New ACLS Guidelines

1. New ACLS Guidelines LCDR Phil Colmenares MD MPH Emergency Medicine Department Portsmouth Naval Medical Center

3. Relation of Collapse-to-CPR andDefibrillation to Survival

4. ACLS

5. ACLS Drugs/Algorithms

6. ACLS Drugs/Algorithms ACS

7. ACLS Drugs/Algorithms ACS Stroke

8. ACLS Drugs/Algorithms ACS Stroke Electrolyte Abnormalities

9. ACLS Drugs/Algorithms ACS Stroke Electrolyte Abnormalities Toxicology

10. ACLS Drugs/Algorithms ACS Stroke Electrolyte Abnormalities Toxicology Environmental

11. ACLS Drugs/Algorithms ACS Stroke Electrolyte Abnormalities Toxicology Environmental Asthma

12. ACLS Drugs/Algorithms ACS Stroke Electrolyte Abnormalities Toxicology Environmental Asthma Anaphylaxis

13. ACLS Drugs/Algorithms ACS Stroke Electrolyte Abnormalities Toxicology Environmental Asthma Anaphylaxis Trauma

14. ACLS Drugs/Algorithms ACS Stroke Electrolyte Abnormalities Toxicology Environmental Asthma Anaphylaxis Trauma Pregnancy

16. This is a schematic of the historical progression of the course from basic mouth-to-mouth and CPR to an evidence-based approach to resuscitative medicine. The fact is that although the new ACLS guidelines are a lot more evidence-based than the previous guidelines, a lot of the evidence is still kind of thin. But it�s getting better�This is a schematic of the historical progression of the course from basic mouth-to-mouth and CPR to an evidence-based approach to resuscitative medicine. The fact is that although the new ACLS guidelines are a lot more evidence-based than the previous guidelines, a lot of the evidence is still kind of thin. But it�s getting better�

17. Linking AHA Evidence-Based Guidelines to ACLS Treatment Recommendations The AHA uses a number of categories to rank the evidenceThe AHA uses a number of categories to rank the evidence

18. AHA Class Recommendations

19. AHA Recommendations Class I As an example, does anyone remember what recommendation category epinephrine fell into under the old guidelines? (Class IIa) How about lidocaine? (Class IIa) How about high-dose epinephrine? (Class IIb) ----------------- Under the new guidelines regular epinephrine has gone from IIa to Class Indeterminate. That�s a big jump. And high-dose epinephrine has gone from IIb to Class Indeterminate. And lidocaine has gone from Class IIa to ???????? (Class Indeterminate). As an example, does anyone remember what recommendation category epinephrine fell into under the old guidelines? (Class IIa) How about lidocaine? (Class IIa) How about high-dose epinephrine? (Class IIb) ----------------- Under the new guidelines regular epinephrine has gone from IIa to Class Indeterminate. That�s a big jump. And high-dose epinephrine has gone from IIb to Class Indeterminate. And lidocaine has gone from Class IIa to ???????? (Class Indeterminate).

20. Ventricular Fibrillation

21. Ventricular Fibrillation

22. High-Dose Epinephrine

23. Standard-Dose Epinephrine (SDE) vs High-Dose Epinephrine (HDE) for Out-of-Hospital Cardiac Arrest

24. High-Dose Epinephrine

25. Vasopressin

26. Epinephrine vs Vasopressin

27. Epinephrine vs Vasopressin

28. Epinephrine vs Vasopressin for Out-of-Hospital Cardiac Arrest

29. Ventricular Fibrillation

32. Magnesium for In-hospital Cardiac Arrest

33. Magnesium in VF/VT Cardiac Arrest

35. Procainamide in VF/VTCardiac Arrest

37. Lidocaine in Shock-refractoryOut-of-Hospital VF This was the first controlled clinical study to evaluate the use of lidocaine in refractory VF. It was done in Tampa Bay, FL, and it used existing ACLS guidelines at the time, which included the use of intracardiac epinephrine. 116 patients were divided into a Lidocaine group and a No Lidocaine group. There 54 in the No Lidocaine group and 62 in the Lidocaine group. And as you can see there was no statistical difference in the amount or type of interventions used between the two groups except for the use of Lidocaine in one group and not the other. This was the first controlled clinical study to evaluate the use of lidocaine in refractory VF. It was done in Tampa Bay, FL, and it used existing ACLS guidelines at the time, which included the use of intracardiac epinephrine. 116 patients were divided into a Lidocaine group and a No Lidocaine group. There 54 in the No Lidocaine group and 62 in the Lidocaine group. And as you can see there was no statistical difference in the amount or type of interventions used between the two groups except for the use of Lidocaine in one group and not the other.

38. Lidocaine in Shock-refractoryOut-of-Hospital VF

42. Ventricular Fibrillation

43. Amiodarone

44. Amiodarone 1962 - discovered in Belgium

46. ARREST Trial: Design Objective Comparison of 1992 ACLS Guidelines with and without IV amiodarone in shock-refractory VT/VF cardiac arrest Methods Double-blind RCT (n=504) Randomization to 300 mg amiodarone or placebo Amiodarone dosing Rapid bolus of 300 mg vial diluted with D5W to a volume of 20 mL in sterile syringe

48. Amiodarone for Cardiac Arrest: Benefit by Subgroups

51. Amiodarone IV Hypotension 16.0 % Bradycardia 4.9 % Nausea 3.9 % LFT abnormalities 3.4 % Cardiac arrest 2.9 % VT 2.4 % CHF 2.1 % Fever 2.0 %

