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ACLS 2005 What is new and why?

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.

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ACLS 2005 What is new and why?

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  1. ACLS 2005What is new and why? Morbidity Rounds Feb 15, 2006 Rob Hall MD, FRCPC

  2. 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

  3. ACLS 2005 Guidelines VISIT www.circulationha.org Circulation 2005. Dec 13: 112(24): p3667-3813 and Supp 11: p 1-211.

  4. 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

  5. CPR/BLS Circulation 2005;112:IV-19-34IV-

  6. 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)

  7. Part 3/4: CPR/Adult BLS • Ventilations • 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

  8. Part 3/4: CPR/Adult BLS • Compressions • 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

  9. 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 ED Interruptions in Compressions

  10. ACLS 2005 After Advanced Airway Device Placed: 100 compression/min 10 breaths per minute (unsynchronized)

  11. ACLS 2005 After Advanced Airway Device Placed: 100 compression/min 10 breaths per minute (unsynchronized)

  12. Adult BLS Healthcare Provider Algorithm Circulation 2005;112:IV-19-34IV-

  13. Electrical Therapies Circulation 2005;112:IV-19-34IV-

  14. Part 5: Electrical Therapy

  15. Part 5: Electrical Therapy Truncated Exponential Rectilinear Biphasic = increased ROSC, no increase Survival to hospital discharge

  16. Lifepak • 12 and 20 are both biphasic (truncated exponential)

  17. Recommended Energy for Defibrillation Lifepak 12 and 20 Peds: 2 J/kg then 4 J/kg

  18. Timing of Defibrillation • Shock First vs CPR First?

  19. Evidence for CPR before defibrillation • Cobb JAMA 1999 • 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 NNT • Overall 24% 30% .04 16 • Response < 4min 31% 32% .87 • Response > 4min 17% 27% .007 10

  20. 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 15% 22% .17 • Response < 5min 29% 23% .61 • Response > 5min 4% 22% .006 5.5 A priori subgroup analysis

  21. 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 5.1% 4.2% .81 (.3-2.6) • Survival to d/c Defib First CPR First P • Response < 5min 0% 12% .25 • Response > 5min 4.9% 3.5% .74 Post hoc subgroup analysis

  22. 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

  23. ALS Circulation 2005;112:IV-19-34IV-

  24. Part 7.2: Management of Cardiac Arrest • ACLS Pulseless Algorithm 2005 • Vfib Algorithm • PEA Algorithm • Asystole Algorithm

  25. Circulation 2005; 112:IV-58-66IV-

  26. Notes on VF and pulseless VT • 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-

  27. ARREST TRIAL DBRCT, N=504 Amio vs Placebo Survival PL Amio P Admission 34% 44% .03 Discharge 13.4% 13.2% NS ALIVE TRIAL DBRCT, N = 347 Amio vs Lidocaine Survival Lido Amio P Admission 12% 23% .009 Discharge 3.8% 6.8% NS Amiodarone for Vfib/pulseless VT Kudenchuk et. al. NEJM 1999. 341(12): p.871. Dorian et. al. NEJM 2002. 346(12): p.884.

  28. 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 Circulation 2005; 112:IV-58-66IV-

  29. 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)

  30. Vasopressin • Wenzel. NEJM 2004. 350(2). P 105-113. • DBRCT, N= 1186 • Out-of-hospital vfib/PEA/asystole • Vasopressin 40IU vs Epinephrine 1mg • Survival all patients AVP EPI P • Admission 36% 31% .06 • Discharge 10% 10% .99 • Survival Asystole AVP EPI P NNT • Admission 29% 20% .02 • Discharge 4.7% 1.5% .04 31 Problem = multiple subgroup analysis (29); suspected type I (alpha) error

  31. ALS Tachy/Brady Circulation 2005;112:IV-19-34IV-

  32. Bradycardia Algorithm Circulation 2005;112:IV-67-77IV-

  33. 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

  34. 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 …………..

  35. ACLS Tachycardia Algorithm Circulation 2005;112:IV-67-77IV-

  36. Wide QRS Tachycardia

  37. AFIB + WPW • Tijunelis. CJEM 2005. Vol7(4)p. 262-5. • 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

  38. Part 7.5: Postresuscitation • Should we induced hypothermia post cardiac arrest?

  39. 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 Induced Hypothermia:NEJM Feb 2002 --what is the evidence?

  40. 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

  41. What really matters? CPR/BLS/Defib Circulation 2005;112:IV-19-34IV-

  42. 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) N = 1391 12 months N = 4247 36 months

  43. 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 11% 15%p.001 Admission Survival to 5.0% 5.1%p.83 Discharge

  44. Why the emphasis on CPR and defibrillation? • OPALS study • Stiell. NEJM 2004. 351(7). P 647-656. • Logistic Regression OR for survival • Witnessed arrest 4.4 • Bystander CPR 3.7 • AED < 8min 3.4

  45. Take home points • 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?

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