outcome with OHCA with epinephrine or
intubation
• Both predictors of low survival

108. Hayashi et al 2012
Circulation Journal
• Epinephrine significantly lower rate
of neurologically intact 1-month
survival
• VF arrests that got epinephrine
within 10 minutes had improved
outcome but delayed epinephrine
did not show benefit

109. Olasveengen et al 2012
Resuscitation
• Adrenaline associated with
improved short term survival
• Decreased survival to discharge
• Decreased survival with
favorable neurological outcome

110. Hagihara et al 2012
Journal of the American
Medical Association
• Prehospital epinephrine increased
ROSC
• Decreased survival at 1-month
• Decreased good functional
outcome at 1-month

111. Ono et al 2015
Journal of Intensive Care
• Epinephrine associated with
increased ROSC
• Improvement in neurological
outcome
• Only in those with CPR 15-19
minutes

112. Straznitskas et al 2015
American Journal of Critical Care
• Initial arrest PEA or asystole
• More frequent delivery of
epinephrine associated with
secondary VF/VT
• Increased mortality

114. Epinephrine and other ACLS drugs lead to more
patients with ROSC but no increase in the
number of patients with good neurologic
outcomes after OHCA.
Actual ACLS recommendation for epinephrine.
“it is reasonable to consider administering
a 1 mg dose of IV/IO epinephrine every 3
to 5 minutes during adult cardiac arrest.”

116. Hemodynamic Directed Dosing
of Epinephrine (HDDE)
• Instead of 1mg q 3-5 minutes
• Individualized dosing based on CPP,
CPR DBP or EtCO2
• Goal to overall give less epinephrine and
potentially avoid bad effects

117. HDDE
• Compare cerebral physiological variables using a
hemodynamic directed resuscitation strategy
versus an absolute depth-guided approach in a
porcine model of ventricular fibrillation (VF)
cardiac arrest.
• Pig study
» Friess et al. 2014. Hemodynamic directed CPR improves
cerebral perfusion pressure and brain tissue oxygenation.
Resuscitation, no. 9 (June 16)

118. HDDE
• 7 minutes of VF, randomized 1 of 3 strategies:
– 1) Hemodynamic Directed Care (CPP-20): chest
compressions depth titrated to target SBP 100mmHg and
titration of vasopressors maintain coronary perfusion
pressure (CPP)> 20mmHg
– 2) D33: Target CC depth of 33mm with standard AHA
epinephrine dosing
– 3) D51: Target CC depth of 51mm with standard AHA
epinephrine dosing

119. HDDE
• Hemodynamic directed resuscitation
strategy targeting coronary perfusion
pressure>20mmHg following VF arrest
was associated with higher cerebral
perfusion pressures and brain tissue
oxygen tensions during CPR.

120. HDDE
• Cerebral perfusion pressures (CerePP )
were significantly higher in the CPP-20
group and higher in survivors compared to
non-survivors irrespective of treatment
group

121. HDDE
• Paradis, Norman A. 1990. Coronary
Perfusion Pressure and the Return of
Spontaneous Circulation in Human
Cardiopulmonary Resuscitation.
JAMA: The Journal of the American
Medical Association. American Medical
Association (AMA), February 23
• Human study

122. HDDE
• Only patients with maximal CPPs of 15
mm Hg or more had ROSC
• CPP above 15 mm Hg did not guarantee
ROSC
– 18 patients whose CPPs were 15 mm Hg or greater
did not resuscitate.
• Of variables measured, maximal CPP was
most predictive of ROSC.

123. HDDE
• Targets During CPR
– Arterial - CVP (CPP>20mmHg)
– Arterial line DBP 35-40mmHg
– EtCO2>20 mmHg
– If DBP < 30mmHG or EtCO2 < 20mmHg
optimize compressions or vasopressors (EPI)

124. EtCO2 Guided Arrest
• Current ILCOR guidelines
– Capnography is useful during resuscitation
• EtCO2 can be marker of cardiac output

125. EtCO2 Guided Arrest
• Gradual fall in EtCO2 suggests CPR fatigue
– -> time to change rescuer
• Abrupt increase in EtCO2 suggests ROSC
• EtCO2 at 20 minutes of CPR is prognostic

126. EtCO2 Guided Arrest
• >20 mmHg at 20 minutes CPR -> higher
chance of ROSC
• <10 mmHg at 20 mintues CPR -> almost
no chance of ROSC

127. Alternative Drugs

128. Mentzelopoulos et al 2013
Journal of American Medical
Association
• Patients with cardiac arrest have
shown improved return of spontaneous
circulation and survival to hospital
discharge with the vasopressin-steroid-
epinephrine (VSE) combination.