52. Hypotension Rarely a cause for discontinuing the drug

53. Amiodarone Begin with a 150 mg IV bolus over 10 min for a perfusing rhythm, and 300 mg IV bolus for cardiac arrest

55. Tachycardia

56. Estimating Cardiac Function

57. Tachycardia

58. Atrial Fibrillation / Atrial Flutter

59. Atrial Fibrillation / Atrial Flutter There is now a much more detailed approach to atrial fibrillation and atrial flutter 1. Is cardiac function impaired? 2. Has a. fib or a. flutter been present for more or less than 48 hours? If the patient has WPW and cardiac function is impaired, then DC cardioversion or amiodarone is used to control the rate. There is now a much more detailed approach to atrial fibrillation and atrial flutter 1. Is cardiac function impaired? 2. Has a. fib or a. flutter been present for more or less than 48 hours? If the patient has WPW and cardiac function is impaired, then DC cardioversion or amiodarone is used to control the rate.

60. Patient clinically unstable? Cardiac function impaired? WPW present? Duration < 48 or > 48 hours? 4 Clinical Features

61. Treat unstable patients urgently Control the rate Convert the rhythm Provide anticoagulation Clinical Evaluation

62. Tachycardia

63. Tachycardia

64. PSVT

65. SVT

66. Tachycardia

67. Simplified SVT Algorithm

68. Simplified SVT Algorithm

69. Tachycardia

70. Tachycardia

71. Ventricular Tachycardia

72. Ventricular Tachycardia Note that it is now acceptable to treat any type of stable VT immediately with cardioversion. That�s a significant change form the old algorithm.Note that it is now acceptable to treat any type of stable VT immediately with cardioversion. That�s a significant change form the old algorithm.

73. Procainamide vs Lidocainein Stable VT

75. Tachycardia

76. Tachycardia

77. WCT of Unknown Type

78. WCT of Unknown Type Note that adenosine has been removed from the WCT algorithm. It was removed because most WCT are VT, and it was decided that too much time is wasted using adenosine merely as a diagnostic tool rather than getting down to treating the WCT. Lidocaine and Bretylium are no longer recommended either. Procainamide is only indicated if cardiac function is preserved. If so, it is a IIa agent, as is amiodarone.Note that adenosine has been removed from the WCT algorithm. It was removed because most WCT are VT, and it was decided that too much time is wasted using adenosine merely as a diagnostic tool rather than getting down to treating the WCT. Lidocaine and Bretylium are no longer recommended either. Procainamide is only indicated if cardiac function is preserved. If so, it is a IIa agent, as is amiodarone.

79. Wide-complex Tachycardia: Ineffectiveness of Lidocaine This is another study done in Illinois, and published in 1988 that should an unimpressive rate of efficacy for the use of lidocaine in refractory VF in 20 patients. However, it�s a small retrospective study so it�s hard to make strong conclusions based only on the results here. Nevertheless, it showed that among 20 patients with refractory WCT, 15 patients were totally unresponsive to lidocaine. 5 patients (4 with VT and 1 with SVT) converted to NSR within 15 minutes of having received lidocaine. To say that it was the lidocaine that converted them is a huge leap of faith for a number of reasons. First 3 of the 5 that converted to NSR had also received Verapamil. In addition, three of the patients that converted to NSR, ended up reverting to WCT, and none of these responded to Lidocaine. So even if you accept that the 2 patients that remained in NSR was due to the lidocaine (which is a big IF), the efficacy is really unimpressive. Of course, this is a retrospective study, it�s small, and there is no control group, but it suggests that lidocaine is not very good for refractory VF.This is another study done in Illinois, and published in 1988 that should an unimpressive rate of efficacy for the use of lidocaine in refractory VF in 20 patients. However, it�s a small retrospective study so it�s hard to make strong conclusions based only on the results here. Nevertheless, it showed that among 20 patients with refractory WCT, 15 patients were totally unresponsive to lidocaine. 5 patients (4 with VT and 1 with SVT) converted to NSR within 15 minutes of having received lidocaine. To say that it was the lidocaine that converted them is a huge leap of faith for a number of reasons. First 3 of the 5 that converted to NSR had also received Verapamil. In addition, three of the patients that converted to NSR, ended up reverting to WCT, and none of these responded to Lidocaine. So even if you accept that the 2 patients that remained in NSR was due to the lidocaine (which is a big IF), the efficacy is really unimpressive. Of course, this is a retrospective study, it�s small, and there is no control group, but it suggests that lidocaine is not very good for refractory VF.

80. Tachyarrhythmic Agents

81. Tachyarrhythmic Agents

82. Tachyarrhythmic Agents

83. Tachyarrhythmic Agents

84. Tachyarrhythmic Agents

85. Tachyarrhythmic Agents

86. Other Minor Changes ETT Placement ETT Placement must now be confirmed by using nonphysical examination techniques like end-tidal CO2 detectors and esophageal detector devices. Prehospital EKG�s are useful in urban/suburban EMS systems and should become standard equipment on all ACLS units. Isoproterenol has been removed from the bradycardia algorithm. The new PEA algorithm requires immediate assessment of blood flow with a doppler or direct ultrasound of the heart.ETT Placement must now be confirmed by using nonphysical examination techniques like end-tidal CO2 detectors and esophageal detector devices. Prehospital EKG�s are useful in urban/suburban EMS systems and should become standard equipment on all ACLS units. Isoproterenol has been removed from the bradycardia algorithm. The new PEA algorithm requires immediate assessment of blood flow with a doppler or direct ultrasound of the heart.

87. Summary

88. Summary

89. Summary

95. Questions?