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New Practices in ACLS

New Practices in ACLS. Rapid Fire Jason Persoff, MD Assistant Professor of Hospital Internal Medicine Mayo Clinic Jacksonville. Evidence-Based Rapid Fire. What new changes to BLS should I be implementing in the hospital setting?

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New Practices in ACLS

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  1. New Practices in ACLS Rapid Fire Jason Persoff, MD Assistant Professor of Hospital Internal Medicine Mayo Clinic Jacksonville

  2. Evidence-Based Rapid Fire • What new changes to BLS should I be implementing in the hospital setting? • What new recommendations related to medications provided during ACLS do I need to know? • Should family members be present during a code?

  3. ACLS Medications

  4. ACLS Medications • Antiarrhythmics • Increase QTc • Increase risk of cardiac arrest • Do antiarrhythmics promote survival in IHCA? • Bloom: amiodarone improves survival • Most others: survival to hospital discharge is lower • Bloom et al. Am J Heart 2007 • Pollak et al. Can J Card 2006 • VanWalraven et al. Ann Emerg Med 1998

  5. ACLS Medications • Medications that have shown survival • Beta Blockers • ACEI • Bloom et al. Am J Heart 2007 • Vasopressin • Pediatrics: survival improved • Adults: seen in higher proportion of non-survivors • Stiell et al. Lancet 2001 • DeMos et al. Crit Care Med 2006 • VanWalraven et al. Ann Emerg Med 1998

  6. ACLS Medications • Calcium • Administration occurs higher in non-survivors • Bicarbonate • Higher rates of death in IHCA • Atropine • Higher rates of death in IHCA • Magnesium • No changes in survival in any subgroup • VanWalraven et al. Ann Emerg Med 1998 • DeMos et al. Crit Care Med 2006 • Thel et al. Lancet 1997

  7. ACLS Medications

  8. Yep Nope V-Fib Pulseless VT Have no idea PEA Asystole or 150J Biphasic Shock Drug Shock 5 Cycles (150 Compressions) ACLS Medications Shockable Rhythm? Pressor (Vasopressin or Epi) Antiarrhythmic (Amiodarone) 360J Mono 150J Biphasic

  9. Family Presence on a CODE • Nursing staff believe families should be present on codes (>75%) • Kuzin et al. Pediatrics. 2007 Oct;120(4):e895-901 • Best review: Critchell and Marik • Am J of Hospice Pall Med 2007

  10. 2008: The Revolution Begins • Bardy, et al. Home use of automated external defibrillators for sudden cardiac arrest. NEJM 2008; 358: Online only at http://www.nejm.org/. April 1, 2008 • Sayre, et al. Hands only (compression-only) CPR. Circulation 2008; 117: Online only at http://circ.ahajournals.org/. April 1, 2008 • Peberdy, et al. Survival from in-hospital cardiac arrest during nights and weekends. JAMA 2008; 299: 785-792. • Chan, et al. Delayed time to defibrillation after in-hospital cardiac arrest. NEJM 2008; 358: 9-17.

  11. Epidemiology • 88% of inpatient cardiac arrest (IHCA) occurs in patients with DNR orders • 12% undergo resuscitation • 1.25-3.8 per 1000 admissions • Most occur in ICU (45%) • Few arrests are unwitnessed (12%) • Sandroni et al. Resuscitation 2004.

  12. Epidemiology

  13. Prognosis • Terminology • ROSC (Return of spontaneous circulation) • SHD (Survival to hospital discharge) • NIS (Neurologically intact survival)—CPC 0 or 1 • NIS • Cerebral Performance Category (CPC) • 0 Normal • 1 Good • 2 Moderate disability (Caffeinated) • 3 Major disability • 4 Persistent vegetative state, coma • 5 Brain death • 6 Me post-call

  14. Prognosis • Pure respiratory events • SHD (reference) OR 1.0 • Vs. VF/VT Arrest: OR 4.2 (1.4-12.5) • Vs. Asystole/PEA Arrest: OR 21.0 (6.2-71.7) • Brindley et al. CMAJ 2002.

