ACLS 2005 Update

1
ACLS 2005 UpdateThe Essentials Whistler -
September 2006
Dr. John PawlovichFraser Lake, BCCCFP,
Assistant Clinical Professor UBC
2

• Main Concepts 2005 ACLS

3
The 5 major changes in the 2005 guidelines

• improve delivery of effective chest compressions
• single compression-to-ventilation ratio (302)
  (except newborns)
• each rescue breath should be given over 1 second
  to produce visible chest rise
• single shock followed by immediate CPR without
  pulse or rhythm check for VF/ PVT cardiac arrest
• AED use in children (1-8 years)

4

• High-quality CPR saves lives!!

5
Important Points
!
Five key aspectsto Great CPR
6
Coronary Perfusion Pressure (CPP)

• (aortic pressure right atrial pressure)
• MAJOR DETERMINANT FOR SURVIVAL IS CPP
• Highly correlated to ROSC
• When CPR is paused, CPP falls quickly
• When CPR is restarted, it takes 3-6 compressions
  to reestablish the previous CPP

7
Compression-Decompression

• Compression
• Compression of heart lungs
• Increased intrathoracic pressure

• Decompression
• Refilling of heart lungs
• Decreased intrathoracic pressure
• Negative with full recoil

8
One Universal Compression-to-Ventilation Ratio
for All Lone Rescuers

• 2005 (New) 302 for all lone rescuers
• 2000 (Old) 152 adults, 51 child and infant.
• Why By-stander CPR is on the order of 30 or
  less. Simplify guidelines to increase bystander
  CPR.

9
1-Second Breaths During All CPR

• each rescue breath over 1 second to produce chest
  rise (Class IIa)
• OR 1/3 of BVM volume (500cc) for average adult
  given over 1 sec
• AVOID HYPERVENTILATION!!

10
Defibrillation (VF/ PVT) 1 Shock, Then Immediate
CPR (NO pulse check, NO rhythm check)

• SINGLE SHOCK MORE CPR
• CONTINUE CPR WHILE MACHINE CHARGES

11
Rationale - 1 Shock followed by Immediate CPR

• The rhythm analysis by current AEDs after each
  shock typically results in 37 sec delay in CPR
• first shock eliminates VF in more than 85 of
  cases. If first shock fails, resumption of CPR
  is likely more beneficial
• it takes several minutes for a normal heart
  rhythm to return and more time for the heart to
  create blood flow after VF is eliminated. CPR
  can bridge that gap.
• Immediate CPR after defibrillation is not harmful.

12
Changes in Advanced Life Support
13
Pulseless Rhythm
14
Main Concept

• priority is good CPR with minimally interruption
• Insertion of an advanced airway not a high
  priority
• In presence of advanced airway, continuous
  compressions (100 per minute) with asynchronous
  ventilation (8-10/ min) (1 breath every 6-8
  seconds).
• minimize interruptions in chest compressions!!!

15
Defibrillation General concept

• Immediate defibrillation if witnessed arrest and
  AED available
• Compressions before defibrillation if unwitnessed
  or arrival at the scene gt4-5 minutes.
• One shock followed by immediate CPR (beginning
  with chest compressions)
• rhythm check after 5 cycles of CPR or 2 minutes

16
Importance of CPRThree-Phase Model
Shock
CPR
?
0
2
4
6
8
10
12
14
16
18
20
Arrest Time (min)
17
Importance of CPRPriming the Pump
18
Defibrillation Energy setting

• For adult defibrillation
• monophasic manual defibrillator 360J
• biphasic with truncated exponential waveform
  150-200J
• biphasic with rectilinear waveform 120J
• biphasic unknown type 200J.

19
1 shock versus 3 stacked shocks

• BIPHASIC eliminates VF after first shock gt90
• AED requires 90 secs for 3 shocks (i.e. NO CPR
  FOR 90 SECONDS)
• Interruptions in chest compressions are harmful
• 1 Shock strategy may be preferable

20
Drug Administration

• IV or IO drug administration is preferred to ETT
  route
• Drugs should be delivered during CPR as soon as
  possible after rhythm checks.
• timing of drug administration is less important
  than the need to minimize interruptions in chest
  compressions

21
Major changes in ACLS drugs

• VF/ pVT/ asystole/ PEA
• epinephrine q3-5 min
• Vasopressin X 1 may replace either the first or
  second dose of epinephrine.
• VF/ pVT
• Amiodarone (Class IIb)
• Lidocaine (indeterminate)

22
Antiarrhythmics

• No evidence that giving any antiarrythmic drug
  routinely during cardiac arrest increases rate of
  survival to hospital discharge
• In comparison with placebo and lidocaine, the use
  of amiodarone in shock-refractory VF improves the
  short-term outcome of survival to hospital
  admission

23
Use of Advanced Airways

• LMA and Combitube should be considered (Class
  IIa).
• Advanced airway may be placed several minutes
  into the resuscitation
• clinical assessment plus a device such as ETCO2
  or EDD to confirm ETT placement (Class IIa).

24
Bradycardia Tachycardia
25
Arrhythmia with pulse

• symptomatic bradycardia
• atropine 0.5mg IV (max 3mg)
• Isoproterenol eliminated
• Tachycardia
• summarized in a single algorithm
• branch points then become narrow versus wide
  complex, and regular versus irregular rhythms
• polymorphic VT should be treated as VF with
  high-energy unsynchronized defibrillation

26
Post-resuscitation Stabilization

• Vasoactive support
• Hypothermia
• cooled to 32oC-34oC for 12-24 hours when the
  initial rhythm was VF (Class IIa).
• may be beneficial for patients with non-VF
  arrests in- or out-of-hospital (Class IIb).
• Glycemic control

27
SUMMARY of AHA ECC 2005 GUIDELINES

• Push hard and push fast with adequate recoil and
  minimal interruptions

28
SUMMARY of AHA ECC 2005 GUIDELINES

• Effective ACLS begins with high-quality
  BLS...particularly high-quality CPR!
• The potential effects of any drugs or ACLS
  therapy on outcome from VF SCA arrest are dwarfed
  by the potential effects of high-quality CPR.