129. VSE
• Group1 (VSE Group)
– Vasopressin + epinephrine + methylprednisolone
• Group 2 (Control Group)
– Saline placebo + epinephrine + saline placebo

130. VSE Group
Higher rate ROSC
(83.9% vs 65.9%)
Increased survival to
discharge CPC 1-2
(13.9% vs 5.1%)

131. Driver et al 2014
Resuscitation
• Use of esmolol after failure of standard
cardiopulmonary resuscitation to treat
patients with refractory VF
• Potential benefit to use of beta blockade
in cardiac arrest

132. VF refractory to standard therapy
– 3+ defibrillation attempts
– 3+ doses of epinephrine
– Minimum of 300 mg amiodarone
6 patients treated with esmolol
– 4 achieved ROSC
– 3 survived to discharge with good
neurologic function despite
prolonged CPR

133. ? benefit with suspected
inhalation abuse
Sensitization of the
myocardium, susceptible
to VT/VF
“Sudden Sniffing Death”

134. Patients who do not respond
to conventional care AND
continue to have shockable
rhythms
Beta blockade may also
benefit suspected inhalant
abuse pre-arrest
Esmolol ideal due to its
pharmacokinetic and
pharmacodynamic profile

135. ROSC
We have a pulse…!!! Now what…???

137. • Focused/Detailed H&P
• Evaluate Airway / ETT
– PaO2 < 300mmHg, SaO2 94-98%, PaCO2 35-45mmHg
• Assess for Neurological Dysfunction
• Labs
• CXR, POCUS, EKG
• Cath Lab: VF/VT or ST Segment Changes
• Pressors or Fluids for MAP 85-100mmHg
• Targeted Temperature Management
http://www.emdocs.net/ive-got-a-pulse-now-
what-post-arrest-care-in-the-acute-setting/

138. Therapeutic Hypothermia
or
Targeted Temperature Management

139. Bernard et al 2002
New England Journal of Medicine
• Treatment with moderate hypothermia
(33°C) appears to improve outcomes after
ROSC from OHCA

140. Holzer et al 2002
New England Journal of Medicine
• HACA (Hypothermia After Cardiac Arrest)
• Patients with ROSC after OHCA due to VF
• Moderate hypothermia (32°-34°C)
increased rate of favorable neurological
outcome and reduced mortality

141. Neilsen et al 2013
New England Journal of Medicine

142. 939 randomized ICU patients
Mortality and Neurological Outcome at 180
Days
80% were VF/VT
20% Asystole & PEA

143. Compared cooling to 32°-33°C vs 35°-36°C
28 hours of cooling at target temperature

144. Survival & Neurological Outcomes
– 36°C
• 52% Survival
• 54% Poor Neurological Outcome
– 33°C
• 53% Survival
• 52% Poor Neurological Outcome

145. Very good study
Likely DO NOT need to
target to 32-33°C
Key factor is to avoid
HYPERthermia

146. Huang et al 2015
Resuscitation
• Meta-analysis of prehospital therapeutic
hypothermia
• 8 trials with 2379 patients
• Prehospital initiation did not improve
survival to:
– Admission
– Discharge
– Good neurological functional recovery

147. To Cath Lab with CPR
• Witnessed VF especially with chest pain
• Bystander CPR
• Young without comorbidities
• Excellent CPR
• Short arrest to treatment
• ED arrest with STEMI/STEMI equivalent

148. To Cath Lab after ROSC
• Conventional STEMI or STEMI equivalent
criteria
• Ischemic EKG that PERSISTS 20-30 minutes
into resuscitation
• Electrical Storm/Persistent Ventricular
Arrhythmia

149. Hollenbeck et al 2014
Resuscitation
• Early cardiac catheterization is associated
with improved survival in comatose
survivors of cardiac arrest without STEMI

150. Hollenbeck et al 2014
Resuscitation
• 754 consecutive comatose s/p arrest
• 269 VF/VT and received TTM
• 26.6% “no MI” had acute coronary
occlusion

151. Survival to Discharge
0
10
20
30
40
50
60
70
EARLY CATH 65.6% LATE CATH 48.6%
EARLY
LATE

152. Survival to Discharge
0
10
20
30
40
50
60
70
EARLY CATH
65.6%
LATE CATH
48.6%
NO CATH
28.6%
EARLY
LATE
NO CATH

153. Hypothermia + Cath Lab
0
10
20
30
40
50
60
70
NO CATH NO TTM CATH +
TTM
SURVIVAL
GOOD NEURO

154. Rab et al. Cardiac Arrest: A Treatment Algorithm for
Emergent Invasive Cardiac Procedures in the Resuscitated
Comatose Patient. JACC July 2015; 66(1): 62-73

160. Cath Lab
• Unwitnessed
• Initial non-VF
• No bystander CPR
• ROSC > 30 minutes
• Lactate > 7mmol/L
• pH < 7.2
• > 85 years
• ESRD on HD
• Noncardiac causes

161. • ACLS is good for your dentist and “newbies”
• High quality limited interruption CPR
• Epi may not be all that good
• Alternative Drugs
• No hands on defib, but keep pauses BRIEF
• Capnography
• Dual sequential defib for refractory VF
• TTM, prevent HYPERthermia
• Consider cath lab in arrest or ROSC

162. The 5 C’s

166. DON’T BE A RESUSCITATION
WANKER
DO WHAT IS HONORABLE