  15. Prognosis • Ventricular Fibrillation/Tachycardia • ROSC 54-76% • SHD 16.5-57% • NIS 58-75% • PEA/Asystole Arrests • ROSC 43-52% • SHD 10-20% • NIS 61-62%

  16. Prognosis • Discrepancies • Men are twice as likely to have VF than women • Herlitz et al. Resuscitation 2002. • Women are more likely to survive (OR 1.66, 1.06-2.62) • Herlitz et al. Resuscitation 2001. • Blacks have a lower likelihood of SHD • Ebell et al. J Fam Prac 1995. • Blacks had statistically robust delays in defibrillation • Chan et al. NEJM 2008.

  17. Prognosis • “It’s a good time to die.”—Some action movie • 1500 “Golden Hour” • Bad time of day: nighttime • Survival lowest 2300-0700 • Brindley et al. CMAJ 2002. • Nocturnal arrest has half the likelihood of SHD • Herlitz et al. Resuscitation 2002. • More likely due to asystole/PEA • Peberdy et al. JAMA 2008.

  18. Prognosis • Nocturnal IHCA • Less likely to have ROSC (44.7% vs. 51.1%) • Less likely to survive 24 hours (28.9% vs. 35.4%) • Less likely to SHD (14.7% vs. 19.8%) • Weekend • Commensurate to nocturnal survival

  19. Basic Life Support • CPR when done perfectly provides only… • 1/3 normal cardiac output • 10-15% normal cerebral blood flow • 1-5% normal cardiac blood flow • Sanders et al. 1985. • Goals • Push hard • Pump fast • Good recoil • How many push ups can you do? • Rotate rescuers

  20. Basic Life Support • In swine… • Rapid compressions: • 80/min 10% survival at 24 hrs • 100/min 100% survival at 24 hrs • Yu et al. 2002. • Continuous vs. Classic • Better coronary perfusion pressures • Higher “neurologically normal” function • Kern et al. 2002

  21. Basic Life Support • Compressions too shallow 62.6% of the time • Compressions too slow 71.9% of the time • Abella et al. 2005. • CPR Good: Survival at 14d: 16% • CPR Bad: Survival at 14d: 4% • VanHoeyweghen et al. 1993.

  22. Basic Life Support • Delay in chest compressions = death • CPR started < 1 minute after collapse: SHD 34% • CPR started 1 minute after collapse: SHD 14% • Skrifvars et al. Resuscitation 2006 • Code team arrival delay of >2 minutes after arrest: SHD begins to decrease • Code team arrival >6 minutes after arrest: SHD 0% • Sandroni et al. Resuscitation 2004

  23. Basic Life Support • What is the appropriate tidal volume for a patient in cardiopulmonary arrest? • 10cc/kg, or roughly 750cc • What is the volume of an adult bag-valve-mask? • 1.5 liters • Designed for 1-handed operation • ETT is misplaced 6-14% of the time • Katz et al. Ann Int Med 2001. • “Iatrogenic hypotension” • Over-zealous BVM use due to • Desire to correct hypoxia • Belief that hyperventilation will correct acid-base derangements

  24. Basic Life Support • Rate exceeded at least 60.9% of the time in humans • In swine models, hyperventilation resulted in… • …increased intrathoracic pressure • …decreased coronary perfusion pressures • …lower survival • Aufderheide, et al. 2004.

  25. Basic Life Support • Phenomenon of auto-PEEP usually referred to patients on a ventilator

  26. Basic Life Support Michard F. Anesthesiology 2005

  27. Basic Life Support • Current clinical controversy • Should we ventilate at all? • April 1, 2008 • No…compressions only in layperson resuscitation • Most animal models show NO BENEFIT to ventilations plus ventilations to compressions only • In humans • Equivalent SHD in typical and compression-only CPR • 1-year NIS similar

  28. Basic Life Support • Striking the balance • No oxygenation without circulation • The longer resuscitation is attempted, the lower the oxygen level • Threshold appears to be 4 minutes into an arrest • Delivery of as little as 2 breaths : 100 compressions after 4 minutes of continuous compressions had better outcomes • Sanders et al. Ann Emerg Med 2002. • Interesting aside…Why don’t people do CPR? • Only 1.4% of bystanders feared disease

  29. Conclusions?

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