ACLS Guidelines 2015

Transcription

1 ACLS Guidelines 2015 Wanda Rivera Bou MD, FAAEM, FACEP Assistant Professor Department of Emergency Medicine University of Puerto Rico School of Medicine AHA - ACLS National Faculty

2 Disclosure Information Wanda Rivera Bou, MD I have no financial relationships with drug or device manufacturing companies

3 Objectives: Will discuss n Identify the ACLS 2015 science updates n Describe the rationale for the science updates n Therapeutic interventions

4 International Liaison Committee on Resuscitation

5 Highlights of the 2015 AHA Guidelines Update for CPR and ECC

6 New AHA Adult Chains of Survival IN-HOSPITAL (note new Surveillance and Prevention link) OUT OF HOSPITAL Including EMS

7 Adult BLS and CPR Quality n There is continued emphasis on the characteristics of high-quality CPR: l compressing the chest at an adequate rate and depth l l allowing complete chest recoil after each compression minimizing interruptions in compressions l avoiding excessive ventilation

8 Chest Compression Rate n It is reasonable to perform compressions at a rate of /min Metronome ü Observational study ü Dec, 2005 May, 2007 ü Sharp decline in survival with rate > 140/min Idris A.H et al, Circulation. 2012;125:

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11 Rapid Compression Rate can Compromise Depth Idris et al, Critical Care Medicine, 2015:43 (4): 840

12 Chest Compression Depth n Chest compression to at least 2 inches (5 cm), avoiding chest compression depths > 2.4 inches (6 cm) Small study: more injuries with compressions greater than 2.4 inches (6cm). (Hellevuo et al, Resuscitation, 2013) Difficult to judge depth without devices Rescuers typically don t push hard enough Stiell I.G et al, Circulation. 2014;130:

13 BLS for HCP Highlights of the 2015 AHA Guidelines Update for CPR and ECC

14 For BLS and ACLS algorithms, please referred to

15 Bystander CPR Early CPR Increases Survival

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17 Adult BLS and CPR Quality n Minimizing interruptions with a goal of chest compression fraction of at least 60% n CCF = It is the percentage of time in which chest compressions are done by rescuers during a cardiac arrest n Fewer pauses in CPR increase the chances of surviving a cardiac arrest (less than 10 sec)

18 Ventilation During CPR with an Advanced Airway n It would be reasonable to deliver 1 breath every 6 sec (10 breath/min)

19 ACLS Summary of Key Issues (New) n Vasopressin and Epinephrine n ETCO 2 for Prediction of Fail Resuscitation n Steroids (ICHA and OCHA) n B-Adrenergic Blocking Drugs n Lidocaine n PCI n ECMO n Targeted Temperature Management

20 Vasopressin and Epinephrine n Vasopressin was removed for simplicity n No benefit of vasopressin over epinephrine n Epinephrine - timing of administration l It is reasonable to administer as soon as possible after the onset of cardiac arrest due to an initial nonshockable rhythm (PEA/Asystole)

21 ETCO2 n Low ETCO2 (< 10 mmhg) in intubated pts after 20 mins of CPR is associated with a low likelihood of resuscitation (shouldn t be used in isolation)

22 Steroids n There are no data to recommend for or against the routine use alone for IHCA (Class IIb, LOE C-LD) n Uncertain benefit for OHCA

23 Post-Cardiac Arrest Drug Therapy: New n B-blocker l There is inadequate evidence to support routine use after cardiac arrest n Lidocaine l There is inadequate evidence to support the routine use after cardiac arrest

24 PCI n Should be performed emergently for OHCA pts with suspected cardiac etiology and STEMI (Class I, LOE B-NR) n Reasonable for select pts after OHCA with suspected cardiac etiology but w/o STE on ECG (Class II a, LOE B-NR) n Reasonable in post-cardiac arrest pts for whom angiography is indicated regardless of whether is comatose or awake (Class II a, LOE C-LD)

25 ECMO n May be considered for select pts, in settings where it can be rapidly implemented (Class IIb, LOE C-LD)

26 Targeted Temperature Management n All comatose pts with ROSC should have a TTM for at least 24 hrs l TT between 32ºC-36ºC, maintained constantly n Continuing TM beyond 24 hrs l Is reasonable in comatose pts to actively prevent fever n Out of Hospital Cooling l Not recommended Nielsen N. et al, N Engl J Med. 2013;369:

27 PROGNOSTICATION for poor outcome USING CLINICAL EXAM n The earliest time for prognostication in pts treated with TTM, may be 72 hrs after return of normothermia (Class II b, LOE C-EO) n The earliest time for prognostication in pts not treated with TTM is 72 hrs after cardiac arrest (Class I, LOE B-NR)

28 Updated Recommendations: Special Circumstances n Naloxone administration in combination with BLS care for opioid-associated life-threatening emergencies n Intravenous lipid emulsion considered for treatment of local anesthetic systemic toxicity n Refined recommendations regarding uterine displacement for CPR during pregnancy

29 Take-Home Messages n Lay provider care saves lives n Defibrillation as early as possible n Medications have modest benefit n Advanced Airway is a lower priority early in cardiogenic arrest l If performed, don t interrupt more important interventions (compressions, defibrillation)

30 Take-Home Messages n Post-resuscitation care is a key component of management l l Targeted Temperature Management Coronary Reperfusion n Do not forget your basic critical care skills

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